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Testimony at a public hearing and scientific workshop to update the Women's Health Research Agenda at the NIH

Moving Into the Future: New Dimensions and Strategies for Women's Health Research for the National Institutes of Health

NIH/Office of Research in Women’s Health National Conference at the University of California,
San Francisco

May 28, 2009

The Office of Research on Women’s Health/NIH/DHHS, the UCSF Department of Obstetrics, Gynecology, and Reproductive Sciences and the UCSF National Center of Excellence in Women's Health co-hosted the second in a series of four public hearings and scientific workshops to update the Women’s Health Research Agenda at the NIH for the coming decade.

My name is Rivka Gordon.  I am a primary care physician assistant, a women’s health care specialist and the director of strategic initiatives with the Association of Reproductive Health Professionals, ARHP. Thank you for the opportunity to speak to the Office of Research on Women’s Health as you explore women’s health research priorities for the NIH for the coming years. For nearly 50 years, ARHP has established itself as the leading source for trusted medical education on reproductive and sexual health. On behalf of its 11,000 members, ARHP applauds the renewed commitment to develop priorities based on sound science and the fundamental value of scientific integrity.

ARHP members represent the full health care team, physicians, nurses, nurse practitioners and midwives, PAs, pharmacists, scientists and educators who provide reproductive health services, educate clinicians, conduct research and influence policy. ARHP provides evidence-based programs on all that is current and urgent in reproductive health. ARHP defines reproductive health broadly and incorporates emerging science into its educational and policy activities. We have taken a leadership role in introducing reproductive environmental health science to the reproductive health field.

The emerging science that links reproductive health outcomes to environmental exposures is compelling and must be incorporated into reproductive health education and clinical practice. But, health care training programs, whether they be in medicine, nursing, pharmacy or health education are woefully deficient in any content that relates to the link between reproductive health and environmental exposures.

Patients ask their clinicians about the safety of plastic baby bottles, whether to eat fish while they’re pregnant and if their breast milk is toxic. Clinicians are challenged to understand the causes of reduced fecundity, early pregnancy loss and pubertal development in very young girls. They are unsure of the best course of action in the absence of clinical guidelines that can take years to develop. All this is complicated by the assumption that animal data does not translate to human health outcomes and has limited application to patient care.

To enable the reproductive health field to address these challenges, ARHP urges the NIH to prioritize investment in:

  • Research that identifies gaps in clinicians’ critical assessment skills that limit their ability to integrate reproductive environmental health science into clinical practice. Ethical concerns prevent scientists from conducting randomized double-blinded placebo controlled studies on women and children, exposing them to chemicals that show clear toxicity in animals. But, the absence of evidence based on human randomized clinical trials does not mean absence of evidence of harm. Clinicians need the ability to assess the strength of the scientific literature, but a gap has been documented over the past decade showing that providers are not receiving critical appraisal skills training in undergraduate and graduate education. (Caspi, et al. 2006; Grimes, et al. 1998.) Because reproductive environmental health data is derived differently, this deficit in appraisal skills is particularly relevant. We need research that will identify the multi-tiered training and knowledge gaps that must be addressed to accomplish the full integration of environmental health into reproductive health care.
  • Based on this research, ARHP urges an investment in effective, innovative accredited educational programs that train the full range of health care professionals in critical appraisal skills so that they can guide their patients and help them to navigate the constant barrage of inaccurate, confusing and often sensationalized information on health risks from the food they eat, the water they drink, the pharmaceuticals they take, the products they use or the air they breathe.
  • Success of these educational programs depends on evaluation of various training and educational modalities for their effectivenessin implementing change in clinical practice. Building on adult learning theories, ARHP recommends developingand disseminating interactive, web based educational programs on reproductive environmental health and comparing the practice change outcomes with more traditional methods of learning. As a pioneer in web based educational programs, ARHP believes that reproductive environmental health topics are particularly suited to web based state-of-the-art modalities. The web provides the potential for reaching a greater number and more diverse cross-section of the health care field. It permits educational sessions to be targeted to providers caring for patient populations that are impacted by particular environmental exposures. The web has potential for creating networks of providers that can share knowledge and experience and, thereby, enhance patient care.
  • And finally, as advocates in support of a healthy environment that provides women and men with the best opportunity to have a healthy child when and if they decide to do so, ARHP urges the NIH to support chemical policy reform and shift the ‘burden of proof’ to the chemical manufacturers to demonstrate the safety of their products. Neither patients nor their health care providers can or should be expected to simply avoid exposures that might affect their health or the health of their families but are everywhere in their homes, schools, communities and work places. ARHP joins with our environmental health colleagues to urge the NIH to support basic and applied research into green chemistry and to underscore the necessity of requiring industry to thoroughly test all chemicals, provide information on health hazards, and phase out persistent bio-accumulative toxicants. These ‘upstream’ measures will provide support for a reproductive health care team that is educated about the effects of endocrine disrupting chemicals and is motivated to improve the health and well-being of the families they care for.

In sum, ARHP represents the reproductive health team including nurses, pharmacists, physicians, PAs, educators and scientists in urging that the NIH prioritize:

  • Development, evaluation and dissemination of evidence-based, accredited reproductive environmental health educational resources that meet the current training and practice gaps in reproductive environmental health education and clinical care, and
  • Support for chemical policy reform that restricts chemicals known to cause harm and invests in green chemistry that will provide safer alternatives that will protect the public’s health and the health of future generations.
Thank you.