Unintended consequences

The Chicago Tribune has released a multi-part series on the history of deployment of flame retardant materials in household furniture.  (http://media.apps.chicagotribune.com/flames/index.html)  It is quite the eye-opener. I am not at all certain about the actual risks of the materials but the history of how these materials got incorporated into our household things and ultimately into ourselves provides lessons into a spectrum of interventions which may lead to unintended consequences.

The idea was quite simple. Make furniture less flammable and prevent household fires which start when furniture is ignited, particularly by an unattended cigarette. What harm could come from this? The problem with this model is that in order to avoid the bad outcome to a small number of people, you need to deploy an intervention that touches millions who would have never been affected. Furthermore, when you start to deal with millions of people, you can never anticipate the nature of the impact you will have. Even impacts on a small percentage of a large number of people can be a large number. Remember Janet Napolitano and her confusion of a small percentage of people screened by the TSA equating to a small number of people.

Now years later, we have entire entire public awash in flame retardants, turning up in breast milk. At best, this is a public relations nightmare. At worst, we have a public health nightmare. We simply do not know. It would have been great if the materials deployed actually had a demonstrable positive impact on public health. That appears to be at best contestable. From the Tribune article:

Many couches, love seats and chairs sold nationwide contain flame retardants to comply with a California flammability rule. But studies by the U.S. Consumer Product Safety Commission have concluded that this standard provides no meaningful protection from deadly fires.

The standard requires that raw foam withstand a candle-like flame for 12 seconds. But, Babrauskas said, upholstered furniture is covered with fabric, and if the cover ignites, the flames from the fabric quickly grow larger than that of a candle and overwhelm even flame retardant foam.

"The fire just laughs at it," Babrauskas said.

The bottom line: Household furniture often contains enough chemicals to pose health threats but not enough to stem fires — "the worst of both possible worlds," he said.

What I like about this story is it embodies so many elements of unintended consequences. The angle of the flame retardant companies was they were the champions of protecting people, especially children from being injured by burns. In order to do so, the approach taken was to expose countless millions of people to flame retardant chemicals, thus posing a different set of risks to the public, including children. Much of this played out the political realm in a relatively but not entirely data free world. There is some data supporting incorporating of flame retardants into sleep wear (http://injuryprevention.bmj.com/content/4/4/313.full). As controversy began to rage and the EPA found itself in the middle, what is an agency to do. It was being forced to choose between taking a position against "life saving" chemicals which prevented baby flambe' and the exposure of millions of people to undefined risks associated with those same "life saving" chemicals.

In a statement, the EPA said it is largely powerless to do anything about chlorinated tris. The agency cited industry's continued use of the chemical as a stark example of why it supports "much needed reform" of the nation's chemical safety law.

Jerome Paulson, a George Washington University pediatrician who last year wrote a stinging critique of the law for the American Academy of Pediatrics, said the system especially fails to protect children. The group wants safety standards for industrial chemicals to be more like those governing pharmaceuticals and pesticides, with chemicals being approved only if a "reasonable certainty of no harm" can be verified.

The system fails children? Children were a major reason these chemicals were added to fabrics and furniture in the first place! I could not find specifics but I strongly suspect the same organization warning us about flame retardants was likely at the forefront pushing for flame resistant clothing. Furthermore, other "experts in the burn world were issuing cautions against any relaxation of regulations requiring incorporation of flame retardants into infant sleepwear. From Pubmed...

J Burn Care Rehabil. 1997 Sep-Oct;18(5):469-76.

Children's sleepwear: relaxation of the Consumer Product Safety Commission's flammability standards.

Cusick JM, Grant EJ, Kucan JO.

Source

Via Christi Regional Medical Center, Wichita, Kansas, USA.

Erratum in

• J Burn Care Rehabil 1998 May-Jun;19(3):267.

Abstract

The Consumer Product Safety Commission voted on April 30, 1996, to relax the existing children's sleepwear flammability standard under the Flammable Fabrics Act. The new amendments will permit the sale of tight-fitting children's sleepwear and sleepwear for infants aged 9 months or younger-even if the garments do not meet the flammability standards ordinarily applicable to such sleepwear. The relaxed standards became effective January 1, 1997. These changes have the potential to increase the number of childhood injuries and deaths resulting from burns associated with children's sleepwear. Burn care practitioners and fire prevention educators must understand the significance of these changes and their associated impact. It is essential that this information be disseminated throughout communities to make the public aware of the potential hazards emanating from these changes. Furthermore, organized and systematic data gathering and appropriate pressure should be exerted on the Commissioners of the Consumer Product Safety Commission to force a reversal of the newly amended regulations.

Then there is California Technical Bulletin 117. This is described in a Scientific American article "Foam Alone" from (http://www.scientificamerican.com/article.cfm?id=do-furniture-flame-retardants-save-enough-lives-justify-environmental-damage). 

At issue is something called Technical Bulletin 117 (or TB 117), an obscure California law enacted in the late 1970s. It requires all furniture stuffing foam in the state to withstand 12 full seconds of open flame, analogous to a cigarette lighter held against a couch with the upholstery ripped off. Furniture flammability is largely regulated by states, and California is by far the toughest. 

While there is no Federal law requiring the addition of flame retardants to furniture foam, this California rule essentially forces all furniture manufacturers to comply with this rule because of fear of being sued. Thus, an  ill conceived rule on one state has unintended consequences in the remaining 49 states.  We are awash in flame retardants to protect us against something, the frequency of which we did not know when we implemented the requirements. Ready...fire....aim.

Perhaps the most striking unintended consequences in all of this are those initiated by and those impacted on Dr. David Heimbach.  Dr. David Heimbach has devoted his medical career to improving the care of burn victims. He has over 160 peer reviewed publications and was the Tanner-Vandeput-Boswick Burn Prize winner in 2010. I do not know him but his accomplishments and life's work appear to be something to admire. However, he screwed up. In reviewing his bibliography, I could find nothing in his corpus of scholarly work which would qualify him as an expert in fire retardants. He apparently was effective as an advocate because he could tell stories. He might have been perceived as an expert and he might have even viewed himself as an expert as well. I hope he can come up with the data which can support the positions that he advocated for. I hope this does not serve as the defining issue of his career. They have already scrubbed the University of Washington site of his bio.

The story  has lessons for the medical community. When you take a stand, think hard about whether the stand you take is data driven and you can represent yourself as an expert or whether you can tell only stories and you are just one of many advocates pushing for something that your feel is the right thing to do. You might be believed and your agenda might have unintended consequences, for yourself as well as others.