CHAPTER Introduction

1
Ditas Cristina D Decena MD MPH

O n October 4, 2015 at the FIGO XXI World Congress held in Canada,

officers and representatives of member countries attended a summit on
“Shaping Our Planetary Legacy.” Under the leadership of past presidents Dr
Linda Guidice (ASRM) and Dr Jeanne Conry (ACOG), the recommendations
from the summit were to:

a) Advocate for policies that will prevent exposure to toxic

environmental chemicals
b) Work in order to ensure a healthy food system for all
c) Incorporate environmental health into health care
d) Champion environmental justice

Recomendation for Preventing Exposure to Toxic Chemicals

Organic
CO2

Eco
Health

BPA

(ASRM) American Society for Reproductive Medicine

(ACOG) American College of Obstetricians and Gynecologists

1
 In November 2016, the FIGO Subcommittee on
Reproductive and Developmental Environmental Health
(RDEH) convened to set the structure that will implement
the above recommendations. From the first Webex

SUMMIT ON SHAPING OUR meeting, three (3) subgroups were created, namely:

PLANETARY LEGACY
a) Advocacy
b) Capacity building and training, and
c) Collaborative research.

The Philippines was tasked to help in the advocacy for a

safer environment. During the presidency of Dr Mayuma
Bismark in 2017, the FIGO-RDEH advocacy project was
started. While locally christened as the POGS Subcommittee
on Climate Change and its Impact on Reproductive Health,
the project continues its representation internationally
as the FIGO-POGS RDEH with Dr Ditas Cristina Decena
retaining a position in the working group. In 2018, the
advocacy project was assimilated into the Committee
on Women’s Health and the Environment (WHE) with
Drs Betha Fe Castillo and Erlidia Llamas-Clark as director
and committee head, respectively. The main thrust of the
advocacy group was to give a series of lectures nationwide
in coordination with the Committee on Continuing Medical
Education (CME).

After two years, the RDEH Committee sees it fit to publish

The International Federation of Gynecology
and Obstetrics XXI World Congress
Vancouver, Canada
October 4, 2015
a primer that can further strengthen the information
and education campaign on how reproductive health
is impacted by the environment. This primer contains
information on how environmental toxins, pollutants and
endocrine disrupting chemicals affect women’s health and
pregnancy. It aims to stimulate the interest of readers so
that they too can become partners in this advocacy.
Believe that investing on the health of women today is
putting premium on the health of future generations.

Be Changed.
Be an advocate!

2 3
 CHAPTER Climate Change
2
Andrea C Santiago MD
Introduction
T he emergence of climate change in the public agenda brought the
creation of the Intergovernmental Panel on Climate Change (IPCC) in the
80s. Its purpose was to assess climate change from both the scientific and
intergovernmental perspectives. The adverse impact of climate change is
already evident and can further intensify over time if not addressed. Hardest
hit will be the most vulnerable due to their geographic, demographic,
governmental and economic characteristics. That is why climate change is
recognized as a fundamental challenge to the modern world.
The Philippines is considered as one of the most affected countries by climate
change [1]. The country has been experiencing extremes in weather like severe
droughts and devastating typhoons. Other important areas affected include
the water system, forestry, agriculture, coastal areas and human health [2].
Human health issues closely linked with climate change are the following:
spread of water-based and vector-borne diseases, increased incidence of
pulmonary illnesses in young children and cardiovascular diseases in the
elderly, increased health risk from poor air quality especially in urban areas,
and reproductive health problems [3].
Climate Change Defined
Weather is the continuously changing condition of the atmosphere, usually
considered on a time scale that extends from minutes to weeks. Climate is
the average state of the lower atmosphere, and the associated characteristics
of the underlying land or water, in a particular region. Changes in the climate
occur over decades or in longer time-scales. Climate variability are changes
around the average climate, including seasonal differences and large-scale
4 5
regional cycles in atmospheric and ocean circulations such as the El Niño/
Southern Oscillation (ENSO) or the North Atlantic Oscillation [4].
The earth’s climate is determined by the complex interactions between the
sun, the earth’s atmosphere and gases. The sun is the principal driving force
for weather and climate. The short-wavelength energy emitted by the sun is
transformed to long-wave radiation when it hits the cooler earth’s surface.
The uneven heating of the earth’s surface (warm near the equator) causes
great convection flows in the atmosphere and oceans, and is a major cause
of winds and ocean currents.
The atmosphere is made up of five (5) concentric layers. The trophosphere is
the lowest layer and extends from ground level to about 10-12 km altitude.
The weather that affects the earth’s surface develops within the trophosphere.
The second layer is the stratosphere that extends to about 50 km above the
surface. The ozone within the stratosphere absorbs most of the sun’s higher-
energy ultraviolet rays. Above the stratosphere are three more layers namely:
mesosphere, thermosphere, and exosphere. Altogether, these five layers
reduce by half the amount of incoming solar radiation to the earth’s surface.
The third component of climate change is gases. Some gases in the
trophosphere absorb approximately 17% of the solar energy. These gases re-
emit solar energy to all directions and warm the surface of the earth called the
“greenhouse effect” (Figure 1). The greenhouse effect is a naturally occurring
The greenhouse effect
3 ...tomost escapes
outer space,
1 Sunlight 2 Infrared
radiation (IR)
allowing the
Earth to cool...
passes through
is given off
the atmosphere by the Earth...
and warms the earth.
4 ...is but some infrared radiation
trapped by gases in the air
(including Co2), keeping the Earth
warm enough to sustain life.
5 ENHANCED GREENHOUSE EFFECT
Increasing levels of Co2 increases the amount
of heat retained, causing the atmosphere
and Earth’s surface to heat up.
Figure 1. Factors that affect climate and the greenhouse effect.
 phenomenon. However, human activity and interference have contributed to Impact of Climate Change
the increasing concentration of greenhouse gases resulting to a further rise
in the earth’s temperature. These greenhouse gases include the following: Geographically situated above the equator and surrounded by large bodies
of water, the Philippines is one of several countries in the world that is most
vulnerable to climate change. This combination of equatorial warm weather
and the Western Pacific Ocean is a recipe for tropical cyclones. On an annual
Water vapor is the most abundant greenhouse gas. It is
1 average, 20 cyclones enter the Philippines with eight or nine making landfall.
increased as the earth’s atmosphere warms, making it an Over the past decade, these tropical storms have struck the archipelago more
important feedback mechanism to the greenhouse effect. often and more severely. (Appendix 1). Moreover, the country lies on top of
2 Carbon dioxide (CO2) is released through natural processes the Pacific’s “Ring of Fire,” where the drifting of crust underneath the Pacific
such as human respiration and volcanic eruptions. However, Ocean leads to the frequent earthquakes and tsunamis.
various human activities such as deforestation, changes The Department of Environment and Natural Resources (DENR) has created a
in land use and use of fossil fuels have increased the map dividing the country into 11 zones in order to identify zone-specific risks
concentration of carbon dioxide in the atmosphere by from climate change (Figure 2). Identified were: intense heating, increased
more than a third since the Industrial Revolution. ocean temperatures, rise in sea level, excessive rainfall and a disturbed water
3 Methane is also produced naturally and through human supply.
activities such as the decomposition of wastes in landfills,
agriculture especially rice cultivation, as well as ruminant
digestion and manure management associated with domestic
livestock.
Nitrous oxide is a powerful greenhouse gas produced by soil
4
cultivation practices, especially with the use of commercial and
organic fertilizers, fossil fuel combustion, nitric acid production,
and biomass burning.
Chlorofluorocarbons (CFCs) are synthetic compounds known
5
to be very destructive to the ozone layer but are nevertheless
used in numerous industrial applications.

Figure 2. Philippine map depicting the 11 zones and their specific risks from climate change.

6 7


1 Global temperature rise. This can bring detrimental changes in the Rise in sea level. Global sea level rose about 8 inches in the last century
3
planet’s environmental patterns and ecosystems. The earth’s average but the rate of rise in sea level has nearly doubled in the last two
surface temperature has risen about 0.9 degrees Celsius (1.62 degrees decades [9]. The coastal resources of the country are highly vulnerable
Fahrenheit). The most warming has occurred in the past 35 years with due to its extensive coastline. Once sea level rise, low-lying islands
the five warmest years on record taking place since 2010 [5]. will face permanent inundation. Coastal communities will face
an increasing threat to life and property due to storm surges and loss of
Drier periods and warmer temperatures, especially during the warm productive agricultural lands due to inland saltwater intrusion.
phase of El Niño could cause forest fires. Such unfavorable conditions
may force communities that are dependent on the surrounding 4 Extreme weather events. Precipitation is expected to decrease in areas
ecology to abandon their traditional livelihood. Changes in practices close to the equator and to increase in higher latitudes. Large
and behavior can lead to further degradation of the environment decreases in rainfall and longer drier periods will affect irrigation services
as people resort to putting more pressure on agricultural production to farmers, limiting agricultural production. Dams could be rendered
in already degraded areas. Agricultural crops suffer low yield whenever inefficient for energy production. Droughts are expected to stay longer
temperatures have exceeded threshold values. Moreover, rises in and become more severe. Forestry, livelihood, health and human
temperature coupled with rainfall changes induce outbreaks of pests settlement are likewise affected.
and diseases, both in plants and animals. In areas where rainfall could be intense during the wet season, flooding
The oceans have also absorbed much of the heat with the top 700 events may pose danger to human settlements and infrastructure
meters (about 2,300 feet) of ocean warming to 0.302 degrees especially those in geologically weak areas [3].
Fahrenheit since 1969. The marine ecosystem is disturbed as observed Ocean acidification. The increasing carbon dioxide in the atmosphere
5
in the migration of fish to cooler and deeper waters, forcing fisher folks due to human has amplified the acidity of the upper layer of ocean
to travel farther out into sea to increase their catch. waters by about 30 percent; the amount of carbon dioxide absorbed by
Decreased yields and inadequate job opportunities in the surface waters increasing to about 2 billion tons per year [10].
agricultural and fishing industries lead to migration. As mega cities
absorb these shifts in population, food security and more congestion
in already depressed urban areas create higher poverty levels,
malnutrition, heightened social unrest and conflict.

Shrinking ice sheets, glacier retreat and decreased snow cover. Recent
2
data[6] show that the Greenland and Antarctic ice sheets have
decreased in mass in the past years. Greenland lost an average of
281 billion tons of ice per year between 1993 and 2016, while Antarctica
lost about 119 billion tons during the same time period. Glaciers have
also been noted to retreat almost everywhere around the world —
including in the Alps, Himalayas, Andes, Rockies, Alaska and Africa [7].
In addition, satellite observations reveal that the amount of spring snow
cover in the Northern Hemisphere has decreased over the past five
decades and that the snow is melting earlier [8].
Reproductive and Developmental Environmental Health 9

8 9
 The Environment and Human Health Eye, ear, nose,
throat irritation
The abovementioned natural phenomena inevitably affect human health Difficulty breathing
(Figure 3.1 and 3.2). The World Health Organization (WHO) estimates about Headache, (O3, PM, SO2,
250,000 additional deaths per year are expected between 2030 and 2050 anxiety (SO2) NOx, VOs)
due to climate change [6]. A study on the health effects of climate change Central Nervous
noted increases in severity of air pollution-related chronic disease (73%), System (PM)
allergic symptoms (63%) and injuries due to severe weather (49%). Other Cardiovascular
health problems related to climate change are vector-borne infections (36%), diseases
diarrhea from food- or water-borne infections (23%) and heat-related effects (PM,O3,SO2)
(34%). Across all categories of health effects, it was concluded that more
harm is expected to occur in the next 10-20 years. Liver, spleen,
blood (NOx)

Impact of Climate Change on Human Health

Injuries, fatalities, Asthma, Low birth weight,

mental health impacts cardiovascular premature birth, Respiratory irritation,
disease
small for gestational age, inflamation, infections,
impaired lung development, asthma, reduced lung
possible birth defects, function,COPD (PM),
Severe Air Malaria, dengue, lung cancer (PM, PAHs)
Heat-related illness
Weather pollution encephalitis, hantavirus, possible autism
and death, (PM, prtoximity
cardiovascular failure Rift Valley fever,
Lyme disease, to traffic)
Changes chikungunya,
Extreme in Vector
Heat West Nile virus
Ecology
Figure 3.2 Health effects of climate change on human organ systems

Enviror- Water
mental Quality Air pollution. Changes in climate affect the quality of air that we breathe.
Degradation Impacts
Forced migration,
Cholera, Warmer temperatures are directly correlated with increasing levels of ground-
cryptosporidiosis,
civil conflict,
Water and Food Increasing campylobacter, level ozone – a component in smog and a harmful air pollutant. Exposure
mental health impacts
Supply Impacts Allergens leptospirosis, to higher levels of ozone can damage lung tissue, reduce lung function, and
harmful algal blooms
cause airway inflammation.

Malnutrition, Respiratory Air pollution is the phenomenon in which change in the physical, chemical
diarrheal disease allergies, asthma and/or biological properties of air results in the air being harmful to public
health and safety, or which will adversely affect its utilization (Figure 4). Its
classification includes outdoor (rural or urban), indoor or transboundary air
Figure 3.1 Health effects of climate change pollution.

10 11
 Inhalation of particulate matter, a category of extremely small particles and Impact on water quality and food supply. Warming water temperatures mean
liquid droplets suspended in the atmosphere, may lead to adverse health effects an increase in water-borne pathogens like vibrio cholera, toxins from harmful
that include lung cancer, chronic obstructive pulmonary disease (COPD) and algal and cyanobacterial blooms in water, and chemicals that contaminate
cardiovascular disease (Figure 5). There are numerous sources of particulate water from various human activities. Warm temperature facilitates bacterial
matter. Some occur naturally like dust, wildfire smoke and sea spray. Many growth leading to food poisoning, gastrointestinal problems and death
are created by human activities like burning of fossil fuel for energy, emitted (e.g. salmonella). Run-off, flooding and storm surge can contaminate water
directly or formed in the atmosphere from chemical reactions of gases such bodies used for recreation, seafood and sources of drinking water. Exposure
as sulfur dioxide, nitrogen dioxide and volatile organic compounds (Figure 6). to contaminated drinking or recreational water may lead to diarrhea, liver
or kidney damage and problems of the nervous and respiratory systems.
Climate change also increases the risk exposure to chemical contaminants
in food. Elevations in sea surface temperatures may lead to higher mercury
concentrations in seafood.
WHAT ARE THE HEATH RISKS OF
PARTICUATE MATTER? Changes in vector ecology. Vector-borne diseases are illnesses transmitted
by vectors (mosquitoes, ticks, fleas) that carry infectious pathogens (viruses,
bacteria, protozoa) from animals to humans. Changes in temperature,
Particulate matter pses a serious heath risk because
it can trave int the respiratory track. PM2.5 is especially precipitation and extreme events widens the geographic range of disease
dangerous because it can penatrate deep into the lungs spread by these vectors and may lead to serious illnesses. Dengue hemorrhagic
and sometimes even into the bloodstream. fever and malaria are classic examples of endemic vector-borne diseases of
HEATH EFFECTS major public health concern in the country. Extreme temperatures influence
the location and number of mosquitoes. Statistics from the Department of
Decreased ung function
Chrnic bronchitis Health for 2010-2014 show an incidence of 178 symptomatic dengue episodes
Increased respiratory symptoms per 100,000 population and a case fatality rate of 0.44%. Most affected by
Cardiac arrhythmias dengue are children aged 5–14 years and more than 80% of deaths occur in
(heartbeat irregularities) the age group below 20 years. (Source)
Heart attacks
Premature death Toxic chemical substances in the environment. Another important and
powerful effect of climate change is how it affects the behavior of toxic
GROUPS SENSITIVE TO PM2.5 chemical toxic substances that are linked ultimately to human health and to
People with heart reproductive health issues, in particular.
or lung desease
Older adults Changes in environmental parameters like temperature, precipitation and
Children salinity could affect the distribution and biological effects of toxic chemical
Pregnant women substances. It is believed that climate change may affect these parameters by
altering the physical, chemical and biological drivers of partitioning between
the atmosphere, water, soil/sediment and biota, including air-surface exchange,
Source: www.epa.gov
wet/dry deposition, and reaction rates. Warming temperature may enhance
Figure 4. Health risks of air pollution the toxicity of contaminants and increase concentrations of tropospheric

12 13
 ozone in certain geographic regions. Elevated water temperatures may also
alter the bio-transformation of contaminants to more bioactive metabolites
and impair homeostasis.
These toxic chemical substances of global significance belong to three broad
categories and include: air pollutants, persistent organic pollutants (POPs) that
include organochlorine pesticides, and other classes of pesticides. Changes in
precipitation enhance the volatility of POPs and pesticides in the atmosphere,
their surface deposition and run-off of pesticides. Most of these chemicals are
ubiquitous and are present in almost everyday household products making
women and children particularly susceptible to exposures. These are just
some of the mechanisms by which climate change can affect human exposure
to toxic substances.
COMMON AIR POLLUTANTS
COMMON AIR POLLUTANTS
Figure 5. Particulate matter that creates air pollution
14
Worldwide Efforts to Address Climate Change
Several policies have been created and implemented to ensure that greenhouse
gases (GHGs) are kept at a level that will not disrupt the climate system. The
employment of cleaner energy systems, safe use of public transport, and
the promotion of active movement such as cycling or walking as alternatives
to the use of private vehicles are just some of the ways to reduce carbon
emissions. Alongside is the need to cut the burden of household and ambient
air pollution that causes over four million and three million deaths per year,
respectively [6].
In 2015, the World Health Organization Executive Board formally endorsed a
plan of action to address climate change [6]. The document included:
1 Interagency partnerships to ensure that health is properly
represented in the climate change agenda;
2 Dissemination of information that climate change presents a
threat to health, and health promotion through the reduction of
carbon emissions;
Carbon
monoxide
3
Particulate Use of scientific evidence that establishes the links between climate
matters 10/2.5
change and health, and the development of a global research
agenda; and TSP Sulfur
dioxide
4 Support for the implementation of public health response to
climate change and capacity building of vulnerable countries.
PAH
Ground-level
Ozone Nitrous oxide
15
 A milestone in the effort to address climate change is the Paris Agreement Appendix 1. List of Tropical Storms in the Philippines Since the 1990’s
where signatory nations agreed to accelerate and intensify actions and DATE TYPHOON COMMENTS
investments needed for a sustainable low carbon future. The following are
November 5, 1990 Mike (Ruping) A total of 116,512 homes were destroyed while
key aspects of the agreement: 294,131 were damaged; Visayas was declared to
be in a state of calamity

October 25, 1995 Angela (Rosing) Affected Metro Manila, Calabarzon and Bicol
● Long-term temperature goal to well below two (2) degrees Celsius regions; costed $241 million worth of damages
while pursuing efforts to limit the increase to 1.5 degrees; November 4, 1991 Thelma (Uring) Reached its peak intensity as it approached the
Visayas region, with 5,081 to 8,165 casualties
● Global peaking of GHGs as soon as possible while recognizing that
November 27, 2004 Winnie Precipitated massive floods and landslides in the
peaking may take longer for developing countries; country and left nearly 1,600 people dead and
751 others missing
● Mitigation or maintenance of a nationally determined contribution
November 25, 2006 Durian (Reming) Wreaked havoc on the city of Albay, worsening
(NDC) per country; the ongoing effects of Mayon Volcano at the
time; final death toll was unknown due to the
● Conservation and enhancement of sinks and reservoirs of GHGs, areas buried with lahar, but estimates ranged
from 800 to 1,000 casualties
including forests;
June 21, 2008 Fengshen (Frank) Known for the capsizing of MV Princess of the
● Voluntary cooperation among member countries/parties; Stars ship during the height of the storm, killing
about 846 of the 922 passengers it held
● Enhancement of adaptive capacity and resilience, and reduction in September 24, 2009 Ketsana (Ondoy) Made its landfall on the borders of Aurora,
vulnerability to climate change in the context of the temperature Baler then quickly approached Metro Manila
causing massive flooding and failure in power,
goal of the agreement; water connection and communication; cost of
damages reached $244 million
● Prevention, mitigation and tackle loss/damages associated with
October 12, 2010 Megi (Juan) Heavy rains and flash floods affected the northern
the adverse effects of climate change, and enhancement of part of the country (Cagayan and Isabela); cost of
sustainable development in risk reduction efforts; damages were over $255 million

● Finance, technology and capacity-building support; September 23, 2011 Nesat (Pedring) Luzon was declared to be in a state of calamity;
Manila had experienced waist deep floodwater
and flying debris due to storm surges and strong
● Climate change education, training, public awareness, public winds
participation and public access to information; and December 3, 2012 Bopha (Pablo) “Strongest tropical cyclone in Mindanao”, ranked
as Category 5 Supertyphoon
● A “global stocktake” to assess the collective progress toward
November 8, 2013 Haiyan (Yolanda) “Deadliest Philippine typhoon of modern era”;
achieving the purpose of the agreement in a claimed more than 6,300 lives; cost of damages
reached $2.86 billion; affected Tacloban city the
comprehensive and facilitative manner. most

July 10, 2014 Rammasun (Glenda) Red alert status in the country due to flash floods,
strong rains, and winds; Major power blackout
within Metro Manila
As more studies on climate and the environment
October 12, 2015 Koppu (Lando) Powerful winds caused widespread damage
emerge, we come to the realization that climate and disruption across Luzon; Category 4 super
change has a big impact in our daily lives and typhoon

therefore, needs to be acted upon in order to December 13, 2017 Kai-tak (Urduja) With about 244, 241 casualties and caused
massive flooding in Western and Eastern Visayas
prevent serious long-term sequelae. regions

(Summarized from the Philippine Atmospheric Geophysical and Astronomical Services Administration/
PAGASA reports) [11]

16 17
 Useful Resource Websites for Further Reading CHAPTER The History Of
Endocrine Disruptors
3
● Intergovernmental panel on climate change (IPCC)- http://www.
ipcc.ch
● Philippine Atmospheric Geophysical and Astronomical Services Grace P Cayabyab MD
Administration- https://www1.pagasa.dost.gov.ph
● United Nations Framework Convention on Climate Change
(UNFCCC)- https://unfccc.int/
● World Health Organization- http:// www.who.int

REFERENCES:

I n 1938, Sir E Charles Dodds of England formulated the first synthetic estrogen,
1 Global climate risk index- https://germanwatch.org
2 Philippine Atmospheric Geophysical and Astronomical Services Administration-https:// diethylstilbestrol (DES), for menopausal symptoms [1]. It was then used
www1.pagasa.dost.gov.ph
3 Albritton DL, Meiro-Filho LG. Climate Change 2001: The Scientific Basis. In: Houghton
for the prevention of miscarriage and preterm birth although a subsequent
JT, Ding Y, Griggs DJ, Noguer M, van der Linden PJ, Dai X, Maskell K, and Johnson randomized controlled trial did not support this view. Following an unusual
CA (eds): Third Assessment Report of the Intergovernmental Panel on Climate Change. occurrence of vaginal and clear cell carcinoma observed in adolescent girls
Cambridge University Press, 2001. in the late 60’s, a case-control study found a strong association of these
4 World Health Organization- https://www.who.int
5 National Aeronautics and Space Administration, Goddard Institute for Space Studies-
malignancies with in-utero DES exposure [2,3]. The toxic effects of DES were
https://www.giss.nasa.gov/research/news/20180118/ attributed to estrogen receptors. The United States of America Food and
6 Philippine Atmospheric Geophysical and Astronomical Services Administration: https:// Drug Agency (USA FDA) issued a bulletin banning the use of DES among
www1.pagasa.dost.gov.ph/ pregnant women. Thalidomide used to control emesis during early pregnancy
7 National Aeronautics and Space Administration California Institute of Technology-
https://www.jpl.nasa.gov
is a teratogen that led to phocomelia (Figure 1).
8 Oerlemans J (ed): Glaciers and climate change: A.A. Balkena Publishers, 2001.
9 Derksen C, Brown R. Spring snow cover extent reductions in the 2008-2012
A pesticide known as dichlorodiphenyltrichloroethane
period exceeding climate model projections. Geophysical Research Letters 2012; 39: (DDT) caused reproductive failure among songbirds that
doi:10.1029/2012GL053387. resulted in the worldwide ban of this chemical for
10 Church, JA, White NJ. A 20th century acceleration in global sea level rise. Geophysical agricultural use since the 60’s. Other chemicals
Research Letters 2006; 33: doi:10.1029/2005GL024826.
11 Sabine CL, et al. The Oceanic Sink for Anthropogenic CO2. Science 2004; 305: 367-71.
have been implicated in cases such as malignancies
12 D’Amato G. Effects of climactic change and urban air pollution on the rising trends of among others, and as mentioned, all have been labelled
respiratory allergy and asthma. Multidisciplinary Respiratory Medicine 2011; 6 (11): 28-37. accordingly as EDCs. In the few years that followed, the
13 Undurraga EA, et al. Disease burden of dengue in the Philippines: Adjusting for under National Institute for Environmental Health Sciences
reporting by comparing active and passive dengue surveillance in Punta Princesa, Cebu
City: Am J Trop Med Hyg 2017; 96(4): 887-898.
was tasked to conduct researches for the purpose of
14 Noyes P, et al. The toxicology of climate change: environmental contaminants in a understanding the influence of the environment on
warming world. Environment International 2009; 35:971-986. human disease. Thus, after three decades of studies on
15 Macdonald RW, et al. Contaminant amplification in the environment. Environmental the progression of human diseases and fetal development,
Science and Technology 2002; 36 (23): 456-62.
the concept of “endocrine disruptor” was introduced [4].

18 19
 REFERENCES:

1 Endocrine-Disrupting Chemicals-The History of EDCs published online by the

Endocrine Society Retrieved from https://www.endocrine.org/topics/edc/
what-edcs-are/history-of-edcs
2 DES Action Retrieved from https://desaction.org/des-timeline/
3 Hoover RN, Hyer M, Pfeiffer RM et al. Adverse Health Outcomes in Women
Exposed in Utero to Diethylstilbestrol. N Engl J Med 2011; 365:1304-1314.
4 Endocrine Disrupting Chemicals: The History of EDCs timeline. Retrieved from
https://www.endocrine.org/topics/edc/what-edcs-are/history-of-edcs/edc-
timeline
5 Damstra T, Barlow S, Bergman A et al. Global Assessment of the State-of-the-
Science of Endocrine Disruptors published by the World Health Organization
(2002) Retrieved from http://www.who.int/ipcs/publications/en/toc.pdf
6 Di Renzo GC, Conry JA et al. International Federation of Gynecology and
Obstetrics opinion on reproductive health impacts of exposure to toxic
environment chemicals. Int J Gynecol Obstet 2015; 131: 219-225.
Figure 1. Effects of in utero exposure to EDC

In 2002, the World Health Organization through the International Programme

on Chemical Safety published the “Global Assessment of the State of the
Science of Endocrine Disruptors” to evaluate the effects of environmental
endocrine disruption in humans and wildlife species. This was subsequently
updated in 2012 [5].

In 2015, various international societies involved in reproductive health such as

the American College of Obstetrics and Gynecology (ACOG), American Society
of Reproductive Medicine (ASRM), the Royal College of Obstetricians and
Gynecologists (RCOG), the Endocrine Society and the Society of Obstetricians
and Gynecology of Canada (SOGC) joined forces to address this reproductive
menace. The International Federation of Gynecology and Obstetrics (FIGO)
released a committee opinion on the reproductive health impact of exposure
to toxic environmental chemicals. [6] It was through this advocacy that our
own society, the Philippine Obstetrical and Gynecological Society formed its
own Subcommittee on Reproductive Developmental Environmental Health.

20 21
 CHAPTER Endocrine Disrupting
How we are
Chemicals
4
Where the ECDs ECD
exposed to
come from example(s)
EDCs
May Anne V Tabaquero MD
Oral consumption Industrial waste or pesticides PCBs, dioxins,
of contaminated contaminating soil or ground perfluorinated
food or water water compounds, DDT

Oral consumption Leaching of chemicals from BPA, phtalates,

of contaminated food or beverage containers; chiorpyrifos, DDT
food or water pesticide residues in food or
beverage

Contact with skin Household furniture treated BFRs

and/or inhalation with flame retardants

Contact with skin Pesticides used in agriculture, DDT, chiorpyrifos,

and/or inhalation homes, or for public disease vinciozolin,
vector control pyrethroids
What is an endocrine disrupting chemical or
endocrine disruptor? Intravenous Intravenous tubing Phthalates

I
Application to skin Some cosmetics, personal Phthalates, triclosan,
In 2002, the International Programme on Chemical Safety (IPCS) of the care products, anti-bacterials, Parabens, insect
World Health Organization, the United Nations Environment Programme sunscreens, medications repellants
(UNEP) and the International Labor Organization published a document that
Biological transfer Maternal body burden due to Numerous EDCs can
provided strong evidence associating certain chemicals having adverse effects
from placenta prior/current exposures cross the placenta
on wildlife, and to a lesser extent, on humans. Years later, it was learned that
the effect of these chemicals on humans were underestimated and a new Biological transfer Maternal body burden due to Numerous EDCs are
term called “endocrine disruptors” has emerged. Chemical or endocrine from mother’s milk prior/current exposures detected in milk
disruptors are man-made chemicals that can alter hormonal responses to
physiologic processes such as reproduction and the immune system. Because Abbreviations:
these exogenous chemicals have the capability to mimic, block or interfere BFR: brominated flame retardant; BPA; bisphenol A; PCBs: polychlorinated biphenyls
with hormones in the body’s endocrine system, they are associated with a
Table 1. Examples of EDC Routes of Exposure in Humans [Gore et al, 2014]
diverse array of health issues [1,2]. Moreover, the effect is not time-bound
spanning across generations.

Identification of these EDCs, knowledge of how humans are exposed to them

(Table 1), an understanding of how they interfere with the different human
physiological processes to cause disease deserve much attention.

22 23
 As the term implies, the mechanism in which these toxic chemicals disrupt
Bisphenol A, Dioxin, Heavy metals,
the endocrine system is through the interference of receptor activity in the

EDC
PCBs, Phtalates, Pesticides, Ethanol, Air pollution,
body’s hormonal pathways. Alteration in the endocrine system are both in Estrogens, Pesticides, PCBs,
Bisphenol A, PCBs
Organichlorine Organochlorine
the cellular and molecular levels (Figure 1). pesticides pesticides

On the cellular level, physiologic responses are controlled by hormonal

receptors, in order to maintain balance of the different normal processes such
as energy conservation or reproduction. In the presence of EDCs, there can TARGETED
be antagonism or agonism in hormonal pathways that can lead to altered APPARATUS/ Reproductive/ Brain/ Pulmonary/
Endocrine Nervous Cardiovascular
responses. These EDCs can also mimic hormones directly, leading to an ORGANS
imbalance in hormonal levels that can produce detrimental effects on the
developmental and reproductive systems (Figure 2).

On a molecular level, these EDCs can downregulate or upregulate DNA/RNA Cancer, Infertility, Alzheimer,
transcription of different enzymes resulting to changes in the quantity of DISEASE Obesity, Diabetes,
Metabolic syndrome,
Parkinson, Learning
disabilities, Reduced
Asthma, Heart
disease,
Hypertension, Stroke
hormones in the body and alter the normal physiologic processes. Reproductive harm IQ

Figure 2. The Effect of EDCs on Various Organs [Scognamiglio et al, 2016]

REFERENCES:

1 Diamanti-Kandarakis E, Bourguignon JP, Giudice EC ET AL. Endocrine-Dis

rupting: An Endocrine Society Scientific Statement. Endocrine Reviews, June
2009. 30(4):293–342.
2 A Joint Endocrine Society–Ipen Initiative To Raise Global Awareness About
Endocrine-Disrupting Chemicals. 2014.
3 Haschek and Rousseaux’s Handbook of Toxicologic Pathology (Third Edition)
2013. Volume II: 1123-1154.
4 Scognamiglio et al. Analytical tools monitoring endocrine disrupting chemicals.
2016.
Figure 1. Mechanisms of Endocrine Disruption [Haschek et al, 2013]

24 25
 CHAPTER Endocrine Disruptors in
the Philippines
5 Michael C Velarde PhD

E ndocrine-disrupting chemicals (EDCs) interfere with normal development

and function of many organs. The developing fetus is especially
vulnerable and is at risk of acquiring permanent and irreversible disabilities
filtration, and activated carbon adsorption have been used for the removal
of EDCs, but the capability of these treatments to completely remove EDCs
are still questionable [9,10,11]. Many EDCs are persistent in the environment
that persist later in life [1]. Several studies implicated the role of EDCs in and may be very difficult to remove. In addition, while water monitoring and
reproduction. For example, in utero exposure to polychlorinated biphenyls treatment are practiced in several countries, regions which practice only
(PCBs) and polychlorinated dibenzofurans is associated with increased basic water treatment remain vulnerable to EDC contaminations [12].
number of sperms with abnormal morphology and reduced motility [2].
Female children with premature breast development have higher levels of
di-isooctyl phthalate [3]. In the Philippines, the impact of EDCs and their
correlation to reproductive failures in Filipinos remain unknown. There is
also a lack of published studies about EDCs in the Philippines. However, with
the poor waste management system and limited sewage treatment facilities
in the country, it is highly likely that EDCs pollute the water systems in the
Philippines and may affect Filipinos exposed to these contaminants.

Chemical waste effluents from industries may contain large quantities of

EDCs, which leech out into the water systems and eventually taken up by
humans through the drinking water and food [4,5,6]. Indeed, EDCs have
been detected in water sources, such as drinking water [7,8]. Water treatment
technologies, such as photodegradation, chemical oxidation, membrane

26 27
 EDC concentrations in water are generally very low, but EDC at nanomolar
ranges is sufficient to elicit biological effects. For instance, presence of
estrogenic compounds in sewage discharges is associated with feminization
of fish and mollusks living in water systems downstream of contaminated
effluents [12]. Presence of EDCs in follicular fluids is linked to reduced ability
of oocyte to mature into superior zygotes [13]. Prenatal exposure to EDC is
linked to many diseases and disorders, including fetal development disorders,
low birth weight, obesity, prematurity, autism, and allergies. Exposure of
developing embryos to EDCs can also cause transgenerational effects,
presumably through epigenetic alterations [14].
4-n-nonylphenol
bisphenol A
pentachlorophenol
28
Many Filipinos depend on the natural water system for fishing and
aquaculture. These bodies of water may contain EDCs that contaminate
important agricultural products. Indeed, phenols, such as 4-n-nonylphenol,
pentachlorophenol, and bisphenol A, have been detected in water samples
obtained from rivers in the Greater Manila Area from 2000-2002 [15].
Particularly, the Meycauayan, Parañaque, and Tenejeros Rivers yielded
concentrations of 4-n-nonylphenol that is approximately 2 to 40 times
higher than the maximum allowable concentrations of 2 μg/L for inland and
other surface waters [16]. Nonylphenols are typical degradation products of
nonylphenol ethoxylates, which are used as surfactants in many household
products [17]. Nonylphenols accumulate in sewage effluents and may have
estrogenic activities [18], implicating the impact of these EDCs on human
health.
The Meycauyan River also showed pentachlorophenol concentrations close
to the maximum allowable concentrations of 1 μg/L [15,16]. In addition, the
Tenejeros and Pasig Rivers also showed the highest concentration of bisphenol
A and 2,4-dichlorophenol. It is more alarming that the level of these phenols
will persist in the river systems due to the continuous effluent of the chemicals
into the rivers, as evidenced by the replenishment of these contaminants even
after the rainy season.
There are very limited publications about the levels of EDCs in the country that
makes it difficult to determine the burden of EDCs in Filipinos. The paucity of
data is very worrisome. The high level of phenols, such as 4-n-nonylphenol
and pentachlorophenol, in the rivers of the Greater Manila Area suggests that
Filipinos are indeed exposed to EDCs and may be at high risk of acquiring
endocrine-related defects. More research support on EDC monitoring needs
to be done to help identify priority regions in the country that are particularly
vulnerable to EDC exposures.
29
 APPENDIX. A study done on surface and bottom waters in selected rivers and coastal REFERENCES:
sites in the Greater Manila Area (GMA), Bataan, Batangas and Subic for two years
in 2000–2002 revealed high concentrations of phenol compounds as show in the
1 T. Colborn, F. S. vom Saal, and A. M. Soto, “Developmental effects of endocrine-
following tabulation. disrupting chemicals in wildlife and humans.,” Environ. Health Perspect., vol. 101, no. 5,
pp. 378–384, Oct. 1993.
Source: Santiago EC, Kwan CS. Endocrine-disrupting phenols in selected rivers and 2 Y. L. Guo, P.-C. Hsu, C.-C. Hsu, and G. H. Lambert, “Semen quality after prenatal
bays in the Philippines. Baseline/ Marine Pollution Bulletin 54:1031–1071, 2007. exposure to polychlorinated biphenyls and dibenzofurans,” Lancet, vol. 356, no. 9237,
pp. 1240–1241, Oct. 2000.
ENDOCRINE GREATER MANILA AREA (lg/L) BATAAN SUBIC BATANGAS 3 I. Colón, D. Caro, C. J. Bourdony, and O. Rosario, “Identification of Phthalate Esters in
DISRUPTING the Serum of Young Puerto Rican Girls with Premature Breast Development,” Environ.
Meycauayan Tenejeros Paranaque Pasig Alangan Malawa-an Pollucan Health Perspect., vol. 108, no. 9, pp. 895–900, Aug. 2000.
CHEMICALS River River River River River River River 4 G. Jungclaus, V. Lopez-Avila, and R. Hites, “Organic compounds in an industrial
4-n- 79.0 wastewater: a case study of their environmental impact,” Environ. Sci. …, 1978.
4.55 5.0 0.46 _* + + 5 V. Lopez-Avila and R. A. Hites, “Organic Compounds in an Industrial Wastewater. Their
nonylphenol highest
Transport into Sediments,” Environ. Sci. Technol., vol. 14, no. 11, pp. 1382–1390, 1980.
Pentachloro 0.91 6 E. Touraud, B. Roig, J. P. Sumpter, and C. Coetsier, “Drug residues and endocrine
+ + + disruptors in drinking water: risk for humans?,” Int J Hyg Envir Heal, vol. 214, 2011.
phenol highest
7 T. Le Thi Minh, D. Nguyen Phuoc, T. Dinh Quoc, H. H. Ngo, and C. Do Hong Lan,
0.80 “Presence of e-EDCs in surface water and effluents of pollution sources in Sai Gon and
Bisphenol A - + +
highest Dong Nai river basin,” Sustain. Environ. Res., vol. 26, no. 1, pp. 20–27, 2016.
8 L. Xuemin, X. Sanhua, Z. Gang, P. Jiang, and F. Tang, “Occurrence and removal of
4-t- phenolic endocrine disrupting chemicals in the water treatment processes,” Sci. Rep., pp.
+ +
butylphenol 1–10, 2016.
9 K. J. Choi, S. G. Kim, C. W. Kim, and S. H. Kim, “Effects of activated carbon types and
4-t-
octylphenol service life on removal of endocrine disrupting chemicals: amitrole, nonylphenol, and
bisphenol-A.,” Chemosphere, vol. 58, no. 11, pp. 1535–1545, 2005.
2,4- 10 J. Q. Jiang, Q. Yin, J. L. Zhou, and P. Pearce, “Occurrence and treatment trials of
0.19
dichlorophe- 0.17 0.18 0.12 endocrine disrupting chemicals (EDCs) in wastewaters,” Chemosphere, vol. 61, no. 4, pp.
highest
nol 544–550, 2005.
11 C. Zhang, Y. Li, C. Wang, L. H. Niu, and W. Cai, “Occurrence of endocrine disrupting
• Levels comparable to compounds in aqueous environment and their bacterial degradation: A review,” Crit.
• GMA rivers have the highest GMA Rev. Environ. Sci. Technol., vol. 46, no. 1, pp. 1–59, 2016.
average concentrations for * Except around the petro- 12 I. R. Falconer, “Are endocrine disrupting compounds a health risk in drinking water?,” Int.
most of the detected phenols. chemical plant and the J. Environ. Res. Public Health, vol. 3, no. 2, pp. 180–184, 2006.
Petron Refinery 13 E. M. L. Petro, J. L. M. R. Leroy, A. Covaci, et al., “Endocrine-disrupting chemicals in
human follicular fluid impair in vitro oocyte developmental competence,” Hum. Reprod.,
vol. 27, no. 4, pp. 1025–1033, 2012.
• Concentrations are higher during dry season; more phenols in
bottom than surface water due to slower flow of water during 14 M. K. Skinner, “Endocrine disruptors and epigenetic transgenerational disease etiology,”
summer. Pediatr. Res., vol. 61, no. 5 PART 2 SUPPL., 2007.
• Data on EDC levels over time suggest continuous input of 15 E. C. Santiago and C. S. Kwan, “Endocrine-disrupting phenols in selected rivers and bays
4-n-nonylphenol and bisphenol A in the rivers. in the Philippines,” Mar. Pollut. Bull., vol. 54, no. 7, pp. 1036–1046, Jul. 2007.
• The absence of a well-planned sewerage system and sewage 16 “EU Directives, 2008. Directives 2008/105/EC of the European Parliament and of the
treatment facilities, and the presence of numerous manufacturing Council of 16 December 2008 on environmental quality standards in the field of water
industries such as food processing plants, textile, pulp and paper, policy, amending and subsequently repealing. Official Journal of the European Union.”
tanning and wood processing surrounding river areas are blamed for 17 A. Soares, B. Guieysse, B. Jefferson, E. Cartmell, and J. N. Lester, “Nonylphenol in the
the enormous amount of phenols detected in the rivers tested. environment: A critical review on occurrence, fate, toxicity and treatment in
wastewaters,” Environ. Int., vol. 34, no. 7, pp. 1033–1049, 2008.
18 K. A. Hwang and K. C. Choi, “Endocrine-Disrupting Chemicals with Estrogenicity Posing
the Risk of Cancer Progression in Estrogen-Responsive Organs,” Adv. Mol. Toxicol., vol. 9,
pp. 1–33, 2015.

30 31
 CHAPTER Reproductive Health and Effects of Endocrine Disruptors on Reproductive Health

Endocrine Disruptors
6
The timing of human exposure to endocrine disruptors (EDCs) and the mode
of action of a particular EDC during one’s life course is important. The window
of susceptibility for the disruption to one’s hormonal system may occur
Erlidia F Llamas-Clark MD MPH PhD during the time of embryogenesis, fetal life, infancy and early childhood,
and adolescence. These periods of susceptibility may be due to the affected
organ’s rapid cell growth, cell differentiation or enhanced individual hormonal
responsivity (Figure 1) [4] [5].

Some teratogenic drugs exert their greatest effect during the first trimester.
On the other hand, exposure to ionizing radiation and lead poisoning
are worrisome in young infants and children. During adolescence there is
increased sensitivity to endocrine promoters of cancers of the breast. Health

Introduction

T
T.T. Schug et al. / Journal of Steroid Biochemistry & Molecular Biology 127 (2011) 204-215
he Industrial Revolution of 18th century Europe ushered in the large-scale
use of chemicals, notably sulfuric acid and lime in the textile industry. With
the development of more efficient manufacturing processes and demand for
high volume production, chemical use extended to glass, soap and detergent, Altered Epigentic Increased
Windows of
paper, cosmetics, medicinal products for human and animal use, pesticides EXPOSURES Susceptibility
Programming of Susceptibility
for agriculture, and for the construction and building industries. Exposures to Somatic Cells to Disease

these industrial chemicals and drugs are mediated through the environment
(e.g. air and water pollution, contamination of the food system), food chain
and widespread consumerism [1]. The altered biophysical environment and
modifications in human behavior contribute to changes in food and nutritional
intake, infections, or stress in human development and life course that can Envirormental Development of Target Organ
ultimately lead to disease. Factors

The impact of environmental chemicals on human health is difficult to quantify

due to the multifactorial nature of disease causation. The development of
disease as a result of the exposure are influenced by several factors that include Figure 1. Exposure to EDCs and Development of Disease
timing and duration of exposure and differences in the level of sensitivity
of the human host as affected by genetics, nutritional status, life stage and
metabolism [2]. Furthermore, identification of the offending chemical may be
Source: Figure 1 in Schug TT, Janesick A, Blumberg B, Heindel JJ. Endocrine disrupting chemicals and
non-conclusive despite the known exposure. In most cases, the best evidence
disease susceptibility. J Steroid Biochem Mol Biol (Internet). 2011 Nov (cited Oct 24, 2018) ;127(3-5).
of the association between the suspected exposure and disease come from Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3220783/figure/F1/ DOI: [10.1016/j.
consistent observed health effects in animal or epidemiologic studies [3]. jsbmb.2011.08.007].

32 33
 care providers need to be aware of these life stages to be able to protect EDCs Bisphenol A
people most especially in the reproductive-aged women. Environmental
toxins such as EDCs may influence future health or fertility, as well as the Bisphenol A (BPA) is an artificial
health of the future generations. estrogen with its phenyl groups HO OH
that can mimic estrogen and has
the ability to bind with estrogen
receptors. It can act either as an
Selected EDCs exposure and Reproductive Health outcomes
estrogen agonist or an antagonist.
For pregnant women, exposure to environmental substances poses a significant In human studies, BPA acts as an
risk to the developing fetus. In humans, the legacy of diethylstilbestrol remains. estrogen agonist with “obesogenic”
Recent reviews evaluated the role of common EDCs play in the development of properties in animal models. Recent
unfavorable conditions and ill-health: phthalates, parabens, triclosan, bispenol data suggest that BPA can interfere
A (BPA), organochlorines (PCBs) and perfluorinated compounds (PFCs). A with normal fetal neurodevelopment and male reproduction. A number
summary of a 16-year evaluation that included well-designed prospective of studies suggest that BPA may affect ovarian function and the early
cohort studies on the effects of EDC exposure on women’s reproductive process of conception in artificial reproduction centers. However, higher
potential using exposure biomarkers showed falls in estradiol (BPA) and anti- concentrations of this chemical were not related to livebirth rate which is the
mullerian hormone concentrations (PCBs), drop in antral follicle count (BPA, most important outcome for fertility.
parabens, phthalates), decline in oocyte quality (BPA, triclosan, phthalates,
PCBs) and fertilization rate (PFCs, PCBs), implantation failure (BPA, phthalates,
PCBs), decline in embryo quality (triclosan, PCBs, BPA), and pregnancy losses
(parabens, phthalates). Human and animal studies have implicated BPA with Phthalates
the development of polycystic ovarian syndrome (PCOS) [6].
Phthalates are used in multiple consumer applications including personal
A more recent review on EDCs interaction with the female reproductive care products such as lotion, shampoo and fragrance. They are utilized as
system, focusing on endocrine disruption in the ovary. There are two major plasticizers to change the physical
mechanisms through which EDCs alter ovarian function: (1) alteration in characteristics of base plastics,
the expression and/or activity of enzymes required for synthesis and/or products with polyvinyl chloride
catabolism of ovarian sex steroids and (2) disruption in the expression of (e.g. flooring, shower curtains,
hormone receptors and/or their ability to bind their endogenous ligands. packaging and some medical
Overall, these changes alter endocrine signaling within the ovary and affect equipments). Human cohort
O
the other reproductive organs. and experimental animal OR
OR’
A more recent review on EDCs interaction with the female reproductive studies have demonstrated
system, focusing on endocrine disruption in the ovary, suggested two major possible associations with O

mechanisms alter ovarian function. The EDCs alter the expression and/or poor semen quality, abnormal
activity of enzymes required for synthesis and/or catabolism of ovarian sex male genital development in
steroids and alter the expression of hormone receptors and/or their ability the fetus and miscarriage [8].
to bind their endogenous ligands. Overall, these changes alter endocrine
signaling within the ovary and affect the other reproductive organs [7].

34 35
 Flame retardants/Polybrominated diphenyl ethers Pesticides

Flame retardants or polybrominated diphenyl ethers (PBDEs) are Pesticides have been recognized
CI CI
chemicals used extensively in foam and plastics. In human and animal to produce adverse reproductive
studies, prenatal exposure to PBDEs was associated with adverse outcomes. A recent prospective
neurodevelopmental outcomes in children. cohort study on among children CI CI

In particular, PBDE concentrations aged 5 to 7 years who were

in the third trimester were
associated with impaired attention
at age 5 and poorer fine motor
coordination at ages 5 and 7.
Studies also noted decrements
in the intelligence quotient of
children at age 7 as validated by
neurobehavioral assessments.
Perfluorinated compounds
Perfluorinated compounds (PFCs) are chemicals used for waterproofing,
stain resistance and lubrication. They include perfluorooctane sulfonate,
perflurooctanoic acid and
perfluorohexane sulfonate.
Some PFCs are found in
F
food packaging and nonstick
cookware. Increasing
concentrations of PFCs
in maternal plasma were
associated with reduced
fecundity and infertility.
O
exposed to organophosphate
O
O
pesticide in utero had lower
intelligence quotients.
O
The role of policymakers and professional organizations
Despite the large body of evidence of the irreversible and long-term health
effects of hazardous chemicals, policies and protection measures in defense of
women’s health are lacking. Certain non-communicable diseases associated
with EDCs like allergies, diabetes mellitus and some cancers are on the rise.
There is a need to increase awareness campaigns, consumer education and
product labelling. Scientific and health professional organizations should
support education, research and advocacy for the prevention of exposure
to environmental chemicals (Table 1) [9]. For health professionals particularly
obstetricians and gynecologists, there is a window of opportunity to making
women and children through advocacy and patient health
education in the reduction of exposure to toxic
FF FF FF O environmental agents, a timely and
OH critical area of health intervention
(Table 2) [10] [11]. Locally, the
FF FF FF FF
Philippine Obstetrical and
Gynecological Society is an
advocate for this cause.

36 37
 To support the goal of empowering women and protecting them from
Table 2. Environmental Exposure Assesment for Pregnant Women
hazardous and potentially EDCs, the following immediate action points are
recommended from an individual/organizational level: TOPICS QUESTIONS
General What do you for work?
Are you exposed to any of
the following at work:
1 Inform and screen the most vulnerable groups like women, children and Metals or chemicals?
Solvents or fumes?
especially the pregnant women for any possible exposure; Radiation?
2 Lobby through regulatory measures and support mandatory labelling of LEAD It can cause brain damage
especially in infants and
all chemicals in consumer products to ensure the public’s children.
right to know;
Have you or anyone living in
3 Encourage women to participate and exercise their right to know and to your house ever been treated
for lead poisoning?
include them in decision-making, discussions and various fora;
Do you live in a house built
4 Implement the precautionary principle for before 1978?
chemicals and protect the population living in Are there any plans to
one’s area and neighboring areas to prevent remodel your home?
any contamination; Have you ever lived outside
the United States?
5 Exercise vigilance in dealing with chemicals
Does your family use
in general, and EDCs in particular which are imported pottery for cooking,
eating or drinking?
harmful or suspected to be harmful to
Have you used any herbal
human health and environment
remedies such as azarcon,
greta, pay-loo-ah or boying?
Have you ever eaten any of
the following:
Clay?
Soil or dirt?
Pottery or paint chips?
MERCURY Mercury is another metal that
can damage the developing
fetal brain. Small children are
also sensitive.
Is there a mercury
thermometer in your home?
In general, do you eat fish
more than twice a week?
The basic science and epidemiology pointing to the possible effect of EDCs to the
rising trend of fertility problems should prompt a rudimentary health precautionary
Do you eat any of the
principle: when the health of humans and the environment are at stake, it may not following types of fish:
be necessary to wait for scientific certainty to take protective action [12].” Shark or swordfish?
King mackerel or tilefish?
Albacore (white tuna)?
38
ADVICE
Always wear any recommended personal protective
equipment for your type of work
Some work exposures, especially to metals,
solvents and radiation, maybe harmful. Contact an
Occupational and Environmental physician with
questions about workplace exposures. www.aoec.org
Eating food enriched with iron (red meat, chicken),
calcium (dairy, green leafy vegetables) and vitamin
C (orange, tomato, green pepper) decreases the risk
from lead.
Family members should have their lead levels tested.
Have your home tested for lead if it was built before
1978. Chipping paint may release lead into the house.
Avoid remodeling or hire a certified contractor. Call
1-800-424-LEAD for more information
Refugees or immigrants from resource-poor areas are
more likely to have elevated lead levels.
Imported pottery or ceramics may contain lead which
can leach into food.
Do not use any lead-containing home remedies.
Do not eat clay, soil, dirt, pottery or paint chips
because they may contain high levels of lead.
It’s important to clean mercury pills in a safe way.
https://www.childrensmercy.org/Clinics_and_Services/
Clinics_and_Departments/ Pharmacology_and_
Toxicology/ Environmental_Health_Specialty_Unit/
Cleaning_up_Liquid_Mercury_Spills/
Use a digital or mercury-free thermometer.
Eat a variety of fish low in mercury twice a week.
Contact your local health department about local fish
advisories.
Do not eat shark, swordfish, king mackerel or tilefish
because they contain high levels of mercury. Albacore
tuna contains more mercury than canned light tuna;
do not eat more than 6 oz per week of albacore tuna.
39

AIR Air pollution is harmful to
POLLUTION pregnant women who are
“breathing for 2” and also for
infants and children.
Do you plan having painting
done in your home during
your pregnancy?
Do you live near an industrial
site or busy roadway?
Do you use a wood burning
stove or kerosene or gas space
heaters?
Does anyone who live in your
home or who will be caring for
the infant smoke?
PESTICIDES Pesticides have many potential
health harms, for both babies
and adults.
Do you use pesticides (bug
killers, weed killers, rat poison)
such as Raid “Weed&Feed”
or OFF:
Inside your home?
On your pets?
FOOD AND Healthy food and water
WATER are very important during
pregnancy and for growing
children.
Do you use water or baby
bottles made out of hard
plastic or polycarbonate
(labeled#7)
Do you eat canned food or
food microwaved in plastic?
Does your water come from
a well?
If your house is old, does it
have lead pipes?
40
HOUSEHOLD Chemicals in personal care These products may contain chemicals
CHEMICALS products, fragrances and household such as phthalates, which are thought
cleaners maybe harmful to pregnant to cause developmental problems for
women or fetuses. growing fetuses.
Avoid exposure to paint fumes, wood strippers, Do you use fragrant personal Use fewer products and purchase
and other products containing solvents. care products such as perfume, fragrance-free if possible.
body spray, lotion or shampoo/
conditioner?
Avoid outdoor exercise on high air pollution days.
Do you use chemicals at home or Practice safe handling techniques if you
work for cleaning or scent? have to use strong chemicals. Try to use
Ensure adequate ventilation of wood-burning less toxic alternatives for cleaning such
stoves, fireplaces, and space heaters (crack a as vinegar, soap and baking soda. Avoid
window if necessary). air fresheners and scented candles.
Make your home smoke-free. Also avoid public
places where smoking is allowed.
If you can afford fruits and vegetables grown
without pesticides (including organic), you and
your family will be exposed to fewer of these
harmful chemicals.
For more information, go to the National Pesticide
Information website:
http://npic.cest.edu/
Avoid sprays, foggers, bug bombs.
Use Integrated Pest Management methods to
control pests.
http://www.ipm.ucdavis.edu.PMG/menu/
homegarden.html
Polycarbonate plastic (even tant labeled “BPA-
free”) often contain BPA or similar chemicals can
interfere with hormones in the body, especially in
developing fetuses.
The lining of food cans may contain BPA-like
additive. Microwaving in plastic increases the
leaching of chemicals into food. Microwave in glass
containers or ceramic bowls. Use a plate to cover
dish rather than plastic wrap.
Well water should be tested routinely for
contaminants.
Run the tap for 60 seconds to flush out sitting Source: Great Lakes Center for Children’s Environmental Health (Region 5 PEHSU), adapted with
water.
permission from Susan Buchanan MD and available from: http://www.ulc.edu/sph/glakes/childrenshealth/
downloads/Env%20history%20form%2010-2013.pd
41
 REFERENCES: CHAPTER Endocrine Disrupting
Chemicals on Maternal
7
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Totowa, NJ: Humana Press, 2007, 3-8.
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and disease susceptibility. J Steroid Biochem Mol Biol (Internet). 2011 Nov (cited
Aug 5, 2018);127(3-5):204-15.
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on the male and female reproductive systems. Environmental Toxicology and Basic concepts on the effects of Endocrine Disrupting
Pharmacology 2017; 51 (April), 56-70. Chemicals on Maternal and Fetal Health
6 Mendola, P., Messer, LC, Rappazzo K. Science linking environmental
contaminant exposures with fertility and reproductive health impacts in the
adult female. Fertil Steril (Internet). 2008 Feb (cited Aug 4, 2018); A Developmental Basis of Adult Disease. In the first Endocrine Society’s
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Reproduction 2011; 142: 633–646. that exposure during fetal development may affect the propensity of
8 Woodruff, T. J. Carlson, A., Schwartz, J. M. and Giudice, L. C. Proceedings of the the individual to develop a disease which may not be apparent early in
Summit on Environmental Challenges to Reproductive Health and Fertility: life but may manifest through adulthood and into the aging years.
Executive summary Fertility and Sterility (Internet). 2008; (cited Oct 24,
2018); 89 (1): e1-e20. Available from https://www.fertstert.org/article/S0015- Window of vulnerability. Any level of exposure may produce an effect
B
0282(08)00212-4/pdf. on human health when exposed during a critical developmental
9 Weselak, Arbuckle, TE. Walker, MC, Krewski, D. The influence of the
window of a particular organ system.
environment and other exogenous agents on spontaneous abortion
risk. Journal of Toxicology and Environmental Health, Part B: Critical C Synergistic effects of EDC. Because the environment is full of
Reviews (Internet). 2008 (cited Aug 4, 2018) 11:3-4, 221-241. Available from potential EDCs, exposure to multiple known and unknown EDCs may
https://www.figo.org/news/environmental-factors-facing-womens-
health-0016037 DOI: 10.1080/10937400701873530). have compounding effects on human health.
10 Grindler et al., OBGYN screening for environmental exposures: A call for action. D Non-traditional dose-response dynamics. EDCs mimic the effects
PLoS One (Internet). 2018 (cited Aug 5, 2018); 13(5): e0195375. Published online
of endogenous hormones but the latter are in physiologic and
2018 Available from DOI:10.1371/journal.pone.0195375
11 Exposure to toxic environmental agents ACOG Committee Opinion No. 575 naturally-occurring. The response of the human body to the absorbed
Obstet Gynecol (Internet). 2013 Oct (cited Aug 5, 2018);122(4):931-5. Available EDCs is not predictable, as it is affected by an individual’s metabolism
from DOI: 10.1097/01.AOG.0000435416.21944.54 and body composition.
12 Zlatnik, M. G. Endocrine-Disrupting Chemicals and Reproductive Health. Journal
of Midwifery &Women’s Health (Internet). 2016 (cited Aug. 4, 2018); 442-455. E Transgenerational effects. EDCs do not only affect the person who
Available from DOI:10.1111/jmwh.12500. was directly exposed to them, whether in utero or as an adult.
Subsequent generations may carry the brunt of exposure to EDCS due
to alteration in gene expression.

42 43
 Developmental Bisphenol A (BPA)
Basis of Adult BPA is used as a raw material in the production of plastics and is present in
Disease
dental fillings, plastic food and water containers, baby bottles, food wrap and
lining of beverage and food cans. BPA has estrogenic effects. Although it is a
weak environmental estrogen and rapidly metabolized within 24 hours from
exposure, it can still stimulate cellular response at very low doses. Moreover,
Transgenerational
it can exert its effect by binding to classical or more recent form of estrogen
effects EDC Window of
Vulnerability receptors.

The Generation R study revealed that increased concentration of BPA in urine

Non-Traditional
dose-response
Synergistic
curve effect
Figure 1: Important concepts regarding EDCs and their effect on human health
List of EDCs and Effects on Maternal and Fetal Health
Lead
A study done on the blood levels of lead among children in the rural area of
the Philippines showed numerous sources of exposure: lead-based paint, soil,
consumption of canned tuna, drink from contaminated water, occupational
exposure (including petrol and motor oil), recycling of batteries, and
breastfeeding [2]. Over twenty percent (21%) of children tested had elevated
levels of lead. The absorption of lead was augmented by the prevalence
of anemia. The Ecowaste Coalition also found lead contamination in skin-
whitening products [3].
Lead is a known neurotoxic agent for both adult and children. More
importantly, the developing nervous system in children make them more
susceptible to the toxic effects of lead. In pregnancy, prenatal exposure of
mothers to high lead levels is associated with adverse pregnancy outcomes
including gestational hypertension, spontaneous abortion, low birth weight
and impaired neurodevelopment [4]. Follow-up of children who were exposed
to high levels of lead in utero revealed mental ability deficits [5].
during pregnancy is associated with a reduction in fetal growth in terms of
fetal weight and head circumference [6]. Prenatal occupational exposure to
BPA was also associated with reduced birth weight [7].
Genistein
Genistein is derived from soy products and the main concern are babies who
are fed soy formula as a follow up to breastmilk [8]. Genistein, an isoflavone,
is a phytoestrogen and basically acts like estrogen. Animal studies show an
increased ano-genital distance (masculinization), accelerated puberty and
irregular estrous cycles in mice following neonatal administration of genistein.
Epidemiological studies of women fed with soy formula resulted in fibrioids,
irregular menstrual cycle lengths and dysmenorrhea [9].
Mercury
The primary source of exposure in the general population is due to ingestion
of contaminated fish. In 2017, the DENR reported mercury poisoning among
residents in Palawan near an abandoned mine site. Exposure to mercury was
by inhalation and skin absorption [10,11]. The Philippine Council for Health
Research and Development (PCHRD) and the Ecological Waste Coalition of
the Philippines cited lipsticks and other cosmetics including whitening creams
sold in the National Capital Region, Baguio City and Davao City, as sources of
mercury [3,12].
Mercury is a neurotoxic substance demonstrated by Minimata Disease.
Neuropathologic studies show cerebral edema followed by atrophy. In animal
studies, it has been shown to have effects on the hypothalamus, pituitary,
thyroid and gonads (ovary and testis) 13].

44 45
 In utero exposure to high levels of mercury due to consumption of sea food Both atrazine and 2,4 dichorophenoxyacetic acid are herbicides used
may lead to cognitive and behavioral disorders in later life [14]. The PCHRD to stop weeds from growing among agricultural crops [16]. The 2,4
published the following advisory on the different levels of locally available sea dichorophenoxyacetic acid is also a synthetic plant growth regulator.
foods (Table 1) [15].
Nitrate is also an agrichemical while nitrite is used for curing meats to prevent
bacterial overgrowth. These chemicals are found in canned and plastic-
LEVELS TYPES OF FISH AND SEAFOOD RECOMMEDATIONS packed processed meats such as hotdog, corned beef, sausage, luncheon
Low Samaral may consume 2-3 servings per week meat and beef loaf and in cured meats such as tocino, longganisa, tapa and
Dilis (anchovies) chorizo. High concentrations of these chemicals in processed meats were
Hito (catfish), 1 serving = 180 gm/6 ounces found in areas studied like Bulacan, Muntinlupa and Las Pinas [17].
Galunggong (mackerel)
Salmon
Tilapia
Atrazine has effects on the central nervous, endocrine and immune systems.
Shrimp Periconceptional exposure to surface water contaminated with atrazine is
Squid and crap associated with fetal gastroschisis. Increased exposure to nitrates is associated
Bangus (milkfish)
with increased rates of fetal loss, neonatal death and developmental delay.
Moderate Banak (mullet) may consume 1-2 servings per week
Conclusion:
Tamban
Maya-maya (snapper) 1 serving = 180 gm/6 ounces The presence of EDCs in the country cannot be refuted. The absence of
Canned light tuna local studies directly linking these chemicals to adverse maternal and fetal
health outcomes are mainly due to the sensitivity of the subjects (pregnant
High Fresh or tuna sashimi Limit consumption to 3 servings in a
Lapu-lapu (grouper) month women and their fetuses) and the complexity of human response to these
Sea bass chemicals, affected by both individual metabolism and genetic background.
As the primary health guardians of women and the children in their womb,
Table 1. Mercury Levels Found In Fish And Seafood In The Philippines
the obstetrician-gynecologists should be
equipped with the knowledge and capacity to
Agricultural chemicals educate them on how maternal and fetal
Agrichemicals include atrazine, nitrates, nitrites and 2,4 dichlorophenoxyacetic health can be affected by the environment.
acid. Exposure to these agrichemicals are through contaminated water and
ingestion of food treated with these chemicals.

46 47
 Appendix 1. Alphabet Soup of Harmful Chemicals and their Reproductive or REFERENCES:
Developmental Effects
1 Diamanti-Kandarkis E, Bourguignon JP, Giudice LC, et al. Endocrine disrupting chemicals:
CHEMICALS EXPOSURE SOURCES REPRODUCTIVE OR DEVELOPMENTAL HEALTH EFFECTS An Endocrine Society Scientific Statement. Endocr Rev 2009; 14 (1): 35-38.
Pesticides Agricultural farming Impaired cognitive development 2 Riddell TJ, Solon O, Quimbo SA, Tan CC, Butrick E and Peabody JW. Elevated blood-
Impaired neurodevelopment lead levels among children living in the rural Philippines. Bulletin of the World Health
Impaired fetal growth Organization 2007; 85(9): 649-732.
Increased susceptibility to testicular cancer 3 Ecowaste Coalition (2018, September 3). Retrieved from http://www.ecowastecoalition.
Childhood cancer org/2018/09/03/baguio-city-government-urged-to-crack-down-on-peddlers-of-dan
gerous-cosmetics-laden-with-mercury-and-lead-skin-whiteners-lipsticks-among-those-
Solvents Occupational Fetal loss found-contaminated-with-heavy-metals/
4 Lead screening during pregnancy and lactation. Committee Opinion No. 533. American
Miscarriage
College of Obstetricians and Gynecologists 2012; 120: 416-420.
Toluene Paints, thinners, nail Decreased fetal and birth weight 5 Unuvar T, Buykgebiz A. Fetal and neonatal endocrine disruptors. J Clin Res Pediatr Endo
polish, adhesive, and Congenital malformations crinology 2012; 4(2):51-60.
lacquers 6 Snijder CA, Heederick, D, Pierik FH, et al. Fetal growth and prenatal exposure to Bisphe
nol A: The Generation R Study. Environ Health Perspect 2013; 121(3):393-398
Phthalates Plastics (packaging). Reduced masculine play in boys 7 The National Workgroup for Safe Markets. No silver lining: an investigation into Bisphe
nol A in canned foods 2010; Retrieved from https://www.cleanwaterfund.org/files/publi
personal care products Reduced anogenital distance
cations/mn/no_silver_lining_report_bpa.pdf
cosmetics, toys, food Shortened gestational age
8 National Institute of Environmental Health Sciences. Retrieved from https://www.niehs.
processing Impaired neurodevelopment in girls
nih.gov/health/topics/agents/sya-soy-formula/index.cfm
9 Zama AM, Bhurke, A, Uzumcu, M. Effects of endocrine-disrupting chemicals on female
Lead Battery manufacturing/ Alteration in genomic methylation
reproductive health. The Open Biotechnology Journal 2016; 10 (Suppl-1): 54-75.
recycling, welding, Intellectual impairment 10 Department of Environment and Natural Resources. Cimatu forms task force to address
jewelry making, toys, Increased likelihood of allergies poisoning in 2 Palawan villages 2017. Retrieved from https://www.denr.gov.ph/news-
water pipes, cosmetics, and-features/latest-news/3074-cimatu-forms-task-force-to-address-mercury-poisoning-
and hair dyes in-2-palawan-villages.html
11 Fabro KS. (2017, June 10) Widespread mercury poisoning recorded in 2 Palawan villages.
Mercury Coal-fired power Reduced cognitive performance Rappler. Retrieved from https://www.rappler.com/nation/172410-widespread-mercu
plants, consumption of Impaired neurodevelopment ry-poisoning-puerto-princesa-villages-palawan
contaminated seafood 12 Alano CM. (2014, February 18) Read my lips: beware of toxic lipstick Philippine Council
for Health Research and Development. Retrieved from http://www.pchrd.dost.gov.ph/
Polychlo- Industrial insulator and Development of attention deficit and index.php/news/library-health-news/3913-read-my-lips-beware-of-toxic-lipstickPhilip
rinated lubricants hyperactivity disorder-associated behavior pine Council for Health Research and Development pchrd.dost.gov.ph
biphenyls Increased body mass index 13 Zhum X, Kusaka, Y, Sato, K and Zhang, Q. The endocrine disruptive effects of mercury.
Reduced IQ Environment Health and Preventive Medicine 2000; 4: 174-183
14 Unuvar T, Buykgebiz, A. Fetal and neonatal endocrine disruptors. J Clin Res Pediatr Endo
Air pollut- Low birth weight crinology 2012; 4(2):51-60.
Birth defects 15 Ong WT. (2014, February 11) Which fish are safe to eat?. Philippine Council for Health
ants
Research and Development. Retrieved from http://www.pchrd.dost.gov.ph/index.php/
Cigarette Miscarriage news/library-health-news/1158-which-fish-are-safe-to-eat
16 Waller SA, Paul K, Peterson SE, Hitti, JE. Agricultral-related chemical exposures, season
smoke Intrauterine growth restriction, low birth
of conception and risk of gastroschisis in Washington State. Am J Obstet Gynecol 2010;
weight, and preterm delivery
202:241.e1-6.
Decreased semen quality 17 Solano LS, Udarbe MA, Arim RH, et al. Household daily nitrite consumption levels
from some commonly consumed processed meats in selected sites/areas in the Phil
Perchlorate Bleach and fertilizer Altered thyroid function ippines. Transactions of the National Academy of Science and Technology 2011;33(1):
207. Retrieved from cinet.dost.gov.ph/union/ShowSearchResult.php?s=2&f=&p=&x
Perfluo- Nonstick cookware Reduced birth weight =&page=&sid=1&id=Household+daily+nitrite+consumption+levels+from+some+com
products food monly+consumed+processed+meats+in+selected+sites%2Fareas+in+the+Philip
rochemicals
containers pines&Mtype=ANALYTICS

48 49
 CHAPTER The Role of the The Obstetrician-Gynecologists: When and where can
advocacy take place?
Obstetrician-Gynecologists
8 in the RDEH Advocacy
Ditas Cristina D Decena MD MPH
Educating the female patient can take place in various clinics:

1 Most women will only go for health visits when pregnancy is

suspected or has occurred. Moreover, pregnancy women are
most receptive to harmful exposures during this time period. That
is why antenatal visits are a good opportunity for EDC counseling.
2 EDC advocacy can be carried into the postpartum follow-up visit,
integrated as part of counseling on breastfeeding, and
contraceptive methods.
3 Primary health care when women come for routine gynecological
screening
4 Partnering with the pediatricians to extend the advocacy at the
well-baby and sick-child visits

A ll basic ingredients to man’s survival have become contaminated by

harmful pollutants due to man’s interference and mindless activities –
the air that we breathe, the food that nourishes the body and the water of Key points to share in this advocacy and references for further reading are
life. The widespread contamination greatly influences health, and in particular found at the end of this chapter (Appendices 1 and 2).
reproductive health because the effect is transgenerational. These topics have
been presented in the previous chapters. Achievements of the FIGO-POGS Advocacy on RDEH
Since its inception in 2017, the Committee on Reproductive and Developmental
What is the Role of the Obstetrician-Gynecologists in the
Environmental Health (RDEH) reports the following achievements:
RDEH Advocacy?

1 Crafted the contents of the lecture on reproductive health and

1 Build and intensify patient’s awareness around a variety of health how it is impacted by climate change in general and EDCs in
concerns related to environmental exposures particular.
2 Identified the target audience (obstetrician-gynecologists, students
2 Incorporate an occupational health history in the evaluation of
and generalists involved in the practice of childbirth and care of
patients
women’s health).
3 Work together with the public for better environment and
3 Identified the delivery method which was through partnership with
improved health for all the POGS Committee on Continuing Medical Education (CME) in
order to bring the advocacy around the country.

50 51
 4 Conducted a total of eight (8) runs in the various regions
of the country. The members of the first committee (2017) were
obstetrician-gynecologists Mary Hedwig Bomediano, Emmanuel
Dagala, Andrea Santiago, Mary Anne Tabaquero and Ditas
Cristina Decena (as chairperson).
5 Participated actively in the workshop on Women’s Health and the
Environment on August 10, 2017 at the POGS Building,
Quezon City.
6 Delivered a lecture on “Environmental health hazards: Effects to
Women and Reproductive Health” on the occasion.

In 2018, the FIGO-POGS RDEH advocacy group reports the following

achievements:

1. Conducted a total of 11 runs in the various regions of the country. The

2018 members of the advocacy group included obstetrician-
Figure 1.2. Picture taken during the Region 5 WHE-RDEH scientific session.
gynecologists: Grace Cayabyab, Andrea Santiago, May Anne
Tabaquero and Ditas Cristina Decena. The advocacy group was joined
by Dr Erlidia Llamas-Clark as WHE chairperson. The areas covered
included Regions 1 [Laoag City], 2 [Isabela], 3 [Central Luzon],
4 [Southern Tagalog], 5 [Bico], 6 [Iloilo], 8 [Tacloban], 9 [Zamboanga],
10 [Cagayan de Oro], Region 11 [Davao City], and 2 NCRs [PENTAMED
and BAYCOG] (Figures 1.1-1.3).

Figure 1.1. Picture taken during the Region III CME-RDEH scientific session. Figure 1.3. Picture taken during the Region 10 CME-RDEH scientific session.

52 53
 2. Represented POGS at the FIGO RDEH Working Group Session: “Bringing 3. Published an advocacy primer on reproductive and developmental
Environmental Health to Your Practice: How FIGO is Leading the Way!” environmental health (Figures 3.1 and 3.2).
in Rio de Janeiro on 16 October 2018 (Figure 2).
Dr Ditas Cristina D Duque presented a lecture entitled “Reproductive
and Developmental Health: Landscape in the Philippines.”

Figure 3.1. The RDEH editorial board and committee members

Figure 2 L-R: Doctors Jeanne Conry, Katherine Main, Linda Guidice, Ivonne Diaz,
Ditas Decena and Lola Gomez Roig

Figure 3.2. The RDEH committee preparing for work on the advocacy primer.

54 55
 Future Plans of the RDEH Committee APPENDICES

Appendix 1. Ten tips for a Healthy Home, Body, and Baby

● Continue working in partnership with POGS ad hoc committee on
Women’s Health and the Environment
Choose fresh or frozen fruits and vegetables.
● Continue information dissemination through scientific fora like POGS Canned foods may contain toxic chemicals.

CME activities and other related venues

● Widen scope of the advocacy by partnership with POGS Committee Keep food in glass or stainless steel containers,
not plastics. Plastics may contain toxic chemicals.
on Community Service for Environmental Health campaigns
through community campaigns
Read labels on foam products, clothing, and furniture.
● Open other delivery systems by collaborating with the various sub Avoid toxic “flame retardants.”

specialties of the POGS and other medical societies in order to

widen the reach of the RDEH information/advocacy campaign: Use insect baits; not sprays, dusts, or bombs.
▪ Philippine Society of Maternal and Fetal Medicine (PSMFM)
▪ Philippine Society of Reproductive Medicine (PSRM) Clean with a wet cloth or mop
instead of a dry cloth. Avoid sweeping.
▪ Perinatal Association of the Philippines (PAP)
▪ Pediatric and Adolescent Gynecology Society of the
Leave shoes at the door to avoid
Philippines (PAGSPHIL) carrying toxic chemicals into your home.

▪ Philippine Pediatric Society (PPS)

▪ Philippine Society of Endocrinology Diabetes and Make a cleaner with 1 cup of
white vinegar + 1 cup of water.
Metabolism
● Create information mats for health care professionals and lay people
Ask for VOC-free and water-based materials
● Strengthen dissemination of information through various social for home improvements.

media platforms
● On the national level, seek opportunities to collaborate with policy
Don’t smoke, and stay away from
public places where people are smoking.
makers, government and non-government organizations on the
issues and concerns of RDEH.
● Lobby through regulatory measures and support mandatory
Use beauty and personal care products
made without toxic chemicals.
labelling of all chemicals in products to ensure the public’s right
to know Appendix 2. Useful Sites for More Information
● Go beyond advocacy: encourage quality research and capacity- 1. Toxic Matter Series at http://bit.ly/TM1prhe
building 2. Follow UCSF Program on Reproductive Health and the Environment on
Facebook: @UCSF.PRHE
Twitter: @UCSF_PRHE
YouTube: bit.ly/YTprhe

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