Book Review

Occupational and Environmental Reproductive Hazards: A Guide for Clinicians

N Engl J Med 1993; 329:1588-1589November 18, 1993

Article

Occupational and Environmental Reproductive Hazards: A Guide for Clinicians
Edited by Maureen Paul. 426 pp., illustrated. Baltimore, Williams and Wilkins, 1993. $80. ISBN: 0-683-06801-6

Physicians are under increasing pressure from patients and the popular press to address occupational and environmental health hazards, particularly in obstetrics. In many, or even most, instances there are insufficient scientific data to allow firm conclusions. Yet physicians must respond to such concern. The editor of Occupational and Environmental Reproductive Hazards has taken on the daunting tasks of summarizing the scientific basis for the relation between environmental hazards and reproduction, providing accurate information for clinicians to give to patients, and offering recommendations for actions that are commensurate with the evidence. No other book currently on the market takes this approach.

Several experts have contributed chapters to this book. After a series of chapters on basic biologic principles, relevant aspects of toxicology and epidemiology, and guidelines for clinical approaches, specific physical, chemical, and biologic agents are considered. The discussions are consistently accurate, but there is variation in how effectively they link current knowledge to recommendations for patients.

The discussions of specific environmental agents, such as ionizing and nonionizing radiation, metals, solvents, and anesthetic agents, are comprehensive and generally evenhanded, acknowledging the areas of substantial uncertainty in the scientific evidence. There is a tendency to favor positive evidence linking agents to adverse outcomes, but it seems appropriate to err on the side of prudence for a clinical audience. Each chapter considers the source of the potentially hazardous agent and exposure to it, followed by the toxicologic and epidemiologic evidence relating the agent to reproductive health.

There is some variation in the ability of the authors to avoid a series of “on the one hand” and “on the other hand” reviews of the literature without a useful conclusion. The chapters by Paul, however, are particularly good in presenting evenhanded reviews of inconclusive material and offering recommendations that balance the risks and benefits of modifying behavior to avoid exposure. For example, in discussing exposure to video-display terminals (Chapter 14), Paul notes that the evidence regarding the absence of a hazard is generally reassuring, but she also makes prudent recommendations for the design and use of a work station.

Some chapters seem to have been written with a different audience in mind. For example, the discussion of pesticides (Chapter 21) is alarmist and seems to be addressed to the specialist in environmental medicine.

Overall, this book will be of great value to reproductive-health clinicians. It is not, by design, an encyclopedia of agents and hazards, as compared, for example, with T.H. Shepard's Catalog of Teratogenic Agents (7th ed. Baltimore: Johns Hopkins University Press, 1992). In fact, the appendix that lists environmental agents is perhaps the least interpretable and least useful section. In contrast, the chapters on the hazards of polychlorinated biphenyls in the community and concerns about working with chemotherapeutic agents provide the best succinct overviews of these topics that are available. Reviews in the scientific literature are often too technical or too concerned with research, whereas this book deals with assessment of the situation and appropriate action. Patients deserve an informed and prudent response to their concerns about environmental hazards, even those thought to be unwarranted, and this book is quite useful in helping clinicians provide such a response.

David A. Savitz, Ph.D.
Michael J. McMahon, M.D.
Andrew F. Olshan, Ph.D.
University of North Carolina, Chapel Hill, NC 27599-7400