Fertility & Environmental Justice: A conversation with Shanna Swan and Annie Hoang

"These toxics chemicals are affecting you—not just the polar bears, the insects, and the birds."

Agents of Change founder and director Dr. Ami Zota sat down with Dr. Shanna Swan and Annie Hoang to discuss fertility, environmental chemicals, and reproductive justice.


Swan, a professor of environmental medicine and public health at the Icahn School of Medicine at Mount Sinai in New York City, recently published Count Down: How Our Modern World Is Threatening Sperm Counts, Altering Male and Female Reproductive Development, and Imperiling the Future of the Human Race.

Hoang is a medical student at the University of California in San Francisco, a masters of public health student at Harvard, and a current Agents of Change fellow.

The Agents of Change in Environmental Justice podcast is a biweekly podcast featuring the stories and big ideas from past and present fellows. You can see all of the past episodes here.

Listen below to the discussion, and subscribe to the podcast at iTunes, Spotify, or Stitcher.

Transcript

Ami Zota

Hello everyone. My name is Ami Zota and I'm going to be your host today for our latest agents of change in environmental health Podcast. I'm joined on this beautiful spring day by Dr Shanna Swan and Annie Hoang, I'm going to briefly turn to them so they can introduce themselves. Let's start with Shanna.

Shanna Swan

Hi, Thanks suddenly for setting this up and given me an opportunity to talk on your wonderful agents of change, podcast, I'm an environmental epidemiologist, I should say environmental and reproductive primarily, and I work at Mount Sinai School of Medicine in New York City. And, um, I've wrote a book called Countdown came out February 23 and it has kept me really busy since then, telling everybody about what's in the book The importance of the book, and I'm really happy to be able to share some of that on your podcast.

Ami Zota

Thank you.

Annie Hoang

Yeah, hi everyone thank you for having me here. My name is Annie, I am currently a medical student, MD candidate at the University of California in San Francisco, or UCSF. And I'm also masters of public health student at Harvard.

Ami Zota

And you're also a current Agents of Change fellow.

Annie Hoang

Yes. Yes, I am a current agents of change fellow and I'm really excited.

Ami Zota

Okay, so why don't we get started, um, Shanna, why don't you kick help us kick off this conversation and I'm sure you've now done this several 100 times can you, you know, tell us a little bit about your new book, what is it about and what motivated you to write it. Sure.

Shanna Swan

So, um, you can't see this, but the title of the book is countdown, how our modern world is threatening sperm counts, altering male and female reproductive development and imperiling the future of the human race. So that's pretty broad and kind of scary. Um, and the way I came about writing this book which by the way, I have a co author. Her name is Stacy Colino and how we came to write this book was that I got called by an agent, after there was a big media. Stir if you will, following the publication of our 2017 paper, a meta analysis which showed that sperm count had declined dramatically over 40 years, and at about the rate a little faster than 1% per year. I've previously written several papers like that of looking at this question earlier, all the way back to 1997, but this was different because, first of all it was a very big study, it was very well done using state of the art methods, and, but it was also maybe coming at a better time. I'm not sure, but what happened was, at this time, people listened and paid a lot of attention, and it was I think the 27th most cited paper in the year. And, um, and was on the cover of Time and Newsweek and all this kind of, so that was exciting and interesting, and led to this agent contacting me and saying would you write a book about this. So, um, I was reluctant because I always thought of myself as an academician I only talk to other academicians primarily and published in academic journals, and I didn't think that I would be able to speak in a way that would reach people, although I felt it was important, and that's when Jane suggested that I find a co author and Stacy Colino had interviewed me for box of covering the 2017 paper, and we'd gotten along and I liked what she did with that story. So we talked and she became my co author, and we, it's a great combination because I have the science behind me, and the experience and she has the voice, and she's able to talk in a way that people hear much better than I. And so, we published this book, and the, the, what the book is about, it's

everywhere. And what I feel and write about in the book is that while there are lifestyle factors driving this, that the primary agents driving this decline, and other reproductive declines are chemicals in the environment, and particularly those that are hormonally active, which we call endocrine disruptors. So I'll stop there.

Ami Zota

Thank you both fascinating and terrifying. Annie, can you share some of your initial impressions of the book was the information, new to you. Was this topic discussed in medical school.

Annie Hoang

Yeah, great questions. Um, first of all, I thought it was a phenomenal read I thought it was written in a very accessible way you're talking about writing to academics and I thought I could read it and really appreciate your message, especially when you. It's always so I guess challenging to go into the alphabet soup of chemicals but I thought it was done in a way that I could really take away and understand and I think many readers would similarly find that engaging and informative. And it was an eye opener for me so most of the information was absolutely new to kind of see the deleterious like that, undeniable trend of how deleterious changes in our environment and the everyday chemicals in which we come into contact can have such a negatively, and yet profound impact on our fertility and reproductive reproduction for generations, that kind of intergenerational impact that I thought you very much emphasize and and how it impacts, like you said both sexes, both men and women. And you also went into how it also affects people kind of along the everywhere on the gender spectrum as well and I thought that was very profound and kind of to quote from your book you call it a reproductive record and I thought that was a very great way of putting it. And, yeah, but most of it was new. But I actually learned about kind of this trend so to speak of sperm counts and in decreasing fertility as on a whole on a whole in in medical school, I think, towards the end of my first year and the beginning of my second year. But that was an elective, that was because I sought it out I thought, you know, you're kind of speaking to someone who have kind of drank the Kool Aid so to speak and understand you know and is into environmental and reproductive justice and that was through an elective through an environmental health program at my medical institution so that was a unique opportunity to learn but that I would say is the exception more than the rule.

Ami Zota

Thank you. But it was great. Thank you for sharing your insight. So our podcast and our program more generally. We're working with scientists and scholars from backgrounds historically excluded in science and academia, so they often come from marginalized populations and one of the themes is you know, they're you know, come from a wide range of disciplines like medicine, engineering, public health, but they're all working in different and unique ways to advance health and justice. And, and so you know I want to kind of steer our conversation in kind of with, you know the crossroads of where the evidence on environmental chemicals and fertility intersects with health equity and justice. So, Shanna, why don't you start us off, what is the state of science, with respect to differential impacts.

Shanna Swan

So, differential impact complicated question. Let me break it down into a couple of parts. First of all we have differential exposure. So, you know and have published on the differential levels of chemicals, environmental chemicals endocrine disrupting chemicals in people across various racial ethnic groups economic groups and so on. So, that is a really big one. We're not all equally exposed. Secondly, what's much less well known, and we actually just have a paper on this being submitted, which is that the effects of a given chemical at a different at a given level is different according to the economic and racial, social position of that person in their lives and in the community, for example, I'll just tell you very specifically, we're we're looking at the association between Bisphenol A and some neurodevelopmental input impacts, and I'm in my study has four centers. That's the time study, and one of those centers is in Rochester, New York, and the others are elsewhere in the country. The Center in Rochester, New York recruits, primarily Medicare patients, and they tend to be disadvantaged, and the other centers include mostly private patients, and they tend to be middle upper middle class white. So we have a very big split in our study based on center. And so we looked at the impacts of Bisphenol A on neurodevelopment, and we found not only that there were higher levels of Bisphenol A in Rochester, but that they had a greater actually an adverse effect on the endpoint, we were looking at, which is social responsiveness. But the other centers actually had a somewhat other not significantly protective effect. So it was huge Lee different for even the same levels, what the impact was. Okay, um, the third part of this is that we had a random relatively small number of people who were disadvantaged and that's because most studies that are done of this kind are done where it's easy to collect information. It's easy to get paid for patients who come in and that tends to be those who are middle class, educated, interested in the science. Busy people with bunches of kids and job problems just don't have time to participate in these studies, so we have, we have problems along the way, and my steady tides is a good example of that.

Ami Zota

Thank you for sharing both the state of the science, as well as current problems in our current approach to public health research and medical research. Annie, I want to pull you in here. Given the lack of data on diverse populations and, you know, the fact that you seek to provide clinical care for the medically underserved, you know, what do you think about the generalizability of these results to the populations that you interact with and, and, and, and, you know, generally, do you think that chemical threats to reproduction is an issue of environmental reproductive justice.

Annie Hoang

Yeah, these are, these are, these are tough questions I think these are great questions in the sense that I guess regarding environmental and reproductive justice. You really can't think one without the other. So obviously when I, when I look at studies and I look at the conclusions that Shauna another scientists have come to I always think about why does this apply to the population. I'm serving, how does this apply to the patient in front of me and that's always a question that I think every clinician is always grappling and and will continue to grapple so I think Shawn's point about being more proactive in representing underserved groups will will will go a long way in mitigating that. And then thinking about chemical threats to reproduction when I think about reproductive justice I think about at the core of it is that bodily autonomy, right, and, and that the core of it is to be able to be able to have children and parent children in a in a safe environment and that is where I see that link to environmental justice, to be able to have a healthy pregnancy to be able to parent your child in an environment. And without being without thinking about how your environment and where you live and what you eat and the water in which you drink can negatively impact your health and your children's health and their children's health as well so I think that's where I really do see the link. And, and I and I guess when I think about chemical threats I think about mostly disadvantaged folks you know like in I think in Shona your your book, you know speaks a little bit about this about, like 111 example, I think everyone has come into kind of a national conscience is water right and water equity, you know, people know about Flint, Michigan, and the current situation in new work and then when you think about that, and you think about the lead that's in the water you, obviously, you think about who lives in Flint and who lives in new work and who's being exposed. And so that's, that's what is kind of on top of my mind and that's how we can kind of start integrating explicitly equity into these conversations.

Ami Zota

and Shanna, you brought up the fact that, you know, it's, it's, it's, it's very hard as an epidemiologist, to, to get, you know, to work with the communities that often are disproportionately impacted because they have less time to participate in these studies and you know there's also this tide, this very kind of real tide of, you know, both contemporary and historical exploitation of black and brown people by medical research. So especially as you're writing this book and you're going around talking and you have your new study out, you know, that's, That's kind of grappling with these differential impacts. Do you have any thoughts or recommendations about how you may, you know, approach research epidemiologic research differently in the future or any thoughts about advice to the to the environmental epidemiologic community.

Shanna Swan

Yes, um, great question. Um, I, um, I think, first of all, that the community broadly across all straight up should be asked about the research they want to have conducted there, and at Mount Sinai, we have a wonderful community outreach program, and there is a lot of participatory research, but I just want to share an anecdote because I think it's really relevant. Some years ago I was asked to investigate a problem in Canada, in a First Nation community. The Algernon who had been exposed to very very high levels of oil of pollution from oil refineries, and they had a very skewed sex ratio, there are very few males being born. You probably haven't heard about this because not in the news now but, um, so I went there and I spent some time I decided I would have to talk to people and have to learn about the community, I actually checked into a motel and stayed there for a while, and I began to meet the elders of their community and talk to people and to go to some community meetings, and what we finally decided was that I would do a study, a small study to ask people whether they wanted to study at all. And, and we did that, um, and the answer was no. And as I dove into that, I realized why they didn't want that. And it was made a lot of sense. First of all, they, their land was sacred. So, if we found a problem, and it meant they had to move, they could not do that. It's something I never would have thought about right without talking to them and understanding them. Then I learned that they worked in those oil refineries, and they were afraid for their job if they participated, and thirdly that if we found that area was dangerous, their property values would go down so even if they wanted to sell, they could. So for all of those reasons they said no, we do not want to study here, and I left. So that's always stayed with me as, as you know, the first responsibility if you will, of an investigator to ask whether the people being investigated really want that study. I don't always do that, but I like to think about that and keep that in the back of my mind.

Ami Zota

A very powerful anecdote, and I think this is one of the first times I've heard a researcher doing almost like a pre study just to find out, you know, in a systematic way whether they're, you know their expertise is wanted. Any Do you have any thoughts or responses or anything you'd like to share about either the work you've done, community work you've done in terms of best practices or or models that you've seen that have or haven't worked.

Annie Hoang

Yeah I mean Shanna's anecdote, really. It gives a powerful lesson and how academics policymaker people of influence and power should should be more responsive to the community. And then that's exactly what you just said and then I thought that was a very powerful way of putting it. And, and, yeah, and as far as best practices, I mean that's, I always go back to the community, anytime I do research, anytime I'm, I'm trying to advocate for a policy or change. I always go back to the community I go back to the community organizing leaders I go back, and I ask permission. And I, you know, ask for, especially if I'm not from that community i i want to elevate their voices and make sure that their voices and preferences are heard, and I think Shawna, put that in a much better way than I did through through her story but that's what I think about.

Ami Zota

Okay, so now I want to move on to really, you know, Shanna has done collated and both has done a lot of the primary research on chemical exposures and reproductive harm and has done this impressive job of collating it in a way that's accessible to a broad audience. So, Shanna you're out there, you're, you're talking about your book people are reading it, um, you know, Who do you think will care about this, and especially with our ongoing crises. We're still in the COVID pandemic, climate change impacts are more and more real every day. How does this crisis of reproduction fit into the mix.

Shanna Swan

Well, we're certainly overwhelmed, on all social strata, I think. And, but a couple of things. One is I'd like to point out that I'm certainly the climate change and reproductive crisis are not separate. Um, so the chemicals that I'm most concerned about are those that are made from petroleum byproducts. And so they, the rise of the production of these chemicals, and the rise of temperatures and other climate problems have gone hand in hand. So I think that the more that I can talk about this intersection, the better I also talked about the trajectory of these problems, which is actually kind of similar, but with the reproductive crisis lagging behind the climate change. So, just quickly, the climate change crisis was ignored for a long time even though there was good evidence, and then it was accepted as a phenomenon, but with people saying it's not anything to do with us, it's just happens, and nothing we can do about it. And finally, people taking responsibility, and I see those three steps happening with a reproductive crisis. Initial reports back 92 were ignored. I myself was skeptical of them. And, but gradually we got more and more information, the 2017 paper was not ignored it was taken actually quite seriously. And, but still people were saying, Well, this just happens, it's nobody's fault, you know, and certainly endocrine disruptors don't have anything to do with it. And now I think we're starting to raise awareness of the risks of the chemicals that we call everyday everywhere chemicals in our lives. So, um, I don't see them completely separate COVID is, you know, a beast of a different, different nature it's infectious of course and non environmental and. But it's important to talk about how the problems of reproductive health have been exacerbated by COVID, and I haven't personally studied this I'm not doing any COVID studies but from what I read and what I hear. This is only making reproductive crisis worse.

Ami Zota

Thank you and I'm Annie I'm gonna ask you kind of the same question Who do you think will care and how can we make people care about environmental justice about the declining fertility, specifically. That's right.

Annie Hoang


I think everyone would care, and, you know, I thought about this. When it comes to like climate change and environmental health. There's something about that word that a lot of people just feel that that over feel overwhelmed right it's kind of like this denial it's bigger than me. I don't know what to do about it. Ah, someone else will do it so you kind of have this like tragedy of the common thing going on. But when it comes to fertility and reproduction. You know that, did I just got personal.

And so, and I think that's a very powerful frame of putting it, Essentially, that, you know, climate change and these environmental changes in these toxic chemicals are affecting you you personally, not just the polar bears, not just the insects and the birds is you.

There's, you know, the biologically things are things are changing in your body and, And if you don't care about yourself okay but your children are affected and your grandchildren and their children and so I think putting it to that personal level I think will go a long way in seeing and seeing that connection as well, and at the same time, of how, and then on the flip side of that of how do we make people care. Again, if you're talking about these crisis, you know these crises, everyone's overwhelmed everyone doesn't know what to do and just say that there's a crisis and there are all these problems, doesn't really get us anywhere and I'm one of the things that I thought that was powerful. From

Shanna's book was the emphasis on also solutions, there are things that we can do as individuals, as policymakers as academics as we start thinking about relevant questions for the community and for the good of society and so there, there are these concrete steps that we can take. So even though there's a downtrend, even though there's this crisis happening, we made it happen so we can work to reverse it and I think that's also a powerful message. So, you know, you, you talk about the problem, but you also have solutions as well and encouraging people and giving that people that sense of hope that there's something we can do on an individual or one in a collective level I think that goes a long way in making people care.

Shanna Swan

That was great. Can I just add something to my answer. Absolutely, yeah really talked about, who could respond to this or should respond to this, but one of the things I wanted to add was that this problem of reproductive health has been a secret for a long time. This is not something that's in public discussion. So you might. And it's also men particularly don't have a clue about their reproductive health. Okay, so it's kind of a black box for them, not something to be talked about in a cocktail party, a man would maybe talk about, oh, I went to the doctor or my cholesterol is high and I got to watch my diet, that's not too embarrassing right you can see that happening. A man coming to a cocktail party saying I went to a hydrologist 100 sperm tested, and it's really low. No way. Right. So there's a lot of ego involved in this, you know, suppressing this information I think people don't want to look at it, they don't want to. They want to feel like everything's good to go. When I'm get ready to have a baby, I'll just do it. And, and I think different talking about differential impact. This is differentially impacting women, women have been made to feel guilty about failures of reproductive health, for a very long time, you know, so it's just, it's assumed that if a couple can't get fertile it's hurtful. If a couple has repeated miscarriages hurtful. That's actually not true. But now we know is about 5050. So I think, you know, maybe people who women who want to, you know, say, wait about a guy is not just on me. You got to get checked we got to figure this out together. Those women should care.

Annie Hoang

Yeah, yeah, yeah, I gotta I gotta add to that, I thought that was probably one of my favorite chapters in the books that you wrote is you emphasize the importance of that male accountability and in a way that is rooted in fact in science that, you know, now she goes, Oh I'm a woman and I'm saying this but it's like this is actual his evidence base, and that ever increasing importance of male factor infertility, it has long been downplayed and you actually says something that I, I, they'll probably stick with me for a while you were like, yeah fertility is an equal opportunity game, and you know just because a man doesn't hear his biological clock ticking doesn't mean it's not taking time and I thought that was very profound and I thought that was a great way of putting it. And actually, when you know in medical school. When we were learning about urology, you know, a urologist told me it was just like, you know, we really applaud the fact that all these lifestyle and environmental exposures in fact, you know, impact, erectile dysfunction, I'm pretty sure you know men would live a much healthier lifestyle. So that was something that, you know, we learned in medical and medical school,

Shanna Swan

Great. I'm glad they told you that.

Ami Zota

So, um, I really love this conversation that's happening, and Shanna I'm gonna see if you have another wonderful anecdote. In this this your spit you know you're my your back pocket of anecdotes, but um, so I think both of you and I, one thing we have in common is we're both scientists that we value science communication because, you know, whether it's a podcast or a book, you know, using these kind of forms of science translation outside of, you know, peer reviewed literature, You know really does kind of help you connect, connect with different audiences and educate a broader swath of people right and. And so to that end, you know you've been, you've been all over the place you've been on so many you know good on TV shows a different podcast. Your book has gotten quite a bit of publicity is there, um, has anyone have any group or have there been any individuals that have reached out to you that seem to have, you know, kind of been, I guess, you know, what's the word illuminated by your book are they, it's made them change their mind or has there been any tangible actions that have really, you know, or policy changes, you know, whether from professional societies or or individuals or, you know, because of your book like Can you share any kind of unexpected kind of consequences or implications from from this work that you're doing and from being such a kind of, you know, public facing scientists, you know, after the publication of your book.

Shanna Swan

So I think it's too soon, honestly, it's, it's the book came out on February 23 In Great Britain, two days ago. But what one of the things is extraordinary to me is that I'm getting requests from, I would say probably 30 countries, or 40 countries around the world, the international impact of this is really kind of staggering to me. Journalists wanting to talk to me, foreign language editions popping up in remote places like Turkey, we just, and, and the fact that these journalists are, and we send them the book, okay and then they then they get educated about it and then they talk about it. So one of the things that's really extremely exciting to me is that we could have this is a world problem this is not a US problem right. And we could, and seem to be starting to have a really broad, you know world based discussion of these problems which is just so exciting to me. But, um, I think, impact in terms of regulation or you know, talking, I've talked to, you know, the President's Task Force on Children's Health I've talked to the EPA children's health office, I've talked, talking to California EPA I'm talking to all kinds, anybody who will ask me actually, because I, I want to get this out and, hopefully, with the new administration, that we there's some opportunity to make change, there clearly people in our government, attending these podcasts at double and triple usual numbers by the way, extremely interested in learning about this. And I think, I hope that it will have an impact, you know, on, on regulation. I'm hoping to talk to more medical, you know, health care professionals or people who teach in medical schools, I've talked to a preventive medicine resident who actually is fairly high in the government, who's going to help me do that and, you know so on all fronts. I'm trying to get the message out to people who will listen, but actually bringing about change. That's a longer haul.

Ami Zota

Yes, fair enough. I feel like I've seen you out in the sphere so much that it doesn't feel like it's only been, you know, less than two months since your book came out because. So thank you for your service in doing all those interviews because that, you know, that takes a lot of time and it can be exhausting. So kind of our last question and, but it's not a small question by any means. So I think one thing that we all have in common is, you know, we don't want science just for the sake of science we want to improve public health we want to advance health equity. So, I know Shauna you talked about this in your book, but, um, you know what, what should people do, and you know I, you know, and maybe a way we could kind of frame this is both, you know, advice for the everyday individual but then, you know also thinking about what is advice also for clinicians and and and then lastly, like if you could see one policy change, you know, what would what would you want that to be so kind of thinking about, you know, kind of your recommendations, starting with the individual, you know, kind of, up through policy.

Shanna Swan

So, I think on an individual level. What I hope is that people will recognize the problem first of all, which like I said, it hasn't been well recognized, they will own the problem for themselves, even if they don't personally want to get pregnant, or don't worry about their own reproductive health but like me said that of their children and their grandchildren. So I think we can't make change unless lots and lots of people recognize the problem, and that hasn't been the case until now. Talk about lifestyle factors and environmental factors, that's the big split, and the lifestyle factors are relatively easy. And I can even say, do what you want to do to protect your heart health, because most of the recommendations for heart health are also recommendations for reproductive health. And while I'm saying that let me just say there has been a movement now to call reproductive health, the sixth vital sign, because people with poor reproductive health, actually die earlier. And they have more heart disease they have more diabetes, they have more reproductive cancers and so on. So, it's actually very early on in life, you can get a signal for your later health in life and so that's another reason people should care, so take care of your health. By not smoking by exercising by not being obese by not binge drinking by eating good foods and that will go into great detail in the book, but on the chemical side which I believe is the more important and much harder sell, if you will, is to think about everything you bring into your house. Just be aware that everything you bring into your house into your body into your mouth. Put on your skin breeze, everything has the potential to impact your reproductive health. So that's that should be the default assumption, so that you say, Oh, I'm buying this product, um, is that okay, You might read the label, you might go on some one of many websites including, I always recommend Environmental Working Group, but there are many others. And, and check it out. So, fortunately there are NGOs that have supplying these resources where you can put this product in and you could say, safe cosmetics, safe, you know, cleaning products safe laundry products safe sunscreen blah blah, you know, and, and do it, just take a minute, doesn't take a long time. There are also apps that people can get to check out the safety of their products. So I think you won't do that unless you believe that it matters. So first you have to believe it matters. And then you can take action. So the regulatory level. One thing you, you, I think. Oh gosh. I think the first, most important thing is that, chemicals, be tested, because most of them are not. And they be tested at human relevant scenarios, so much of testing has little to do with our exposure, doesn't look at mixtures doesn't look at low doses doesn't look at various rounds of exposure. Doesn't look at us, and we want to be seen. We want testing that affects our health directly.

Ami Zota

I appreciate both the individual and the policy, you know perspective and I, you know, one thing I think I would add is that this testing happened before these chemicals are introduced into the marketplace not afterwards because, you know, then it's once the genies out of the box, you know, like a PFAS forever chemicals you can't you can't get rid of them so.

Annie, do you want to add anything here in terms of, you know, thinking about recommendations or especially for kind of advancing health equity or considerations.

Annie Hoang

Yeah, absolutely. And I have to I have to echo about kind of the toxic chemicals, regulation, especially from an equity perspective because we're, you know right now what we're doing is we're taking kind of a innocent until proven guilty approach to a lot of chemicals and by the time we realize that it's already too late, and those chemicals, when they leach out into the water those forever chemicals for example there, they are disproportionately affecting underserved populations and so changing that from the root and Evelyn Rashanna said of making it relevant to the human experience having us be seen. That's going to be key into preventing all of these downstream effects that will, that, that at the end of the day have differential impacts. That's something I would add.

Ami Zota

All right, well thank you so much. This has been incredibly interesting. You know also just as a scientist in this in this space, I'm glad we've had a chance to have this conversation and I just, I think it's an exciting time for people working on environment and public health, especially with the change in administration so I think this is, you know, this is the time to raise awareness, because hopefully action will be coming.

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