Maine's PFAS Crisis: Dr. Rachel Criswell

And today I have with me Dr. Rachel Criswell, who in addition to being a colleague in family medicine, as a family medicine physician, is also an environmental researcher and published within the medical field on the field of PFAS, which is very interesting to me. Nice to have you here today. Thank you so much for having me, I'm impressed because your background is so broad. You've done work in the humanitarian field, you've done environmental research, you are practicing family physician up in Skowhegan with Redington-Fairview, and yet you managed to juggle all of that and apparently have two children and a successful family life. So how have you made the choices that you've made to kind of encompass this broad range of activities? The thing that has sort of been a thread through all of my choices career wise and family wise is service, as corny as that might sound, but I feel like I come from a place of privilege and I feel very lucky to be able to access education and excel at it. And so I really do feel like I want to use that to help others. So my work in global health, one of the things I really loved about that was that I felt like I brought a skill to the table and I could work with a lot of other people to compliment their skills and all of us using creativity to do that. And then I found something similar in rural health and in environmental health. So that's sort of been a theme through all of it, I guess. And along the way I've been lucky to have two of the coolest children who somehow are excited to join me for these things and are interested in things like PFAS and medicine. And so that's been really exciting as well. I love that you're pointing out that creativity is a much bigger thing than just maybe being a painter or being a musician. I mean, creativity really is fundamental to the practice of medicine, but specifically in rural medicine where you are called to really do a lot of troubleshooting, I would say, and evolving systems maybe with resources that are a little bit limited, but in research similarly, you don't always have all the answers. In fact, you probably don't have many of the answers, so you have to figure things out as you go along. So creativity is really just a necessary element of both of those things. Absolutely, and I think especially in family medicine, that's what really drew me to it. We learn protocols and medication doses and things like that, but I find myself relying much more frequently on thought processes and critical thinking to figure out how to make these protocols fit with the person in front of me and not just the person in front of you, but the fact that they can't get electricity or they live three hours away or their mother can only come over on Sundays or whatever. Funny thing is sort of going on in their lives. And I think that what I really like about research and how it compliments rural family practice is that it is a way to maintain an evidence base, even in these weird flexible situations, if that makes sense. So rather than just going on your previous biases or experiences, you can ask a question and then get some evidence to make the best answer for the community. One of the things that I've noticed when it comes to medicine is that we don't always have the time or the space and sometimes the inclination to do research clinically. And so I know you and I both having been in family medicine, we are very much the beneficiaries of other people's research, which gets kind of filtered down and put into protocols. And then, I mean, I'm very grateful that people do this, but sometimes the translation into the world of the front lines and our ability to actually engage in this is limited by time, money, other resources. And I think it's really wonderful that you're able to practice clinically in a rural setting and also be doing research, which very much has a bench element to it. I'll be honest, it's a challenge. I don't think the rural clinical world is really set up well. And it's unfortunate that we have research sort of siloed into these academic centers, which are often, even rural academic centers are pretty cosmopolitan and have a lot of resources. And so often the research that gets done there is very difficult to apply to a situation like a rural critical access hospital like you say. So it's been a challenge trying to incorporate a research career into a family medicine practice. That said, I think it's so important that those of us on the front lines are asking the questions and are connecting our patients to the answers. And one of the most exciting things that I've been able to do in my practice is translate research and clinical trials directly to patient care. And I'm in a little bit of a unique position just because PFAS is such an unexplored area or evolving area I guess is what I would say. So I can take a clinical trial and say, Hey, look at this evidence, let's try this out for you. And my patients are excited to hear about it and excited to try new things. And I love the fact that, again, that translational side of things is really important because when you have a patient who's sitting in front of you and they say, I've been reading in the news about PFAS, which are the forever chemicals, which we know have been kind of making their way into our water sources, and there's things have been spread upon the farmlands and the fields and that have health implications and particularly in the part of Maine where you've been practicing and where I was practicing previously, and patients come to you with their health issues and they say, I've been reading about these forever chemicals and what does this mean? And when you're the person who's sitting in front of them and you're saying, well, I know that means something, but we're still trying to figure out what that is and I'm looking into it. I mean, there must be something really gratifying about that. It is. It's so gratifying. I think one of the things that I really have appreciated about the position I'm in now is that first it's an opportunity to translate kind of esoteric research into real terms for patients. So it's so cool when a patient comes and says, I have this condition, could it be associated with PFAS? And I can say, well, look, I looked at a bunch of articles. These are what these mouse models say, this is what it means for you. Usually the answer is we're still trying to understand it. But I think the really exciting thing is that a lot of my research questions come right from my patients. So if I hear something over and over again from patients about a concern they're having or whether this symptom is associated with PFAS, I've been able to work with my colleagues to sort of get that to be our research question. And I have a master's and a background in research, but I really find the most grounding thing is answering questions that the patients have. I think that's the most relevant and important research. Tell us what PFAS is and why it's important to human health. Absolutely. So PFAS stands for PER and poly Floral Alcohol Substances, and these are chemicals that were invented in the 1930s. They're used to make things oil and water resistant, so lots of consumer products have them. Anything from Teflon pans to goretex jackets to fast food packaging, it's even in dental floss. It's really become integral into our consumer products. It's also used in a lot of industrial processes and most notably in aqueous firefighting foam or a F. So it's particularly the phone that's used to fight fires that are started with oil. So especially at military bases and airports, there's some evidence that everybody in the US and the world has a little bit of PFAS in their blood. And that's again, just because it's in all our consumer products, it gets into the water and we're exposed that way. But in Maine and in some other communities, there's very high levels of exposure because of contaminations. And often the contaminations happen near an industrial site or an Air force base where the PFAS gets put into, runs off into the water supply mains is pretty unique, as I know you're familiar with because of our industry. The paper industries, the biosolids or basically solid waste after water is treated, was applied for a long time as fertilizer on agricultural lands through a state program. And because of where we are, because of the industries we have, there was a lot of PFAS in that sludge or this biosolids, and that has leached into some water supplies and it's also sort of contaminated our food chain as well. I think one of the things that makes Maine really unique in this sense is that we're a very, I say agricultural, but also just agrarian society. Even if we're not on farms, a lot of people have backyard chickens or grow their own gardens, things like that. And so we are really dependent on the local food chain. We're really dependent on our land as part of how we live. And so some folks have been really, really, really highly exposed, like some of the highest levels in the world, even because of this contamination. For me, when I was practicing up in that area, one of the things that was so chilling was that you'd be talking to patients who lived on literally acres of land and they'd be thinking to themselves, well, I'm out in the middle of nature and I'm eating apples from my orchard and I'm eating eggs from my chickens. And there's this sort of feeling of safety, Alma, almost around that, that you've surrounded yourself with things that should be really good for the human body and then for them to find out that there were contaminants that have started to impact them directly. I mean, it really seemed so, it seemed well profoundly disheartening for one thing. Absolutely not to mention scary. And then you also had generations of people who would live on the same land and they're like, what am I supposed to do now with my farm? Nobody's going to want to buy it, and I have to stay here and raise my children or my grandchildren. It was so hard for me as a clinician to have an answer because there really isn't one. Yeah, absolutely. I think it's been such a tragedy for folks up there for farmers and also just people who've bought their forever home or their little piece of land where they want to grow a family and a garden and hunt. And you're right. I think that community up there, one of the things I love about it, and I live on a farm too in central Maine, one of the things I love about it is you really feel like you're part of the ecosystem. So to have that upset I think has been, aside from the human health consequences, I think that mental strain has been really stressful for people as well. I remember one of the doctors that I actually worked with was very similarly. She was living on a farm in the middle of this sort of catchment area, and she and her daughter and her husband, and they had moved there so that they could actually be part of the community. And she had worked there for many years and I think it just tore her apart that she had to find another place to go because she couldn't live there anymore. And I think she actually felt a little guilty that she had the ability to move away. She was caring for patients that really couldn't. And for me, I just think that when you're addressing again, a level of privilege that you mentioned that some people have and some people don't, and you and I both being physicians, we do probably have that level of privilege and we're caring for patients that don't. And so for me, I've never been able to reconcile that. How do you reconcile that? It's an enormous question and maybe there isn't an answer. I don't have one. Yeah, it's really hard. I am really lucky that I live on a farm that's not in the PFAS contamination area, and I'm conscious all the time when I'm speaking to farmers who either have lost their land or can't farm anymore or are trying to pivot and grow something else, that I am a doctor living on 45 acres and not having to deal with this. Again. I think just trying to root my work in my community's needs has been the most important thing for me, and I feel an incredible amount of privilege that I've gotten to be a part of state and national conversations about where funds go for PFAS testing and treatment and what kinds of research we need and what kinds of policies we need. And I really try to take the words of my patients and the concerns of my patients to those forums and so that it's a constant practice and it's really important to me to continue to be on the ground in SCO Hagan meeting daily with my patients so that I can be that conduit. You did a pilot and now you're in the second phase and you actually have a grant from the NIH, which is very impressive, and you're simultaneously managing patient care. So are there a lot of physicians like you in Maine who have similarly NIH grants and are doing this sort of work? No, I think I'm in a pretty unique situation, and I am there because of my particular background, but also because of the complimentary support of a lot of colleagues. My hospital has been really responsive and accommodating, so I work at a critical access hospital. We are absolutely not a research institution, but my administration recognizes that this is an important thing for the community and they recognize that we are the place that needs to happen. So they've been really accommodating in terms of supporting my research and supporting me to connect to the community to do that. And then I have a partner in Portland who's a nationally renowned PFAS researcher who has been just such a fantastic collaborator, and I think her expertise in the NIH world and in the research world really works well with my sort of community base and our partnership has been really important in getting this grant and looking to the future to make sure that we can care for patients. There's so many things about what you just said that really appeal to me. One of them is that Redington Fairview as a critical access hospital, which means that it really doesn't have a lot of beds. You're 25 beds, and you're right on the front line and you're doing things for people right there in that area before sometimes and often need to be moved into higher availability of services So that you have that support, but also that you're working with somebody who is nationally known in this area. And I know you have a background working with people globally who have done this sort of work. So I love that you have the local, but then you also, you've expanded your network and you've continued to build on your network so that you're able to do the work that you want to do, which is a really interesting thing that I think has continued to evolve over the last, well, certainly since Covid, but definitely in the last 10, 15 years. I think Covid and sort of the move to remote work and that sort of shift has really enabled this. So yeah, I have partners all over the globe, but in particular I'm working a lot with folks at Dartmouth and at the main health Institute for research. And so the fact that we can connect over email and Zoom and some of these people I've worked with for years and never met in person, I think the shift towards more remote work has really helped that. You and I share, which I don't think you knew this when we asked you some of the questions ahead of time, but you and I share a favorite book, and this is "Braiding Sweetgrass", which is just a wonderful kind of meditation on the importance of understanding philosophically the import of nature, but also scientifically the import of nature because Robin Kimer is a writer, but she's also a Scientist. And for me, I've had always this sense that in order to be a physician, I have to be able to look at things philosophically and emotionally and scientifically, and to be able to have all those things working in my brain and my body at once has been a really interesting experience. I am wondering what your experience has been in this. The thing I really love about that book and how it's really helped center me as a physician is reconciling at the risk of sounding too woo woo, the spiritual with the physical of being a physician. So in Western medicine, we're so trained to look at symptoms and pathologies and individual systems rather than the whole body. And I have struggled through medical school and residency with missing kind of like a whole person or whole holistic approach to humans. I think a lot of other medical traditions hold that, and ours does not. And I found that reading braiding sweetgrass and how Robin Wall Kimber marries her indigenous traditional knowledge with her scientific background really helped me find a way to meld those two things in a nice way that we can give people antihypertensive medicines, we can put them on aspirin, and also we have to know that they're the experts in their bodies and their experience and respect their experience as a whole person. I think that's a really cool trend that's happening right now. After Braiding Sweetgrass came out. I think there's a lot more books and writing about what we don't know about science and nature and how there's beauty and importance in that as well, and the respect for the unknown and the unknowable is a really exciting thing for me. You've said that so eloquently. Thank you. This idea that we should respect it, but it is interesting that I think your response that at the risk of sounding too "woo woo", I mean, I believe that that is something that for me, I've personally, I've come to terms with, I'm completely fine with people if they would like to consider me "woo woo", I don't really care. But why did we actually need to have that happen is my question. Right? I don't know the answer. I mean, I think I value the people that came along with medical education and with the Flexner report back in what, 1910 and said, oh, medical education, we need to kind of line it up and make it more consistent and rational. But then I also think, what did we lose? Because there was a whole tradition actually in Western medicine that was very healing and whole person, so I'm glad that we're coming back around to this, but this respect that you're talking about, just the fact that it kind of went away for more than a hundred years to some extent, woo, under the radar. It's just something I think about a lot. One of the things that surprises me most in my medical practice is how often I say to patients, well, I know this is not something dangerous and it's not these conditions, but I don't know what's going on, and I don't think we're going to find an answer for you, so let's try to figure out how to make this work in your life. I came to medicine because I love answers and truth and reason, and the amount of times that I just have to state the limits of our knowledge is humbling, I'd say, and kind of a cool practice. I think it helps my relationships with patients to be able to say, this is what I know it's not, and let's try to make you feel better even if we don't know the etiology. That's such a great and validating acknowledgement for patients. I hope so. Yeah. I mean, I know that a lot of patients will show up and they'll be like, please just give me an answer. I'm looking for an answer, and it's not going to be satisfying to have us say we don't know the answer. However, they're probably coming to us realizing because in the age of Dr. Google, we know that they have access to a lot of information just like we do. So they're probably coming to us and they're thinking, you know what? I suspect that in the more complicated areas you are probably not going to come up with something quickly, if at all. But there's still always the hope. But I do think your willingness to say I don't really know, again, is another step away from what we've had as a tradition of paternalism, frankly, within the medical system. I know everything. You don't know anything. And I actually kind of like the fact that you're able to just meet with people and say, okay, we're humans. I have this academic background, but I know the limits of my knowledge. What I would love to develop a stronger collaboration with alternative medicine practitioners because I do think there's a lot of things in Western medicine that we don't know. I mean, there's a lot of things we treat wonderfully, and there's a reason I keep practicing as a physician. I really do believe in it. But for things that are at the edges of our knowledge, I think that traditional knowledge really does, can offer some relief or answers in a way that we can't yet. And I would love to be able to say to patients, look, you don't, none of your tests tell me that you need a pharmaceutical and this area like this specialist or this sort of complimentary practice might be really helpful in alleviating your symptoms or helping you to understand what's going on in your body in a way that western medicine and sort of bench science. I've only been in practice in my area for about six years, so that's something I'm working on. And I would love also for there to be more of a thawing, I guess, between traditional traditional medicine and western medicine so that we could have that kind of collaboration. I think there's a little bit of antipathy there. Yeah, I think you're right. And also now having practiced in Maine for many, many years, I think that that actually we've been very successful in creating more of an integration, and maybe it's just making its way up to where you are in your area. It's absolutely about me just knowing who's here and understanding the network. Absolutely. Because I do think there is a strong network that does exist, and I think you're raising a great point that your training has been kind of along one set of lines, and now you are in a place where you're practicing and you've been practicing for six years, and you're like, okay, who else is out there? Exactly. The thing that I find so appealing about this conversation is that even as you're saying, I don't really know the answers. Somebody else might know the answers. I don't know the answers, but you're still looking for the answers. So you've still got something in front of you. I mean, there's some linearity to it. We're going to measure these things and we're going to see what actually happens from a health impact of PFAS, and we're going to see what we can come up with, and I think that's really important. It's an exciting and scary place to be. I think one of the things that's been nervous making and also exhilarating is that I is sort of realizing once in a while, oh gosh, I'm one of my colleagues down in Portland and I might be the only people doing this protocol, and I'm not backed by Harvard. I'm not backed by a huge institution. I am a little country doctor up in Skowhegan, Maine trying out this new treatment, especially in the era of Covid where there was a lot of different therapies being applied. It's a little bit of a nervous place to be, but again, I think it's very important and I think it's such a cool way to take what has long been a siloed area of research and put it into practice. I would also suggest to you that you're also part of an additional tradition, which is clinician researchers. So if you look back over the decades and centuries, there are many, many physician researchers who kind of came from the edges, in fact, needed to come from the edges because it enabled them to have a different viewpoint on things. And so I think I'm going to say that you probably are just continuing in your own way, that tradition of people like Samal Vice, for example, and others that contributed to the body of knowledge around clinical medicine. So it is exciting, and I'm sure it is scary, but I give you a lot of credit for wanting to continue to do this work. Thank you so much. I feel really lucky to be where I am. I'm going to continue to see how your career is going. I feel like big things are in store, but also you're currently in a place where you're doing a lot of good for people in many different ways. So you're continuing this tradition that you started with your global humanitarianism and your environmental research, and I'm sure your children, you as a parent as well. I hope so. Thank you for all the work that you're doing. Thank you so much Lisa. And I do encourage those of you who are not familiar with the Forever Chemicals PFAS to spend a little time looking into it. And certainly I expect big things for Dr. Criswell from Dr. Criswell in the future. Thanks for joining me today. Thanks so much.