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5 SUSTAINABILITY LINKS TO OCCUPATIONAL AND CHILDHOOD HEALTH This chapter focuses on opportunities for sustainability with regard to occupational and childhood health. The first presentation provides an overview of exposure and risk profiles among agricultural workers within the United States and Egypt, and summarizes innovative solutions that are being developed to protect worker health. The second presentation provides a broader view of the connections between sustainability and global worker protection and outlines challenges that exist with regard to safety hazards and toxic chemicals in the workplace. The third presentation looks at exposures during child development that contribute to risk of disease, and outlines an indicator approach to address this problem area. A summary of the presentations follows, along with a summary of the discussion that took place. EXPOSURE AND RISK PROFILES IN THE AGRICULTURAL WORKPLACE: OPPORTUNITIES FOR SUSTAINABILITY Richard A. Fenske, Ph.D., M.P.H Professor and Associate Chair of Environmental and Occupational Health Sciences University of Washington Richard A. Fenske began by noting that the Occupational Safety and Health Act of 19701 tries “to assure so far as possible every working man 1 Occupational Safety and Health Act of 1970, Public Law 91-596, 91st Cong., December 29, 1970. 89

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90 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY and woman in the Nation safe and healthful working conditions and to preserve our human resources.” Fenske noted that Figure 5-1 is a commonly used diagram that illustrates the components of sustainable development. He asked the group to consider where occupational health and safety fits into this type of diagram, which highlights the intersection of social, environmental, and economic factors. Fenske noted that past U.S. legislation on sustainability has lacked language focusing on the health and safety of workers. For example, while the Food, Agriculture, and Conservation Trade Act of 19902 states that a goal of sustainable agriculture is to “enhance the quality of life for farmers and society as a whole,” it does not discuss health and safety specifically, and worker health remains unaddressed. He added that in the 1991 National Research Council report Sustainable Agriculture Research and Education in the Field, there is no mention of occupational health and safety (NRC, 1991). In 1997, he said, a report from the President’s Council on Sustainable Development (1997) laid out nine policy recommendations without a mention of worker health and safety. Similarly, these issues are absent from a 2003 report entitled 21st- Century Agriculture: A Critical Role for Science and Technology from the U.S. Department of Agriculture (2003). He noted that these add to the separation between health and the environment that is continually seen in policy development. Fenske stated that even the Agenda 21 report from the 1992 Rio Earth Summit (see Chapter 2 for additional background information) does not include worker health and safety in the chapter on sustainable agriculture and rural development. However, one section is devoted to the role of workers and trade unions, in which there is a call for  mechanisms on safety, health, and sustainable development;  reductions in occupational accidents, injuries, and diseases; and  increases in the provision of workers’ education, training and retraining, particularly in the area of occupational health and safety and environment (UN, 1993). He noted that it would be beneficial to apply this language to current policy development within and outside the United States. 2 Food, Agriculture, and Conservation Trade Act of 1990, Public Law 101-624, 101st Cong., November 28, 1990.

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LINKS TO OCCUPATIONAL AND CHILDHOOD HEALTH 91 FIGURE 5-1 Components of sustainable development. SOURCE: Johann Dréo (http://en.wikipedia.org/wiki/File:Sustainable_ development.svg). Reducing Workplace Exposure in the Northwest Tree Fruit Industry When workers are interacting with pesticides, Fenske stated, the U.S. Environmental Protection Agency (EPA) Worker Protection Standard emphasizes the use of personal protective equipment, restricted entry intervals, and worker training. In practice, he said, the use of restricted entry intervals and worker training are resource intensive and difficult to maintain. He noted that the premise of restricted entry involves monitoring exposure levels in the field and allowing for reentry once the levels are safe; however, these levels are difficult to calculate. Similarly, while training is an important component of ensuring worker safety and health, he said, the transient nature of the workforce requires frequent training and retraining, which can end up being impractical. In looking specifically at the tree fruit industry, high pesticide exposures exist because of the use of airblast applications, the absence of cabs on tractors, and the open loading systems, which can result in chemical spills and splashes. To exacerbate the problem, he said, the vast

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92 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY majority of pesticide handlers are Spanish speaking, with low education levels, but since the pesticide labels and instructions are in English, the inadvertent misuse of the chemicals is common. Fenske noted that pesticide exposure among tree fruit workers has been a controversial issue. He explained that a decade ago in Washington State, growers stated that there was no pesticide safety problem in the agricultural workplace, but farmworker advocates argued that a silent epidemic of poisoning existed in the fields. He added that this argument led to a ruling by the Washington State Supreme Court in 2004 that cholinesterase monitoring should be provided to agricultural workers.3 This program is not part of the federal standard, and in 2011, Washington and California were the only two states to monitor cholinesterase for worker safety. Cholinesterase is an enzyme required for proper nerve impulse transmission, and certain classes of pesticides act as cholinesterase inhibitors in the human body (Furman, 2010). Depression in cholinesterase levels inhibits the control over nerve impulses to the muscles, which can lead to serious health consequences. Fenske stated that under this initiative in Washington (see Figure 5- 2), a significant cholinesterase depression will trigger a workplace evaluation or even reassignment of the worker if the depression is severe enough. When the program started in 2004, he said, 20 percent of monitored workers experienced cholinesterase depression that exceeded regulatory thresholds; this figure was cut to 3 percent in 2010. He noted that this monitoring program can benefit everyone involved by reassuring relevant stakeholders such as farmers and workers, and enabling state regulators to better monitor worker safety and health. Fenske explained that researchers at the University of Washington School of Public Health are piloting another approach to developing practical and cost-effective solutions to reduce pesticide exposures. He stated that an expert working group, which included the field workers themselves, was assembled to discuss these agricultural workplace safety 3 The Washington State Cholinesterase Monitoring rule “requires agricultural employers to provide medical monitoring for workers who handle toxicity Category I or II organophosphate or N-methyl-carbamate cholinesterase- inhibiting pesticides…workers who handle cholinesterase-inhibiting pesticides for 30 or more hours in any consecutive 30-day period are covered by the medical monitoring requirements of the rule” (http://www.lni.wa.gov/Safety/ Topics/AtoZ/Cholinesterase/Providers.asp [accessed May 17, 2013]).

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LINKS TO OCCUPATIONAL AND CHILDHOOD HEALTH 93 FIGURE 5-2 Washington State Cholinesterase Monitoring Program: Percent of workers with cholinesterase depressions that exceeded regulatory thresholds. NOTE: The Washington State Cholinesterase Monitoring Program demonstrated that a substantial percentage of workers have exhibited cholinesterase depressions that exceeded regulatory thresholds; however, these levels have decreased over time. SOURCE: Fenske, 2011. concerns. He noted that a reoccurring theme after 4 years of evaluation was the sentiment from field managers and workers that safety equipment requires a level of compliance that is not always enforceable, and that this practice has not been normalized into the workplace. Overall, the team identified a need to promote a safety climate and culture in the workplace. To help communicate this, he said, fluorescent tracers were incorporated into the pesticides and air-blast applicators in the field and the field workers were later photographed under ultraviolet light. He noted this can be effective in showing people the patterns of skin exposure that occur, even underneath protective clothing. Fenske stated that multiple other dynamic factors may alter the risk profile of pesticides in the near future. He noted that many new agricultural chemicals have been developed with significantly lower mammalian toxicity that require much less product to treat the same acreage of land. However, adoption of these chemicals is very slow due

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94 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY to the enormous risk farmers take in using new chemicals, since ineffective products may reduce crop yields and lead to financial hardships. Currently, he said, the Washington State University Pest Management Transition Project is working with farmers to gradually switch to the use of these compounds. He noted that there remains a need to incentivize more large-scale transition toward adoption of such new, reduced risk agricultural chemicals. Fenske explained that further changing the agricultural landscape is a new trend in orchard design. New apple trees are now being supported physically with an architectural structure called a V-trellis in order to promote more automation into the maintenance of apple orchards. He noted that new innovations in spray equipment are allowing for reduced chemical drift and improved pesticide delivery for the efficient treatment of trellised apple trees. Additionally, sprayer prototypes are being devel- oped that may eliminate the need for a driver in the future. He emphasized that designing these orchards with safety in mind can significantly reduce exposure risks for workers. Reducing Workplace Exposure in the Nile Delta Fenske noted that a project funded by the U.S. National Institutes of Health (NIH) is under way in Egypt with the aim of identifying new biomarkers of neurotoxicity in the human population. In Egypt, cotton fields are sprayed with pesticides by hand with a team of workers spraying a field together. He explained that they commonly do not wear shoes, gloves, or other protective clothing and are openly exposed to the chemicals on a regular basis. During the growing seasons, urinary metabolite data were collected from the pesticide applicators, technicians, and engineers working in cotton production4 (Farahat et al., 2010). The results indicated that high levels of these pesticides were internalized and persisted in the body days after exposure (Farahat et al., 2010). When compared to the Washington State exposure rates in tree fruit workers, metabolic pesticide levels among cotton pesticide 4 “Each field station has a team of employees in three job categories with potential pesticide exposure: (1) applicators who apply pesticides with backpack sprayers, (2) technicians who walk each row with the applicator to direct the path of the applicator and point out any heavy insect infestations in the field, and (3) engineers who periodically walk the fields but more often direct the application process from the edge of the field” (Farahat et al., 2010).

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LINKS TO OCCUPATIONAL AND CHILDHOOD HEALTH 95 applicators in Egypt were over 50 times greater, and supervisor levels were nearly 4 times greater. He emphasized that the Egyptian cotton workers were experiencing significant exposure to pesticides and resulting neurobehavioral deficits. Fenske stated that understanding the social landscape is also important to shift attention toward farmer protection. He explained that physical laborers often belong to underprivileged or otherwise at-risk groups, both in the United States and abroad; but, researchers can utilize the expertise of these individuals through focus groups to develop, test, and evaluate potential worker health and safety solutions. For example, with the aid of focus group discussions in Egypt, practical personal protective equipment that could be made from inexpensive, readily available materials that were realistic in the local context was developed to reduce dermal exposure. He noted that testing of this new clothing (which looks similar to pants or chaps) is currently under way, with biological monitoring to determine exposure reduction rates. He stated that initiatives such as these hold promise in successfully reducing workplace exposures and incorporating health into sustainable agricultural practices. Final Remarks Fenske stated that reducing pesticide exposure among agricultural workers, within and outside the United States, requires both robust research programs and community engagement. He noted that research programs need to include a balanced group of experts in health, safety, and workplace environments to have rigorous yet realistic research initiatives. Additionally, building trust through mutual respect and building capacity in communities are essential components to developing a sustainable agricultural system. With respect to the Rio+20 conference and other upcoming meetings, he said, some of the ideas that were already presented in Agenda 21 could be emphasized. He noted that this could include developing an inventory of international pesticide use, developing surveillance programs for agricultural workers, and supporting integrated pest management practices. He stated that these programs and practices would better inform the future of a sustainable agricultural workplace throughout the world.

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96 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY SUSTAINABILITY AND HEALTH: IMPACTS FOR WORKERS David M. Michaels, Ph.D. Assistant Secretary of Labor Occupational Safety and Health Administration U.S. Department of Labor David M. Michaels noted that when thinking about sustainability and the use of resources into the future, clearly one set of resources we have to think about preserving is our workforce and the health and safety of our workers. Within many of the basic issues of sustainability, he said, the workforce is often forgotten or neglected, so there is an opportunity to raise some attention around these issues. In planning sustainable development, Michaels said, the carbon-based economy is of particular concern. In addition to the more well-known environmental issues linked with the production and use of fossil fuels, he said, these activities are associated with high levels of injuries, illnesses, and fatalities among workers employed in coal mining and oil drilling and refining. He noted that shifting away from carbon dependence provides hope for improving worker health and safety. However, Michaels stated, a shift to renewable energy and recycled or “green” products does not necessarily equate with improved health and safety in the workplace. For example, workers involved with wind turbines are at increased risk of injury from falls and arc flashes. He noted that the lesson to learn is that old hazards are often still associated with these new technologies and jobs. When looking at recycling facilities, a component of sustainability, he said, workers are exposed to increased fatality rates compared with the general waste management industry, with regular fires occurring from the chemicals or metals (including arsenic, cadmium, and other heavy metals) brought to the facility. He noted that these workplace hazards are seen in the United States and other countries. Michaels explained that much of the discussion and advocacy on issues of toxic chemicals fails to recognize that workers are often akin to “canaries in the coal mine” as their chemical exposure levels are far higher than those which occur in communities. While the workers may be healthier than the children or some of the elderly population exposed to various pollutants, he said, their exposure levels can be many times higher and quite concentrated. He noted that it is for this reason that

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LINKS TO OCCUPATIONAL AND CHILDHOOD HEALTH 97 much of the epidemiological research done on toxic chemicals is performed on workers; measuring the effects on less exposed nonworkers is more difficult. For example, a series of studies were performed on Bisphenol A (BPA)—a chemical found in plastics used to make products such as water bottles—involving chemical workers in China who were exposed to BPA through the manufacturing process (Li et al., 2011). The researchers found lower sperm counts and sperm vitality among these workers compared with men who did not have detectable BPA levels (Li et al., 2011). While this is an important research finding, he said, little discussion or advocacy has taken place to protect these workers, and to link occupational health and public health in chemical manufacturing. Michaels stated that some progress is being made to incorporate sustainability initiatives into occupational and public health in the United States and abroad. He noted that one area of promise is the U.S. health care sector. Under the banner of the Healthier Hospitals Initiative, hundreds of the nation’s leading health systems are working in collaboration to integrate the “three safeties”—patient safety, environ- mental safety, and worker safety—into hospital operations. Michaels noted that worker safety is also becoming a component of the Global Reporting Initiative (Food and Agriculture Organization of the United Nations), an effort by many multinational companies to increase awareness of their global social and environmental impact. He pointed out that the American Industrial Hygiene Association, the American Society of Safety Engineers, and the Global Reporting Initiative have also formed an alliance to develop ways in which the participating corporations report on worker injury and illness rates. Michaels noted the need to consider our larger role in global worker protection and determine the responsibility we have to workers who are clearly exposed to safety hazards and toxic chemicals at levels that would not be permitted in the general populations of our countries. He stated that there is a great challenge ahead of us to develop sustainable activities and productions that are good for the health of people, good for the earth, and make us feel good.

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98 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY EARLY CHILDHOOD EXPOSURE AND HEALTH RISKS: INCORPORATING SUSTAINABILITY Lauren Zeise, Ph.D. Chief, Reproductive and Cancer Hazard Assessment Section Office of Environmental Health Hazard Assessment California Environmental Protection Agency Lauren Zeise explained that the mosaic of environmental laws that are supported by risk assessment address a defined set of environmental chemical risks that affect child health. However, she said, numerous environmental chemical stressors are likely not covered. She stated that the overall impact of environmental chemicals on a child’s well-being can be worsened by poor access to health care and psychosocial stressors. She noted that concern about health being harmed—even if all activities in a community are in compliance with environmental regulations—combined with the fact that vulnerable and disadvantaged groups bear a disproportionate burden of harm, has motivated the development of methods to address these environmental justice concerns and cumulative impacts. Using indicator approaches, these methods attempt to measure the overall impact of environmental burdens at the community level. Zeise pointed out that California is exploring the use of these techniques to identify highly impacted communities for priority attention and investment. At the international level, she said, children’s environmental health indicators are being developed and used to track a child’s environmental health and provide the basis for measuring the effectiveness of policies that seek to improve environmental conditions for children. She noted that initiatives like these complement existing risk-based approaches and show promise for incorporating a broader set of sustainability concerns in decision making that can improve outcomes affecting child environmental health and well-being. Early Life Susceptibility Zeise stated that fetal and childhood stages of life can include periods of increased susceptibility to environmental exposures, chemicals, and other stressors. When exposures to carcinogens occur in utero and in childhood, she said, there is more time for the disease to manifest itself over the life course. She noted that there is also enhanced inherent susceptibility in early life, a period of rapid growth and development in

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LINKS TO OCCUPATIONAL AND CHILDHOOD HEALTH 99 the life cycle. The concern for enhanced susceptibility has been established through human studies, she said, and cancer is used as an exemplar end point. She explained that rates of radiation-induced thyroid cancer are considerably greater in individuals exposed as infants or in early childhood than as adolescents or adults. She noted that other examples include dramatic increases in vaginal adenocarcinoma in offspring of women who took the drug diethylstilbestrol for morning sickness during pregnancy, and greater rates of lymphoma in children and adolescents who took immunosuppressive drugs (often part of transplant therapy) as compared to adults. Zeise stated that protecting the vulnerable is a key feature in all major environmental laws. She added that the decision-making processes that provide for protections from environmental chemicals and pesticides in air, drinking water, and food all rely on risk assessment methods. She noted that changes in risk assessment methodology require adequate scientific evidence to better address early life sensitivity. Thus, she said, California and the EPA reviewed the scientific literature to answer key questions regarding environmental chemical exposures during early childhood, including  Are large increases in early-life sensitivity common?  How much do age sensitivities differ chemical by chemical and across early age windows?  What specific changes should California adopt to address age-at- exposure differences in cancer susceptibility? Zeise pointed out that the literature included experimental data from studies on environmental chemicals in which animals exposed during early life stages were compared with animals exposed to the same chemical during adulthood. She noted that the results of these experiments were systematically compiled and analyzed to address the above questions for carcinogens. She added that other efforts were undertaken to consider changes to non-cancer risk assessment methods. Zeise explained that the analyses of the animal model studies with fetal-only and adult-only exposure groups showed variability in susceptibility across the environmental chemicals studied. At the mean, she said, the fetus was 20 times more susceptible to carcinogens than the adult; however, the median susceptibility was higher by only a factor of 3, reflecting a skewed distribution. That is, she said, for some chemicals the fetus exhibited very high susceptibility, while for some others it was less susceptible. However, she noted, the established practice has been to

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100 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY not include this prenatal exposure window at all in estimating cancer risk among populations. Zeise stated that another aspect of risk assessment is exposure assessment. She noted that numerous environmental factors can cause young children to experience higher rates of exposure to chemicals than adults. For example, she said, bottle-fed infants tend to experience close to an order of magnitude more exposure than adults to drinking water, on a per-body-weight basis. She stated that exposure through certain foods can also be many times higher in infants and young children than in adolescents or adults. She added that the increased breathing rates of children also can increase their exposure. Finally, she said, behavioral factors such as crawling, hand-to-mouth activity, restricted diets, and activities associated with adolescence all can increase rates of chemical exposures in young people. She noted that systematic analyses of data on such exposure parameters also support changes in methods to adequately address the young in exposure assessment. Sustainability, Risk Assessment, and Risk Management Zeise explained that under the current regulatory structure and risk assessment paradigm, toxicity data generation cannot keep pace with need. A 2007 National Research Council (NRC) report, entitled Toxicity Testing in the 21st Century: A Vision and a Strategy (NRC, 2007), introduced a new toxicity testing paradigm to address this problem. She noted that the testing would focus on upstream events rather than frank toxicity outcomes like cancer and birth defects. She stated that a suite of different toxicity tools including short-term tissue culture tests and toxicogenomics screens of cells and cell components would provide the basis for chemical evaluation and decision making. She added that considerable resources and research are required for implementation. Through a memorandum of understanding among key federal agencies, work to realize the vision has been ongoing and promising, but time frames predicted for a fully functional testing system are long (15 to 20 years out). She noted that it is widely recognized that the current risk assessment/risk management paradigm—that relies on data that are costly and time intensive to generate—is unable to address a large array of environmental chemicals (GAO, 2005; NRC, 2007, 2009). Zeise stated that formal consideration of predictions based on sparse information (e.g., physiochemical properties, structural activity modeling, and available short-term tests) have been promoted as a way

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LINKS TO OCCUPATIONAL AND CHILDHOOD HEALTH 101 forward (NRC, 2009). However, regulatory agencies would be attempt- ing this in an atmosphere that has been challenging even in information- rich cases (NRC, 2009). With few exceptions, she said, the regulatory agency has the burden of proof to show harm before taking action. She noted that a shift in the burden of proof is a key feature of some proposals to reform chemical policy (Woodruff et al., 2011). In California under the Proposition 65 program, the burden of proof is on businesses over a certain size when they cause significant exposures to chemicals “known to the state” to cause cancer or reproductive (including developmental) toxicity. Zeise added that roughly 270 chemicals are listed as causing reproductive toxicity within the program, many because of effects on development from in utero exposure. She stated that violations can lead to relatively stiff fines if a business has knowingly caused exposures for a protracted period. She noted that this shift in burden has led to protections in child health as products that contain known developmental toxicants are reformulated or removed from the market. DISCUSSION A discussion followed the presentations and the remarks are summarized in this section. Lynn Goldman questioned whether the personal protective equipment for the cotton field workers described by Fenske in the Egypt example goes far enough, given that the protective clothing only covers the legs, still leaving the arms and front and back of the upper body exposed. Fenske noted that while in the Washington State example improvements in exposure tend to be technological, in Egypt smaller steps, including getting workers to wear shoes, will have an impact. He noted that the physical environment in Egypt should also be considered, and the protective pants are important because workers still wear them even in high temperatures (which may be transferable to agricultural workers in similar climates). Fenske stated that in addition to protective clothing, researchers are working with the field workers to better understand the issue of drift, so people can remain upwind of the drift and decrease pesticide exposures. While this is a starting point, he said, better methods still need to be developed for the Egyptian cotton field workers. John Balbus then asked whether the personal protective clothing, or intervention component of the study, was included in the

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102 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY research proposal and also asked if the right design elements appear to be funded in global environmental health programs. Fenske noted that while the intervention was part of the original study design in the proposal, it was a small component compared to the exposure monitoring and neuroscience pieces. Fenske stated that the invention component alone likely would not have been funded, which is unfortunate. Kirk Smith introduced the topic of environmental justice and noted that workers tend to be exposed to higher risks than is the general public; sometimes this increased risk may be justified by a benefit from the job, but at other times the worker does not understand the risk being taken. Smith noted that part of any sustainability framework should include moving to a system where workers are not treated differently than the general public because we are all workers in one place or another. He added that the real environmental injustice in the United States, and most of the world, is likely the increased relative risk that exists between occupational and public realms with regard to chemical exposures. Smith then asked what would the world look like if we protected workers just as much as we protect the public. Smith noted that we should try to link this thinking to broader discussions of sustainability. Carlos Corvalán added to this by noting the need to look at the social gradient when comparing occupational risks among workers. Corvalán stated that jobs with the highest risks likely correlate with the bottom part of the social gradient, whereas the social elites are likely connected to jobs with minimal risks. Similar to what Smith outlined, Corvalán emphasized the need to link social determinant issues with environmental health justice and sustainability topics in high-level meetings and discussions within and across countries. John Spengler commented on the presentation from Michaels, noting the complexity of the Global Reporting Initiative and the reporting difficulties given that many multinational companies subcontract their workers. Michaels noted that with the Global Reporting Initiative there is an attempt to integrate at least basic injury illness rates into the voluntary reporting of the multinational companies involved, but as Spengler noted, it can be difficult to track contractor employees. Michaels explained that when workers are hired by subcontractors, the workers are often transferred for short periods of time to different facilities, which benefits the subcontractor in terms of avoiding paying taxes or health benefits, but makes collecting health and safety data and assessing responsibility quite challenging.

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LINKS TO OCCUPATIONAL AND CHILDHOOD HEALTH 103 Fenske pointed out that in the United States in Washington State contract labor is a growing industry, similar to that seen in California in agriculture, but noted that associations for these workers (such as the Washington Contract Loggers Association) are being organized and include members interested in improving the health and safety of the workforce. Fenske asked Michaels to share his thoughts. Michaels stated that he is seeing this same model developing across the United States, and noted that these associations should be included when considering reporting and discussions with different employer groups. Fenske then emphasized that the problem of the worker being moved from place to place and the lack of responsibility to track exposure data for that worker still appears to remain with this model, which may be remedied by having the contractor take a role in protecting worker health and safety. REFERENCES Farahat, F. M., R. A. Fenske, J. R. Olson, K. Galvin, M. R. Bonner, D. S. Rohlman, P. J. Lein, and W. K. Anger. 2010 Chlorpyrifos exposures in Egyptian cotton field workers. Neurotoxicology 31(3):297-304. Fenske, R. 2011. The sustainable agricultural workplace. PowerPoint presentation at the Institute of Medicine workshop on Ensuring and Strengthening Public Health Linkages in a Sustainable World, Washington, DC. Furman, J. 2010. Chlorinesterase monitoring for agricultural pesticide handlers: Guidelines for health care providers in Washington state. Seattle, WA: Department of Labor and Industries, Division of Occupational Safety and Health. GAO (U.S. Government Accountability Office). 2005. Options exist to improve EPA’s ability to assess health risks and manage its chemical review program. http://www.gao.gov/products/GAO-05-458 (accessed January 9, 2013). Li, D.-K., Z. Zhou, M. Miao, Y. He, J. Wang, J. Ferber, L. J. Herrinton, E. Gao, and W. Yuan. 2011. Urine bisphenol-a (BPA) level in relation to semen quality. Fertility and Sterility 95(2):625-630. NRC (National Research Council). 1991. Sustainable agriculture research and education in the field: A proceedings. Washington, DC: National Academy Press.

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104 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY NRC. 2007. Toxicity testing in the 21st century: A vision and a strategy. Washington, DC: The National Academies Press. NRC. 2009. Science and decisions: Advancing risk assessment. Washington, DC: The National Academies Press. President’s Council on Sustainable Development. 1997. Building on consensus: A progress report on sustainable America. Washington, DC. UN (United Nations). 1993. Agenda 21: Earth Summit; the United Nations programme of action from Rio. New York: United Nations. USDA (U.S. Department of Agriculture). 2003. 21st century agriculture: A critical role for science and technology. Washington, DC: U.S. Department of Agriculture. Woodruff, T. J., A. R. Zota, and J. M. Schwartz. 2011. Environmental chemicals in pregnant women in the United States: NHANES 2003–2004. Environmental Health Perspectives 119:878-885.