Health for Women, Health for All

The Food and Drug Administration (FDA) and Environmental Protection Agency (EPA) recently updated their nationwide consumption advisory on mercury contamination in fish. The advisory, which focuses on women of childbearing age and children, aims to "make it easier than ever" to determine which fish species to eat and which to avoid. It seeks to ensure that women and children don't have to forgo the health benefits of eating fish in order to avoid consuming the potent neurodevelopmental toxin.   

Despite its stated goals, the advisory has already generated criticism because it continues to require families to navigate a complex public health message. As NPR reporter Clare Leschin-Hoar observes, "Critics say the government advisory has done more harm than good, scaring many pregnant and nursing women (and let's be real — pretty much everyone else) away from eating seafood altogether." 

But this criticism just scratches the surface of the problem, a problem that the new Trump administration appears poised to make worse.  

Fish consumption advisories are an example of a quasi-regulatory strategy that relies on "risk avoidance" rather than "risk reduction." That is, rather than require polluters to reduce or prevent toxic releases in the first place, the government calls upon those exposed to inform themselves and alter their practices in order to avoid contact with these toxic contaminants in our environment. Other risk avoidance measures include ozone alerts, boil water notices, beach closures, and institutional controls. 

Of course, health and environmental professionals across administrations have recognized the need to communicate clearly with the public about the risks of contamination in our water, air, and soil. But it is one thing to issue warnings and advisories as a stopgap measure while earnestly pursuing efforts to clean up, reduce, and prevent pollution. It is another thing to embrace risk avoidance in lieu of risk reduction – as Trump's anti-regulatory agenda promises.   

From reversing regulations on mercury emissions from coal-fired utilities, to thwarting the transition away from a coal-centric energy policy, to rolling back limits on ozone and other air pollution, the new administration can be expected to allow a good deal more contamination – leaving those exposed to try to protect themselves. 

Proponents of risk avoidance argue that the approach is more cost-effective, affording "the same amount" of human health benefits at a fraction of the cost of emissions controls. It is generally cheaper, they point out, to post a sign, print a pamphlet, or maintain a website. So long as people then comply with the relevant warnings and advice, they won't actually be exposed to the mercury present in the fish or ozone pollution in the air. Of course, this argument doesn't address the point that risk avoidance measures shift the costs of contamination from source to "sink," i.e., to people and the environment. But proponents also sometimes count this occasion for increased "individual responsibility" as an upside of enlisting risk avoidance.  

In practice, however, risk avoidance not only fails to deliver on the promise of providing "the same amount of" protection as risk reduction, it also introduces a host of additional perils for human and ecological health (as I have argued elsewhere). 

First, risk avoidance is often ineffective. Fish consumption advisories may not reach or be understood by target audiences. Studies consistently show that only a fraction of those to whom advisories are aimed are aware of their existence or content. This is perhaps unsurprising, given the language, technical, and other barriers that plague such public health messaging.  

A woman seeking safely to serve fish to her family, for example, would have to consult the FDA and EPA advisory (in English or Spanish) in order to avoid species high in mercury and then cross-check this list with the latest state or tribal advisories in her area in order to avoid species laden with PCBs, dioxins, or other toxic contaminants that can cause cancer and other harms. She would need to constantly monitor for updated information and to know her skipjack from her yellowfin. Moreover, even if advisories successfully reach and inform their intended audience, those at risk may have few options for avoidance – fish can be a low-cost source of protein, particularly for families who catch their own. "No fish" may mean no dinner. And, given the cultural and spiritual dimensions of fishing and fish consumption, members of the fishing tribes in the Pacific Northwest, the Upper Midwest, and elsewhere may feel it is simply not possible to limit their intake or alter their lifeways in accordance with advisories. 

Second, paradoxically, risk avoidance sometimes overreaches. Advisories and warnings may prompt target audiences to give the risky practice wide berth, in effect over-complying with more nuanced advice. Although previous FDA and EPA guidance urged pregnant women to eat up to 12 ounces of fish each week while avoiding a handful of species identified as harboring high levels of mercury, many women responded by forgoing fish entirely. As Leschin-Hoar recounts: 

According to a spokesman for the Food and Drug Administration, the agency analyzed fish consumption data from more than 1,000 pregnant women in the U.S. and found that 21 percent of them ate no fish whatsoever in the previous month. And those who did eat fish consumed far less than recommended by the Dietary Guidelines: Some 50 percent ate less than 2 ounces a week and 75 percent ate less than 4 ounces. 

And advisories can have spillover effects. Recent studies have found that older women and men of all ages have reduced their fish intake in response to consumption advisories for mercury, despite the fact that these warnings are aimed at women of childbearing age and children. Similarly, family members outside the target population for ozone and other air quality alerts have curtailed their own time outdoors as they care for asthmatic children or older parents who are vulnerable to air pollution.  

Thus, risk avoidance can introduce risks. If people eat less fish and refrain from exerting themselves outdoors, they may be subjected to a new set of health concerns. The nutritional benefits of frequent fish consumption are well known. Recent studies have shown significantly reduced risk of coronary heart disease, colorectal cancer, and cognitive decline with age when people consumed ample amounts of fish – ranging from three to seven or more fish meals a week. Moreover, fishing itself is a healthful activity, and for some people, a culturally important or essential activity. 

Similarly, regular physical activity has been shown to have a host of physiological and psychological health benefits for children and adolescents. The American Academy of Pediatrics recommends that youth "accumulate at least 60 minutes daily of moderate to vigorous physical activity," that "parents become good role models by increasing their own physical activity," and that parents and caregivers "encourage children to play outside as much as possible." Risk avoidance counsels behaviors that are at odds with these healthful practices.   

Third, risk avoidance is myopic. Because risk avoidance measures target only specific, direct threats to human health, they fail to address adverse effects on any non-human components of ecosystems. Signs along our waters warning against fish intake obviously don't reach the eagles, bears, and other species that depend on fish. Websites are not consulted by a wood thrush. Of course, threats to non-humans often come back to impact people: a recent study in the Great Lakes found that mercury's adverse impacts on fish include harms to their reproductive success and survival – resulting in depletion of many species relied upon by humans for food. 

Finally, risk avoidance is unjust. As the environmental justice movement has shown, the harms of environmental contamination fall disproportionately on indigenous peoples, communities of color, and low-income neighborhoods. As I have argued elsewhere, government decision-makers tend to opt for risk avoidance in lieu of risk reduction when it is members of these groups who are most exposed – and, thus, who will be left to change their ways if they are to protect themselves. Moreover, these decision-makers may fail to appreciate the limitations and costs of risk avoidance for these groups. Decision-makers may assume, for example, that families can simply afford to buy alternatives to fish, or they may fail to grasp the cultural affront (not to mention legal issues) occasioned by the suggestion that a tribal member fish "elsewhere." They may imagine that asthmatic children have memberships to large gyms where they can play indoors. 

Among the many and varied messages of the millions gathered in protest at the Women's March on Washington and around the world this past weekend was a sign reminding us that women are "half of humanity." Fish consumption advisories leave half of humanity to "choose" between the harms of mercury and the health benefits of fish. To the extent that a Trump administration relies on such risk avoidance measures in place of risk reduction, it will fail not only women, but also the children and men around them.