This study features the largest number of chemicals ever tested for in the same group of people – 210 chemicals were tested. The results were staggering – each participant tested positive for an average of 53 known human carcinogens, 55 chemicals known to cause birth defects or developmental delays, and a host of other chemicals. Each participant tested positive for chemicals that damage the brain or nervous system, that weaken the immune system, and chemicals that cause reproductive abnormalities. Perhaps most disturbing: these 210 chemicals tested represent only a small fraction of people’s exposure. More than 500 chemicals are used in the U.S. as active ingredients in pesticides alone. More than 3,200 chemicals are regularly added to foods. More than 2000 new chemicals are registered for use in the U.S. each year – most with no safety testing.

Combinations of chemicals can be far more damaging than individual exposures. We do know that just as drug-drug interactions can cause serious side effects, chemical-chemical interactions can multiply the risks. For example:

This Body Burden Report shows PCBs and dioxin in the same people. These often appear together – even in breast milk. Researchers looked at liver damage caused by the two. By themselves, the PCBs caused no liver damage. Dioxin did cause some. But mixed together, the two chemicals produced 400 times the damage of the dioxin alone. (Van Birgelen, A.P.J.M., et al. Environmental Health Perspectives (1996) 104:550-557.)

Some pesticides in common use can act like the female sex hormone estrogen. Researchers at Tufts University School of Medicine measured the effects of 10 such pesticides. Taken one at a time, they had no measurable effect on human tissue. But when different combinations were tested, these same low levels of pesticides now showed a strong estrogen effect. (Soto, A. et al. Environmental Health Perspectives (1994) 102: 380-383.)

Two commonly used pesticides, aldicarb and atrazine, are found in our food and our drinking water – and in our bodies. When tested individually at levels found in the groundwater in the U.S., they showed no adverse effects. But when combined – the way they are in the water – the combination produced immune system impairment. (Porter, W.P., et al. Toxicology and Industrial Health (1999) 15: 133-150.)

In short, the Body Burden study reminds me of a smoke detector or a carbon monoxide alarm – alerting us to a silent but serious danger, hopefully in time to wake us from our sleep. This study leaves no doubt about the pervasive pollution of our bodies with large numbers of toxic chemicals in combination, most of which didn’t even exist when my parents were born.

Notes

• Work was done by the Environmental Working Group in partnership with the Mt. Sinai School of Medicine and with Commonweal.
• Published January 2003.
• Work was published in Public Health Reports and online at www.ewg.org/reports/bodyburden/

Major Recent Studies

• Organophosphorus pesticide exposure of urban and suburban pre-school children with organic and conventional diets. October 2002.
• Loss of neuropathy target esterase in mice links organophosphate exposure to hyperactivity. March 2003.
• Second National Report on Human Exposure to Environmental Chemicals. January 2003.
• America’s Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses. February 2003.
• Related Tidbits

Related concepts:

German measles, Congenital rubella syndrome, Third disease, French measles, False measles, Scarlatina morbillosa, Hybrid measles

Introduction to rubella:

How tragic when a mild illness, scarcely worse than a cold, can cause such devastating effects on babies. Young parents, beware!

What is rubella?

Rubella is one of the classic rash illnesses of childhood. In ancient times, it was lumped in with measles, scarlet fever, and smallpox. For a while, it was thought to be halfway between measles and scarlet fever. It became known as scarlatina morbillosa (which means measles-like scarlet fever), rubeola scarlatinosa (which means scarlet-fever like measles), or hybrid measles.
A little more than a hundred years ago, it became clear that while rubella was similar to both measles and to scarlet fever, it was different. It became the third of the non-pox childhood rash illness (third disease). German scientists did most of the work (German measles), although some French scientists made important contributions (French measles). For a while, it was also called roseola, though we now know that rubella and roseola are distinctly different infections.
The main value in identifying this illness was that parents could relax! Rubella was much less serious than either measles or scarlet fever. If your child had a rash and a fever, this was the diagnosis you wanted the doctor to make.
Then in the 1940s everything changed. An Australian ophthalmologist named Normann Gregg observed that large numbers of cataracts and other birth defects occurred right after rubella outbreaks. He suggested that if pregnant women caught rubella, the unborn baby might be damaged. And Dr. Gregg was ridiculed.
At the time, the idea that an infection could hurt a baby was considered preposterous! The placenta was considered an unbreachable barrier that protected the baby from all illnesses, chemicals, toxins, drugs, alcohol, tobacco–any insult from the outside world.
Dr. Gregg became a laughingstock. But within a few years, his observations proved true.
This opened a new era in children’s health.
Today rubella is known as one of the TORCH infections (toxoplasmosis, others, rubella, CMV, and herpes). These infections in the mother cause many miscarriages, and affect up to 5 percent of all babies who live to be born. They are among the leading causes of birth defects and newborn deaths. A baby born with birth defects resulting from its mother’s rubella infection is said to have congenital rubella syndrome. Thankfully this is now exceedingly rare.

Who gets rubella?

Rubella tends to arrive in epidemics, with major epidemics every six to nine years. The virus that causes rubella was first discovered in 1962, which helped scientists to learn a great deal by studying the 1964 epidemic.
There were 1.8 million people known to be sick with rubella in that epidemic. There were 20,000 known fetal deaths and about 30,000 infants born with severe birth defects.
An intense, worldwide effort to develop a rubella vaccine began in 1965.
Immediately after the introduction of the rubella vaccine in 1969, epidemics virtually disappeared in the U.S. Since then, there have been fewer than 120 cases of congenital rubella syndrome reported each year in the U.S., a reduction of well over 99 percent.
In the U.S., most women who get rubella are unimmunized women who catch the disease during an outbreak at a college campus.
Epidemics still occur in many countries around the world, only one plane flight away. Rubella is most common in the late winter and early spring (March, April, and May in the northern hemisphere) both during epidemics and in the off years. Only humans get rubella.

What are the symptoms of rubella?

For children and adults who get rubella, it is usually a mild disease (often very similar to an adenovirus or enterovirus infection). The classic illness includes a rash, swollen glands, and low-grade fever. Sometimes there’s a sore throat. Adults usually feel sick before the rash; for children, the rash is often the first symptom.
The rash usually begins on the face and spreads down and out to the hands. Swollen glands are prominent, especially behind the ears and on the back of the head. But many people have rubella without the swollen glands or without the rash–often with no symptoms at all, except for the effect on an unborn baby.
Sometimes rubella can cause arthritis, either briefly or permanently. Other complications, such as encephalitis, are more rare.
Congenital rubella syndrome (the possible result of a baby being infected before birth) is usually much more severe. The birth defects can include blindness, deafness, heart defects, behavior disorders, mental retardation, bone disease, liver disease, and “blueberry muffin skin” (dark areas of pooled blood).
The early first trimester is the period of greatest risk, when most babies of infected mothers will have birth defects if they survive. By the fourth month, the risk of congenital rubella syndrome when a mother is infected drops to about 5 percent.

Is rubella contagious?

Rubella is very contagious. People can be contagious for up to two weeks before they have symptoms, and for six days or more afterward. Rubella can be spread by direct contact, airborne transmission, and droplet transmission.
Ninety to 100 percent of people who are not immune will get rubella if exposed.

How long does rubella last?

The rash in uncomplicated rubella usually lasts for three days in a child or adult. If it weren’t for the rash, most would feel fine going to work or school even during the height of the illness. Some remain uncomfortable for 7 to 10 days.
Complications from rubella can be permanent.
Congenital rubella syndrome is a lifelong consequence of a brief “cold” that may not even have been noticed by the pregnant woman.

How is rubella diagnosed?

Rubella infection in children or adults can be diagnosed by blood tests or by nasal swabs.
Congenital rubella syndrome can be diagnosed with blood tests if the testing is done in the first year of life. After that, it is very difficult to be certain what caused the defects, although certain patterns make some causes more likely than others.

How is rubella treated?

For children and adults with rubella, treatments are aimed at relieving symptoms, if any.
For congenital rubella syndrome, an array of support services may be helpful, such as physical and occupational therapies, cardiac surgery, or eye surgery.

How can rubella be prevented?

Rubella vaccine within three days of exposure might help to prevent rubella, but it should not be given to pregnant women. (And women should not become pregnant within three months of having the vaccine.)
Routine rubella vaccination of young children is the best way to prevent congenital rubella syndrome. It is stunningly effective. Even one dose generally gives long-term immunity in 95 percent or more of those immunized.
People who attend or work in schools, day cares, health-care facilities, or who might spend time around pregnant women or around those who do, should take particular care to be immunized.
Women who might become pregnant should verify that they are immune.

Related A-to-Z Information:

Adenovirus, Airborne Transmission, Arthritis (Juvenile rheumatoid arthritis, JRA), Cataracts, Cerebral Palsy, CMV (Cytomegalovirus), Congenital Heart Disease, Contact Transmission, Deafness, Diphtheria, Droplet Transmission, Encephalitis, Enteroviruses, Exanthems, Fetal Alcohol Syndrome, Fifth Disease, Herpes Simplex, Influenza (Flu), Measles, Mononucleosis (Mono), Mumps, Parvovirus B19, Pertussis (Whooping cough), Roseola, Scarlet Fever, Smallpox, Tetanus, Toxoplasmosis

The first trimester of pregnancy can be a vulnerable time. Some medicines taken during that period can have catastrophic effects on the baby. The third trimester is generally safer. Evidence published in the February 11, 2000 issue of Science suggests that drinking alcohol even once during the third trimester can permanently damage the brain of a baby.

Alcohol has its biggest effects when the synapses (connections) of the brain are being formed – during the last trimester of pregnancy and the early childhood years.

When the developing baby is exposed to alcohol for even a few hours, a number of brain cells and synapses are permanently deleted.

Thalidomide, the drug that was prescribed to relieve morning sickness in the late 1950′s and early 1960′s, caused a worldwide epidemic of severe birth defects. The drug is not kind to certain growing tissues. This turns out to make it very powerful in treating leprosy, AIDS, cancer, diabetic retinopathy, and perhaps a number of other conditions. In 1998, the drug was put back on the market. The same drug that put so many in wheelchairs is now helping others get out of wheelchairs — and saving people’s eyesight.

Dr. Cynthia Moore, of the Centers for Disease Control,  reported that less than 20% of young women know about the dangers of thalidomide. I suspect young men are even less well informed. Even one tablet can cause severe birth defects. No man or woman taking thalidomide should conceive a child while on the medicine. Two forms of birth control, including condoms, should be used. Thalidomide is extremely powerful — a powerful boon for some, but devastating for unborn babies.

Trisomy 13 (also called Patau Syndrome) occurs in up to 1 out of 5,000 newborns (Smith’s Recognizable Patterns of Human Malformation, Saunders 1988).

The 13th chromosome contains blueprints that direct a baby’s development in the early weeks following conception. When a child has an extra 13th chromosome (three copies, instead of two), as is the case in trisomy 13, the genetic messages are confused and contradictory. This results in multiple significant defects in major organ systems.

The brain is often the most severely affected. Most children with trisomy 13 also have some kind of heart defect. It’s not unusual for these children to be born blind, deaf, and with no sense of smell. Children with trisomy 13 may also have abnormalities in the shape of their lips, eyes, ears, fingers, toes, and bones.

Trisomy 13 was first described in 1657, but four hundred fifty years of medical knowledge have not improved the outlook for children born with this syndrome.

Most babies who are conceived with trisomy 13 die early in gestation. Of the babies who live to be born, about 44 % die within the first month and 69% die by six months. Only 18 percent reach their first birthdays — and these children tend to have severe mental defects and seizures (Smith’s Recognizable Patterns of Human Malformation, Saunders 1988).

A blood test, called the AFP (alphafetoprotein) or triple screen, may help a pregnant woman find out her baby’s risk of several diseases, including Trisomy 21 (Down Syndrome) and Trisomy 13, though it can not give a definite answer.

Trisomy 13 is often detectable on ultrasound as early as 10 weeks. Chorionic villous sampling can detect trisomy 13 by 12 weeks. Amniocentesis, usually performed after 16 weeks gestation, can give a definite answer if any question still remains.

Often trisomy 13 is associated with older mothers. Even so, the risk of having another baby with trisomy 13 is usually very low.

A trisomy 13 translocation is not associated with mom’s age, but is a hereditary chromosome problem. The risk of recurrence in some types of (balanced) translocations can be quite high.

Dr. Greene’s Answer:

The gastrointestinal system is a long convoluted tube extending from the mouth, through the body, down to the anus. During development a portion of the tube may not form. This is called atresia (for example, in esophageal atresia, a section of the esophagus is missing). More commonly, a portion of the tube is too narrow. This is called stenosis. In pyloric stenosis for example, the pylorus (the valve at the outlet of the stomach) is too tight to permit stomach contents to pass through easily. Anorectal anomalies occur in about 1 of every 4,000 live births and include a wide spectrum of defects — some are minor and easily treated, some are complex and very difficult to manage.

Very early in development, the urinary tract and the embryonic rectum and anus are all part of the same structure. They separate by the seventh week of gestation. At the time of separation, the urinary tract already has an opening on the skin, but the anus is covered by a thin membrane. By eight weeks of gestation, the anal opening typically appears.

Anal stenosis refers to a narrowing of the anal opening, which makes it difficult for stool contents to pass through easily. Symptomatic children tend to be particularly colicky babies, because of the discomfort associated with the stool backing up. The stool may exit under pressure and look almost like a squirt gun. Treatment of this disorder usually involves gentle dilation of the anal opening. This is typically done twice a day. Every week a slightly larger lubricated dilator is passed to stretch the anus until it reaches normal size. In very mild cases, softening the stool may be sufficient until the anus grows sufficiently. Suppositories can make the child comfortable in the short run, but do run the risk of dependence. At around 4 months, apple or even prune juice may help the child to pass stool. Rarely, surgery is needed to insure an opening of adequate caliber. If this is an isolated anomaly, the prognosis is excellent.

Some children are born with no anal opening at all. This is called an imperforate anus. The rectum ends in a blind pouch, about 2 cm inside the perianal skin. Usually the sphincters are well developed. For these children, a colostomy is indicated during the newborn period, but once the final surgery corrects the defect, the prognosis is likewise excellent.

The most frequent anorectal defect seen in boys is the recto-urethral fistula, or a communication between the rectum and the lower part of the urethra. These children also require a colostomy before the definitive repair period. The long term prognosis for normal urethral and rectal function is good.

The rectovesical fistula is a communication between the rectum and the bladder. These children usually also have poorly developed sacral bones and sphincters. The prognosis for normal bowel function is poor.

For all anorectal malformations, there is a very good correlation between the degree of development of the sacral bone with the final bowel and bladder functioning after correction. Children with an absent sacrum will almost certainly have permanent incontinence. Those with a well-developed sacrum will generally have an excellent outcome.

Based on the treatment your doctor has prescribed, I can only assume your daughter has a very mild case of anal stenosis. Although her condition is concerning to you now, in a few months you will probably be privileged to change many dirty diapers each week.

Over the years we have received numerous requests from high school and university students, who are in the midst of choosing a career, asking what it is like to be a physician. Here is Dr. Greene’s reply –

It was a bad hair day.

Two hours earlier, I had been dreaming happily of flying over the beach at Cabo San Lucas — without an airplane — when the harsh ring of the phone burst the scene into quickly forgotten fragments. It was a call from the hospital; they needed me for an emergency Cesarean Section. After a blizzard of activity, the emergency was over, and a picture-perfect little girl had been born. Still awash with the glow of the miracle of birth, I glanced at my watch. The emergency had come at that awkward time when I would normally be home showering. Instead, I shaved in the on-call room (no time for a shower), rushed through the cafeteria line, and ate breakfast while walking to my office. I am a pediatrician.

I arrived late, harried, and wearing part of my breakfast. I know that it’s a very minor inconvenience, but the feeling of wearing a stained shirt or having unkempt hair embarrasses me. I was not looking forward to the rest of the morning.

The waiting room was jammed. The first few patients I saw were delightful children I already knew, who had come in with minor complaints. I sped through the morning, pausing to smile at each child, but hurrying to get back on schedule.

The next chart in my in-box had an unfamiliar name on the cover. I stepped into the exam room and saw a nine-year-old boy. Large clefts marred the middle of his face. Although a scar suggested that his cleft lip had been repaired, he was still left without nose or eyes. He did wear glass eyes in an attempt to make his visage more presentable.

“You must be Stephen,” I smiled, “I’m Dr. Greene.” I reached forward, took his hand in mine, and shook it warmly. The hand at the end of his shortened arm was missing three fingers.

I recognized Stephen’s condition as the Amniotic Bands Sequence, which affects only about one in 25,000 otherwise normal children. When Stephen was still waiting to be born, his forming face fused to the membrane lining of the amniotic sac. Normal development arrested, resulting in the large clefts in his mid-face. Part of the amniotic membrane ruptured, and the sac that was supposed to protect him, instead entangled his developing limbs in shriveled, fibrous, amniotic strands. Decreased circulation to the limbs caused multiple deformities and amputations. Normal intellect and normal emotions were framed in a twisted, blind body.

“I’m glad this sweet boy will never see his own face,” I thought. Thumbing through his chart, I looked up to ask a question, and saw tears making their way down the crevices of Stephen’s face. Mild surprise that his tear ducts functioned gave way to genuine concern over what had made him cry. I placed my hand gently on his shoulder and asked what had provoked his tears.

“I’m just happy, Dr. Greene… you smiled at me!”

This boy with no eyes had felt my smile, just as he had felt the averted gaze of many passers-by. And the smile had touched him deeply.

How striking that a gift as simple as a smile could be so powerful. When we see someone afflicted, whether emotionally or physically, it is easy to turn away. What an important act of humanity to look in the eyes (even if there are none), and see a person, not just a problem.

But it’s not just the disabled who need reassurance. In our mobile society, our moorings both to place and to people have been loosened. We are adrift in a rolling sea of humanity. By looking with fresh warmth and compassion at the people who surround us each day, we create new connections. By seeing beyond surface appearances to the unique miracle of each individual, we are all buoyed.

As I stood in the exam room with Stephen, the two of us beaming at each other, we both felt beautiful, bad hair day and all.

P.S. Stephen went on to have plastic surgery on his face, despite others’ objections that he did not need it, since he was blind. He is an absolutely delightful young man, and I am honored to count him as a friend.