Marya Zlatnik, MD, is an OB/Gyn with the Program on Reproductive Health and the Environment (PRHE) at UCSF. She specializes in high-risk pregnancies and has done abundant research into the pre-natal effects of environmental exposures, including recent work on the pre-natal exposome and pre-natal wildfire smoke exposure. I have read her work with interest for years, and it’s been such a pleasure to serve on the CHPAC with her, where she is definitely on the side of the angels. Marya attended medical school at University of Iowa – my alma mater, and the med school I would have attended had I chosen that path – and knew some of my friends who ended up there. It’s a small world, and I am grateful to have allies like her in it.
This interview has been lightly edited for length and clarity.
JMK: Hey, Marya! Thank you so much for taking the time to talk with me. I do have a list of questions, but mostly, I just want to get your stories. I know of course that you trained at The University of Iowa. What first prompted your interest in OB/Gyn and the health effects of environmental chemical exposures, and more recently, the effects of climate change? Is there some story from your childhood or early training about how you got interested?
MZ: That is a good question, and I don't think I have a single point in time, as maybe Mark or some of the other people do. I grew up in Iowa, and I ended up going to college in the Pacific Northwest at a small Liberal Arts College. And so that is when I started to have more of an appreciation of the environment and learning about recycling and other environmental issues. I don't actually remember when I first learned about climate change – maybe in the mid-eighties. A lot of my best friends are from those years, as well as a lot of my political beliefs. Those were very formative years for me, as I'm sure they are for many people.
I went back to Iowa for medical school and was busy enough that I wasn't super focused on environmental issues, but I had a little bit of an awareness. I didn’t think it would be part of my career; I thought of environmental issues as part of my personal life. And then I moved to Galveston, Texas to do my residency and fellowship.
I thought I was going on an adventure to Texas, that this was going to be a cultural experience, which it was, but I learned how different things were there. For example, recycling: I had grown up in Iowa, where there had been a bottle bill since I was a very little kid, so you always recycled at least your soda cans and newspapers. To recycle in Texas, there was a place that was open one Saturday a month – but if I had to work in the hospital that day, then I missed it for the month.
My fellowship comprised four years of OB/Gyn and then three years of maternal-fetal medicine (MFM) or high-risk obstetrics. The fellowship included doing what was called a Master of Medical Science; my thesis project had to do with oxytocin receptors. This was pretty basic science, but I also took some graduate courses: a stats course and an epidemiology course – because those were the ones that seemed to make sense.
In the Epi course, I remember one of the professors talking about how common cancer was in that part of the Gulf Coast of Texas. Galveston is this Barrier Island right off the coast of Houston, and then there is the ship channel. A lot of industry goes in and out of Houston right by Galveston, and I was across the bay from Texas City. There are refineries all up and down there, but Texas City has some of the biggest ones, so when you looked out across the bay from where I lived, it looked like you were looking at a city lit by all these lights, but it was the petrochemical plant. It often had flares going. At the time, I had no idea they contained anything potentially harmful. But that was what I looked at every day. And then this epidemiology professor was talking about how the incidence of cancer was really high in that area – and implied that it had to do with the petrochemical industry.
At the time, the Residency Director at the beginning of my residency retired because he was old enough – but he had developed lung cancer. He had been a smoker, but in the distant past. When I was a Fellow, one of the OB anesthesiologists got pancreatic cancer, and then one other person I didn’t know well who was older also got cancer, and then one of the OB/Gyn oncologists also got cancer. So it may all have been random or genetic, but a message started to sink in about something that I had not had any training in during my medical career – about how everyday environmental exposures, things that the government in the U.S. thought were safe, could be harmful to health.
So that idea was planted there, and then I ended up going to Virginia after my fellowship for a couple of years to get some more ultrasound experience. And then I came to UCSF in 2002, and sometime around 2007, I first joined the Program for Reproductive Health and the Environment (PRHE).
PRHE was looking for an OB to join their group and asked my boss if she could spare an OB to join their group for a little while. I don’t think there was any salary or anything. So then I started going to meetings, and I was pregnant not long after that. And so obviously, I was receptive to the information. D d
I remember being at one of these little PRHE meetings, talking about trying to do something like the Pediatric Environmental Health Toolkit, which eventually became Toxic Matters. And I remember I had this Nalgene water bottle that was supposed to be BPA free, which I know now had BPS in it. Back then, I didn’t know.
JMK: And why would you?
MZ: Exactly. That was how I got into it. I liked the people. I don’t know about the PhDs, and the pediatricians in the PEHSUs may not all be as wonderful as Mark, who is in his own league, but they are all nice people who care about the world and are trying to make things better. They were all excited to welcome me in as the first OB/Gyn who was part of that community. They knew that a lot of these exposures start in the womb, so they needed to get OB/Gyns involved. They appreciated me having that slightly different perspective, and I’ve been able to learn from them because so many of them are THE experts.
If a pregnant person has exposure to lead or whatever I’m dealing with, and she’s pregnant, the people I go to are the PEHSU people, who know more about whatever it is during pregnancy than I do because they’ve been the only ones doing it for so long.
JMK: My experience with everyone in this field has been that it selects for really great people. I have been just delighted to talk with Mark and get to know him – and many others. And so Tracey Woodruff was probably with the group from the beginning, right? She has been publishing with PRHE for decades – did she start it?
MZ: Yes, Tracey started the group with Linda Giudice at UCSF. She is not retired, but I think she has been ill. She’s a reproductive endocrine infertility specialist. She has always been a basic science researcher who has done a lot of important work on endometriosis.
When she was at Stanford, she had a patient who couldn’t get pregnant or kept having miscarriages. I don’t know the details, but the patient asked her, could the fact that she grew up on Love Canal have anything to do with this? Linda said, I never thought about that. That was the genesis of the group, and this patient who never got pregnant and who had money was one of the major funders of PRHE. She provided seed money to start the research program, and that happened at the same time as Dr. Giudice came to UCSF from Stanford. So I don’t know if the original plan was hatched at Stanford or UCSF, but part of her plan was to start this program in reproductive health and the environment. She knew enough to hire Tracey Woodruff – fresh out of the EPA. That was how it started.
I don’t know if any of the other original crew are still around at UCSF. There was Patrice Sutton and her partner Bob Gould, who was a pathologist at Kaiser with a long history – one of the founding members of the Bay Area Physicians for Social Responsibility (PSR), which was originally an anti-nuclear group. They were always politically active, and now are interested in other things, although nuclear has not quite fallen off the list of things to worry about. And Patrice had an MS and did a lot of the writing, organizing, and making things happen. She was great, but she has retired.
In 2006 or thereabouts, Tracey started at UCSF. I think she was at the EPA for a long time – and may have retired from there.
JMK: Wow – that is a great history. It’s surprising that so little was done before then.
In preparation for this and over the years, I’ve read quite a few of your articles. I’m a little bit of a fangirl for all these people I’ve been reading for years, which is fun. Recently, I read a couple of recent ones on wildfire smoke and prenatal exposures, as well as the pre-natal exposome. I saw you were looking at chemicals that had not previously been detected.
MZ: I’m the OB consultant for these exposome projects. I'm not running the mass spec or analyzing all that data. But I think it's really important work, because obviously, it's finding stuff that we didn't know we needed to worry about.
JMK: Yes, absolutely – like you said about the BPA/BPS – it’s important to not just look at the usual suspects but at the 80,000+ [now estimated at 350,000+] chemicals in common production.
In all the work you've done in this area, is there one thing, or are there a few things, of which you are proudest?
MZ: That is a good question. I would say that the work that I have done of which I am most proud is in teaching and translation of information. I have not had any of the ground-breaking scientific ideas. The paper you mentioned on wildfire smoke, I did with one of our fellows. I have done writing work on the review papers, but really, it’s trying to take information in the Epi literature or that I’ve learned at PEHSU or CHPAC meetings and put that in the context where an OB/Gyn in practice should think about it.
I give a lot of talks – I do mostly elective talks for the medical students. I get invited to give talks to the Stanford medical students every last however many years. I spoke at Thomas Jefferson – some student got my name from somewhere, and it’s a little bit of a time commitment, but if the student emails from across the country and says, this isn’t in our curriculum, and my fellow students and I want this information, I feel like that is something I can do.
Even if I do not convince any of them, or if they don’t end up in OB, there are still people in the world of medicine who have been exposed to the idea that the environment is important and that we can’t just think about genetics and medications.
JMK: That is so important. I was talking to Susan Buchanan not long ago. She is my PEHSU director. She supervised my MPH internship, and we’ve remained friends – and I didn't realize until she told me that she only gets a half day with the UIC medical students to cover environmental health. There is so little public health in the medical curriculum.
MZ: I think the students have some awareness that that needs to change, at least when it comes to climate change. There is a medical student group called Medical Students for a Sustainable Future. A few years ago, they started what they call a planetary report card. Basically, they grade medical schools on their curriculum in reference to climate change and sustainability. It’s now international. That sort of information doesn’t necessarily get a medical school to change their curriculum, but most pay some attention to what the students are asking for. Students are trying to drive some change.
JMK: That’s awesome. How does Iowa rank?
MZ: I don’t know if it’s on there. Certainly, Iowa would have gotten an F when I was there, though I don’t know now. Even UCSF is B+ or something even though we’re doing some things.
JMK: You are still practicing every day, right?
MZ: My son is a teen; shortly after he was born, I went three-quarters time, and so my time that is not paid goes towards this. I think I may be on a PEHSU grant at about 5%. But that time does not go very far. I try to go to talks and meetings and educate myself – and participate in CHPAC. All of that gets wedged into the 20-25% of my time.
JMK: You still have your hand on that pulse. This question is about how you have that conversation with parents, and especially pregnant people who need to know these things, and yet learn that every child is born exposed to toxic chemicals.
MZ: I struggle with that. I am not typically the first person someone sees during pregnancy. The best time to get the information to someone is before pregnancy – it’s worth making changes later, but for persistent chemicals, changes made in pregnancy might not impact the pregnancy at all – it’s well before. Many people don’t know they are pregnant until partway through the first trimester. In some ways, the horse is out of the barn, although certainly the kind of anticipatory guidance that a pediatrician can do starts during pregnancy, like talking about healthy foods, thinking ahead about contaminants like lead paint and house dust. How old is your youngest?
JMK: Oh, my youngest is 21 – they are all grown up.
MZ: The genetic screening has gotten so complicated. And so when a patient comes for their first visit, they get information about how we are a teaching institution, and how they are going to have residents at their delivery, and that we have midwives. They get information on genetic screening, and then we ask if they are having symptoms: bleeding, constipation, or other health complications. And so there is a little bit of advice – no drinking and smoking – but how much of that is said out loud?
We have an information book. One of the pre-interns and I made up a spiral-bound book, a big tome personalized for UCSF. It’s all been revised and written by our people. We expanded the avoid alcohol and tobacco section to include the Toxics Matters information. For those people who get it, it’s all there, but people who aren’t going to read the book may not get the information. Most people I see in a consult setting – because they are having high blood pressure or other health impacts – it probably doesn’t come up. It might come up if we’re having a wildfire smoke event. If I see someone for a consult because they had a prior pre-term birth – if they seem receptive to more information – I will say a bit more, like how to avoid phthalates in personal care products, get an air filter for wildfires, and that kind of thing.
When I talk to our diverse patient population, the smart, well-read tech people already know this stuff, already don’t use plastic, though they may not know everything.
But some people are marginally housed, so I am always very nervous when I know that a lot of the things you could do as an individual are expensive. I try to get a sense of how much information they want and what they can handle, like washing hands, leaving shoes outside the door, avoiding second- or third-hand tobacco smoke. These are things everyone can do. And then some patients are PEHSU referrals, and some of them formally come through the PEHSU. And then some are informal in that colleagues know I am interested in this and have a patient who asks. Usually, it’s someone worried that they stayed in an Airbnb, and it smelled like mothballs, not that they work in a nail solon with horrible ventilation or that their husband is a pesticide applicator. A real pesticide applicator hopefully knows some safety information, but the farmworkers who are in the fields after the pesticide applicators don’t get educated.
JMK: Some of these lawn applicators and even farmers get the illusion that since they have had training, they are safe. And of course, we know how inadequate that is. But you're in a position to really make a difference.
MZ: I talk about it less than I feel I should. Part of that is just time. And they come in with their agenda, whether it’s diabetes, horrible back pain, or depression – there are things that take time and that are important that derail other things I might like to talk about. Alexandra Destler has a website called My Safety Nest. She educates about environmental toxicants and pregnancy for the average person. She has made a push to increase accessibility to women of color and low-income women. She knows Tracey, which is how I originally got connected with her. We have done trainings with local doulas on lead, water, paint, pesticides, dust, and personal care products. The goal is that the doulas would be armed with this knowledge to share with their clients – like the promotora model – a community health worker who can relate to people. That might be the ideal person to do a lot of that.
JMK: Well, they presumably get to women sooner – probably even women who are trying to get pregnant. I was lucky enough to have midwives.
MZ: The group we are working with specifically cater to women of color, and I don’t know what their funding model is, but they have services for most people for free through grant funding. They are trying to provide the service to people who would otherwise not be able to get that service on their own.
JMK: That’s wonderful!
The next question moves in a different direction. If you suddenly had complete power, and you could re-create U.S. policy regulating environmental chemicals – and let’s throw in climate change – what would the policy look like?
MZ: I don’t know if you get the same answer from all of us. Clearly, chemicals that are going to be interacting with people or the environment should go through a process more similar to the FDA – precautionary. Let’s have evidence that this chemical is safe before deploying it into the food supply or wherever. That would be huge. And then obviously, we should stop pulling fossil fuels out of the ground because even if we are not burning them for energy, they are getting turned into plastics and other petrochemicals that we are learning are hazardous to people’s health.
JMK: Yes. I think a lot of people are under the impression that there's some process like the FDA at the EPA. It seems like a very careful process, and that chemicals can be pulled if dangerous, and I sometimes wonder if it's worse that people have the impression that the EPA is protecting them because the protections are so scant. People are shocked to learn there have only been five chemicals banned in the history since TSCA.
MZ: Yes. You can make a new water bottle plastic and start selling it and say it’s better without having any reason to say that.
JMK: Even Europe is better than we are – not perfect, but better. And to answer your question, most scientists I have interviewed say the same. And many people do point right to the money in our politics. And of course, petrochemical companies have huge resources they use to influence our elections.
MZ: Citizens United – I would name that as well.
JMK: Right? I remember that ruling in 2010 and just feeling this huge sense of dread.
The central question that I've been looking at, I approached from a cultural and historical perspective in the last book, and from a policy and regulation perspective in this one. But the question is, if we know we are poisoning our children, and that we are destroying the only planet on which life exists, and that there are solutions ready at hand, why are we not implementing them? And I've been summarizing this as, how can we be this stupid?
MZ: Well, I have wondered that myself. I think honestly, it's because most of the power is in the hands of old white men who are the least impacted and who don't care about people – other than the few people they are related to or love. And they somehow think the joy they derive from having their own private jet outweighs killing the planet.
It’s astounding because the petrochemical industry knows that climate change is real. Most of the people making the decisions at least over the last twenty years knew enough to know that they were causing harm. It is probably true now that some people in positions of power see reality the way FOX News does, and so they don’t understand some of the science. But I think that is a symptom rather than a cause.
JMK: Yes. I teach my students all this. We just finished reading The Road by Cormac McCarthy. That's our post-apocalyptic book. And then we read Barbara Kingsolver’s Animal, Vegetable, Miracle, which is our pre-apocalyptic reading. And I feel so badly sometimes just laying this out for them. Most of them don't realize coming into the class how bad the situation is. And eco-anxiety is important to address as well.
What do you think will be the status of children’s health in the year 2050?
MZ: I am an optimist. My hope is that … I am repressing the fact that Trump could end up president again. But if that does not happen, then if you look at the data on the deployment of clean energy and at some of the things the Biden administration has done, it’s plausible we could get to the point where we get to a two-degree centigrade increase but that we have already made enough changes to bend the curve.
We are having atmospheric rivers here right now. We are seeing destabilized climate and weather disasters, and that could be the new normal. People could get used to it as long as it’s not your home that is lost. Things will get worse before they get better. But I’m hopeful. By 2050, either we will all be toast, or it will be better.
JMK: Ha! Can I quote you on that? I love that – and I think it is true. It doesn't seem like there's a lot of middle ground. I don't know if you've seen The Lancet’s Countdown. They put out a little video in 2019 that says we have two paths, and one is all happy – we solve climate change, and children have cleaner air, and everything is nice. And the others is not so nice, and climate change is ruining everything, and everything is worse – we’ll be toast – very pithy. I try to tell my students that it depends on what we do right now. But it’s a lot of responsibility.
This last question is, is there anything you want to ask about me, my experiences, or this project?
MZ: Well, I have a question for you, and this maybe even relates to talking about pregnant women, though not exactly. I have a friend whose youngest child was diagnosed with leukemia.
JMK: Oh no!
MZ: The last time that I saw her in person, the baby was probably less than a year, and when the baby was about two, she was diagnosed with leukemia.
It's hard to know how to talk to people who are going through that. What do you say? She never asked me about whether environmental exposures caused the leukemia. And I don’t know what they might have been exposed to.
JMK: It's so hard – we were talking about communicating with a parent whose child is already diagnosed with cancer, when, of course, there's already that guilt and fear, right? And on the other hand, I have read research that subsequent exposures can lead to relapse, and so those exposures could be very important. We believe that my daughter's exposures, which we did not realize were occurring, caused her initial cancer, and then also probably contributed to her relapses. And so if I were her, I would want to know that.
And if you can share things with her – perhaps saying, here's a resource that I share with my patients, and I don't know if you would find this helpful, but here it is. If you're asking me what you think you should say to her, I would say offer the helpful tips you know. You could always add them as an attachment or a link. She could look or not look, depending on where she is right now. But I just know that when Katherine was sick, I was, first of all, just so pressed for time, and we felt like all the focus had to be on her and on her illness. There was only so much time we had for doing the research.
But I have amazing friends, and one of my friends was training at Harvard / MIT at the time, and I just delegated some of the research to her. So it's awesome that she has friends who have the resources and know how to do this research for her. I would always have been receptive to that myself because you're looking for anything that can help, anything that can slant the odds for your child.
And two is so young – gosh. Is that what you were asking me?
MZ: Yes. You want to keep in mind it can feel very awkward to know what to say to someone who's suffering so much.
JMK: I agree it can feel very uncomfortable to know what to say to someone who's suffering. Yet you know that person is already suffering. There's not that many things you could say to make it worse – I can only think of one person who said something after Katherine died that made it worse, but that was very rare. Mostly, people were very kind, and I would rather someone said something to me, because I am always aware of my story, right? I am always aware of that loss, and when she was sick, always aware that she was sick.
So I was more likely to be pleased when people felt like they could say something than when they felt they had to hold back, especially if they had something that could be helpful. I did have one person who, God bless her, was sharing information about electromagnetic fields, and some sort of woo-woo cure, but I still understood the intention was a good one. But that's very different from you who have all the credentials and all the resources at your fingertips.
MZ: Yes.
JMK: But yes – I’m so sorry for her. That is really hard.
MZ: Yes. In Mark’s current project, when do you get a critical mass of people knowing, when does that start to add up? Not everyone is going to automatically know the environmental causes of disease, but when does it become well enough known that most people have some sense of it?
JMK: I think that's one reason Mark was very generous with his time with me, and I assume many other people – because we need to get the word out, and I'm not counting myself as the best person to do this. I'm just considering, where can I help with this? And I'll do my part. And I'm lucky – I teach. And so I have lots of opportunities to communicate these things. Half my classes now are environmental health. I do think we need to get this out in the general public a lot more. It's hard in this polarized environment.
MZ: Yes. And I think it’s very difficult for industry representatives to respond to you.
JMK: Good. And you know, some of the things industry representatives have brought up in my presence about flame retardants – it's such a red herring, and it has been looked at and dismissed long ago. The Chicago Tribune did an exposé on this a decade ago. And so yes, I do think we have to speak out against that. I'm not always sure how much I should bring my personal story in. But now that people know, I guess I won't even have to say it. I want people to remember that I am speaking for a lot of people who will never have a voice.
MZ: Right? No, your voice is sadly a very important one.
JMK: Thank you. It brings me pleasure to know that I have allies versus the industry perspective.
MZ: Oh, good!
JMK: I do not know how people do that – represent an industry view they know is harming people.
Thank you so much for talking with me, Marya. I really enjoy just chatting with you.
MZ: Likewise, and thank you for your work. And I will hope to see you in May!
JMK: Take care!
