Mark Miller: Stalwart Defender of Children’s Environmental Health.

Dr. Mark Miller, MD, MPH is Director Emeritus for the Western States Pediatric Environmental Health Specialty Unit (PEHSU). He is legendary in the field of Children’s Environmental Health (CEH) and author of many important practical materials that help to educate providers and parents about the hazards of environmental exposures. One of the best is the Pediatric Environmental Health Toolkit, a resource he developed with colleagues, including at the Pediatric Environmental Health Specialty Unit Network. In the most robust interview yet, Dr. Miller describes a major inspiration for his work – visiting the Minamata Disease Victims group as an undergraduate – and shares insights about the field to which he contributed so significantly over the decades. We connect over findings, family, friends, and Pope Francis.

This interview has been lightly edited for length and clarity.

JMK: Hi, Mark!

MM: Hello! What a pleasure it is to meet you!

JMK: And you, too. Thank you so much for taking time to talk to me today. I was just doing some work for the CHPAC and looked at the TENDR Consensus. And there you are on that as well; you've done so much amazing work over the years!

MM: I think it’s a great idea to highlight people in the profession. There is a bunch of history available right now from the people who go way back, people who are not that old, but we are moving to where we're going to start losing people.

JMK: Absolutely. Some years ago, I interviewed Aaron Blair and Shelia Zahm; I remember they were among the first researchers I was reading. And so yes, I appreciate that perspective. And I feel that maybe the public, at least academics, are ready for a message now and are beginning to understand the chemical environment in which we live.

MM: There’s certainly an audience that feels strongly and tries to advocate, and all that. But that may be different than being able to break through on some of the larger political issue.

JMK: Yes, that is really difficult to witness, isn't it?

Well, mostly I want to hear your stories, and so, I have this loose list of questions, but I am happy for you to guide me and tell me whatever you think I should hear. How did you get where you are now? What in your training prompted your career? I saw that you had been in Minamata in Japan and witnessed the mercury poisoning there.

MM: I have lots of stories. I often tell these stories for trainees. I think it’s important because there is not a nice clear path to becoming a professional in Children’s Environmental Health (CEH), particularly for clinicians. I, like many of the people you’re interviewing, got into this when it was just becoming a thing. [We both laugh.] I had an untraditional education. My college was Friends World College – a Quaker school with two concepts: world education and experiential education. I worked in rural Mexico in a remote area of the Sierra Madres with a fellow who started a clinic there – as an undergraduate, I worked there for two years as a medic. That’s where I decided that I would like to pursue medicine because I was already doing it. I was at an outpost clinic that was a 12-hour mule ride from our base clinic – alone. A child was brought in who had been kicked in the face by a mule and had a large gaping wound under his eye and cheek. I had to build a fire and put on the pot to boil the instruments and anesthetize the area and sew it up. That’s a complex area to do a repair because an infection, even if it’s superficial, can get behind the eye and cause meningitis. I was quite worried about it and how it was going to look because it was his face, but it turned out very nicely. I said, okay, if I am going to be doing this, I need a real education. And so I went to medical school.

My last semester – at my college, you had to spend time in two cultures other than your own – I went to Japan. I chose Japan as there was an outside examiner for my senior thesis, who was working on multi-level village-based healthcare system on an island off the coast of South Korea. While I was in Kyoto, the United Nations (UN) had a second world conference on the environment, and a friend of mine, who was also a student in Japan, got permission to attend it as a student observer. There were 400 scientists from around the world in environmental science. And during the conference, there was a presentation from a Minamata victims group; at the end, they invited all 400 attendees to come at their expense to Minamata so they could show them the impact on the community in person. Only three or four wanted to go, and my friend said, I am just a student observer, but could I join this? Minamata is at the southernmost tip of the southernmost island in the Japan Archipelago, and I’m going on from there to Okinawa – so she asked, can my friend, who is really interested in Minamata, come? I had found this book, which I highly recommend to you by Eugene Smith and his wife. He was a war photographer and was invited to come and do photojournalism for Life Magazine. They included me, and I spent a week in and around Minamata; we stayed a couple of nights with a fisherman’s family who were affected, and we basically went 14 hours a day meeting people and seeing the story and talking with victim groups. A pediatric neurologist helped with some of the tour, and then he and his wife invited my friend and me to Nagasaki to see the Peace Park. That is seared into my mind. You know the story?

JMK: Yes – I especially think of the photo of the mother holding her disabled daughter. I have blogged about it – I think of it as a modern Pietà.

MM: They recently did a movie about Eugene Smith with Johnny Depp.

I had spent some time with the founding President of Friends World College – Morris Mitchell – who is a story in himself. He was retired and living on a farm in northern Georgia. One of the concepts he had for college-aged people was something he described as discovering an emerging concept to work on. For him, emerging concepts included modern forestry techniques, as well as regional environmental planning. At his little farmhouse that he had built on 10 acres, he had planted white pines in the early 1930s. Managed forestry was the cutting edge of thought. I was there in 1971, and there was a very healthy 40-year-old forest that was spectacular and very, very healthy. What you want to do, he said, is identify something to devote your career to so that when you’re his age – 80 years old – you can look back and know you contributed positively to the world.

JMK: Wow!

MM: Yes. And so my original plan in medical school was to do what is now called global health, or health in the Third World, as it was then called. For whatever reasons, I ended up in a small private pediatric practice in rural Northern California, and once I had my feet on the ground with that, I came back to the idea of first, I should have a special interest that I was involved in and cared about – and environment and health was it. Before that, I had looked into what training would be needed for this kind of work. I called around to different public health schools and said, I’ve got this idea for a two-year program, and this is what it would include. And the response was that you could do a Masters in Epidemiology. [He laughs.] Children’s Environmental Health (CEH) wasn’t on anyone’s agenda in 1983-84. And so I drew back to my experience in Minamata, where you clearly heard from the people that they saw their experience, their lived experience, as a warning to the world. And it was essential that we change how we were doing things to prevent mass poisonings, possibly Earth-changing exposures.

JMK: If only we had listened to them!

MM: Yes. They put themselves on the line. It was really impressive because in Japanese society, particularly at that time, it was very traditional, and you don’t draw attention to yourself or your community like that – and they went way out on a limb because they wanted their experience to matter.

In my pediatric practice, I thought, what can I do from where I am? I was taking care of a wide variety of people in this little community – a lot of farmworkers, Hmong immigrants, and a mix of middle-class people. I thought, I’m here. I can educate families about these exposures – which ones are particularly concerns. And so I developed materials to hand out about smoke, woodstoves and fireplaces, pesticides, etc. And in 1991, that led me in to the first conference on CEH put on by a new NGO, CEHN, in Berkeley, and I met some other people on the same track. Eventually, that led me to joining the California chapter of the American Academy of Pediatrics (AAP) committee on environmental health, one of the few AAP Environmental Health (EH) Committees in the country. A few early leaders were from California, like Dick Jackson and Lynn Goldman. After a year on that committee, Dick said it’s your turn to be chair. [We both laugh.] So then I was chair for a couple of decades.

Then I was on the National CEH Committee for AAP. It was a reiteration of my experience about why I went to medical school. I was doing this work on CEH at AAP, and I was invited to speak on things. We were developing the first edition of the Green Book, the Pediatric Environmental Health handbook for the AAP– I wrote the pesticide chapter. I was never trained to do this work. My career was never oriented toward academics. I wrote no papers and did no research. I was a practicing general pediatrician. A friend who was an epidemiologist and pediatrician in public health said you should do a Preventive Medicine residency. The State of California had a sponsored Preventive Medicine Residency, where they funded you to get a Masters of Public Health (MPH) and spend a year internship with a county or state agency of your choice. And I did that at the CA Department of Public Health Environmental Health Investigations Branch. That gave me a Master’s in Environmental Health Sciences, which gave me some background in toxicology. And when I finished that, I did a little freelancing on childhood lead poisoning with the Lead Poisoning branch of the State Health Department. This same friend called me up and said, hey, there’s a position open at the Office of Environmental Health Hazard Assessment.. The job description was written like they were looking for me – and I knew there were no other me’s. I’ve been there almost 25 years. Then around 2000, the PEHSU network was developing. Colleagues asked if I would support UCSF in getting one of these and be on the advisory board and help organize the effort, and I did. Then they asked if I would be willing to direct it. So I was Director of the Western States Pediatric Environmental Health Specialty Unit (PEHSU) for about 20 years. I recently handed it over to a younger colleague.

JMK: Yes – the toolkit you developed is so well known. It’s one of the main ones out there and so helpful.

MM: Thanks. We’ve done a lot of creative and fun things with very little funding with our PEHSU. I’ve had some colleagues that I’ve worked with for a very long time. Maria Valenti helped develop the toolkit, originally in print, as well as the Story of Health eBook. She was the Executive Director of Boston Physicians for Social Responsibility (PSR) at the time. She now works through Commonweal, Bolinas California.

JMK: I will share with you the handouts I did for my internship with the PEHSU at UIC. I put those together from scratch and then afterwards found your toolkit. It’s important to get information in the hands of clinicians so that they know how to talk to patients because, as you know, there’s so little done in medical school, even now.

MM: There is amazingly little done in medical school, unfortunately – not just on CEH – there’s amazingly little on public health. It’s just a minimal part of the training at most institutions. The focus in medicine is largely on treatment with very little focus on prevention.

JMK: Yes, and that is such a shame. It seems part of the American mindset now. For the CHPAC, we're going to get to talk to the people working on the Cancer Moonshot program. And I think that is a point I will bring up: when I looked at that program, they are still focused mostly on treatment, when so many more gains are to be made in prevention, and it's low-hanging fruit. We know what to do, and yet it's so little funded, as you know. That's something that Bruce Lanphear talks about quite a bit.

MM: Yes – we did that video with him and put the leukemia part of that into it, and then published the 2015 paper surveying clinicians– do you know that paper?

JMK: Yes. Such a small percentage feel comfortable talking to patients.

MM: Also, few had training, and they are absolutely unfamiliar with the literature about environmental health associations with risk for childhood cancers. There are reasons why: these things are not presented at their meetings. We did an analysis of two years of abstracts at the key children’s cancer meetings, and only a handful of abstracts could be identified as about causation other than genetics. When we looked at that, it was clear that the publications were in journals that the clinicians don’t read. They were not being published in Pediatric Hematology & Oncology and others like that. They were being published in Epidemiologyor Environmental Health Perspectives. I just spoke at a meeting, and the person before me was somebody from the National Cancer Institute (NCI), and he went through the current funding – and there is almost none for the kind of research that would lead to preventive action. Funding is almost entirely treatment-related, which is, of course, really important. But we could spare a few percent more for things that might allow us to make better policy and give families guidance.

JMK: Absolutely. I don't know a parent whose child has been sick with cancer or other environmentally linked illnesses, who wouldn't rather have prevented it to start with, because, for all the obvious reasons. Right? Even if your child survives, there are late effects from the treatment.

MM: Yes.

JMK: I think that's so important. And that was one reason I was just thrilled when I saw your 2016 article in Pediatrics. Childhood leukemia is preventable. People don’t even use that word.

MM: That was preceded by a Physicians for Social Responsibility (PSR) forum on prevention, where they invited different practitioners to write about environmental health. I had written a couple years before a column for them about prevention of childhood cancer, saying this is the time for examining this, time for action. And in those years, you could not find any place where “prevention” was in the same sentence with “childhood cancer.”

JMK: No, I was waiting for it because the research from the first literature search I did when my daughter was diagnosed in 1998 was clear; Zahm and Ward's review of literature came out that same year. How many decades, how many more children need to die before we say that we could prevent all this? But of course, there are many reasons why that might be the case.

MM: Well, there are. We’ve been struggling with those for some time. How do you make that change?

JMK: The next question on the list is really linked to this: you have done so much important work, and I wondered if there one thing that was most pivotal and of which you are proudest?

MM: I have a hard time with what’s the most important. There were many things where I learned a lot or contributed; certainly, trying to move forward the idea of prevention of childhood cancer is one big area that’s been very important, and we’re making a little bit of progress. We started collaborating between our PEHSU and the Center for Integrative Research on Childhood Leukemia and the Environment (CIRCLE), which is based at Berkeley. I was the community outreach and translation core lead for a number of years. I was able to have a focus on prevention, highly supported by Catherine Metayer, who was the PI on that and was super supportive, out of which arose these various materials, including infographics for families. We had a program where we trained community health workers, promotores salud, who worked in Latino communities to include preventative messages about key things that have been identified as risk factors: tobacco smoke – including pre-conception use by the father, exposure to solvents, use of paint during pregnancy or when the child is young, and ambient traffic air pollution. There are several kinds of exposures that have been substantially documented. And what I noticed is that you would see a paper come out that had some major finding, and it would get some press coverage. They would interview someone from the study team talking about how it should lead us to policy, and then another maybe researcher would add to that, and then at the end of the article, they would interview a practicing pediatric oncologist, who would say we don’t know what causes childhood cancer. And I thought, okay, we have to get to these people because they are torpedoing our message. The American Cancer Society (ACS) through all these years and until today – that is their line. Except for some genetic contributors, they say we don’t really know what causes cancer – they have written off the environmental health contributions entirely.

That brings me to another issue – an early one that I’m proud of, which is my work with The State of California. We did a review of environmental tobacco smoke that was part of listing it as a toxic air contaminant. In that review, I identified second-hand smoke as a risk factor for breast cancer in pre-menopausal women and that the most vulnerable period was exposure between menarche and the completion of your first full term pregnancy. This had a lot of implications that were contrary to common understanding and to the Surgeon General’s reports at the time. It got a lot of worldwide press, and some other places, like the Philippines, added breast cancer to warnings on tobacco packages. Eventually, the Surgeon General came around to more or less supporting that same kind of thinking; more studies came out after our evaluation that strengthened that finding. And now, recently, I’m seeing publications from the European Union, in which their public health authorities wrote a paper about the attributable risk of second-hand smoke for women’s breast cancer, which asks – how many cases per year are caused by exposure to second-hand smoke? In order to do those calculations, there is an assumption that secondhand smoke causes breast cancer, so you know that that’s really important, and I learned a tremendous amount through that process, including insight into the political framework for disease. Who did we get negative feedback from besides the Surgeon General? We also had pushback from the ACS.

JMK: Yes, that is so frustrating. I know there's an argument between toxicologists and epidemiologists, but I once heard a toxicologist say that he just doesn't really believe in epidemiology. I was shocked, and I just don't know what to say to something like that.

MM: Look how many epidemiologists are on the staff at the USEPA.

JMK: True.

MM: Not very many. I was just at a meeting where there was a presentation about pesticide analysis they have done that wants to remove from an organophosphate pesticide the label of developmental neurotoxicant based on the New Alternative Methods (NAMs), which are the non-animal testing methods. So there is evidence of developmental neurotoxicity in human studies, and yet they want to override that because these limited-value non-animal studies didn’t show something. These NAMs include studies that use in vitro studies or in zebrafish or other organisms like that. There are actually all kinds of different ones, meant to look at different processes that underlie the development of disease, but they are not at all good at identifying developmental neurotoxicity, so the fact that there was nothing identified is moot. They are valuable for identifying red flags of risk rapidly for large numbers of chemicals and identifying which ones ought to be particular concern for further study. But it doesn’t rule out that ones that don’t show something aren’t a problem, and particularly when we’ve got other really more substantial evidence from animal or human studies.

JMK: Yes, it's outrageous that they're dialing back restrictions that are so meager to start with. I was really fascinated to hear what you said, which I have known from Devra Davis's Secret History of the War on Cancer, about the complicity of the American Cancer Society with the chemical and tobacco industries. I'm also not surprised to hear about oncologists, who you would think would understand. My daughter's beloved oncologists had done enough of a literature search so that they were at least receptive to my explorations. But I think that line that you described – we don't really know what causes cancer – I wonder how much of that comes from the industry.

The next question is this: you know the guilt and fear surrounding environmental contamination, and especially children's cancer. And some practitioners may not want to make people feel responsible for their cancer or for their child's cancer. And so that's perhaps why they're not communicating about it. But do you have advice about communicating about an issue that is both essential to prevention and productive of anxiety?

MM: That is a big question in environmental health, particularly children’s environmental health. And we are quite sensitive to it at the PEHSU’s. You don’t want to immobilize people from life with the concerns they could have. You need some perspective on all this and to understand where we actually have information. When I started, there was almost no knowledge about the toxicity of environmental chemicals on growing and developing children. We had to largely try to extrapolate in risk assessment based on the data available from occupational exposures, which meant adult, healthy males. There was not much exposure information for women, for during pregnancy, and almost none for during childhood. There was not much relevant information in the animal toxicology realm because generally, the studies started around adolescence in animals so that you couldn’t really pull out and identify risks from these studies for pregnancy or early childhood. Now we do have much more information.

In the pediatric oncology realm, I think you’ve correctly identified that one concern that clinicians have is that they don’t want to exacerbate parental guilt for something that it is uncertain. At this stage, it is rare that we could with certainty attribute any individual’s case of cancer with a particular exposure. Larger study information lets us say there is an overall connection between this exposure and this cancer. But that doesn’t say that for any one individual case. What do you say when you have population-based data, and how do you transform that discussion to what it means for an individual? They are concerned about making parents feel guilty. It neglects a couple of things in my view. Number one, in general, parents who are bringing up these questions already have some concern. They may already have gone to the web and identified papers that justify that concern. Commonly, the clinician might not know that literature so that they can speak with some knowledge. Two, when you do bring it up, rather than exacerbate guilt, you can say that it can be a risk factor, and at the same time, if you structure your conversation well, you may actually reduce guilt.

JMK: Yes.

MM: Because rather than saying my child had this exposure, you’re already thinking this caused it. But for example, almost all children are exposed to pesticides, and many are exposed at significant amounts, yet few go on to have cancer – there is more to it than that. I think the language of risk can be translated to parents – both to validate their concern and to alleviate guilt. Yes, maybe that risk contributed. It’s unlikely, actually, for an individual that that’s the case just by numbers. And yes – there is risk you would want to avoid for future children.

I’ve had pediatric oncologists say, “why should this be important to me?” What I am given is a child who has cancer, and my job is to take them from that point through treatment, to get the best outcome possible. What caused it is not part of it. It seems a little short-sighted. They have some vision that somebody else already does that. Public Health doesn’t do that. Cancer registries have data, but they don’t really do that. And it leaves out that there are a lot of parents who are interested. I have a parent advocate who pointed out that when her daughter was going through treatment at a major medical center, they were offered all kinds of consultations: psychological help for the child and for the family, physical therapy, occupational therapy, dance therapy. They were asked if they would like to see the clown.

JMK: Right?!

MM: But when the mother asked about these environmental exposure factors and what she should do going forward, the doctor said, “well, I don’t know anything about that.” And it wasn’t like, you could go ask these people, or we could look into something. It was just – sorry. And her idea was – they have all these other teams to refer you to when you have these questions; why don’t we have that for environmental health exposures? She had questions. Okay, my daughter is being treated with chemotherapy, and she’s going to school, and at their school, every week, they have a little fire and toast marshmallows as a treat. She was concerned about the smoke. And it’s beyond a normal question because she’s a child with cancer and under treatment. No answer: so we actually took that up. And in this year’s program of the Childhood Cancer and the Environment Program, we are putting that into a training at a large pediatric oncology center. Part of the deal will be to work and support a small consultative team at the institution, so that they will commit to developing this small team for patients who have these questions. That way, the clinician doesn’t have to worry about it, but they can say, you can see this team, which hopefully will have a nurse practitioner, maybe a social worker, and somebody who is interested and understands the science – maybe an epidemiologist. They can share knowledge – just like our toolkit.

JMK: How valuable that would have been when my daughter was diagnosed! I credit our pediatric oncologists because I knew I had had exposure to chlorpyrifos in an apartment, and I immediately thought of that when my daughter was diagnosed. I was breastfeeding, and you know what? They agreed to test my breastmilk to make sure that it was okay to keep breastfeeding my son, and that was unusual, then, to pay any attention to that. I'm really glad to hear that you're trying to institutionalize those kinds of resources. That's wonderful.

MM: My hope is to make inroads so that trainees routinely get exposure to this information and ideas about how to deal with that. So there are a few people similar to you who have had this experience as a parent and have related knowledge and experience and are trying to address this. So you’re familiar with the Childhood Cancer Prevention Initiative (CCPI)?

JMK: Yes – absolutely. I got in on it after the major publication was underway, but I was able to attend a year or two of meetings. There are some wonderful parent advocates. And what a great thing – even the name of it made a huge point.

MM: So they just had their first conference, and I spoke. It was quite heartwarming.

JMK: Wonderful. I'm really glad to see the connection with businesses as well because to have some businesses at least weigh in on how we can transition to a cancer-free economy – that's really heartening.

MM: Yes. It’s a big transition that is moving forward within the childhood cancer community. There’s something to be said for a clinician’s concern – they have a role – but not the only role. The general pregnancy care providers, the general pediatric care providers, and those in family practice all play a key role. By the time you are at the oncologist’s, that’s too late. There is a whole new issue. A lot of clinicians are busy in their lives just doing their job. Not everybody is built to be a clinician advocate. The question is, why is this relevant to me? Early studies about exposures going forward are very important; one paper identified that in regard to ambient particulate air pollution, children who have had chemo, if exposed to higher levels of PM2.5, have double the risk of hospitalization because of respiratory illness. So that is some evidence to answer this question about, is it a problem for my daughter to be around the fire pit? It is more of a problem for her; she will be more susceptible because of her chemotherapy, so clinicians could at least provide some reasonable advice – there is beginning to be evidence about things that make a difference during treatment and among survivors. Survivors may be at greater risk after their treatment and probably for the rest of their lives.

JMK: I have also seen a few articles that looked at relapse rates and subsequent exposures. We know that cancer is multi-causational.

MM: There’s very little – one on tobacco smoke. There’s a new paper that just came out by Catherine Metayer on parental tobacco smoke and early relapse. Long-term outcome and mortality in ALL are worse. There was a previous paper like that from Spain. We’ve emphasized in some of our materials that many of the exposures are a concern pre-conception. There is actual evidence that preconception exposures, often via the father’s germ cells to smoking or in utero environment for the mother are linked to higher rates of cancer. Adequate folate is protective. There is a particular window of exposure that is important, and that includes pre-conception and early post-conception, so before a woman normally might be seen for her pregnancy. So starting a prenatal vitamin at two months might be a little too late.

 JMK: Absolutely. There was a review by Ma et al. in 2002 looking at that preconception window, and I remember a physician friend of mine reacting negatively to that, not being able to stomach the idea that risks could occur preconception. But now we know more. Right? I mean, obviously the mother's body burden continues to expose the child. So yes, I think those are all reasons everyone should care about these exposures.

MM: So why was I drawn to do this? We’ve been trying now for 35 years to draw attention to the importance of environmental exposures on children’s health and on early life exposures toward lifetime health. So cancer is one area, but pulmonary and neurologic health are also important.

JMK: Absolutely. The book will have chapters not only on cancer, but also on Autism Spectrum Disorder (ASD), ADHD, lower IQs, autoimmune disease, birth defects, and health impacts of climate change.

MM: To prevent cancer, population-based changes – so reducing exposures to air pollution, reducing exposure to chemicals through food packaging or agricultural techniques, and on and on – the things we might do relevant to these exposures have to be done on a population level through regulation. That will never occur for a rare disease like cancer, even as costly as it, because it will never show a positive cost-benefit analysis, which our government is prone to feel like they need before doing anything. However, all of these exposures, both the risk factors and the protective factors – they are all associated with a host of other health impacts – including common ones like asthma. The impact on that of reducing air pollution – all of a sudden, if you look at all the combined impacts (for all of the health endpoints) and costs, both in children and in adults, then it makes lots of sense. There are papers that do the cost-benefit analyses, but they are less impressive in relation to childhood cancer because it is so rare.

The organized lobby for cancer funding for adults has been much more successful. It’s something people know about and have family connections to. They care about it. And so we need to tie overall risks with the overall outcomes. Then it makes both cost-effective sense, and it brings the important emotional content, the attention that childhood cancer can bring. They are all connected. We don’t have great data for many forms of childhood cancer, but as you know, so many neurodevelopmental disorders are linked to these same exposures. We have information about the constellation of exposures, including social exposures and the bigger environment, racism, etc. This makes a big difference in combination with chemical exposure; it intensifies impacts.

JMK: I really appreciate that some papers have tried to put that big picture together. But it's hard because to learn about things, people have to subdivide problems, atomize problems. But then, to see the whole picture, you have to put those pieces back together.

MM: A fundamental problem in moving forward is that governments feel they need to have this label of causation attached to something, which can be a very high scientific bar. For example, almost all the important studies on childhood cancer are case-control studies. Some say, it’s interesting for us to develop hypotheses based on that, but there are people who say we need a prospective cohort study to say that something’s causative. Well, when you have a rare disease like childhood cancer, you would need a cohort study of millions of children. A high-quality case control study, or a series of them, can provide better quality information than a cohort study with serious limitations like poor exposure assessment as is often the case.

JMK: And it's just not really happening. I think about the Agricultural Health Study, which has a large sample size, and some indicative results. But yes, it's definitely a problem.

I want to move to the next question about policy. You and I both know the policy has failed in the past. If you had charge of environmental policy going forward to protect children, what would that look like?

MM: I’m not kidding in this answer. I’ve often been asked over the years, well, what is the most important thing that we should be doing to protect children from environmental hazards? What’s the biggest hazard? What’s the most important thing we can do in response to reduce these problems? My answer has been, campaign finance reform. That’s what we are talking about—we already have plenty of evidence. We don’t need exhaustive evidence to protect children. In the early days, risk assessments by the California EPA would be six pages long; now, they are often 300-1000 pages. The more studies that are developed in science, the higher and higher the bar gets to establish causation. We need to take a more precautionary approach for children, for chemical policy; we should be looking at where is the evidence that a chemical is not hazardous, rather than have we identified a hazard because most chemicals do not have the kinds of studies done that would fully enable us to say it is safe. There are 80,000+ chemicals out there that we are exposed to on a semi-regular basis, and the requirement is not that we have to prove it to be safe before we expose 50 million children to it.

JMK: I could not agree with you more, of course, and I like the succinctness of your answer.

MM: In order to do that, we have to change how things run in the political world, and more and more, the limited abilities we have had through the regulatory structure are under attack. It’s not moving forward.

JMK: Yes, we see this in real time.

So I wondered if you could give me a perspective on the central question I'm occupied with, both in my previous book and in this new one. Basically, how is it we are poisoning our children and destroying our climate? What could we do to turn that around? Or basically, how could we be this stupid? And I suppose your previous answer is part of that. But I wondered if you had anything else to add to that.

MM: There has been a long-term, thought-out, well-funded propaganda machine that has fought against doing anything against these things if there is a profit to be made. So even when there are clear alternatives that are safer and perhaps only minimally more expensive, industry has been often willing to fight tooth and nail to avoid progress. And there are many examples where that fight went on, and industry was forced to make the change, and then the change was made, and it was really no problem, and the cost of the products did not go up. Or it’s a change in a manufacturing process or using an alternative chemical. PCBs used to be in all kinds of products. When they made companies take it out of White-Out, it was accomplished with no problem. And now you wouldn’t think about it. So we can do this. It’s a matter of effort. And we need to do it. The EU has advanced on some of these things beyond what we’re doing in the U.S. The industry makes one product for Europe, one for the U.S. Synthetic food dyes carry a warning label in Europe – that change was accomplished without a lot of problem. And yet the industry will say, we can’t do that – it will make our food unpalatable. And voilà! It will cost way more. It’s just like with seat belts. We can’t put seat belts in cars because cars will become too expensive for people to afford. Now, there’s no thought about that.

JMK: I think that's a very good analogy.

So this question is about children's health in the year 2050. What do you think the status of children’s health will be?

MM: So not just focused on the chemical environment, but in general?

JMK: Yes – I mean, it seems like the solution to climate change and environmental chemicals is the same in many cases, right? Getting off fossil fuels?

MM: I hate to talk about it. I’m not an optimist. I try to do what we can. And yet, there is time still for us to change our ways and to put children and health first, as we should do. Pregnant women and children first: if we can make the world safe for them, we will make it safe for everyone. What’s hopeful today is one, we have a lot more knowledge, not just about chemical hazards, but the hazards of social stressors, the built environment, and the chemical environment. Climate change is related to all that and increases many of these impacts. So that helps us to develop measures that mitigate both climate change and these other exposures. We have to think about the fact that these are all connected. It's human change impacting the Earth that we should think about – urban design, climate change, and air pollution; many exposures can be mitigated by urban planning and mass transit. The right solutions cut across these different problems. That’s where there is hope – we’re understanding that. And there is a possibility of change and development addressing these interacting ecological measures.

I think we are only beginning to address in Environmental Health how important the social environment is in the impacts of chemical environment. By that, I often point to a series of exposures in rodents. They gave these rodents lead (Pb) as newborns, and then followed them to adulthood without further exposure. Besides the control group of non-exposed, lead-exposed rodents were divided into two groups – one with a normal social environment and one with an enriched environment (toys, company, handling). In the hippocampus, there are these receptors that are called NMDA receptors, which are key for learning and memory, and a reduction in the number of these receptors is related to neurocognitive and neurobehavioral impairment in rodents, and a reduction in these receptors’ activity is also associated with exposure to lead. It’s also associated with an increased response to stress and behavioral impacts. But if you look at rats that were exposed but in an enriched environment, not only did they perform as well as adults, like the unexposed rats – but the activity in their NMDA receptors reverted to an unexposed level. So, at least to some degree, this indicates that an enriched social environment can help to mitigate some toxicologic hazards.

There are a couple of messages in here. One, it’s not built in stone. There’s hope that there are things you can do to improve the outcome, even post-exposure, with lead. We can extrapolate with some early learning center studies like the Brookline Study in Massachusetts from the 1960s. Children in low-income families were enrolled in a very high-quality, early education environment. And they saw impacts of that through high school and into early adult life, with more completion of high school, more children going on to college, less involvement with juvenile criminal activity. What were they treating? These were also children with high lead exposure. Nobody measured the children’s lead, but maybe you’re actually treating, in part anyway, their lead exposure. We know things that are healthy for children – social contact, reduced stress, good education, good nutrition, a whole host of things. We have lots of evidence about that. We can add – reduction to chemical exposures that we know cause these poor outcomes. We need to think of all things together. So the treatment isn’t one of these things; the treatment is addressing all of these things.

There is an impressive young woman – Ayana Johnson – who’s been active in climate change activism. And she asks a question that I think is really important – and is kind of your question right here: what would it look like if we got it right? It looks like addressing all of these things. We have to put forward in our decision-making and our concerns our children. And we have to think about it as a multi-generational impact. We have to make our decision-making about – just like some Indigenous people say – the seventh generation. We need to think long-term and bigger picture so that we value the things that are valuable to us all.

JMK: I could not agree more. Actually, in my previous book, I wrote a scenario near the end – an inverse of Rachel Carson’s Fable for Tomorrow, which goes from Paradise to Wasteland. I tried to imagine what it would look like if we did everything right and moved from Wasteland to Paradise. And I also invoked the seventh generation.

MM: I spent a whole day with a couple who were NY Times reporters. They came out to the Bay area, and in the end, they quoted a bunch of people, but they had one quote from me, which was, “all of healthcare is political.” 

JMK: Yes, I believe that too. People may say, oh, I'm not interested in politics. Well, politics are how we make decisions as a whole.

MM: The Story of Health came out of collaborations between the our PEHSU, Science and the Environmental Health Network, Commonweal, the CDC, and OEHHA. We’ve had over 20,000 people get continuing education (CE) credit for physicians, nurses, or health educators through the CDC. In August, we came out with the updated information and included brain tumors and rare cancers.

JMK: I especially love how you handled the cancer story – I read it with a lot of attention and thought it was very well done.

MM: The approach was to present the material in a way that looks at a constellation of interacting exposures. These different concepts are so important: windows of vulnerability are also windows of opportunity. If being exposed is a vulnerability, not being exposed is an opportunity. For example, if being exposed to lead is a vulnerability, because you’re very vulnerable during early childhood, then not being exposed to lead is an opportunity, as is providing an enriched environment.

JMK: I completely agree. The other day I told my son that if we solve climate change and environmental contamination, these interlinked problems, it will be the greatest Public Health success story ever.

MM: When we were talking about 2050, there’s this quote I used to use from Paul Hawken. Do you know who he is?

JMK: Yes – he does Project Drawdown and Nexus: Project Regeneration.

MM: His Drawdown demonstrates what an influential kind of character he is. He’s a business person. He started Smith & Hawkens, which sold these wonderful English garden tools. He also started Erehwon, one of the first organic food companies. Then he sold his companies and became a writer, and one of his books about activism around the world was called Blessed Unrest. It described community-based organizations for change around the world. He went all around the world and interviewed all these different people to look for commonalities and asked, what can we learn?

JMK: I will put that on my reading list.

MM: He said, he traveled around the world, and talked with all these people involved with activist NGOs of all sorts. And he said something like, he didn’t know of a society that values its people and not the environment, nor of a society that values the environment and not its people. They are intimately connected.

JMK: Yes – absolutely! I'm at a Catholic university, and we were so happy in 2015, when the Pope came out with Laudato Si’,which links people and planet intimately.

MM: I’m a signatory of Laudato Si’!

JMK: Oh my goodness!

MM: I was President of ISCHE, and they wanted a bunch of environmental epidemiology societies to sign on. I’m Jewish, but whenever something comes out about the Pope, I always say, that’s my Pope.

JMK: That’s pretty cute. [We laugh.]

MM: I may not agree on everything, but he’s such an important model and so progressive on environmental health and how all these things connect to how we value people. It comes back to the same thing. What do we have to do? We have to value people and the environment. And we need to build our structures around that and use the examples we know already about how science can inform that, how we can develop products that are water-based, rather than petroleum-based, how we can use biomimicry to come up with products that are less hazardous, how we can use our knowledge about how natural systems do these things. You know, an oyster doesn’t attach to a rock by using something that’s going to kill it or its food, so we know about these things. We have to foster that knowledge, and we have to value the true costs. We can’t ignore the externalized costs to everything.

JMK: I could not agree more. On biomimicry, have you ever read Cat’s Paws and Catapults?

MM: No – who is the author?

JMK: Steven Vogel. He tries to imagine how we could do better by imitating nature. I love how you’re talking about these alternatives. And after Laudato Si’, I don’t notice people pitting people against planet as much as they had done before.

You know I've been gathering in such riches by talking to people like you, and the thought occurs to me that some of this maybe shouldn't wait for the book. So I'm hoping maybe over the holidays to work on an op-ed. And who knows?

MM: It’s important to tell a story people can relate to talking about childhood cancer and the environment; there’s a good case to be made that people will relate to. People care about it; they pay attention to it, more so than asthma. Asthma may affect a lot more people, but it’s easier to relate to the emotional costs of a child dying from cancer, or even surviving with these huge impacts. It’s not just money costs, but emotional costs, not only to the child and the family, but to the community.

JMK: Yes – I could certainly speak to that. I love that idea – thank you.

MM: I need stories like that because that’s when I want to push this agenda we have. They are not funding this stuff. The Childhood Cancer Prevention Conference (CCPI) was really inspiring. Prevention was mostly me, at least primary prevention. There were a lot of presentations about treatment, or treatment-related sequelae, and there was a mostly theoretical aspect of prevention that focused on early-life screening to identify high-risk groups genetically. Identifying it early before the onset of the clinical disease would allow you to do something to prevent it. It was interesting: there were these researchers, and then there were a lot of people like you – parents and survivors of childhood cancers, many of whom had lost their children and now devote a bunch of their lives and have their own foundations. They were a great group, and it was a really good discussion. It was astounding to have a conference on that. When I started writing this stuff, you couldn’t even put those two words together – cancer and prevention – people would look at me like, what are you talking about?

JMK: I know! I’m so glad that it’s now become more accepted. I do need to follow up with some of those parents. What else are we going to do with our lives? Certainly, that gives us some purpose.

MM: I think you parents are just like the people in Minamata. I see this thing – what can I do to help others not go through what we went through?

JMK: Yes – I was really struck by what you said – that they wanted their experience to count, and I think that is true for us as well.

MM: So I went there and had that experience, and then I came back to the U.S. to start medical school. I was thinking this is a seminal thing, it’s really important – but I’ll never see something like that here. And then, there was a huge mercury exposure in Canada in this watershed where there was a big papermaking factory. They used mercury as a catalyst in production and released it into this largely indigenous population north of Lake Superior, which was my region. It was a huge issue about doing something about that. The Chair of Occupational Environmental Medicine at UCSF wrote a book entitled How Everyday Products Make People Sick, Updated and Expanded: Toxins at Home and in the Workplace about the consequences of exposures. He described how we keep having the same problems and the same exposures over time. It starts that lead is identified as a problem for containers of wine in the Roman period, and eventually people stop using leaded containers. And then lead was identified in the early 1900s related to paint. Sweden outlawed lead in paint around 1910. We didn’t outlaw it until 1978. And then we started putting it in gasoline in the 1920s. It just shifts – a new industry comes up, and they don’t learn the lessons we should already know from the previous ones. We should be careful before the widespread use of new chemicals. It’s really concerning what is happening now with NAMs. They are being used to reduce protections we already have through these new tests.  

JMK: And we’re just uncovering new environmental hazards, like PFAS and microplastics, and the list goes on.

MM: We’ve got to reset the system so that it’s to industry’s benefit to be proactive. There was a big push for Green Chemistry a few years ago; it is still there but has lost some momentum. I don’t know what happened.

JMK: I'm just delighted about all that you are telling me. I have one last question, and that is turning the tables and asking if there's anything you would like to ask me about my project or my experiences.

MM: Yes – I would like to know all about it – what turned you to this project?

JMK: You know, I watched my daughter get sick. And so, as you said, it is true that most people cannot identify the cause of their cancer. But we put the pieces together. I told you I'd had some preconception exposures to chlorpyrifos, which caused heart palpitations and thyroid disease – and then we had some mysterious illnesses in our family, and it wasn't until I found out that they had been spraying for mosquitoes, and I heard it outside my window. It just all clicked together, and I realized that's what had caused her cancer. It had probably caused her relapse. And both of my children were affected – both had been acutely ill. Katherine emerged with cancer. David has learning disabilities but is otherwise okay. I always say that we have every reason to believe that our daughter's leukemia was caused by exposure to chlorpyrifos. When she first got sick, and I looked into the primary literature, I couldn't believe that it is so little talked about in the public sphere. And, as you said, the American Cancer Society says nothing about environmental exposures. And yet in the scientific literature, it was conclusive, even when she was diagnosed in 1998. Mostly, I was focused on her, but I also was determined to stop mosquito spraying in my town. We were either going to move, or I was going to get my town to stop. She even accompanied me in a little stroller, though she was very ill, and we went around town spreading the word. We succeeded in getting a referendum on the ballot, and we got our town to stop spraying for mosquitoes. Sadly, it was too late for her. After she died, I worked with my town to protect my other children by getting them to stop treating lawns with pesticides. And so I began as a regional activist, feeling like David and Goliath for sure. At my university, it took me 10 years to get even some lawns to be healthy. I had to get students to come with me to the President and say, we are young women of childbearing age, and we do not want these exposures. I had my PowerPoint presentation with the evidence, and the students said their piece, and if we finally got Healthy Lawns at my university.

So then I realized to get a book done, I would need to get the Masters in Public Health. So I did that 2012 through 2018, one or two courses at a time, and at the end of that, I had done that internship with the PEHSU at the University of Illinois, Chicago, with Susan Buchanan. After she linked me up with the APHA CEH group and UCSF’s SAN, it just took off.

I have started doing half my career on this. I do my day job, which I love, and this is my other job. But I'm also lucky to be at an institution that has let me have this kind of flexibility. And so I can say now, my teaching, research, activism – everything is directed primarily towards children’s environmental health. I teach Global Environmental Health, and I feel fortunate that I get to do what I think is the most important thing I possibly could do now. So that's my story. I started with science. For my PhD, I was won over by medieval literature, while also maintaining an interest in science. And now I’ve circled back again.

MM: Cool! It’s nice that you are able to do things at your institution that are directed by you.

JMK: Yes – it is very fortunate. We’re small enough that I can do that.

You've spent so much time with me, and I am so grateful not only for that, but all the things that you have done over your whole life to protect children, and I am just more grateful than I could say.

MM: I would love to find ways to collaborate.

JMK: I would love that too!

MM: I need people like you in order to move things forward. That’s what the digital media lab said. Yes, research is good, but you’ve got to get the information out there in a way that makes it difficult for people with the ability to make stuff happen to ignore it.

I have a poster memorializing Chico Mendez who organized Amazonian natives to protect the rainforest; you can  increase nut production and gathering in the rainforest, but once it’s affecting the ability to create cattle ranches, people are going to start showing up dead.

JMK: Yes – at least environmentalists aren’t showing up dead in the United States – yet. I look forward to talking more.