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Dr. Philip Landrigan ’63 has taken on lead, pesticides, and Twin Towers dust. Now he takes aim at all the avoidable illnesses of childhood
On a fine afternoon in early november, Dr. Philip Landrigan ’63 is back in his hometown for a few hours, hurrying through the halls of the new convention center in South Boston. He’s headed to a session on terrorism and public health at the annual meeting of the American Public Health Association (APHA), at which he’s due to give a presentation on the “Health effects among New York City residents as a result of 9/11.”
Landrigan has taken the shuttle from New York, where he chairs the Department of Community and Preventive Medicine and directs the Center for Children’s Health and the Environment at the Mount Sinai School of Medicine. Immediately after the late-afternoon session on terrorism, he’ll fly to Washington, D.C., for a two-day planning meeting on the National Children’s Study (NCS), a major effort to examine environmental influences on children’s health.
At 64, Landrigan looks fit and tanned, with a shock of white hair and engaging blue eyes. He gave up marathon running in the mid-1990s and now steers through the crowd at a brisk clip. For the past 36 years, he has been on the front line of the environmental health policy wars. His investigations into lead poisoning in children contributed to the United States’ phaseout of lead in gasoline starting in 1976, and consequently to a 90 percent reduction in blood lead levels among American children. From 1988 to 1993, he chaired the National Academy of Sciences committee whose report on pesticides was the basis for the Food Quality Protection Act of 1996. He served on the Presidential Advisory Committee on Gulf War Veterans’ Illnesses and as senior advisor on children’s health to the U.S. Environmental Protection Agency, during the late 1990s. In the pediatric and epidemiological community, says Dr. Michael Shannon, chair of the American Academy of Pediatrics’ Committee on Environmental Health, Landrigan is acknowledged as “one of the pioneers.”
The National Children’s Study, of which Landrigan is a chief architect, is an ambitious project, a summation, in many ways, of his career-long campaign to protect children from environmental poisons. If the vast longitudinal research project gets the federal go-ahead, it will shine a floodlight on the environmental roots of disease in children, much as the Framingham Heart Study has for 59 years illuminated the causes of stroke and heart failure in adults.
Through the convention center’s floor-to-ceiling tinted windows, Landrigan spots a familiar low building amid the new construction on the South Boston cityscape: It’s the EFP Burns Company warehouse, he says with a smile, where as a Boston College undergraduate he spent three weeks every June, packing up rental academic caps and gowns after graduation season before heading to Cape Cod to lifeguard. Landrigan now lives with his wife on Long Island Sound. At home, the restless energy that drives him to travel, teach, research, write, and campaign finds an outlet in carpentry. “I love the precision of doing it well,” he says.
With 13,000 participants and a program the size of a telephone directory, navigating the APHA conference is the immediate challenge. And Landrigan has the fate of the National Children’s Study on his mind. As he leads the way across the crowded exhibition floor, he explains that funding for the NCS is in limbo, following President George W. Bush’s unexpected withdrawal of support in his budget message to Congress in February 2006. A day before the mid-term elections, Landrigan has already cast his absentee vote back in Westchester, and hopes that the looming ballot results will improve the study’s prospects.
In room 253b of the conference center, Landrigan’s subject is a public health predicament of another kind. He tells an audience of some 70 public health officials and doctors that the 2001 terrorist attacks on the World Trade Center represent the “largest acute environmental disaster that has ever happened in New York City.” He proceeds to encapsulate the findings of five years’ research with the World Trade Center Worker and Volunteer Medical Screening Program, which continues to provide medical screening for individuals who were involved in rescue and cleanup at Ground Zero and related sites.
An estimated 40,000 workers were exposed to caustic dust and airborne toxic pollutants in the immediate aftermath, Landrigan tells his audience. The health monitoring program coordinated by his department at Mt. Sinai and offered through a number of metro-area occupational medicine providers has seen about 16,000 firefighters, law enforcement officers, volunteers, construction workers, and utilities, telecommunications, and transit employees.
Almost 70 percent of the examined individuals developed new or worsened respiratory symptoms during or after their exposure. “We had no idea the number would be so high,” says Landrigan. What’s more, he says, 40 percent of those affected had no health insurance, and another 40 percent had inadequate health insurance. Treatment programs had to be quickly patched together by charities and state and federal governments.
Landrigan’s tone is measured, even mellow. According to Michael Shannon, that is his invariable style: “Phil is laid-back and quiet, but he’ll slay you with data,” he says. In a later conversation, Landrigan will say bluntly that the fate of those workers highlights “how fragmented health care is in this country: It’s like the total contract has just unraveled around these people.” Landrigan closes his presentation on a positive note: The U.S. Department of Health and Human Services has just allocated $75 million to the WTC clinical consortium and the New York City Fire Department to meet the medical needs of WTC workers through 2008. Weeks later, he will note that this figure is now speculative, as the 109th Congress departed Washington without appropriating a final budget for 2007.
Landrigan’s office in the Department of Community Medicine at Mt. Sinai Hospital is about eight miles due north of Ground Zero, between the northeast corner of Central Park and the high-rise housing projects of Spanish Harlem. On a bookshelf stands a black-and-white photographic portrait of Dr. Irving Selikoff, his predecessor at Mt. Sinai and the man who launched the discipline of environmental medicine with his work uncovering asbestos-related disease. The chance to succeed Selikoff was one of the reasons behind Landrigan’s move to Mt. Sinai in 1985, after 15 years in the U.S. Public Health Service.
Over the course of more than an hour’s conversation in late November, the complexity of Landrigan’s working life begins to emerge. Today, he will be locked in back-to-back meetings, in his role as department chair, responsible for managing 150 faculty members. After fitting in a couple of tutorials with students, in the early evening he will present the guest speaker in an introductory course in public health that he directs for the master’s in public health program at the medical school. As December approaches, the pediatrician in him is looking forward to putting on a white coat and becoming a ward doctor for a month, something he always does at this time of year, when the office is relatively quiet, the hectic travel schedule slows, and younger faculty with small children like to take time off. Clinical medicine, he says, is a refreshing contrast to the delicate politics and methodical data crunching that constitutes most of his work. “The thing about clinical medicine is that it’s very immediate, and that’s very different from public health, where the gratification is often long-delayed,” he says.
A prime example would be the current impasse over funding of the National Children’s Study, after six years of preparation and $50 million in federal expenditures on infrastructure. The mood at the recent NCS planning meeting in Washington, D.C., Landrigan reports, was one of cautious optimism, in the light of the Democratic takeover of both houses of Congress in the midterm elections. Landrigan is quick to emphasize, however, that support for the NCS crosses party lines: “We’ve tried very hard not to let the study fall victim to partisan politics,” he says. “We think it’s too important to let it be identified with only one party.” Senators who spoke out in favor of federal funding in 2006 included Arlen Specter (R-Pa.), and Tim Johnson (D-S.D.).
To show what is at stake, Landrigan breaks open a box of offprints from Pediatrics, the journal of the American Academy of Pediatrics, and hands a visitor a copy of an article from the November 2006 issue, with the title “The National Children’s Study: A 21-Year Prospective Study of 100,000 American Children.” Landrigan is the lead author of the paper, written with 12 colleagues. The project’s origins go back to 1998, Landrigan says, when he spent a part-time sabbatical in the office of the Environmental Protection Agency (EPA) administrator, Carol M. Browner: “We realized how little we knew about the toxic effects of chemicals on children’s health, and we realized in a way not understood even five years earlier that children are very vulnerable to toxic chemicals in the environment, much more so than adults.”
A crucial contributor to this new understanding was the work Landrigan directed from 1988 to 1993, as chair of a National Academy of Sciences committee studying children’s exposure and vulnerability to pesticides. The group’s final report, Pesticides in the Diets of Infants and Children, led to unanimous passage by both houses of Congress of the Food Quality Protection Act, in 1996. Landrigan was invited to the White House to see President Clinton sign the bill into law. But in the politically vulnerable field of public health, triumphs can be short-lived. Following a period of “aggressive enforcement of pesticide regulation” from 1996 to 2000, Landrigan says, enforcement has slackened under the current administration, and the EPA has largely reverted to a default position “in which children [are] given no special protection in pesticide regulation.” Encouraged by the latest swing of the political weather vane, Landrigan plans to lobby the new Congress to hold oversight hearings on the EPA’s performance.
In 1998, Landrigan began making his case for a major epidemiological study of children, outlining a proposal in meetings with the EPA’s Browner, Health and Human Services Secretary Donna Shalala, and the heads of the Centers for Disease Control (CDC) and National Institutes of Health (NIH). He emphasized the known impact that large-scale, long-term studies have had on adult health, projects like the Nurses’ Health Study, begun in 1976, and the Nurses’ Health Study II, started in 1989, which have identified risk factors for chronic disease in women, and the Framingham Heart Study, which helped establish the link between cigarette smoke and heart disease in the 1960s, and between hypertension and stroke in the 1970s. Over the years, he noted, the blueprint for prevention plotted by the Framingham study alone has saved millions of lives and billions of dollars. The study he proposed would leverage every technological advance, from data handling to blood assay techniques and genetic profiling; its particular targets would be environmental risk factors for asthma, birth defects, dyslexia, attention deficit/hyperactivity disorder, autism, schizophrenia, and obesity. For the first time, he said, it would be possible, using DNA from mothers and their children on a large scale, to seek “a critical missing piece in the understanding of how environmental factors affect human health,” to take stock of the interplay between exposure and individual susceptibility.
The study would follow 100,000 children from birth—and, in some cases, from before birth—to age 21, using subjects statistically representative of all babies born in the United States during a four-year recruitment period. So compelling were Landrigan’s arguments, that in 1999 a federal planning group was convened to start work on the complex protocols required for such monitoring. Costs at this stage were minimal, and they were absorbed by the NIH budget. Those who know Landrigan well were not surprised by his success. Dr. Anthony Robbins, past director of the National Institute of Occupational Safety and Health and a former boss of Landrigan’s, says, “He’s very eloquent. He does a superb job of explaining in understandable language what environmental and occupational health are about.”
Through the Children’s Health Act of 2000, cosponsored in the Senate by Bill Frist (R-Tenn.), Jim Jeffords (I-Vt.) and Edward Kennedy (D-Mass.), Congress directed the National Institute of Child Health and Human Development (NICHD), part of NIH, to support the children’s study; between 2000 and 2006 some $50 million was spent on project design and development of a nationwide network of researchers. Included in the funding were contributions from the CDC, the EPA, and the Department of Health and Human Services.
In September 2005, the NCS awarded contracts to seven academic institutions to set up pilot sites across the country, from Orange County, California, to Duplin County, North Carolina. Carefully chosen to represent a broad spectrum of social, ethnic, and other demographic attributes, the centers are prepared to begin recruitment of women of childbearing age in 2007. Landrigan himself will head a team of 25-plus researchers in the borough of Queens, east of Manhattan. This is the most diverse county in the nation, he notes, with residents speaking 150 languages. “It’s important to involve folks from the local community, so you get off on the right foot,” he says, and following the announcement of the sites in 2005, he saw encouraging signs of community mobilization. He is concerned that with the present, enforced “treading water” phase, community partners will lose enthusiasm.
Throughout the planning process, says Michael Shannon, Landrigan has been the project’s “most visible and vocal advocate,” as the NCS has collected endorsements from the March of Dimes, American Heart Association, American Academy of Pediatrics, Children’s Environmental Health Network, and ECOS, the council made up of the heads of the 50 state environmental agencies. At the same time, the NCS has stirred some opposition within the pediatric community. According to Shannon, the study’s estimated 25-year price tag of $2.7 billion strikes some researchers as an unacceptable concentration of government resources given that federal funding for research has, at best, ceased to grow. The Boston Globe has noted that the $69 million sought to begin enrolling subjects in the National Children’s Study in 2007 represents 2 percent of the current federal budget for pediatric research.
The cost of the study is not trivial, Landrigan readily concedes, but in comparison with the costs of the diseases its findings might prevent or ameliorate, “it’s really very small.” Learning disabilities alone affect between 5 and 10 percent of the four million babies born each year in the United States, he points out. “If we could find preventable causes for even 10 or 20 percent of those, we’d improve the lives of literally tens of thousands of children,” and the savings would extend beyond medicine into education, child care, and the workplace.
Phil Landrigan did not embark on his medical career intending to become a custodian of the public health. The eldest of four sons of schoolteachers who preached education as the primary route to success in life, he decided on medicine as a teenager, inspired by his opthalmologist uncle, Fred Landrigan ’38, and by Dr. Bill Walsh, the family GP in West Roxbury. “Both were exceedingly kind and gentle men,” he says, “masters of both the art and science of medicine.” After a rocky few years at Boston Latin School, when Landrigan was often in trouble, according to his brother Richard Landrigan ’66, JD’73, a lawyer in the Boston area, Landrigan went through a Prince Hal–like transformation in his junior year, winning a National Merit Scholarship. “I was a rebellious youth,” says Landrigan, but academic ambition won out in the end. Pre-med studies at Boston College—where he met his future wife, Mary Magee ’64, in the organic chemistry lab in Devlin Hall—led to Harvard Medical School, followed by a residency at Children’s Hospital in Boston.
Landrigan’s goal at that point was to become a pediatric neurologist, remembers his friend and fellow pediatrician-in-training, Dr. Stephen Gehlbach, dean emeritus of the School of Public Health and Health Sciences at UMass–Amherst. But the Vietnam draft was in place. Landrigan and Gehlbach, like many young male physicians of their generation, chose to fulfill their national service obligation in the U.S. Public Health Service; they joined the Centers for Disease Control as Epidemic Intelligence Service officers in 1970. Gehlbach remembers traveling with Landrigan from damp, chilly Boston in April of that year into the soft southern spring of Atlanta.
At first, the two doctors were assigned the traditional CDC task of chasing epidemics of infectious disease, tracking outbreaks of measles in Texas, rubella in Minnesota, and hepatitis in Arizona. But in the winter of 1971, recalls Landrigan, a city health officer in El Paso, Texas, requested an investigation of toxic emissions from a lead smelting plant owned by the American Smelting and Refining Company (ASARCO). While reviewing documents related to the plant’s sulfur dioxide emissions, the local official had stumbled across evidence that a thousand tons of lead dust, with quantities of zinc, cadmium, and arsenic, had belched from the company’s stacks during the preceding three years.
Landrigan and Gehlbach had seen the effects of acute lead poisoning in the emergency room at Children’s: two- and three-year-olds suffering convulsions, severe abdominal pain, coma. In an old city like Boston, the main culprit was crumbling lead paint, or paint dust, which small children would chew on or suck from their fingers. The El Paso investigation, says Landrigan, marked one starting point for the discovery over the next decade that at levels of exposure too low to cause manifestly severe symptoms, lead could still cause brain damage to children. It also inspired his career-long dedication to protecting vulnerable groups, whether children or workers, from the harm caused by chemical pollutants.
An initial, small-scale study conducted by Landrigan and Gehlbach showed that virtually every child in the neighborhood of the El Paso smelter had a highly elevated blood lead level. The two doctors next embarked on what Gehlbach calls classic “shoe-leather epidemiology,” a door-to-door blood-sampling sweep through a large swath of the town. Landrigan, says Gehlbach, combined the charm required to get access to a stranger’s home and draw blood from a child with the doggedness needed to parse the data and deliver conclusions, however unwelcome the news might be. In this case the results showed a pattern, with the highest lead levels being found in children who lived closest to the plant. The evidence armed the researchers to “push the local health authorities to begin to make the smelter clean up its act,” says Landrigan.
When Landrigan and a CDC team returned to El Paso the next year to conduct a follow-up study of the effects of subclinical lead poisoning, ASARCO successfully pressured the local Board of Health to stonewall them. Leaving his team to cool their heels in El Paso, Landrigan headed for Austin and complained to the state’s attorney general, who informed the company that the work of the federal officials was not to be hindered. The result, says Landrigan, was “really a breakthrough discovery,” showing that children with high blood lead levels but no obvious symptoms compared poorly with children from the same communities but with lower lead levels, on a range of measurements from IQ to reflexes. The study, published in the British medical journal Lancet in March 1975, corroborated the results of parallel research being carried out by another pioneering lead investigator, pediatrician Herbert L. Needleman, director of the Low Level Lead Exposure Study at Children’s Hospital in Boston.
The lead industry vigorously opposed the conclusions of Landrigan’s and Needleman’s research, arguing that the results could be attributed to “poor mothering, or inherently stupid children, or other variables we’d failed to consider,” says Landrigan. From 1974 to 1977, he recalls, it took “hard, hard fighting in dreary rooms at the EPA to win that battle,” and even then, he acknowledges, other factors were crucial in hastening the reduction of lead in gasoline. From 1975 onwards, following the Clean Air Act Extension of 1970, new cars were required to have catalytic converters to reduce smog-causing emissions of carbon monoxide, sulfur dioxide, and oxides of nitrogen. The platinum catalysts were destroyed by the tetraethyl lead in gasoline, which gave the auto industry a compelling commercial reason to get the lead out.
Between the El Paso studies and his entanglement in the politics of lead poisoning on the national level, Landrigan spent two stints overseas. In Nigeria, in 1973, he and a CDC colleague helped carry out a World Health Organization smallpox eradication program. After taking tea at the palace of the emir in the ancient walled city of Kano, at the southern edge of the Sahara, and receiving his blessing to deliver smallpox vaccinations to the villages of Kano state, they set out in a Jeep with a driver and a refrigerator in the back crammed with vaccines, for the children, and bottles of scotch, for the village elders. “We’d vaccinate kids during the day, then late in the afternoon drive on to the next village, present the scotch to the village chiefs, be given a chicken, sleep in a hut, immunize the kids the next day, then move on,” Landrigan remembers. The only exception to their usually warm welcome was in a small village where cholera had struck a few days after their first visit. When they went back a month later to catch stragglers they had not already vaccinated, they were accused of carrying disease and chased away with rocks.
The following year, Landrigan made three sweeps across El Salvador as advisor to a national vaccination campaign, delivering vaccines to combat measles, rubella, DPT, polio, yellow fever, and tuberculosis. “My Spanish got better as the year progressed,” he recalls. (Even today, says his brother Richard, Landrigan often stops to chat in Spanish with the many Hispanic workers who staff Mt. Sinai’s security desks and parking garage.) Apart from being shot at on one occasion by Honduran border guards, the campaign went smoothly.
Landrigan’s relish for the adventurous side of his profession has found expression most recently in his overseas ser-vice as a captain in the Medical Corps of the U.S. Naval Reserve, which has taken him to Singapore, Korea, and Ghana. In July 2004, he was in charge of the West Africa Training Cruise, a medical humanitarian mission to largely rural Senegal that reached over 11,000 patients. A photograph from the trip shows him in camouflage uniform, at the center of a group of about 50 colleagues.
But in 1974, as a young father of three, Landrigan turned down an offer of a year in India, on the grounds that his children would no longer recognize their father if he continued to spend so much time overseas. His elder daughter, Mary Landrigan-Ossar, now an anesthesiologist at Children’s Hospital, Boston, says that one of her earliest memories is of riding in the car in Atlanta with her mother and asking, “When is Dad coming home from vaccinating all those people?”
When Landrigan returned from El Salvador in 1974, it was to set up a new unit at CDC known as the Environmental Hazards Activity—which later became CDC’s National Center for Environmental Health, a radical development for an institution rooted in the study of infectious diseases. With a couple of newly hired colleagues, Landrigan says, he “started chasing round the country looking at episodes of lead poisoning, pesticide poisoning, chemical spills.” En route to investigate a spill of phenol in Wisconsin, and frantically reading up on phenol on the plane ride, he realized that he could use some training in environmental and occupational medicine. So in 1976, the Landrigan clan left Atlanta and moved to the north London suburb of Finchley while Landrigan, on secondment from CDC, studied at the London School of Hygiene and Tropical Medicine, at that time one of the foremost centers of public health training.
From this English base, says daughter Mary, the Landrigan children were “dragged around Europe to see Mona Lisa and the Coliseum” on a budget; their parents once sneaked cans of baked beans into a hotel to feed them. Son Chris Landrigan, a pediatrician and researcher at Children’s Hospital, Boston, remembers dismissing Roman ruins as “Roman rubbish.” The once reluctant tourist, now himself a parent of two, still finds it hard to keep up with his globe-trotting father. At the recent APHA conference in Boston, father and son met unexpectedly—neither had realized that the other was presenting a paper.
Landrigan’s wife, Mary, is a health educator and public health administrator who is now a deputy commissioner in the Westchester County Health Department. Daughter Elizabeth, a geologist, was brought in as a consultant on water pollution for a book Landrigan and his wife wrote with Herbert Needleman, Raising Healthy Children in a Toxic World (2001), for parents concerned about protecting their children from environmental hazards. If health has become something of a family business, says Chris Landrigan, his father has been a major influence. “He’s passionate about what he does,” the son says, “and he’s driven by a sense of inequities.” Asked about his father’s apparent calm in the face of uncertainty about the future of the NCS, he says that the elder Landrigan does “get up in arms,” but that he has weathered many grant cycles as a researcher, and is stoical about soldiering on in the knowledge that “grants come and grants go.”
Landrigan names as his personal heroes visionary activists like Irving Selikoff and Bill Foege, one-time head of the CDC and former senior advisor to Bill Gates on global health initiatives. They are, he says, “people who dared to have enormous dreams about using scientific findings to control disease.” The fate of his own grandest dream remains in the balance. There have been signs of late of a move within the federal government away from supporting health research that is dependent on field investigations, in favor of laboratory-based research. In response, Landrigan and other NCS supporters point to the study’s expansive range, its potential to help children suffering from not one but many diseases. It takes a study of this size, they say, to tease out significant data about pressing but relatively low-incidence conditions such as autism and schizophrenia. They cite the fact that children under the age of 18 account for a quarter of the U.S. population and that the costs of fighting diseases targeted by the National Children’s Study amount nationally to some $640 billion annually. Daniel P. Gitterman, assistant professor of public policy at the University of North Carolina at Chapel Hill, who has studied trends in NIH funding of pediatric research, says that with expressions of support for the NCS from within both the House and Senate Appropriations Committees, the new Congress is sure to hold hearings on the study, but that no change in the status quo is likely until the 2008 budget. His contacts at NICHD “continue to be hopeful,” Gitterman says.
For all his formidable ability to deploy clinical data and cost analyses, Landrigan never forgets the human dimension of science. He likes to quote an axiom of Selikoff’s, that “statistics are people with the tears wiped off.” When he speaks of the unique vulnerability of babies and small children to environmental poisons, he is thinking not of abstractions, but of his own five—soon to be six—grandchildren, to whom he dedicated Raising Healthy Children in a Toxic World. Landrigan’s contribution to making their future safer has already been substantial, by any measure. If his calm coalition-building succeeds and his vision for the National Children’s Study can be realized, says the American Academy of Pediatrics’ Michael Shannon, that will be Landrigan’s greatest legacy.
Jane Whitehead is a writer based in the Boston area.
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