[Senate Hearing 107-318]
[From the U.S. Government Publishing Office]
S. Hrg. 107-318
CHILDHOOD LEUKEMIA CLUSTERS
IN FALLON, NV
=======================================================================
FIELD HEARING
BEFORE THE
COMMITTEE ON
ENVIRONMENT AND PUBLIC WORKS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
ON
RESPONSES BY THE FEDERAL GOVERNMENT TO ``DISEASE CLUSTERS'' RESULTING
FROM POSSIBLE ENVIRONMENTAL HAZARDS
__________
APRIL 12, 2001--FALLON, NV
__________
Printed for the use of the Committee on Environment and Public Works
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WASHINGTON : 2002
____________________________________________________________________________
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COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS
one hundred seventh congress
first session
BOB SMITH, New Hampshire, Chairman
HARRY REID, Nevada, Ranking Democratic Member
JOHN W. WARNER, Virginia MAX BAUCUS, Montana
JAMES M. INHOFE, Oklahoma BOB GRAHAM, Florida
CHRISTOPHER S. BOND, Missouri JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio BARBARA BOXER, California
MICHAEL D. CRAPO, Idaho RON WYDEN, Oregon
LINCOLN CHAFEE, Rhode Island THOMAS R. CARPER, Delaware
ROBERT F. BENNETT, Utah HILLARY RODHAM CLINTON, New York
BEN NIGHTHORSE CAMPBELL, Colorado JON S. CORZINE, New Jersey
Dave Conover, Republican Staff Director
Eric Washburn, Democratic Staff Director
(ii)
C O N T E N T S
----------
Page
APRIL 12, 2001--FALLON, NV
OPENING STATEMENTS
Clinton, Hon. Hillary Rodham, U.S. Senator from the State of New
York........................................................... 8
Ensign, Hon. John, U.S. Senator from the State of Nevada......... 4
Gibbons, Hon. Jim, U.S. Representative from the State of Nevada.. 5
Reid, Hon. Harry, U.S. Senator from the State of Nevada.......... 1
WITNESSES
Beardsley, Tammy, Fallon, NV..................................... 12
de Braga, Marcia, Assemblywoman.................................. 9
Prepared statement........................................... 66
Falk, Henry, assistant administrator, Agency for Toxic Substance
and Disease Registry, Atlanta, GA.............................. 47
Prepared statement........................................... 143
Gross, Brenda, Fallon, NV........................................ 11
Guinan, Mary, MD., Ph.D., Nevada State Health Officer............ 27
Prepared statement........................................... 160
Guinn, Hon. Kenny, Governor, State of Nevada..................... 5
Hearne, Shelley, executive director, Trust for American's Health. 53
Prepared statement........................................... 202
McGinness, Hon. Mike, State Senator, Nevada...................... 7
Naughton, R.J., Rear Admiral, Fallon Naval Air Station, Fallon,
NV; accompanied by Captain D.A. ``Roy'' Rogers, Commander...... 30
Prepared statement........................................... 167
Prescott, Stephen, MD., Huntsman Cancer Institute, University of
Utah........................................................... 14
Prepared statement........................................... 151
Sinks, Thomas, associate director for Science, National Center
for Environmental Health, Centers for Disease Control and
Prevention, Atlanta, GA........................................ 49
Prepared statement........................................... 196
Tedford, Hon. Ken, Mayor, Fallon, NV............................. 32
Prepared statement........................................... 171
Responses to frequently asked questions about Churchill
County Leukemia Cases...................................... 174
Todd, Randall, State Epidemiologist, Nevada State Health Division 25
Prepared statement........................................... 166
Trovato, E. Ramona, director, Office of Children's Health
Protection, Environmental Protection Agency, Washington, DC.... 51
Prepared statement........................................... 198
Washburn, Gwen, commissioner, Churchill County, NV............... 34
Prepared statement........................................... 172
ADDITIONAL MATERIAL
Letters:
Bobb, Bonnie Eberhardt....................................... 102
Churchill Economic Development Authority..................... 191
Fallon Auto Mall............................................. 191
Shepherd Miller, Inc......................................... 222
Shundahai Network............................................ 205
Recommendations, Water Sampling Practices, Nevada State Health
Lab...........................................................179-189
Reports:
Bench Scale Test Results for Arsenic in Fallon, NV, Shepherd
Miller, Inc................................................ 278
General Accounting Office, Health, Education, and Human
Services Division, Washington, DC.........................105-150
Groundwater Sampling and Analysis of Fallon, NV, and Naval
Air Station, Shepherd Miller, Inc.........................321-594
Leukemia Hearings, Fallon, NV, February 12-14, 2001..........67-102
Pew Environmental Health Commission.......................... 207
Treatment Technologies for Arsenic in Fallon, NV............. 233
Statements:
Reid, Mary E., area specialist, Water Resources, University
of Nevada, Cooperative Extension........................... 190
Savitz, David A., Environmental Exposures and Childhood
Cancer..................................................... 152
Study, Household Solvent Exposures and Childhood Acute
Lymphoblastic Leukemia........................................154-160
CHILDHOOD LEUKEMIA CLUSTERS IN FALLON, NV
----------
THURSDAY, APRIL 12, 2001
U.S. Senate,
Committee on Environment and Public Works,
Fallon, NV.
The committee met, pursuant to notice, at 9:00 a.m., at the
Fallon Convention Center, 100 Campus Way, Fallon, NV, Hon.
Harry Reid (acting chairman of the committee) presiding.
Present: Senators Reid, Ensign, and Clinton.
Also present: Representative Gibbons.
OPENING STATEMENT OF HON. HARRY REID, U.S. SENATOR FROM THE
STATE OF NEVADA
Senator Reid. The United States Committee on Environment
and Public Works is called to order.
First of all, I'd like to welcome everyone here. This is
what we call a field hearing. I'm particularly thankful for the
support that we've gotten from the community in Fallon. It's
been a lot of work to put this together and the hosts have
worked very hard to provide this facility for us and to work
with the staffs of the various Members of Congress who are
concerned about what's taking place in Fallon. This has been a
community effort, as I mentioned. All local officials have been
cooperative, and especially the parents of the children who are
sick.
I'm fortunate today to have with me my two colleagues from
Nevada, Senator Ensign and Representative Gibbons. Senator
Clinton will be here shortly. Her plane is about to land. When
she arrives, I'll say a couple things about her. I want
everyone to know, by virtue of my being the Ranking Member of
this committee and also under the auspices of Chairman Bob
Smith of New Hampshire, I have extended an invitation to
Senator Ensign and Representative Gibbons to act as de facto
members of this committee today. I'm also pleased, of course,
to have with us the Governor of the State of Nevada, Kenny
Guinn, Assemblywoman de Braga, and Senator McGinness, who have
expressed to me their deep concern about the incidence of
leukemia in Fallon. I want to extend a special welcome to our
witnesses, some of whom have traveled great distances to be
with us here today. We're extremely fortunate to have national
experts on a range of issues important to the community,
including children's health, childhood leukemia, cancer
clusters, and environmentally-related health problems, as well
as State, local, and U.S. Navy officials, with a wealth of
expertise and a demonstrated commitment to addressing the
difficult circumstances surrounding the citizens of Fallon.
The second goal of this hearing is to examine the Federal
Government's approach to identifying and responding to so-
called disease clusters, including health problems that may be
linked to environmental conditions. There's a widespread
concern among the citizens of this country about our being
exposed in our day-to-day lives and about what we're exposed to
and what effect exposures may have on our health and especially
the health of our children. While a number of Federal agencies
are doing an excellent job of supporting State and local
officials in addressing community health concerns, the support
system often seems uncoordinated, ad hoc, too little, and many
times too late. So I believe the time has come for the Federal
Government to craft a coordinated approach for responding to
the needs of communities for support and guidance in
identifying and addressing disease clusters and outbreaks.
Now, here's how we're going to proceed today. After the
opening statements of my colleagues, we're going to have three
panels of witnesses. The witnesses on the first panel will make
remarks of up to 5 minutes, then we'll have questions of the
panel members from the Members of Congress, and then we'll
proceed to the second and third panels the same way. Preceding
these panels, we're going to hear from the Governor of the
State of Nevada, Kenny Guinn. After the third panel has
finished with questions, there will have been circulated in the
audience little cards, and any questions that people have to
ask Representative Gibbons, Senator Clinton, Senator Ensign, or
myself, we will be happy to answer those, time permitting.
Those questions that are in writing that have your address on
them, if we don't have the opportunity to respond today, we
will respond to those in writing. The cards are in the lobby,
and we'll make sure that they're circulated also, for those of
you who missed them when you came in.
We must complete this hearing by one o'clock today. There's
another event scheduled to take place in this room this
afternoon. Mayor Tedford has worked minor miracles to provide
us the space, and I have assured him, my staff has assured him,
that we'll wrap this up in time for him to set up for the next
event. If anyone wants to submit written testimony, please do
so. The hearing record will remain open for 1 week. Testimony
provided by April 19 will be included in the record.
I think also one of the important things that I want to
talk about is--and we make mistakes here. My staff gave me my
pages in reverse order. So I'm now on page 3--I'm on page 2,
I'm supposed to be on page 3, but it's a minor problem. We're
going to look at a very complex problem, as I've indicated. I
have 5 children and soon will have 11 grandchildren, and I can
think of nothing more heart-breaking than a childhood suffering
from a serious health condition and nothing more frustrating
than not knowing the cause of that condition. So, today, we're
going to examine all of this, and we've got people who will
help provide some answers. We're facing a very complex problem,
people should understand, and I'm not going to pretend that
there's going to be easy answers to the questions, but this
committee is committed to give the full weight of the Federal
Government toward answering the many questions that have been
posed. In this room today we have a unique opportunity to share
in the experience of working on the goals of Fallon and
nationally. One of these goals is to find ways in which the
Federal Government can help join Federal, State, and local, and
even private sources, to support ongoing investigations in the
high incidence of childhood leukemia in this community and
address any other environmentally-related concerns. I want to
applaud the State of Nevada, Governor Guinn, for the work that
has been done at this point. I think that other States could
take a lesson from the work that has been done here, and from
those of us who work in Washington, we've watched and certainly
applaud your efforts.
We're going to now hear from Senator Ensign, Representative
Gibbons, and then Senator Clinton will probably be here by
then.
[The prepared statement of Senator Reid follows:]
Statement of Hon. Harry Reid, U.S. Senator from the State of Nevada
I'd like to welcome everyone to this field hearing of the U.S.
Senate Environment and Public Works Committee.
I'd particularly like to thank the Fallon community for the hard
work and support that has gone into hosting this event. And, I'd like
to recognize in advance the family and community members, and local
officials, for participating in the hearing: as the people closest to
the issues to be addressed, your testimony is vital.
I'm fortunate to be joined by one of my newest colleagues on the
committee, Senator Hillary Rodham Clinton. In addition to her
longstanding commitment to children's health and to a clean
environment, Senator Clinton is facing some of the same challenges
facing us here, in connection with a cancer cluster in a community in
her State of New York.
I have also by virtue of my being the ranking member of this
committee, and under the auspices of Chairman Bob Smith of New
Hampshire, invited my colleague John Ensign and Congressman Jim Gibbons
to act as de facto committee members.
I'm also pleased to be joined by Governor Guinn, Assemblywoman de
Braga, and Senator McGinness, who I know share my deep concern about
the high incidence of childhood leukemia in Fallon.
And, I want to extend a special welcome to our witnesses, some of
whom have traveled great distances to be here. We are extremely
fortunate to have national experts on a range of issues important to
the community--including children's health, childhood leukemia, cancer
clusters, and environment-related health problems--as well as State,
local and United States Navy officials with a wealth of expertise and
demonstrated commitment to addressing the difficult circumstances
facing the citizens of Fallon and the surrounding area.
Today we will examine what I consider to be one of the most
pressing issues facing this community and our Nation: how we can
support and enhance the response to environment-related health threats,
and health outbreaks such as the high incidence of childhood leukemia
here in the Fallon area. Quality investigations into the factors that
contribute to these health problems will enable us to better protect
public health through preventative measures, and through more effective
response when disease clusters and outbreaks do occur.
As the father of five children, and grandfather of soon to be
eleven, I can think of nothing more heartbreaking than a child
suffering with a serious health condition, and nothing more frustrating
than not knowing the cause. Yes, we are facing a highly complex
situation, and I'm not going to pretend that I think there are easy
answers. But, this committee commits to give the full weight of the
Federal Government toward answering the many questions herein posed.
Here in this room today we have a unique opportunity for sharing
experience and expertise toward our common goals, in Fallon and
nationally.
One of those goals is to identify ways in which the Federal
Government can help to join Federal, State and local resources to
support ongoing investigations into the high incidence of childhood
leukemia in this community and address any other environment-related
health concerns. I applaud the State of Nevada for its tireless work on
this issue.
A second goal of this hearing is to examine the Federal
Government's approach to identifying and responding to so-called
disease ``clusters''--including health problems that may be linked to
environmental conditions. There is widespread concern among the
citizens of this country about what we are exposed to in our day to day
lives, and what effect exposures may have on our health and the health
of our children. While a number of Federal agencies are doing an
excellent job supporting State and local officials in addressing
community health concerns, the support system often seems
uncoordinated, ad hoc, and too little too late.
The time has come for the Federal Government to craft a coordinated
approach for responding to the needs of communities for support and
guidance in identifying and addressing disease clusters and outbreaks.
Here's how we'll proceed. After brief opening statements by my
colleagues, we have three panels of witnesses. Witnesses on the first
panel will make remarks of up to 5 minutes each. Then we'll ask some
questions of the panel. The same for the second and third panels.
After the third panel has finished with questions, and if time
allows, we will provide answers to questions raised by people attending
this hearing. You may submit written questions by filling out one of
the cards located on the table in the lobby--these cards also will be
distributed by staff. If we do not have time to get to all of the
questions, we will send a written response if you include your address
on the card.
We will need to complete the hearing by 1 p.m., as another event is
scheduled to take place in the room this afternoon. I recognize that
Mayor Tedford has worked minor miracles to provide us this space, and I
have assured him we'll be sure to wrap up in time for the room to be
set up for the next event.
If anyone wants to submit written testimony, I encourage them to do
so. The hearing record will be open for 1 week--testimony provided by
April 19 will be included in the record. With that, I welcome my
colleagues.
Senator Reid. Senator Ensign?
OPENING STATEMENT OF HON. JOHN ENSIGN, U.S. SENATOR FROM THE
STATE OF NEVADA
Senator Ensign. Thank you, Mr. Chairman. I want to
personally thank you for not only convening this hearing, but
also for inviting Representative Gibbons and myself to appear
at the hearing and to participate. This is an incredibly
emotional issue. I think all of our prayers and sympathies go
out to the families. I myself have three children. Two of our
children have had fairly serious medical problems--and the
nights that you spend in a hospital with your children are very
painful, probably more painful for parents sometimes than they
are for the children. So I think all of our sympathies and
prayers go out to the families.
It's because of those emotions that we're here to recognize
work that is being done by everybody concerned. It's important
because we need to, find causes for these clusters. Most of the
time we aren't able to find the causes, but that should not
stop us from pursuing them. What if this happens to be the
cluster that gives us the breakthrough to stop, clusters in the
future. That's why maybe some good can come out of this tragedy
that has befallen this community. This situation illustrates
the importance of everyone working together--the Federal
Government, the State government, the local government, private
entities, and the military--putting their best effort forward
to be able to try to come up with a cause so that we don't have
these types of things happening in the future. We all know that
prevention is the best type of medicine, and if we can discover
a cause, perhaps we eventually can come up with prevention
measures in the future.
So I want to, once again, thank the chairman. Senator Reid
and I have been working together since I took office in the
Senate. I just was informed today that I've been a Senator now
for 100 days as of today, along with my colleague, Senator
Clinton. As all of you know, Senator Reid and I had kind of a
rough and tumble election 2 years ago. However, this is the
type of positive relationship that the people of Nevada can
look forward to, with the two of us working together, with the
rest of the congressional delegation, other Senators and our
Governor and members of the State senate and assembly, working
together to try to find solutions for Nevada problems. As
you'll hear later from Senator Clinton, this is not just a
Nevada problem. This is a national problem, and even a
worldwide problem.
So thank you, Senator Reid, for allowing me to be here.
STATEMENT OF HON. JIM GIBBONS, U.S. REPRESENTATIVE FROM THE
STATE OF NEVADA
Mr. Gibbons. I want to associate myself with the remarks of
Senator Reid and Senator Ensign with regard to the importance
of this issue, the sympathies that we have and share with
families who are afflicted by this disease. All of us sitting
here today have children, all of us know and understand the
importance of their lives and their future and the effect that
something like this could have, not only on them, but on their
community as well. The purpose, I believe, of this hearing
today is for us to gain the information, for us to gain the
knowledge, if it is possible, to help both the families, the
children, and this community survive and overcome this terrible
incidence of leukemia.
There is so much to be learned, there's so much that we
don't know. It is very difficult, in my mind, to find the
answer or to point a finger at this point in time as to the
culprit of this disease. So we are here today--and certainly it
can be shown, by the number of people in this room and their
acute interest in this subject, the high profile that this
issue has. Hopefully, as Senator Ensign has said, what we will
receive is information that will help us overcome this issue,
and will help not only the families and the children afflicted,
but also the community, so that this community can move on and
remain one of the great Nevada communities that has already
been and will be in the future.
So thank you, Senator Reid, once again for having me here
today. It's indeed my pleasure to sit on a dais with such
distinguished members of the U.S. Senate.
Senator Reid. I've just been advised that Senator Clinton's
airplane has landed. We'll reserve her statement until she
arrives.
Governor Guinn.
STATEMENT OF HON. KENNY GUINN, GOVERNOR, STATE OF NEVADA
Governor Guinn. Thank you very much, Chairman Reid, Senator
Ensign and Congressman Gibbons. It's a pleasure to have you
here and soon, hopefully to arrive, Senator Clinton.
We here in Nevada have been working with this problem over
the past year or so now, and we want to certainly thank all of
you for having the interest to come here to hear the expert
testimony that you will receive from Dr. Guinan and our staff.
They have worked very hard. They have been focused on the
issues at hand in terms of leukemia and cancer, the problem
that we have here with the ALL in this community. It is
certainly a serious concern for all the parents and the
children who are involved, but it's also a serious concern for
those who live in Fallon and for those of us who live in the
State of Nevada. So it's greatly appreciated, the fact that you
would take the time out of your busy schedule to come here to
hear this testimony that you will hear today.
Dr. Guinan and her staff have worked diligently and they
have been very closely coordinated with the CDC, which has
given us great guidance and help, and also the expert review
committee that is set up. So, today, as you see the process
that they travel through and the great detail that they have
been working on, I think you will be impressed. By the same
token, this is not just a Fallon issue or a Nevada issue, I
truly believe that cancer clusters have been established
throughout this country over the years. Some have been unknown
for the last 20-plus years. It is time for those of you who
have the wherewithal and the ability to coordinate this on a
national level to do so, and I truly appreciate--and hopefully
that will be your guidance as you come out of this program here
today, after hearing the testimony.
Certainly, it is the unknown that causes the frustration.
When there is an issue like this--and we know about cancer, but
if you do not know the agent that is creating the cancer
cluster, then it becomes an area that is of fear and not
understanding that unknown. So, today, when you hear these
issues, if there's anything you can do to help us to promote it
more on a coordinated basis, which I'm sure you will do, and
take it throughout this great land of ours in America, then we
will all be better for having this hearing here today.
I will leave the rest of the information that you'll get
from the State of Nevada, certainly from these experts, who
have worked day and night. Over five full-time staff people
have been allocated to this, but the real support that we've
received so far is from the staff of the CDC and also from
these expert oversight members, who come from some of the very
best cancer research areas of the universities. So hopefully
today you will hear a great deal of detail on what the study
has been doing, and if there's anything you can do to help us
after that, I'm sure the citizens of Fallon in this great State
of ours will most appreciate it.
Senator Reid. Governor Guinn, we appreciate your being here
today. You and I spoke before the hearing started, and we
understand you have a legislative session that's in full blow
at this time and you've got to get back and protect the
interests of the State, and we want you to do so. We appreciate
your taking time out for this. There's no busier time than when
the legislature's in session. So you're excused, and we
appreciate your being here.
Governor Guinn. Thank you very much. We will cooperate and
provide you with all the data and do everything we can to help
you formulate your plan and your ideas for all Americans. Thank
you very much.
Senator Reid. We would now like to hear from Mike
McGinness, who is the Senator who represents this area. Senator
McGinness, we also appreciate your being here, with the
legislature being in session. We would ask you to address the
committee now and tell us what you feel is appropriate.
STATEMENT OF HON. MIKE McGINNESS, STATE SENATOR, NEVADA
Senator McGinness. Senator Reid, thank you very much. I
appreciate the opportunity to be here. Senator Ensign,
Congressman Gibbons. As you mentioned, Senator Reid, I too will
be heading back to Carson City. The judiciary committee has a
large work session today. Congressman Gibbons and I were
freshmen in the judiciary committee in the assembly in 1989. We
do have some deadlines, but I appreciate the opportunity to be
here today.
For the record, I'm Nevada State Senator Mike McGinness,
representing the central Nevada Senatorial district. I
appreciate the opportunity to provide testimony. Fallon, NV, is
my birthplace. In fact, about a hundred yards down the road
here, there was a clinic where I was born. I'm here because of
the concern for the children and these families that are facing
such trials. Again, I wish to thank the committee for making
these children such a priority. Your attention to their illness
can only contribute to the awareness and assist in the current
investigation. I would like to thank Governor Guinn. When he
convened all the parties earlier this year, there was a genuine
spirit of cooperation to work toward seeking information and
peace of mind for the children and their families, and I
encourage a continued collaboration in the investigation.
I have great confidence in the leadership of this
community. There's a rich history of strong progressive
leaders, individuals that have acted responsibly since the
discovery of this cluster. Many of us have difficulty dealing
with the negative publicity, since the very reputation of this
community has been questioned. The community has responded to
the needs of the families at every available opportunity, and I
know they'll continue to do so. We want the community, the
State, and the Nation to know that Fallon, NV, will find the
cause and cure for this malady today, if possible.
Particularly pleasing is news that the Centers for Disease
Control will move the investigation to a new level. The CDC
will be in Fallon on Tuesday to begin phase two of the
investigation. As Federal officials, anything you can do to
expedite their investigation will be appreciated. The community
can take comfort in the fact that government at all levels is
acting responsibly. I would hope that the committee finds that
credit is due to the city of Fallon, Churchill County, the
State of Nevada, the U.S. Navy, and the Federal agencies for
their response. Anything that can be done will be done.
In closing, let me thank you again for coming to Fallon and
making the care and comfort of these children and their
families a priority, and I appreciate the opportunity.
Senator Reid. Senator, good luck on the remaining 60 days
or so.
Senator Clinton, you came at a very appropriate time. We've
just completed hearing from Governor Guinn and the State
Senator who represents this area, Senator McGinness. We
indicated that your plane was a little bit late. Let me say to
everyone here assembled, as Senator Ensign indicated, Senator
Clinton--this is her hundredth day of being in the U.S. Senate,
and this is the first time that she has traveled outside the
State of New York to do business. We all have been involved in
things in Washington. I personally am very glad that she's on
our committee, the Environment and Public Works Committee. As
you've seen reported in the press in recent days, she has done
a tremendous job on this committee and in the Senate, and we're
fortunate that she's here in Fallon with us today.
Senator Clinton, would you give us an opening statement?
OPENING STATEMENT OF HON. HILLARY RODHAM CLINTON, U.S. SENATOR
FROM THE STATE OF NEW YORK
Senator Clinton. Thank you, and I'm delighted to be here. I
apologize for being a little bit late. It took longer than I
thought, but I got to see some beautiful country as I flew
over. I'm very pleased to have this opportunity to join the
Congressman and my colleagues, Senator Ensign and Senator Reid,
for this important hearing. I know that we wish we weren't here
in a way. We wish we were here for some other reason. I'd love
to come back to Fallon and get to know more about what goes on
in this community and have a chance to learn more about what
our naval base does or what the agricultural interests are, but
we're here because we have a very sensitive and difficult issue
to address, and it's one that I care deeply about.
As Senator Reid might have said, we have cancer clusters
throughout our country. We certainly have them in New York, and
I think even some of the witnesses we're going to hear from
today will speak of some of those. There's a high school in a
place called Elmira, NY. For reasons we haven't yet been able
to determine, there are a number of cancers in our children who
attended that school, and, suprisingly, there's no way yet that
we can understand the reasons for it. We know it's built on an
old industrial site. We know that's a community that has had a
lot of heavy industry, going back to the Civil War. So we're
looking for answers. We have breast cancer clusters throughout
New York. Some of the highest rates of breast cancer can be
found anywhere in our country. This is not something that is
confined to Nevada or New York, it's something that we face
around America, and I think that the Congressman and the
Senators and I are here today to hear from you and to hear from
experts who have been looking into the issues surrounding the
leukemia here in Fallon with the hope that we will be able to
put together some information and recommendations that could
possibly lead to answers.
I want to thank my friend, Senator Reid, for holding this
hearing. It's such a pleasure working with him, serving with
him. I'm delighted that it's also the hundredth day for Senator
Ensign, whom I've had the pleasure of getting to know over the
last months. I've known Senator Reid for a number of years, and
I see Mrs. Reid here, and there aren't two people who are more
dedicated and devoted to the people of Nevada than they are,
and the service that he's given over the years really stands
alone and what he does every day to make the Senate run, which
is no easy task, I have learned, is remarkable in and of
itself. So I want to thank him, not only for his leadership,
but for his friendship as well.
We're going to work in a bipartisan way to deal with the
environmental challenges that face us, the health care
challenges that we confront. I'm looking forward to hearing
from the witnesses, because they're really the reason for this
hearing, and then taking what we learn and going back to
Washington and, again, working in a bipartisan manner, working
with members of the House as well as the Senate to try to find
some answers, and I appreciate all of you giving me the honor
of being able to attend today.
Thank you very much.
Senator Reid. The first panel that we're going to hear from
today consists of Assemblyperson Marcia de Braga, who has
devoted weeks and weeks of her life to the problem that faces
her district, her assembly district; Ms. Brenda Gross, a mother
of a child with leukemia from Fallon, NV; and Tammy Beardsley,
a mother of another child with leukemia in Fallon, NV. On this
same panel, if you would step forward, please, we're going to
hear from Dr. Stephen Prescott. Dr. Prescott is from the
Huntsman Cancer Institute at the University of Utah, in Salt
Lake City. Dr. Prescott is one of the leading experts in the
world on cancer generally, and we're very fortunate that he's
traveled to Fallon from Salt Lake to share his expertise with
us.
I would remind the witnesses that we all have a lot to say,
we have a number of questions that--we've reviewed what you're
going to talk about and the questions we want to ask. So if you
would do your best to stay within the 5-minute guideline, it
would be appreciated. You'll see these little lights up here.
Green means you're in good shape, yellow means you have a
minute to go, and red means you're out of time. So do the best
you can. We're not going to call for the sergeant-in-arms to
throw you out if you go a little bit over, but we do have to
meet the responsibilities that we have with the mayor in
getting us out of here by 1 o'clock. We're going to take no
breaks during the hearing. The court reporter's fingers are--we
have a reporter that has the best fingers in northern Nevada.
She said she can take testimony for 4 hours, and we're going to
test her and see if she can.
Assemblywoman de Braga, please proceed.
STATEMENT OF MARCIA de BRAGA, ASSEMBLYWOMAN
Ms. de Braga. Thank you. It's a great pleasure to welcome
you to Fallon, and we want to thank you for convening these
hearings. In the fall of 1999, I read with sadness a story in
our local newspaper about a fund-raiser for a 5-year-old who
had ALL, acute lymphocytic leukemia, and then there were a few
more cases and more sad stories. I called the State health
division and asked if they thought that four cases of ALL in 3
months was an unusually high number in a small community like
ours. I was told it might be just an isolated cluster, but they
would look into it. In less than a year, eight more cases were
discovered. The statistical probability of this number of cases
occurring in an area with our population is 1 in 10
quintillion. In other words, there is almost zero possibility
that this cluster happened by chance.
In mid-February, the Assembly Natural Resources Committee,
which I chair, held 3 days of legislative hearings. The purpose
of the hearings was to bring together the experts, the data,
the research, the knowledge, funds, and other resources in an
effort to expedite the search for an environmental cause or
contributing factors. The hearings also served to attract
considerable media attention and with it a great many offers
and promises from individuals and agencies and from local and
State and national officials to work together for a common and
urgent purpose.
Others testifying will give you statistics and progress
reports. What I want to focus on is what I learned through the
legislative hearings and through listening to the people whose
lives have been affected by this tragedy. As a result of the
hearings, we prepared a list of possible causes created from
our research and the testimony we received. The entire list is
in your packet, along with the names and agencies of
individuals that our recommendations have been forwarded to. It
basically asks those in authority to leave absolutely no stone
unturned. Our recommendations also include providing
information to the public and expanding the scope of the
investigations to cover a longer period of time, other disease
groupings, the analyzing of water, soil, and air, and the
testing of blood, bone, tissue, and hair of the children. I'm
happy to report that yesterday the Assembly Ways and Means
Committee approved $500,000 to be used specifically for those
purposes.
In addition, the committee recommends cleaning up the
things that our community is concerned about, and doing it now
and not waiting for science to catch up or to provide positive
proof. We unanimously agree that the cancer registry and other
data must be processed in a rapid manner, so that information
is current and readily available to help the environmental
officials and the general public.
This leukemia cluster may only be a part of the whole
picture. An eminent pediatric oncologist has advised us to
investigate all marrow diseases and to look for any increases
in other forms of cancer among children and adults. We know
that two additional ALL cases were diagnosed in 1992, and in
1991, a 5-year-old died from myelodysplastic syndrome, a less
common form of leukemia. We know that earlier this year a
youngster was diagnosed with aplastic anemia, another marrow
disease. We know that there may be additional cases that are
connected to Fallon but were not diagnosed here, and we know
that there are clusters of other diseases that are also
suspicious.
I think it's vitally important that everyone involved be
proactive and not rely on old data, that we look beyond the
environmental improvements that are already being done to what
needs to be done next, and that we approach our problems with
the hope and optimism that through determination and
perseverance we can, if not find a definitive answer, at least
eliminate possible causes and add to our information base.
Our legislative committee has sponsored a bill that would
require public and private entities certified to do
environmental testing to report to the Nevada State Health
Division or NDEP any findings of specific values that exceed
the established maximum contaminant levels. Those findings
would have to be made public if a significant health risk was
posed. I think it's imperative that we put these protections
into law and aggressively pursue our search for causes. That
includes working to eliminate known contaminants. In so doing,
obviously we improve the general health of all contributors.
Why do I feel so strongly that we have a responsibility to
move forward in every way possible? Because this is about
children, children whose lives have been turned upside down by
something terrible that's beyond their control. This is about a
beautiful, smiling little girl whose hair is gone. This is
about a promising young athlete whose energy now lasts for only
minutes. This is about a teenager whose HMO won't pay for a
bone marrow transplant. This is about furthering what is known
about cancer so that communities might be spared what happened
here. I applaud your efforts to create a nationwide team to
deal with these situations, if and when they arise.
Senator Clinton, I read that you said, ``There is no such
thing as other people's children.'' You, Senator Reid, Senator
Ensign and Congressman Gibbons have clearly demonstrated that
belief by coming to Fallon to hold these hearings. We can't
thank you enough for your concern and your willingness to help
our community and communities like this everywhere.
Thank you.
Senator Reid. We're going to now hear from Brenda Gross.
She really has raised the consciousness of the entire community
to this terrible disease. She's the mother of four children.
Her testimony was one of the highlights of Assemblywoman de
Braga's hearings.
Would you, please, proceed.
STATEMENT OF BRENDA GROSS, FALLON, NV
Ms. Gross. Thank you and good morning.
I would like to thank you for allowing me this time to
express my thoughts and share with you some of the hardships
that my son and my family went through. I'm here today speaking
to you to stress the importance of an aggressive approach on
this investigation. My son, Dustin Gross, is 5 years old. He
was diagnosed April 17, 1999. He is doing very well today, and
I'm very thankful for that. We went through some very hard and
trying times. As a parent, when your child is very ill like
that and there is a possibility that you could lose them, it is
frustrating, because you do not have any--you're the parent,
you're supposed to take care of everything and you cannot. You
have to rely on the doctors for this, and thank goodness for
the doctors.
One thing that I would like to stress is that when going
through these things, your child going through many, many blood
transfusions, surgeries and such things that are needed, and
the chemotherapy treatments, you often wonder, as you're
watching this, What did I do? Did I need not feed him
correctly? Did I allow him to do things incorrectly? Did I--
what, as a parent, did I do wrong? That's why I feel so
strongly that we need to find the cause, because we do not want
another child to go through this. I feel very strongly that
there is a cause. I don't know if it's environmental, I don't
know what the cause is, but I do feel that there is a cause
here in our community. It is not by coincidence that 12
children have a certain type of leukemia.
I would like to give my thanks and tell my appreciation to
the State health department. They have been doing a very good
job on their research. Obviously, I wanted to be more
aggressive, but I do understand their approach. Some of my
ideas are maybe perhaps helping with the State health
department, such as needed funding, needed manpower, expert
team assistance, CDC assistance, whatever it takes, whatever
type of testing it takes to protect our children.
A couple of my concerns--and I have mentioned this to the
State health department--that I'd like to express to you is, on
some of the testing--and I want to stress I'm not pinpointing
any of this as being the cause, but when they do the research
on the base, the naval base, and look at how they release--
we'll just say the jet fuel, because that's been an issue--and
how this is monitored and tested and researched, my
understanding--and I may be incorrect, but my understanding is
that it is the Department of Defense and the naval base and the
Government that does this research and tracks and monitors all
of this. I would like to see an outside company come in. I'm
not saying that they are doing anything incorrect, but they do
this, my understanding, on a continuous basis, these tests and
checking things out. It might become habitual to them, because
it is their job, and maybe we need an outside firm or company
to come in there and look things over in a different point of
view.
Another thing is, I feel that the research with these
clusters, we should try to check the other clusters in our
Nation, see if there's a common link there. I just think a
national-type--and if we could do a national panel or what
not--I mean, I don't know how that works, but I think that that
would definitely benefit the research.
Also, third, I do not know if our State of Nevada has a
location or a center for the doctors to send their reports to
for these cancers. Do we have one--I know that a lot of it goes
to CDC, but do we have something that is just for the State of
Nevada for tracking? Because sometimes, to my understanding,
the CDC gets behind on some of this. Do we have something here
for our State to track these clusters or cancers?
Senator Reid. You'll hear from Dr. Prescott. He has some
information on that.
Ms. Gross. Great, thank you.
I would also like to thank our community. This community
has been wonderful and overwhelming and very supportive, and I
love living here and I love Fallon. My focal point throughout
this whole testimony is to continue the aggressive research on
this, not to let up on it. Even as we continue in our lives and
this--hopefully we don't have another childhood that gets
leukemia--and it kind of goes by the wayside, I hope we don't
let up on it. I want to stress to push this very strong. It
sounds to me these clusters have been going on for many years,
and that's too many years.
Senator Reid. It's very difficult to have a mother of a
sick child come and testify in front of TV cameras and all the
people here assembled. We're fortunate that not only have we
heard from Brenda Gross, but we also are going to hear from
Tammy Beardsley, who did not want to be here, but she's here.
Would you, please, proceed.
STATEMENT OF TAMMY BEARDSLEY, FALLON, NV
Ms. Beardsley. Thank you, Senator Reid.
Forgive me if I'm a little nervous. I threw this together
very quickly, and I probably won't be as well read as Brenda,
but I'm going to try and speak from my heart. I also was born
and raised here, and I also love this community very much and
I'm here just to help.
I'm here to represent my 5-year-old son, Zach, who was born
healthy, no list of health problems, no history of health
problems and, yet, he has cancer. If I'm a bit shaken, he just
got back from Oakland last night for some procedures and he's
recovering today. So my husband's not here. So my emotions are
a little high. Forgive me if I whittle my words.
I'm not sure what made Zach so sick, and while I don't
think it has anything to do with the arsenic in the water, I do
think we need to make better choices when it comes to our
environment. I drive by and I see cows, hundreds of them, in
one pen, and when they waste on each other, we give them lots
of antibiotics to make them healthy. We want them to produce
fresh meat and eggs and cheese and all the rest of it and, yet,
their living conditions aren't healthy. I think we need to look
into that. I think we need to look into how much stuff are we
gonna throw out, how much stuff are we gonna buy, how much
money do we all need, how many new homes do we need to build?
We really need to talk about this. I'm talking from my heart
now to my fellow human beings. If we don't stop buying more
than we need, if we don't stop eating more than we need to eat,
if we don't stop throwing out food, if we don't stop wasting so
much of our planet, we're going to start seeing more and more
sick children.
I come from a very healthy family. I'm in the fitness
business, I'm in the nutrition business. My children have lived
healthy lives, and now we're fighting cancer. I don't know how
I got in this mess, and, of course, I want out of it, but I
think we need to take a look at the way we're treating our
home--not our home, but our planet, because I think we're going
to create more disease and I think we're going to create more
sick children. I think we need to take a look at the way we
treat animals, the way we treat our home, the way we treat each
other, and maybe we can stop creating sick children.
Senator Reid. Thank you very much.
We now have the opportunity to hear from Dr. Stephen
Prescott, who's the executive director of--who is accompanied
by Dr. Joseph Simone, the senior clinical director of the
Huntsman Cancer Institute in Salt Lake City, part of the
University of Utah.
This cancer clinic, Dr. Prescott, I hope you'll tell us a
little bit more about it, but we in Nevada are so fortunate
through the good offices of the University of Utah, especially
the generosity of one man, John Huntsman, who has given about a
quarter of a billion dollars of his own money to establish this
institute, and the reason it's so important to the State of
Nevada is that much of the work that is done there takes into
consideration what goes on in northern Nevada.
So, Dr. Prescott, first of all, I would like you to outline
your academic background, so the people here in Nevada have
some knowledge of who you are and how you came to your job, and
then tell us a little bit about the Huntsman Cancer Institute
and specifically tell us something about this disease.
STATEMENT OF STEPHEN PRESCOTT, M.D., HUNTSMAN CANCER INSTITUTE,
UNIVERSITY OF UTAH
Dr. Prescott. I will do so, Senator Reid. Thank you for
having me here and thanks to all the members of the panel. I
share Senator Clinton's views. It's very hard to say that I'm
pleased to be here, because it's such a sad situation that
brings us here.
Speaking of my own background, I'm an immigrant to the
Great Basin region. I'm originally from Texas. I've been on the
University of Utah faculty since 1982, and for the 10 years
before I joined Huntsman Cancer Institute, I was a co-director
of the Eccles Institute of Human Genetics, where we focused on
trying to find the genetic basis for diseases. We were one of
the original centers in the human genome project. We developed
much of the technology behind it and its application to human
disease. I then became the director of research at Huntsman
Cancer Institute and then, about 2 years ago, the executive
director.
Senator Reid. You are a medical doctor?
Dr. Prescott. I am. I have a medical degree from Baylor
College of Medicine, which is in Texas.
Senator Reid, this year, about 2,400 children in the United
States will be diagnosed with acute lymphoblastic leukemia,
which is what's happened to these children here in Fallon. This
is the most common form of childhood cancer. The good news, if
there is any to be had, is that the chances for cure for these
children is really remarkably different today than it was 25 or
30 years ago. At that time, only about 10 to 20 percent of the
children survived this disease. Today, somewhere between 75 and
80 percent will survive. In large part, that was due to the
efforts of Dr. Joe Simone, our senior clinical director, when
he directed St. Jude's Children's Medical Center in Memphis,
TN, where those first dramatic improvements occurred.
These improvements continue, and we believe that one day
this will be an entirely curable disorder, but despite this
success, there are many challenges ahead of us, and that first
one is, quite obviously, as I've just said, the cure rate isn't
100 percent, and until it is, we must work toward that goal.
The second goal is that we have to be able to cure these
children with fewer side effects. To achieve this, we must
uncover the causes of childhood leukemia, and in this regard,
we believe the future to be bright. Although we don't know it
today, there is great cause for optimism. We just now are
beginning to understand the events that cause a single cell to
become cancerous, and these advances can be attributed to many
types of research, but particularly in the area of genetics.
I want to pause for a minute, because genetics can mean two
things. The one easily understandable is, genetic means when
you inherit a risk from your parent, and I'm not talking about
that today. What I mean, in this case, is the second type of
genetics, if you will, in which we acquire damage to our genes
during our lifetime. All the rest of the genes in the body are
normal, except those that are in the cancerous cells. We now
know that ALL happens through this mechanism. The gene that
regulates the growth of a cell becomes damaged and it begins to
grow abnormally, out of control. It no longer responds to
signals from the body that say ``stop growing now.''
But, as we've heard this morning, the most difficult
questions that comes up for a physician or for our government
representatives to answer are when a parent asks--and this
happens all the time--``Why did my child get leukemia, and was
there anything I could've done to prevent it?'' It's easiest to
answer the second question, and the answer to that is, clearly,
no, there was nothing you could've done to prevent it. The
answer to why is, unfortunately, we don't know yet.
When clusters, or these dramatic increases in the number of
cases in small geographical areas, occur, we always revisit
this issue of whether a cancer-causing agent from the
environment or an infection resulted in the increased number of
cases. It's unfortunate that thus far this approach has not
identified any causes for acute lymphoblastic leukemia, but we
would argue it is possible that we're missing some subtle
relationships, if an environmental or infectious cause is
present in the community but only affects a certain fraction of
the population. That is, they may have a particular genetic
makeup that renders them more susceptible to this infection or
to a particular environmental agent. The studies today have not
examined that issue, because they simply didn't have the
capacity to do so.
The recent completion of the sequencing of the human genome
and the technology that it has created has given us an
unprecedented opportunity to revisit some of these questions,
both about the cause of cancer, such as ALL, and new ways of
treatment and prevention. Our specific focus at Huntsman Cancer
Institute is exactly this--to understand the genetic blueprint
of cancer, and one of our approaches is to use what are called
DNA chips. Investigators in our childhood cancer program, led
by Dr. Bill Carroll, have used this now to define specific
pathways in different types of leukemia, but particularly in
ALL. With the understanding of these new pathways, we believe
we'll invent new ways to treat children more effectively and
with fewer side effects.
We also know that certain of these pathways are unique to
groups of patients who will respond well to current treatments
and those who will be resistant to treatments or will have
relapses. We believe it'll be possible to use these genetic
fingerprints to assign children to the two different groups--
standard therapy will work or they need a different type of
therapy. In fact, this approach will be implemented nationwide
within the next few weeks through the Children's Oncology
Group--again, on protocols led by Dr. Bill Carroll from our
organization. We believe that this someday will lead to the
ability to tailor therapy, like a custom-made suit. What will
be the best treatment, for this particular type of leukemia in
this particular patient, to optimize the chance of cure and to
minimize the number of side effects?
As I said before, we believe the same approach could be
applied to clusters of ALL or other cancers to try to
understand why they occur. For example, we would ask, Is there
a specific genetic pathway, one specific pathway that's damaged
in all these children in Fallon who have ALL? If this turns out
to be the case, it would suggest that there is a common cause
in these children. It wouldn't tell us yet whether it's
environmental or infectious, but it would say they all followed
the same pathway to their cancer. To do this, responding ad hoc
now to Senator Reid's question, one of the things that will be
essential is a mechanism to rapidly report the cases to a
centralized body and to collect samples. As you know, your
expert panel recommended a scheme exactly like this, and I
believe it to be crucial that there is a prospective way in
which to identify cases, report them rapidly to a central body,
and to collect samples under a defined protocol so that we can
carry out this type of testing to try to find these pathways.
So in conclusion, although these various projects to define
these genetic pathways are just underway or, in some cases, not
yet implemented at all, we've made remarkable progress and we
believe that by combining sophisticated analysis of DNA changes
in patients and in tumors--or in this case, the leukemia
cells--that we will have better diagnosis, more rational forms
of therapy, and ultimately invent new forms of therapy and
prevention.
Thank you.
Senator Reid. Now the panel will ask questions of the
witnesses, and we'll have 5 minutes to ask questions before we
go to the next person, and if we need more questions, we'll do
more than one round.
Assemblywoman de Braga, I've heard from a number of people
here in Nevada who believe that the number of cancers and other
diseases in this area may have been elevated for years, that
this isn't something that's new. Do you have any thoughts in
that regard?
Ms. de Braga. Thank you, Senator.
I think that's a real possibility. I spoke to that a little
bit in my testimony. I personally know of three other cases,
but we also have somewhat of a transient population. So there
is a good chance that there are cases that were diagnosed
elsewhere but that have their basis here. I heard from a lady
who lives in San Diego, and I spoke about that in my testimony
as well. She's not included in this present cluster. However, I
think we need to expand that, because I think that there are
more cases and more marrow diseases.
Senator Reid. Is this San Diego woman sick?
Ms. de Braga. No. She had a baby in San Diego. They moved
to the base in Fallon when the child was a month old, lived
here for over 3 years, and moved to Japan when the baby was 4.
He died when he was five. She said--and I didn't know whether
to laugh or cry--she said, ``You know, when my son died, I
thought God wanted him and that was why he died.'' And she
said, ``After reading this, the environmental possibilities,
I'm not so sure.'' And what she wanted to tell me about was
mosquito spraying when she lived here, the fogging that was
done, and she thought, after reading a lot of this, that that
was a real possibility. There's a lot of stories out there
that----
Senator Reid. That's interesting, Marcia. There was a
lawyer in Las Vegas, a young man doing very well. He spent most
of his time--I just thought of this as you mentioned this. He
was a Mormon missionary in New Zealand, and he and his
companion were walking, and there was heavy spraying taking
place and they were sprayed, and his family felt that's why he
died at such an early age. I don't know if it has anything to
do with that or not, and maybe Dr. Prescott can tell us.
Also, would you give me your thoughts about--you've spent
as much time as anyone else on this issue, and I'd like your
thoughts as to what aspects a cluster investigation would most
benefit from the involvement of the Federal Government. Do you
have any ideas?
Ms. de Braga. I'm sorry, what aspects of the----
Senator Reid. What do you think the Federal Government can
do, in your layman's opinion, to help with this investigation?
Ms. de Braga. A lot, because I think there are a lot of
resources through the Federal Government that aren't available
to us in the State of Nevada, and I think that was just
demonstrated here this morning, that there are a lot of
resources. I think that when you're limited in the amount of
data, research, and experts that you have available to you, it
narrows the scope of your investigation, and I think that's
where the Federal Government can play a huge part. I'm not just
talking about any dollars that are available, I'm talking about
the new knowledge that's out there, that's going to speed this
up and help us to find a cause.
Senator Reid. Marcia, one of the other problems that I
face, Senator Ensign and all of us up here face, is the
delicate line we walk between what Brenda Gross wants and the
fear that is around in the community generally. Does what we're
doing here have an adverse impact upon the community? As you
know, Senator, the work that you've done in this regard, it's a
real delicate line that we walk. What is your comments? Has
what has taken place regarding this investigation been damaging
to Fallon?
Ms. de Braga. I've heard a lot of people say that, yes, it
has, that we don't want this attention, that focusing on--and I
think somebody mentioned it this morning--the negative aspects
hurt real estate sales, those types of things. Of course, we
don't want our community to have a bad image, but I don't
believe that's--I would rather live in a place that cared more
about its children than it does its image and that it's being
proactive, fixing the things, whether they are the direct cause
or not, so that they're doing everything that can be done to
protect children. So the economy slumps a little. I don't
personally believe that's the case. I think the attention
that's focused here is absolutely phenomenal. We can go along
pretty complacent and say, ``Oh, my gosh, this is sad'', but
unless we make a real aggressive effort like is being done
here, like Brenda commented on, we don't draw the attention and
we don't get the forces moving to solve the problem. So I think
maybe we have to give up a little, but I'm not sure that's
true. I think this is the kind of image we want, that this is a
community that cares more about its kids.
Senator Reid. I'm confident, in the long run, that we'll be
here.
I'm going to hear now from Senator John Ensign. What those
of us in Nevada tend to forget is that this is Dr. John Ensign.
Before coming to Congress, John Ensign was a veterinarian, and
as we all know, the training of a veterinarian is very
comparable to the training for a medical doctor, and he's been
a big help in helping me understand some of the scientific
problems we face here.
Senator Ensign.
Senator Ensign. Thank you, Mr. Chairman.
First, I want to say to both of you, obviously, our
sympathies go out to you and we'll pray for your children. As
bad as what you're going through, at least it's not 20 years
ago. Our treatments today are much more successful. We have
people like Dr. Prescott out there doing the research. So 20
years from now, it'll even be better. But, once again, it is
important that we focus on the preventive aspects so children
don't end up with this and we don't have them go through some
of the treatments. Even though we're happy those treatments are
there, they're still brutal for children to go through.
I want to also thank you, Assemblywoman de Braga, for the
work that you've done on this. You've been a leader on this
issue. I think your efforts should be applauded. I want to ask
some questions of Dr. Prescott. One of them has been puzzling
to me, because I hear reported often, in most of the reports I
hear, ``lymphocytic leukemia'' and ``acute lymphocytic'' are
mentioned yet, you mentioned ``lymphoblastic.'' All the reports
I thought used the term ``lymphocytic.'' Can you address that?
Dr. Prescott. They are pretty much the same thing. It's
just a distinction based on the way that these white blood
cells called lymphocytes look, and the children, in its acute
form, usually have a less developed form of those cells. It can
be either called lymphoblastic or lymphocytic. Adults typically
have a much more mature--they may have a similar type of
leukemia, but they have more mature white blood cells.
Senator Ensign. Are you aware of other clusters or how many
clusters are discovered throughout the world, let's say in the
last 30 years, and how extensively they have been studied?
Dr. Prescott. I think there'll be other experts much more
knowledgeable than I am about this, as that particular area--
the epidemiology of clusters--is not my expertise. I can't
answer that. Very many is the answer, but I can't tell you
precisely. I can say that, unfortunately, as I believe you
alluded to earlier, none of them have yielded a specific cause,
the investigations of it.
Senator Ensign. Have we ever come up with a cause for any
of the leukemias?
Dr. Prescott. Yes. In some of the adult forms of
myeloplastic leukemias, there's certainly a much stronger
correlation with some types of bone marrow toxins in those
cases, but it appears to be not the case, at least thus far,
with ALL.
Senator Ensign. When you were talking about the genetic
pathway, who would be in charge of investigating this genetic
pathway, and who would be responsible for coming up with the
protocol for making sure that this is consistent? Where can we
come up with some information?
Dr. Prescott. Excellent question. At a national level, it's
being done by the Children's Oncology Group. This is an
organization that includes all of the major cancer centers in
the United States, and most children with cancer, including
leukemia, are treated in major centers. That's because--
although that 2,400 is a large number if it's your child,
that's a relatively small number compared to, say, breast
cancer in the United States--the expertise to care for those
children typically resides in large urban centers, and so most
children get referred there quite promptly. I was thinking just
earlier, with respect to Nevada, this creates something of a
problem geographically. If patients live in the northeastern
part of the State, they would come to us, without a doubt. In
the western regions of the State, I suspect they'd go to
Oakland or UC Davis or maybe to Stanford. If they live in Las
Vegas, they would go probably to Los Angeles.
So from the point of view of the State trying to understand
the incidence rates of a cancer like this and the approach, it
would be quite fragmented. I think there's a risk that you
could miss something, because the children are referred in
different directions, and we would argue for some rapid
reporting mechanism of Nevada residents, even if they're
getting their treatment outside of the State.
Senator Ensign. Right, but the question would be, first of
all, do we have--we're trying to find out what's the best way
for us to, maybe, direct the Federal Government. What's your
recommendation as far as investigating these children and their
genetic pathway to the potential causes?
Dr. Prescott. I'd like to second the recommendation of the
expert panel, and that is to establish a registry of these
children and a mechanism here, since we know there's a cluster
going on now. I would argue that a really important component
of that is rapid acquisition of a blood sample that could be
used for various studies--of course, with the consent of the
families and the child, but if they consent to that, it could
be rapidly put into the system. They exist in the Children's
Oncology Group now. So that could be taken advantage of
immediately.
Senator Ensign. Have those blood samples been taken from
the children? In the acute form, do these genetic pathways
change? Do we even know when they're in the acute form of the
disease, versus farther down, maybe they're in remission? Would
we still be able to identify their genetic pathway if they're
farther down? Do we have these samples ahead of time, already
drawn?
Dr. Prescott. I can't answer that, because I wasn't
involved in the initial investigation, but I'm sure that Dr.
Guinan or someone can. But the answer to the second part of
your question is that, in the cases where children have already
responded well to treatment, then we would not be able to do
the type of test that I just described.
Senator Reid. Senator Clinton.
Senator Clinton. Thank you, Senator Reid, and I want to
thank the panel. I particularly want to thank both Brenda and
Tammy for being here today. I know this is not an easy kind of
experience for you, and I join John in wishing your sons well
and all the other children.
I'm particularly impressed by what Assemblywoman de Braga
has done and I am grateful that she took this issue on, and the
kind of leadership that she's shown at the local and State
level to leave no stone unturned is exactly the kind of
leadership we need across the country. You responded to Senator
Reid's question about the kind of help that might be useful in
responding to the cluster that has been identified here. Have
you given some thought and does the assembly, with the approval
of the $500,000 for investigations and bringing the cancer
registry up to the current, have specific suggestions about
what we at the Federal level could do to assist you in
expediting what you're attempting to bring about with response
to the cluster?
Ms. de Braga. Yes. Thank you, Senator.
Again, both in terms of making available to our State or
helping our State assemble the resources that are not
available--readily available in our State, I think the Federal
Government--because, obviously, there has been a lot of
research already been done. This isn't the first cluster. One
of the things that's unique about this cluster is it happened
in such a very short period of time. So there may be something
new to learn here, but I think it will take more funding,
because our staff is limited, and it will then take some
specific work on the part of either the present expert panel
that's been formed or one like it, so that we can avail
ourselves of the experts that are out there and the research
that's already been done. Senator Reid, I think, said in a news
article that we don't want to reinvent the wheel. So if we can
start at a point that is past what's already known and rely
on--and this is going to take a tremendous amount of help from
the Federal agencies--then I think we can speed up this
process. I think that's very important. We don't want what
might be a readily findable cause to disappear because too much
time has gone by.
I also think that we need some means of having a central
repository for information, that it can be somehow up-to-date.
That's critical, I think. I asked some health division people,
if we hadn't brought this to their attention, how soon would
they have found it on their own through the normal channels,
and they said it would be at least 2 years. In 2 years' time,
if there's a readily findable cause, more children will become
sick.
Senator Clinton. I think that--and I hope that the Fallon
community will see this in the years to come--because if we are
able to do what every one of the panelists recommended, then
Fallon will have made a great contribution to preventing a
disease in the future, because, clearly, we are now at a point,
as I understand Dr. Prescott's testimony, where technologically
we can really seriously engage in the kind of discovery that
was beyond our means just a few years ago. The human genome
project, the advance in information technology, the ability to
correlate associations that we may find of interest but don't
know whether they're causal, such as pesticide spraying or
arsenic in the water, all of these things, we can now track
much better than we ever could. So I think that, in a very
important way, advances in determining how to prevent cancer
could really be attributed to the extraordinary response in
this community, and for that, I think the entire country and
maybe even the world eventually will be grateful to Fallon, and
I hope the people of Fallon will understand how important this
is.
Senator Reid. Brenda, it's my understanding you've been
receiving phone calls--you and other parents who have sick
children have been receiving calls from around the country from
other parents who have sick children. Is that true?
Ms. Gross. Yes, it is. I've gotten E-mails, phone calls,
and letters with lots of information that's been very
interesting.
Senator Reid. Other parents have received the same types
of communications; is that right, Tammy?
Ms. Beardsley. Yes, lots.
Senator Reid. This is more than one or two E-mails or phone
calls; is that right?
Ms. Gross. Yes.
Senator Reid. If you added them up, the 12 families who
have sick children, it would be dozens and dozens of people who
have made contact with you?
Ms. Gross. I'm not sure on the other families, but, myself,
I have received dozens, several dozens.
Senator Reid. Tammy, you've also received----
Ms. Beardsley. I have received dozens.
Senator Reid. I think that's important, based on what
Senator Clinton has said. I think we have to have a better
method, as Dr. Prescott indicated, of rapidly identifying these
clusters, and when we find something that appears to be a
cluster, I think we have to have some way of responding as
quickly as we can, and we don't have that right now.
Dr. Prescott, in your experience, is it common for
childhood leukemia to occur in clusters?
Dr. Prescott. No, it's not. Most of them do not occur in
that manner.
Senator Reid. So this is an unusual situation, from your
experience?
Dr. Prescott. Absolutely.
Senator Reid. You've indicated that in the past, when we've
had these clusters, that we've been unable to find a cause.
Now, you've read all the material that we've sent you regarding
this and you understand we have arsenic in the water and you
understand, here, we have a large agricultural community and
whatever goes with that agricultural community, and we have a
very large and important military installation here. Some
people say there's a--some studies talk about a virus that can
be communicated. Do you think that it is possible that there
could be a combination of things that I've outlined and other
elements that are available that could lead to environmentally
causing this condition?
Dr. Prescott. Yes. I think it's less likely that it's a
combination of things, but I want to apply an important caveat.
I'd like to know the answer to the question I posed. It may be
unknowable in this case, but I'd like to know the answer to
that. Do all these children have a common pathway to their
cancer? If so, I would be virtually certain that there's
something from the environment. Now, speaking from genetic
terms--I would even include a virus in the environment or
anything outside--I would surmise that it's more likely that
it's one thing that affected all of them than a combination of
20 percent this, 40 percent that, but I'm just speculating. I
don't know the answer to that, but I believe that to be much
more likely or more probable. But you're right, in these cases,
we know that many things--we know that viruses can cause
cancers. We have many examples of that. We know that some
environmental toxins can cause cancers. It's just the specific
case of ALL where we've never been able to make a connection
between those. Part of it comes back to this issue that I
mentioned before--and I'm reluctant to say this in front of
people who recently suffer with this, but it's a relatively
uncommon disorder. We only have 2,400. It sounds like a huge
number, but it's a very small number compared to the other
types of cancers we study. So we're often in this position of
sort of scrambling after the fact trying to go back and say,
``Gee, I wish I had a blood sample from a month ago, I wish I
could test this or test that.'' There just aren't big enough
numbers of cases and samples of blood or samples from the
environment to make really robust associations so that we can
really get to those root causes.
Senator Reid. Dr. Prescott, having grown up in an era
where--even though I lived in a very small rural community in
Nevada, as a little boy, I was scared to death I was going to
get polio. No one knew what caused it, but we knew that the
disease was devastating and children like me all over America
worried about this terrible disease. People in Fallon--even
though this is certainly nothing comparable to polio, people
here worry, Is this something I can catch, is this something
that can be communicated from one person to another? What are
your thoughts in that regard for the people of this community?
Dr. Prescott. I grew up not being able to swim in the
summertime as well, Senator Reid, because of the fear of polio,
and I remember those days very strongly with some of my
classmates who were afflicted with it. This is obviously a
crucially important question from a public policy point of
view, public health point of view, to try to reassure families
where we can, and we need to do so in an honest and legitimate
way. I certainly couldn't say to the people here that if there
were a virus that did this, that we could be absolutely
confident it's not still here somewhere. What I can say is that
that's highly unlikely. First of all, there's never been such a
virus described. We don't know if that's what the cause is or
not, and we know historically, from these many clusters that
have been described around the world, that they tend to be
self-limited. So it would be really quite unprecedented.
I know that's an incomplete answer, but I think that one
can be relatively optimistic that it won't continue, but we
can't--since we don't know the root cause, we can't say for
certain. Polio was different. Once we knew the type of virus
and once a vaccine prevention was available, then we could
approach that with a lot more confidence.
Senator Reid. Senator Ensign.
Marcia, I join with the rest of the Senators up here on the
issue of giving you great credit for your effort and your
leadership in this regard, as I'm sure the community does as
well and the families of those affected children. To the
mothers that are sitting here, Brenda and Tammy, your
contribution to this hearing is greater than you imagine. It's
greater than--the fact that you sat there and told us about the
trying hardship of your children. It's greater because we now
have a greater empathy for this issue and a greater commitment
to work on solving this problem. I have no questions of you. I
just want to thank you for your effort, your courage and
willingness to share with us your stories on this, and you do
have our sympathies.
Dr. Prescott, I really appreciate your insight, because as
you testified, it was as if a light bulb had gone on that we
had for so long been looking externally for causes.
Dr. Prescott. Absolutely. Adult leukemias also often have
these translocations that I've described in my written remarks,
which is where one piece of DNA from one chromosome gets
switched over to another chromosome, and if that happens in
just the right place to where the switch was made--there's a
gene that controls the growth of cells--now we have a bad
situation, where they begin to grow abnormally, and that
absolutely happens in all types of cancer.
Representative Gibbon. Dr. Prescott, what can you tell us
about clusters of adult leukemia?
Dr. Prescott. There have been clusters of adult leukemia.
It's not necessarily the case that you would assume there
should be adults in Fallon with leukemia, because these
diseases are so different. Adult types of leukemia are so
different from childhood leukemia, and it would depend on what
that external signal was. If it were something from the
environment or an infection, it's perfectly plausible that it
would affect only childhood leukemia or it would lead to an
increase of breast cancer. We talk about cancer as one thing,
but it's really at least a hundred things. It's probably on the
order of several hundred things, if we get down to the absolute
root causes of it. So it's not improbable at all that we would
see childhood leukemia without adult leukemia. Just as in this
cluster it's only ALL and not other types of childhood
leukemia.
Representative Gibbon. Although our research and science
into the trigger mechanisms lead us to look at the genetic
sources that may be found, what other considerations should be
raised, at this point? Are we focusing our effort too broadly?
Should we be narrowing that effort? What is your opinion?
Dr. Prescott. It's a question I like to be asked, as the
former director of research of the Huntsman Cancer Institute.
First, I'd say that Congress has been very generous to the NIH
budget, funding basic research. There's always more that can be
done, and I think the one place that we don't have an effective
strategy in place is to apply some of what we've learned from
the genome project broadly to clinical problems, I mean, really
specifically. One thing that's often overlooked in that process
is the clinical aspect of it, finding those patients quickly
and obtaining proper samples, with appropriate informed consent
and confidentiality, because we tend to focus on the very
attractive high technology, because it's amazing what we can do
with sequencing today. That's actually the part now that's
simple to do, to be honest. It's simple to sequence the DNA.
The hard part is organizing a system so that you identify
childhood leukemia cases rapidly, that you get those samples in
the appropriate way, that you collect information about the
treatment they had and the outcomes they had, and you can
correlate that with the DNA sequences. That's the way that
we're really going to unravel the basis of many types of human
disease and get into an area that's sometimes called
individualized treatment, which is what I was speaking about.
We know that perhaps this type of leukemia might have six
subsets and that one type of treatment will be better for one
subset than the other, one type of treatment will cause more
implications than the other, but if we can clearly get down to
very precise typing, we'll do much better for the patient with
respect to curing the disease. This is true of all types of
cancer.
It's a long-winded answer. I apologize. To get back to you,
I would say that in a strategic sense, we don't yet have a
global approach to how to do that, and I would argue that
that's the next great leap forward, applying those DNA studies
to understand human disease and leukemias in children.
Senator Reid. Senator Clinton.
Senator Clinton. I just wanted to add on to what the
Congressman was saying, because I think what Dr. Prescott just
said is so critically important. Would it be fair to say, Dr.
Prescott, that it would not only assist us in better curing
cancers by understanding more about the individual disease, but
also in preventing it. The more information globally that we
can collect and that we then use both for cure and treatment,
we also--if we have the appropriate plan to do this--will be
able to begin to, perhaps, find answers to some of these
questions that, right now, we can't answer.
Dr. Prescott. Absolutely. In the ultimate realization of
this, of applying this information about DNA sequences and our
genes and how we're predisposed to the likelihood of disease,
the distinction between treatment and prevention goes away. If
you could diagnose early--prevention is the treatment, and it
absolutely is the great promise of this technology.
Senator Clinton. One of the things that certainly strikes
me, just as a layperson, without any of the expertise that Dr.
Prescott obviously has, is that if we survey the way we're
living--and this goes back to something that Tammy said, which
I don't want to lose in the discussion. We are living very
differently than our grandparents lived. Whether we live in
Nevada or Arkansas or New York or wherever we're living, we're
living differently, and in the course of that different living,
we've had so many blessings that we're grateful for, but I
think it is appropriate for us to take stock of what are some
of the unintended consequences of the ways in which we are
living, so that we don't overreact, but we also don't ignore
changes that could be made that could keep us healthier longer.
This is something that may not directly fall in the realm of
science today, but without adequate research being directed
toward determining--What are the environmental contaminants
that we expose ourselves and our children to on a regular
basis? What is the cumulative effect of those contaminants over
time? What is the distribution of viruses? What's the
assessment of exposure to things that we didn't really have in
our homes or that we didn't understand the impact of?
I know that there are people who will say, ``Well, but
we've lived this way for a long time and we don't suffer any
ill effects.'' I'm often reminded of meeting the 95-year-old
smoker who says, you know, ``I've smoked all my life. It didn't
hurt me a bit.'' Well, that's a unique case, because we know
it's hurt a lot of other people. Our genetic makeup may have
protected us over time against some of those assaults, but the
accumulation of the assaults may break down or find that
genetic pathway.
So I think that, you know, we do have to ask ourselves
these hard questions. That's one of the reasons why
environmental health is, to me, the real frontier of where we
go now in medicine, because we've made so many advances. Now
let's take a step back and figure out how do we prevent these
things, not just enough that we can cure with extraordinary
medical research childhood leukemias that are way beyond
whatever was dreamed 25 years ago, but how do we change some of
the environmental impacts or better understand the virus
transmissions and the exposure assessments, so that we can
prevent it, we can relegate it to the dustbin of history. I
think what Dr. Prescott said, I hope, will inform the Congress.
I'd like to thank this panel very much. It's been most
illuminating, and I'm sure that the information we're going to
take back to Washington as a result of this panel, alone, will
have made our trip worthwhile. Thanks very much.
Senator Reid. We're now going to hear from Dr. Mary Guinan,
the Nevada State Health Officer. She has worked for the Centers
for Disease Control and Prevention over 20 years and now leads
our State's response to the Fallon leukemia cluster. She has
extensive expertise and her relationships within the national
public health community has given the State a unique access to
assistance in conducting this cluster investigation. We're also
going to hear from Dr. Randall Todd, Nevada State
epidemiologist. Dr. Todd is an associate of Dr. Guinan and is
responsible for the technical elements of the State's efforts.
He's primarily responsible for developing many of the programs
within the State. We're also pleased to have with us Rear
Admiral R.J. Naughton, who's accompanied by Captain D.A.
``Roy'' Rogers, commander of the Fallon Naval Air Station. We
also are going to hear from the mayor of the city of Fallon,
Ken Tedford, who has worked with us so well and so hard in
arranging for this hearing, and Ms. Gwen Washburn, who's the
commissioner with the Churchill County Commissioners.
We're first going to hear from Dr. Guinan.
Dr. Guinan. Senator Reid, I'm going to ask Dr. Todd to
first give us a presentation of his findings. Dr. Todd has been
the lead scientist in the investigation of this cancer cluster,
the first phase of the study, and he will present those
findings.
STATEMENT OF RANDALL TODD, STATE EPIDEMIOLOGIST, NEVADA STATE
HEALTH DIVISION
Dr. Todd. Thank you. Good morning, Mr. Chairman and members
of the committee. For the record, my name is Dr. Randall Todd.
I am the State epidemiologist and work with the Nevada State
Health Division. I'd like to briefly describe the Health
Division's investigation into the cluster of childhood leukemia
in Churchill County and discuss the role of Nevada's Central
Cancer Registry assisting us with that investigation.
The initial phase of our investigation consisted of
confirming the diagnosis of each reported case and conducting
an interview with each case family to identify any potentially
common characteristics or environmental exposures that might
point to a preventable cause. I should mention that we're
indebted to the Centers for Disease Control as well as the
Massachusetts Department of Public Health for their assistance
in providing us with model interview instruments.
The case family interviews were conducted face to face with
each family. This involved a detailed review of the family's
residential history, from the date of diagnosis back to a point
in time 2 years prior to conception of the ill child. For each
residence, we inquired as to the source of water, in-home
treatment of water, and uses of water. We also inquired about
known exposures to chemicals from agricultural or home use of
herbicides and pesticides, as well as indoor uses of chemicals
and solvents. For each parent, we inquired about occupation and
occupation-related exposure to chemicals, dust, or radiation.
We conducted a detailed review of the child's medical history
and the mother's pregnancy and breast-feeding histories.
Finally, we asked case families about any hobbies, sports
activities, or typical travel destinations that might have
brought them into contact with chemicals, fumes, or radiation.
From this interview process we learned that half of the
case families had spent 2 years or more in the Fallon area. The
others had resided in the area for shorter periods of time.
These 12 case families had resided in a total of 88 different
homes over their respective time periods of interest. Of these
88 homes, 22 were located within Churchill County, and of these
22 local residences, half were served by public water systems,
while the others obtained their water from domestic wells.
Our initial analysis of the occupational, medical,
environmental, and other historical information provided by the
case families has not suggested any particular common
denominator that would link these cases together. We recognize,
however, that some of our data is subject to recall limitations
on the part of the families. Specifically, they may not have
known of an environmental exposure that did, in fact, exist or
they may have forgotten about it. For this reason, we are
currently taking steps to obtain additional data through
objective environmental sampling. This constitutes a second
phase of the investigation.
We're now in the process of obtaining water samples from
these current and former case residences in Churchill County
that are served by domestic wells. These samples are being
subjected to the analyses that are routinely done for public
water systems. In other words, any test required by the safe
drinking water act for public water systems is also being
conducted on the water samples obtained from the wells of
residences where case families have lived. The results of these
analyses are pending at this time.
We've also invited the Centers for Disease Control and
Prevention, as well as the Agency for Toxic Substances and
Disease Registry, to assist us in identifying and analyzing
completed pathways for other sources of environmental
contamination. This would include industrial, agricultural,
military, or other sources.
On a parallel tract with these environmental studies, we
are also collecting data on the overall population dynamics of
Churchill County. This includes looking at size of various age
cohorts over the last 10 years, school enrollment information,
and military populations. This analysis will help us determine
if Churchill County matches the profile of other communities
around the world where population mixing has been suggested as
a possible explanation for increased rates of childhood
leukemia.
In closing, I would like to make some brief comments as to
the importance of cancer registries in the conduct of cancer
cluster investigations. Nevada has maintained a population-
based cancer registry since 1979. This activity has been
funded, in part, through a grant from the Centers for Disease
Control and Prevention since 1995.
I should mention that all disease reporting systems,
including cancer registries, do experience a lag in time
between the diagnosis of a case and the reporting of that case.
With a disease such as cancer, the patient record may not be
complete enough to warrant abstracting information until about
6 months from the date of diagnosis. Additional delays in
obtaining information beyond this 6-month time period relate to
workload and staffing. In more rural parts of Nevada, this
situation is made even more difficult due to the distances
involved and the relatively low number of acute hospital beds
in each facility, making it costly and time-consuming to
collect rural data. For these reasons, if a cancer cluster is
identified through a cancer registry, it's likely to have been
going on for some time.
The increased incidence of childhood leukemia in Churchill
County was not identified through analysis of cancer registry
data. The local hospital, physicians, and community leaders
noted the cases and perceived the numbers to be unusually high.
Nevertheless, Nevada's cancer registry has been invaluable in
helping to place the observed number of childhood leukemia
cases in historical and geographic context. Only through this
analysis of cancer registry data have we been able to calculate
the usual rate of childhood leukemia and determine that the
local cases do, in fact, represent a significant excess over
the expected.
I'd be happy to entertain any questions the committee might
have.
Senator Reid. Dr. Guinan.
Dr. Guinan. Yes, thank you.
STATEMENT OF MARY GUINAN, NEVADA STATE HEALTH OFFICER
I'm Mary Guinan, State Health Officer. I've been asked to
speak today on the status of the continuing investigation and
also Federal roles in the investigation of cancer clusters.
On February 15, after Dr. Todd had finished the first phase
of the investigation and after the analysis showed no
particular environmental or infectious agent that we thought
was common among the cases and would be a likely causative
agent, we asked a panel--we invited an expert panel consisting
of experts from the Centers for Disease Control, the National
Cancer Institute, the University of Minnesota School of Public
Health, the University of California at Berkeley School of
Public Health, and others, several from Nevada, University of
Nevada School of Medicine, and we asked them to review all of
the data and to help us plan the next steps of the
investigation. That occurred on February 15.
The committee made six recommendations. The first was to
expand case-finding efforts by seeing if you have all of the
cases, are there other cases, and we're doing that. We're
working with the Navy to see if there are any Navy families who
have been through Fallon and whose children may have developed
leukemia, and that search is ongoing, and Admiral Naughton will
speak to that.
We also want to expand our case search with the Children's
Oncology Group. Children's Oncology Group is a group of
treatment centers around the country. As you know, cancer in
children is rare, and we're very grateful it's rare, and so in
order to get appropriate treatment protocols, the treatments
are concentrated in groups around the country--California,
Utah. We do not have one in Nevada. So the children with
leukemia--over 90 percent of the children with leukemia in this
country are treated at these children's oncology centers, and
they have a data base. So what we want to do next--and we're
waiting for the funds to do this--is working with--especially
the California oncology groups--working with them to search
their directories to see if we have Nevada patients who were
diagnosed in those centers. We have no pediatric oncologist in
Northern Nevada. So that all of the cases would be referred
out. Most of the cases from Fallon are referred to California,
and there is a pediatric oncologist that comes from California
to Reno on a regular basis and continues their treatment, but
the diagnosis is done in these oncology centers. So we will be
expanding that.
The second recommendation was to categorize the ALL cases
by clinically relevant biomarkers, and Dr. Prescott has
mentioned some of those. What happens is, we need to really
look at the leukemia tissue in order to do those studies, to
look at the diseased tissue. So what we have to do now is to--
many of the protocols of these oncology centers require saving
tissue specimens. So we are going to be in the process of
identifying each of the centers where the child was--where the
bone marrow biopsy was done and what kinds of testing were done
at that center. There are a number of tests that can be done.
The first broad test that's done is to identify two types
of lymphocytes. Which cancer is it? Is it B lymphocyte or is it
T lymphocyte? B lymphocyte cancer, or lymphoblastic leukemia,
is much more common than the T cancer, and our cases reflect
that. We have nine B-cell and we have three T-cell cancers. But
there are subdivisions of that. In other words, each of the B
cancers have subdivisions and very distinct analysis, which I
think we need to move forward on, to see if those genetic
breaks, those chromosome breaks are similar. Because if they're
similar, then they're more likely to be linked to the same
source, and that is a critical issue, that if we had known in
advance and collected, we would know of specimens. We do not
know whether we have those specimens available at the present
time.
No. 3 was to identify potential excess environmental
exposures unique to the community. Dr. Todd has told you that
we're in the process of that. Next week, members of the Centers
for Disease Control and the Agency for Toxic Substance and
Disease Registry will be here looking at all of the
environmental testing that has been recommended, seeing how we
can approach that and who's going to do it and how we're going
to do it, and also to do a pathways analysis to say, ``If there
are environmental chemicals that are toxic in the community, by
what pathway do they get to people?'' That's extremely
important for us to analyze.
The next recommendation was to collect and bank biological
samples for future study, and we are waiting funds for that. We
need to identify a repository for specimens. We would like to
collect specimens from the families, as well as the cases. The
technology is rapidly advancing, as Dr. Prescott said. So maybe
in 2 months we might be able to have a test that would tell us
something about causation. It's extremely important for us to
save those specimens, and we don't have a national sort of
comprehensive group looking at that, saying this is what we
have to do for every cancer cluster.
The fifth recommendation was determine time course and
characteristics of population movement into the Fallon area,
and that's to address this population mixing theory, which
was--it is just a theory, which came out of Britain after an
investigation of a number of clusters, and that is that a rural
population has an influx of people and, for some reason,
there's an increase in leukemia or cancer in that community,
and the reasons for it are very complex. In Fallon, that
particular scenario may exist. In other words, that we have a
small town relatively isolated and then the in-migration of
various groups, either through the military or others, that
come and go. So this is a possibility to test evidence for this
population mixing theory, which go well beyond what the State
of Nevada would do, but something that the National Cancer
Institute should be doing, identifying and--there is no
mechanism for the National Cancer Institute to give us funds
for research. Their budgets are to study months and years in
advance. So it's really important for there to be a
comprehensive plan, as we suggested, for a study to advance the
causation theory.
The last recommendation was to maintain the expert panel,
which they have.
Now, about the lessons learned--all of the panelists serve
without--we do not pay for them, they volunteer. They're
wonderful experts, and we have been really blessed to have
their interest, and they are volunteering to be here and help
us, and they have done a tremendous job. One of the lessons
that we have learned with regard to Federal agency roles in the
investigation of cancer clusters, although hundreds of cancer
clusters have been recognized and investigated during the past
30 years by State and local health departments and Federal
agencies, little information is available on appropriate
scientific methods of study, especially with regard to
determining the causative factors or associated risk factors.
Well over 90 percent of these investigations have found no
associated suspect causative agent, and no Federal agency wants
to expend scarce resources for the investigation of cancer
clusters that are likely to show nothing. It's an investigation
which you know that 90 percent of the time you will not find
anything. So there is a reluctance to invest resources in
something that has such a low probability of an outcome of
interest.
Senator Reid. Ms. Guinan, I think we're going to ask you
some questions and you'll be able to expand on the rest of your
statement. I'm going to make your entire statement a part of
this record. You've answered one of the questions the panel
already asked directly. We asked Assemblywoman de Braga about
what the Federal Government can do, and you've told us very
specifically. I would also just comment that 90 percent is
great, but if you're part of the 10 percent, you want to make
sure that's investigated also.
We're going to turn now to Admiral Naughton. I would say,
before you begin your testimony, to explain to Senator Clinton
and some of the audience who may not know, which I'm sure there
are very few--Senator Clinton, in Nevada, we have two very
large military installations, of which we're very proud. In the
southern part of the State, we have an air force base, Nellis
Air Force Base. It is the largest fighter training facility the
air force has in the world, and I'm told by everyone, most
important, if you want to have a Ph.D., so to speak, in the air
force and be a pilot, you have to go through Nellis. The same
applies if you're a Navy pilot. We have here in Fallon the
Fallon Naval Air Training Center, which is something we're very
proud of. Top Gun is here. It's something that has been great
for our State, but also certainly for our Nation.
We recognize how important it is to the State of Nevada,
but we're going to have some tough questions to ask when we get
to the part of this hearing when we ask questions. Admiral
Naughton and Captain Rogers has been through a lot of things in
their careers, and they understand we're only trying to get to
the bottom of things. We're going to ask questions about when
you weren't even at the base. So my point is, the directness of
the questions has no bearing on how important we feel your work
is here.
Admiral Naughton.
STATEMENT OF ADMIRAL R.J. NAUGHTON, FALLON NAVAL AIR STATION,
FALLON, NV; ACCOMPANIED BY CAPTAIN D.A. ``ROY'' ROGERS,
COMMANDER
Admiral Naughton. Yes, sir.
Senator Reid, Senator Clinton, Senator Ensign, and
Representative Gibbons, my name is Richard Naughton. I'm the
commander of the Naval Strike and Air Warfare Center, which is
located at NAS Fallon, NV. Here with me this morning is Captain
David Rogers, who's the base commander. We do welcome this
opportunity to testify before the Environment and Public Works
Committee on the military activity that takes place in Fallon,
in particular, how it may pertain to Churchill County's recent
childhood leukemia cluster. I'll talk a little bit about the
background that the Senator talked about, about the mission and
operations at Fallon, followed by some remarks that I know are
of special interest to the committee, and we look forward to
your questions afterwards. Let me assure the committee and the
local community members that the U.S. Navy is committed to
public health and to assisting this investigation in every way
possible.
One of the cases in question is the child of a military
family member who was formerly stationed at Fallon. Our base
population is about 7,200 personnel, which includes all the
military and civilians and their families, and of that 7,200,
three quarters live in the local community. So we're very
involved in the local community and we want to be sure that
we're part of this solution. The Navy's Bureau of Medicine has
just completed extensive screening of naval medical cases,
which might be related to the Fallon cluster. They reviewed
over 12 million records looking for cases of ALL from 1997 to
the present, and just the one Navy case that I've already
identified was the only one that we came up with.
The Navy is also committed to exploring the expert panel's
population theory--population mixing theory, and we have shared
data on the transient activity of NAS Fallon with the State.
This military data is one of the three transient data
collection efforts recommended by the expert panel.
As many of you may know, NAS Fallon began operation in 1942
as an Army Air Corps base. The focus at that time, until about
1984, was unit level air-to-ground combat training. When the
Navy established the Naval Strike Warfare Center in 1984, we
began
focusing on entire air wing training of about 1500 people and
70 aircraft in an integrated fashion. The mid-eighties also saw
the development of the Fallon Range Complex, an instrumented
military operating area flown over 6.5 million acres east of
Fallon. The majority of the land we fly over is unpopulated and
managed by the Bureau of Land Management. The Navy actually
only controls 204,000 acres. The third major change in the mid-
eighties was the out-sourcing of many of the functions on the
base. As a result, 55 percent of our current base population is
civilian contractors.
In 1996, with the closing of NAS Miramar and the Base
Realignment and Closure Act, all graduate level aviation flight
training moved to Fallon, with the arrival of Top Gun and Top
Dome from southern California and the establishment of a senior
two-star officer on the base as the commander of Naval Strike
and Air Warfare Center. As NSAWC, or Naval Strike and Air
Warfare Center, I report directly to the chief of naval
operations and provide oversight of the training of
approximately 55,000 personnel a year here at Fallon and at our
weapon centers and weapon schools at other fleet concentration
areas throughout the United States. Over the past 5 years,
flight operations have really only increased about 4 to 5
percent at NAS Fallon, with an average of about 40,000 flights
per year. There has been an investment in Fallon infrastructure
at NAS Fallon since 1984 of over $300 million.
I would like to discuss the specifics of our operations out
there, as they may affect this investigation. First, the
consolidation of all our training here in 1996 did not
appreciably change the way we conduct operations. As a matter
of fact, our two biggest years of operations at NAS Fallon were
in 1990 and 1991, preparing for Operation Desert Storm and
Desert Shield. From an environmental perspective, the flight
training that NSAWC conducts has changed very little in the
past few years.
Second, NAS Fallon's environmental, safety, operations, and
weapons departments are responsible for the administration of
all our environmentally-sensitive material. For anything we
use, there is a safety handling program and a way of disposing
it properly, where applicable. We follow the guidelines
established by Federal, State, Department of Defense, and U.S.
Navy agencies and are probably more heavily regulated than
anyone in the private sector. Programs such as our fuel
handling, air emissions, hazardous material disposal,
electromagnetic radiation effects, and installation restoration
are all inspected on a regular basis. We have received high
marks for compliance, and we've shared data on each of these
with the State Health Division and the expert panel. Next week,
when the Agency for Toxic Substance and Disease Registry
visits, we will share our data with them also.
Third is NAS Fallon's drinking water supply for the 3,000
personnel who work on the base and the up to 2,000 transients
that we have there at any one time. It is separate from the
city of Fallon's, but it taps into the same Basalt Aquifer, and
the water chemistry is essentially identical. The base tests
our water supply routinely and monitors for contamination of
the 8,000 acres of the air station property through the use of
218 environmental monitoring wells. No DoD activity-related
contaminants have ever been detected in the Basalt Aquifer or
leaving the base property. While the State and select panel
investigations have not established a link between Fallon water
arsenic levels with the leukemia cluster, these are a matter of
concern to our people and to the U.S. Navy, and we're working
very aggressively with the city to build a DoD/city of Fallon
water treatment facility.
My detailed written statement previously submitted contains
lots of information about NAS Fallon and it may be relevant to
this investigation, and it also lists points of contact. I
thank you for your attention.
Senator Reid. We would also order that that be made part
of the record.
We're going to now hear from the mayor of the city of
Fallon.
Mayor Tedford.
STATEMENT OF HON. KEN TEDFORD, MAYOR, FALLON, NV
Mayor Tedford. Thank you.
Recognizing that my time is brief today, let me begin by
saying that the city of Fallon sincerely appreciates the
efforts of the Senators and the Congressman and your staffs,
just as we appreciate the help that we've received from the
Governor's office and also from the State Health Division.
These are trying times for our community, and while we've
pulled together in the only way we know how, it is comforting
to know that others want to help. I'm not going to spend any
time discussing the cluster's cause or possible links between
the children. I believe the State Division of Health and others
will do that. The city has cooperated in every way we know.
First, as the steward of the municipal water system and, later,
as we began to assess other city-owned facilities. Thus far,
nothing has been found. We recognize that the health division's
expert panel believes that an environmental link may not be
found, due to the fact that the ALL found in this cluster
generally is not typically caused by environmental triggers.
Nonetheless, we will continue to cooperate in that search in
any way we can.
Our efforts, indeed, have been focused on the children, the
affected families, and public education. The city council and I
have formed a group called Fallon Families First, which is
comprised of local community leaders and social service
providers to coordinate these efforts. I asked my wife,
Jennifer, to chair that committee, and they're doing yeomen's
work. Please realize that our city does not have a social
service infrastructure. We're too small. So we've had to reach
out to groups like the FRIENDS Family Resource Center, the
local hospital, mental health professionals, the clergy, the
school district, the county, and others. Fund-raising is
handled through the Mayor's Youth Fund. You can see the white
ribbons worn by guests here today. This was a suggestion by a
mom of one of the patients. It's the latest step in our effort,
and we plan to continue raising funds as long as there are
needs.
Fallon Families First recently held its first public
meeting, a panel discussion focused on the disease itself.
Local physicians, a mother of a stricken child, a mental health
professional--these people, who people know and trust in our
community, helped answer questions that are weighing heavy on
the minds of those attending. Efforts like this will continue,
as they are needed. A series of informational mailings is also
being coordinated with the county and the local telephone
company. This week, the city launched its first website. Part
of this effort has been driven by not only the need to
communicate about the leukemia cluster, but part of our desire
was also to be generally more accessible.
So what remains to be done? I can tell you without
hesitation that the most frustrating part of this process for
me has been the lack of information. People want answers and I
don't have them. The investigation's ongoing, but it's bound to
take a long time. Where do people go for answers? I believe, in
cluster situations like this, a clear sense of communication
needs to be established early in the process. Perhaps if the
State health officer declared a cluster to be in existence,
that could trigger a Federal, State, and local partnership. The
mayor's office seems to be the place where people automatically
go, but in small towns like ours, we don't always have the
information people want. I have assembled my own team of local
citizens and other experts who can help the city, but in other
towns, the mayor might not be so fortunate. I think a standard
support team should be made available to towns like ours.
Finally, I would be remiss if I didn't speak briefly about
the arsenic in our water. I know the Senators are aware of this
situation, just as I know the experts will testify that
arsenic's probably not linked to this leukemia cluster, but the
two things have become linked in the media and in earlier
meetings. So I feel I, at least, owe you an update of where we
are today. Fallon's municipal water supply contains arsenic
levels of a hundred parts per billion. The USEPA has ordered us
to remove the arsenic, which is naturally occurring here in
Fallon. As you are well aware, the EPA standard has long been
under review. It was 50 parts per billion. It was temporarily
lowered to 10. Now it's back to 50. We have no idea where it
will finally be set. But for the city of Fallon, it doesn't
matter anymore. We are proceeding to treat and we will get
there.
The city of Fallon, through its environmental engineering
firm, Shepherd Miller, has begun pilot testing of the
technology we will use to remove this arsenic. It appears that
a filtration process called enhanced coagulation is working
best. We will finish the pilot testing by the end of May, then
we will design and site a treatment facility. Our goal is to
have construction finished in time to comply with the EPA
order, which gives Fallon until September 2003. This date is
significantly earlier than any other public water system in
America, and it's still not clear how much arsenic we will have
to remove. Nonetheless, we are proceeding, and we are doing so
without regard to cost or where the money will come from. We
also have been in consultation with the U.S. Navy and their
officials about a joint treatment plant.
My suggestion to this body today is that you make Fallon a
test case. The issue of the EPA standard revolves around the
best available science and the fact that there is no off-the-
shelf technology to remove arsenic on our level at our
municipal scale. Things like household reverse osmosis systems
won't work on a system as large as ours. We believe that since
Fallon is required to remove its arsenic more quickly than
other municipalities, there may be benefits to those who follow
from learning what we have. Perhaps the Federal Government
could pay for the cost of our treatment facility in exchange
for the availability of science and treatment methods resulting
here that could be utilized by all those who follow. We're
dedicated to treating the city water. Others will have to
address the many private county wells that have high arsenic
levels, and all of us will have to address public education
issues and outside media attention that now surround the
arsenic. But with your help, we can put this chapter in our
history behind us and focus all of our energies on this
leukemia cluster, the children and their families.
We must maintain our focus on these families. As I've said
earlier, this is a lonely time for our town. Many people want
to speculate, many others are well-intentioned in their
scrutiny, others are just curious, but when the camera lights
are off and the media attention fades, our families and our
town will be left to care for these children and assess the
long-term impacts of this cluster on our community. Your
presence here today is a chance to change that. I hope you will
be able to stick with us, and I thank you very much for taking
the time to be with us today.
Senator Reid. Thank you very much.
Commissioner Washburn.
STATEMENT OF GWEN WASHBURN, COMMISSIONER, CHURCHILL COUNTY, NV
Ms. Washburn. Good morning, Senators, Representative
Gibbons.
I'm Gwen Washburn, the chairman of the Churchill County
Commission, and I want to tell you that we've not had the phone
calls, I'm sure, that the mayor has, but we've been working
closely with him. I do want to tell you that the county
administration is, first and foremost, concerned about the
health and well-being of its citizens, and I'm happy to have
the opportunity this morning to address the leukemia cluster
that's been identified in this community and also to discuss
ways to investigate or mitigate the issue. I'll tell you a
little bit about Churchill County and what the county
commission is doing. You have several pages of written material
in your packet, and I'll attempt to summarize those at this
time.
Churchill County has sustained a steady growth of about 3
percent over the years and now is home to about 26,000 people.
This population is expected to double in the next 15 years.
We're a progressive small community, boasting modern schools, a
community college, an art center, and the most modern hospital
in western Nevada. We have a mix of long-time agricultural-
oriented families, military personnel, young working families,
and retired people. Many people are born here and grow old here
with nothing more than average health problems. So, our
community is alarmed and feels helpless in the face of a
childhood leukemia epidemic.
This community has reacted to this crisis in a quick and
calm manner, working cooperatively together with all agencies
in an attempt to find an answer or a common link between the
cases. The county commission is very concerned about the health
and welfare of not only our 26,000 residents, but those that
visit us each year as military personnel or tourists.
Certainly, none of us are experts in the health field, nor are
we research scientists. So we have no choice but to leave those
investigations to those experts, but what we can do and have
done and will continue to do is to support all scientific and
responsible efforts to find the answer. So far, we've actively
participated in all efforts of all the agencies in the
investigations and in the efforts to educate the residents and
to ease the burden of the affected families. We've assisted in
reactivation of the University of Nevada's Nevada GOLD Program,
which is Guard Our Local Drinking water, and we've also
tightened some of our own business permit ordinances for
business and industry.
We are anxious to locate and take reasonable and
responsible corrective action for any environmental cause that
may be found to contribute to the incidence of leukemia or any
other health risk in our community. A thorough and scientific
study of all the possibilities will take many years and
millions of dollars. The medical experts have already expended
many resources examining the patients and their families. The
community and individuals have all lent their support. The
State of Nevada is considering committing money. So now I will
ask you, on a Federal level, to commit Federal resources, and
there are many, but I'm going to list ones that I think at this
point are most important. No. 1 is to provide a funding
mechanism to assure proper medical care for the victims; No. 2
is to assure thorough scientific research through Federal
grants; No. 3, grants to the University of Nevada-Reno and
Churchill Community Hospital to assure continued public
education on health and nutrition; and No. 4, to assist
individual well owners with testing and treatment of water.
Best guess, this community has 4,500 domestic wells that our
citizens are relying on.
The written comments that you have before you will expand
on these thoughts and cover several others. So for the sake of
time, I won't go into all those comments, but I hope you'll
take the time to read and consider those, and I'll be happy to
clarify and expand upon any of those at your convenience.
On behalf of the Churchill County commissioners, I want to
thank you for taking your time to listen to our concerns and
our ideas. We sincerely hope that you'll be able to assist our
community in some way to ease the suffering of the leukemia
victims and their families and to help us find the ways and
means to lessen or, better yet, prevent more occurrences of
this and other cancers.
Senator Reid. Thank you very much. Your full statement will
be made a part of the record.
Before moving to questions of this panel, I would like to
say to those people who filled out the forms for asking
questions of the panel, if you'd be kind enough to pass these
cards to the center aisle, they'll be collected, so they can be
given to us following the third panel.
Dr. Guinan, we've heard testimony about the possibility of
this being a virus. Now, there's no danger of this being
transmitted--if a child has leukemia that, by chance, is caused
by a virus, there's no danger of that child transmitting the
virus to his friends, is there?
Dr. Guinan. No, there is not, there is no danger. Leukemia
is not contagious.
Senator Reid. That's so important, that people here
understand that.
Admiral one of the things I wanted to talk to you about, in
the written testimony that you've given and other people from
the Naval Air Station have given, you've indicated that in the
last 5 years there's only been 40 gallons of fuel spilled, or
words to that effect. I just want to make sure that the
record's clear, because I can remember spending a lot of time
out there 10 years ago relating to a spill of fuel. There was
some dispute as to how much had been spilled, from a thousand
gallons to 30 thousand gallons. We really never got to the
bottom of how much that was. Also, during that same period of
time, people came forward and indicated that there was fuel
contaminated soil that was burned for 5 or 6 days in a row at
the base. This spill and the other information is not part of
this record, it's simply not there, and much information has
been gathered up to this point.
I would like to have the Navy supply whatever information
you have to Dr. Guinan regarding these prior incidents. It's my
understanding, and I've read very clearly the testimony given
in the past, that this information has not been forthcoming in
this investigation. I'll also say, Admiral, that I don't know
if burning soil for 5 or 6 days would have any bearing. I
simply don't know. I don't know if the fuel spill would have
any bearing on the work that's being conducted here, but I
think it should be part of the information gathering, so that
Dr. Guinan and others will have this at their fingertips.
Admiral Naughton. Yes, sir, we'll provide that, the data of
the 1988-89 spills. There was lots of discussion on how much
was or wasn't spilled, where it went, and I know there was much
confusion. That's one of the reasons that we have these 218
environmental monitoring wells there right now, to be sure that
there's nothing--there's no pathway off the base. We will
provide that data.
The burning of fuel for 5 or 6 days, I think, perhaps is
local legend, sir, but we will find out in much more detail. We
can't find anybody that has any firsthand knowledge of that,
but we will provide all that data. Again, as I say, our
strategy is, we want--public health is our primary concern. We
want to be part of the solution, and we will cooperate fully
and provide all data humanly possible.
Senator Reid. I appreciate that very much.
It's my understanding, Admiral, that the Navy has, during
the past 4 or 5 years, used a different kind of fuel for the
jet airplanes. Is that true?
Admiral Naughton. Yes, sir. We've moved from JP5 to JP8.
Senator Reid. Can you tell me why you did that and what the
difference in fuels is?
Admiral Naughton. Well, JP5 has--it's actually an economic
issue--JP5 has a higher flash point and must be used on the
ships. JP8 is the airforce-based fuel. It's almost all
kerosene, with some additives. The only difference between JP8
and the jet fuel that's used in commercial airliners is that we
have an anti-icing ingredient that's added to it. So it's
essentially identical to what is burned in every airport around
the world, including Reno-Tahoe.
Senator Reid. Is it classified information, Admiral, as to
how much fuel is used at this base over a year?
Admiral Naughton. No, sir. We use about 40 million gallons,
about 50 percent of what they use at Reno.
Senator Reid. At the airport in Reno.
Admiral Naughton. Reno-Tahoe, yes, sir.
Senator Reid. The other question about the monitoring of
the wells--and Dr. Todd, Dr. Guinan, you can chime in here if
you feel it's appropriate. One of the concerns I have about the
monitoring of the wells is that I've been told that there's
really two areas of water that we need to look at here. The
first is the deep water, and that's what's being monitored----
Admiral Naughton. No, we're monitoring the shallow water.
The deep water in the Basalt Aquifer is where we get our
drinking water, but we monitor the shallow water wells.
Senator Reid. It's the shallow, at least in my opinion,
that we have to be concerned about----
Admiral Naughton. Yes, sir.
Senator Reid [continuing]. Because that water moves around.
Admiral Naughton. That's the pathway that we're looking
for, and we have not seen one--in the monitoring work between
the Nevada Department of Environmental Protection, they are
part and parcel of what we do there.
Senator Reid. The water that you talked about, you have 218
wells that the Navy monitors, itself, as to where the water
goes; is that right?
Admiral Naughton. Yes, sir. If there's any contamination,
we do test the deep water well routinely, just like the city
does.
Senator Reid. Senator Ensign.
Senator Ensign. Admiral, when they were talking about the
mixing, I just thought about something. In your investigation,
when you're looking at mixing of populations, we've heard about
the possibility that maybe a virus is one of the environmental
causes. During this period of time, when maybe some of the
exposures of these children to some people in the community
occurred, was there a certain part of the world that some of
our service personnel came from? Have they looked at trying to
isolate that? We know that there are very rare diseases in
different parts of the world that Americans are never exposed
to, and you can become a carrier without even knowing you were
already exposed. We should look at all possibilities.
Admiral Naughton. I'm afraid that it'd almost be an
infinite set. You know, you talk about 50,000 people coming
through here each year. We have been everywhere. Of my own
personal experience, I've been on almost every continent. The
people that come through here, it would almost be impossible to
track where they each have been. I'm not saying that we can't
look at it, but we can do some analysis with CDC and the naval
environmental health agency. We'll try and take that on, sir,
but I'm a little nervous that it probably would be such a huge
set of where they came from and what they did, and individually
tracking each individual is not something that we do because of
that, but we'll certainly look at it.
Senator Ensign. Dr. Guinan.
Dr. Guinan. Yes. I'd just like to say that the theory on
population mixing is one that suggests, perhaps, a viral cause,
but it's not a new virus or an exotic virus. The theory is that
it's a common virus and a mild virus that, for whatever reason,
there's been an abnormal immune response to and that follows a
community of relative isolation that has been exposed to the
virus before and maybe are a little older and have a different
response to the same virus. That's why it's so difficult to
find, we think, because it's a common virus, but an abnormal
response to the virus.
Senator Ensign. Has that community mixing theory, then,
been mainly of cancers in older people and not in younger
people?
Dr. Guinan. No, it's younger people.
Senator Ensign. It is.
Dr. Guinan. In England, there is a cancer cluster in an
area that's been ongoing for years, and they have put millions
and millions of dollars into investigation of causes, and
nothing has turned up. I think one of those things--out of that
observational analysis came the population mixing theory, and
as I say, it's just observational and a theory, but the expert
panel felt that we could provide evidence to support or refute
the theory with the cluster in Fallon, for a number of reasons.
No. 1, the timeframe between the cases was so short, that we
are a rural population with an influx of migration, and also
that, if we could look at tissue and demonstrate there was some
similarity, the more likely we could possibly say a virus is
more likely.
Senator Ensign. You were talking earlier about the B cells
versus the T cells and that even the subtypes of the B cells
being different in some of these cases. Does that not suggest
different genetic pathways, or could they all be the same
genetic pathway, and in the end, they branch off?
Dr. Guinan. Well, I believe that for the B cells--if we
thought they were linked and if they were all the same, we
would be much firmer in our belief that they're linked. Since
we really don't know what the cause is, we really don't know,
but I think the lines of evidence suggest that T-cell may be a
different type of etiology than B-cell, but the evidence is
still relatively sparse, and as I say, there really is no known
cause. So if we could come to, at least, some understanding of
the pathway, we would be more likely to pinpoint a cause,
whether it's environmental or infectious.
Senator Ensign. I want you to make one comment. It really
has nothing to do with the particular case today, but it raises
a question that we're dealing with in Congress where we're
talking about all this epidemiology. When you're dealing with
that whole issue, privacy is a big concern. We're hearing about
reporting and trying to make sure--especially for cluster
cases--to have rapid reporting. How do you relate that to the
concerns for privacy and how do you protect people's privacy?
We have to make policy concerning privacy, but at the same time
be able to share information to be able to solve some of these
cases in the future.
Dr. Guinan. That's a very important question, and I think
that it's raised each time we ask that a disease be reported.
As you know, the State has primacy in matters of health, and
it's the State who decides--the State legislature--what
diseases are reported, in what form. With cancer, there are
many people who do not want to be reported, because they want
privacy. All of the information that's reported on individuals
to health departments is strictly confidential. Nothing about
personal identifiers comes out of the health department.
However, in small communities like this, people know who the
people are and they're identified for fund-raising in the
newspapers, but no personal identifiers are ever revealed, and
that is one of the things that we have to do, and as a health
officer, I have to maintain that confidentiality.
We have HIV reporting by name, we have all sexually
transmitted diseases, we have cases of leprosy, tuberculosis,
all of those are reported to us, so we can do the appropriate
public health work that needs to be done around these diseases,
and they're all done and we haven't had a break of
confidentiality. In other words, we maintain it, we take it
very seriously. We have to deal with it now electronically,
since records are being transmitted electronically, and
understanding how you can guard the privacy and confidentiality
of records that are being transported over the Internet, there
are large Federal looks at that, on how to protect the
confidentiality of data.
Senator Ensign. Well, Dr. Guinan, we look forward to
continuing to work with you on this type of issue. I know it is
a big concern for a lot of people--to make sure they have their
privacy, but at the same time, to recognize there are public
health concerns.
Senator Reid. Senator Clinton.
Senator Clinton. Dr. Guinan--I don't know if I should say
this here in Nevada, but I understand you're actually a native
New Yorker.
Dr. Guinan. Yes. Could you tell by my accent?
Senator Clinton. Well, I also know that you've worked, in a
very distinguished career, with the CDC and with Dr. Phil
Landrigin--who's at Mount Sinai Hospital in New York--who is
very concerned about many of these issues that we're speaking
about today. Your written testimony is extremely enlightening
and informative, and I want to, through you, thank the expert
panel that served with you for putting in their time to come up
with the recommendations that they've put forth.
Dr. Guinan, as someone who has been on the forefront of
public health as you have and, I know, played a major role back
in the early 1980's in identifying HIV, AIDS, and recognizing
it as a new disease, what would be your priorities for us to
take back to Washington? Because one of the things that I'm
concerned about is that we really come out of this hearing with
some real priorities that all of us can take back to our
colleagues and tell them that this is a pathway for us to
follow in trying to get a handle on some of these issues,
because I think there are going to be more of them. Maybe it's
going to be better identification, better reporting, whatever
the explanation. I think we're going to have more and more of
these kinds of environmental health issues raised, clusters,
and other kinds of incidences.
What would you ask us to do and how would you rank the
priorities as to how we could respond to Fallon, but more
generally to these issues?
Dr. Guinan. Well, I have suggestions on two fronts. One is
on cancer cluster investigations. It seems to me that there is
no repository of information on this. There should be. We don't
know whether the clusters are increasing, decreasing, staying
the same, and we really don't know what the results of most of
the investigations of these clusters are, because there's no
mode of reporting, in other words, there's no reporting on
them. Sometimes they get published, maybe years after; in the
Woburn, MA case, for example, from the identification on the
cluster of leukemia to the final report was 18 years. In the
meantime, we cannot benefit from the ongoing information they
have gathered and advance the science. There may be 10 leukemia
clusters being investigated right now, but we don't know about
them, and I think it's extremely important to know that. In
other words, if there are similar clusters ongoing, are they
related, is there some relationship?
So the epidemiology of clusters should be done, not with
the idea that some Federal agency has to investigate each one
of them, but that there is some repository of information that
the States and local health departments can go to and know and
be able to contact those other people and find out what they're
doing and not have to reinvent the wheel, as Senator Reid has
said, that we can start from the most recent scientific
evidence and move forward, and we need resources and we need to
be able to identify those clusters that have the most potential
for advancing the science of causation--what are the
characteristics--and then some money to be able to put the
resources into those that are most promising.
With regard to environmental substances that are toxic,
there is no standard surveillance system for environmental
agents, and it seems to me that there should be. We're always
being asked about environmental agents, have we collected
information on air quality, water quality, food quality, who
collects it, how do they collect it, and no agency or group of
agencies have come together and said these are the basic units
of environmental surveillance that every health department
should have. We should have air, water, and these are the
things that we should have. Many States have particular
environmental health concerns, like Nevada, about radiation,
that we should have our own system also, besides the core, and
there is not this kind of thinking. There is the communicable
diseases. We know that there are communicable diseases and
everybody agrees that these are the diseases that we should
report, but there's no agreement on environmental. So I think
it's extremely important that some thought process go into it
and then some funding of infrastructure for the States to be
able to develop those systems.
Senator Clinton. Thank you very much. That's very helpful.
Admiral thank you for your being here and for your service.
This reminds me, back in my prior life, in the White House
years, I was asked to head up an investigation into the Gulf
War Syndrome, because we had so many service men and women
returning from the gulf with unexplained illnesses, and I met
with a lot of those veterans, I met with a lot of the people
treating them, and we've made a little bit of progress in
trying to determine why apparently very healthy young people
after their service--which really was of limited duration,
thank goodness, because the operation was so successful so
quickly--returned home with terrible rheumatic and other kinds
of diseases. So this is not only something that concerns
cancer, we have other concerns, and oftentimes our people in
the military are on the front lines of a lot of these
inexplicable diseases and conditions, and I appreciate that
very much.
One of the things I was curious about, though--it relates
to Dr. Guinan's point--is that just yesterday the EPA released
its new toxic release inventory data. We're trying to get a
better handle on what we do release into the air and what kind
of emissions and other contaminants might be available in the
environment. I was wondering, does the Navy and the other
services report releases to DoD and EPA or just to DoD? Do you
know that, Admiral?
Admiral Naughton. There's a lot of things we report. We
report the release of radio-nucleotides from our nuclear power
ships to DoE and DoD, and we report our release of chemicals
through DoD, and I, quite frankly, don't know for sure if we
report to EPA. I would be surprised--if it's not, it goes
through DoD, because, as you know, we're a pyramid structure
and we all work for somebody. It would go through DoD, would be
my guess on that, Senator.
You talked about the Gulf War. I'm very familiar with it. I
commanded a ship that was in Kuwait City. One of the very first
cases of Gulf War disease was an MS-2 that was on my ship. I
don't know why. I spent all day on the bridge and I didn't get
sick. He spent all day inside and he did. So I don't know. But
we do report all of our emissions and it is collected and it is
reported to DoD, and we work through the Navy, through the
Department of Navy health organization on everything we do.
Senator Clinton. Thank you.
Senator Reid. Congressman Gibbons.
Mr. Gibbons. Thank you, Senator.
Admiral I want to applaud you and Captain Rogers as well
for your contribution, not only to this Nation in terms of
making sure we are secure in our Nation's people and our
interests abroad, but also your contribution to this community.
The Fallon Naval Air Station, I think, has been one of the
premiere institutions that this community has oftentimes relied
upon for technology, for assistance, for help in times of
emergencies or whatever, and I do want to applaud you for your
effort to share the information with the Naval medical studies
that you're undergoing in this regard. I think that shows that
you're leading the way and that you're willing to be a working
partner in the solution to this. As somebody who has also
shared the technology of training in some of your facilities, I
also want to thank you for being there when we needed you. It's
always been very important.
I really don't have any questions for the Navy, other than
the fact that I did want to say that my understanding is that
JP4, JP5, JP8, all very similar, maybe except for, as you say,
the flash point temperature at which they ignite changed,
primarily due to safety. Jet Fuel A, without the de-icing
additive in it, is essentially the same as JP8.
Senator Reid. Jim, I think you're just showing off now.
Mr. Gibbons. I couldn't keep up with you guys in the
medical field. So I thought I'd tell you where I do have some
knowledge.
But, anyway, when you talk about fuel burned and the effect
of having a military aviation operation and comparing it to
Reno-Tahoe International, Reno-Tahoe does burn JP8, with the
fact they've got National Guard airplanes there that burn that.
So I think there's, you know, an interest there, but one which,
I think, will fail in comparison to say that it is the effect
of the operation of the airplanes that is a causal factor in
that, unless we start seeing clusters in Nevada in other
locations, whether it's McCarran, Reno, Fallon, due to the
combustion of this fuel.
That would be a question I would ask Dr. Todd. Have you
seen other clusters in Nevada like this that you've seen in
Fallon?
Dr. Todd. No, we have no other clusters at this time of
childhood leukemia. In fact, when I look at 1999 data
statewide, I find only 15 cases of childhood leukemia reported
throughout the State. If I go back over a 5-year period, I find
only 53 cases reported statewide. So, clearly, that's well over
half million 0- to 19-year-olds in my denominator coming to
Fallon, with less than a thousand 0- to 19-year-olds in the
county population. Having eight cases diagnosed in only 1 year
is clearly significant. We've not seen that elsewhere
throughout the State.
Mr. Gibbons. Let me turn to the mayor and the county
commissioner and thank them for their appearance here as well.
Mayor, I know that oftentimes we have read in the newspaper
that the city of Fallon is dragging its feet with regard to
dealing with arsenic removal, but I know you, I know the work
that this community has done, and just for the record, would
you help us by describing what the city has done in any effort
with regard to moving forward on the arsenic removal?
Mayor Tedford. Well, as you know, the arsenic issue goes
back to--I was a sophomore in high school in 1969, and the
discussion that began then--I certainly didn't start it, but I
will be the one that ends it in 2003, that discussion. I think
I could go back to the compliance agreement with the State that
we signed in 1990 that we would meet the permanent standard
when it was set. There's a lot of history, I think, that
doesn't really need to be gone through today, but it should
suffice to say, when we heard around 1997 that this standard
was finally going to be set, after 10 years of waiting, we
formed an arsenic team with the city. They went to various
venues around the country, to EPA-sponsored meetings on what
the standard might be and what the technology was. We had been
told that there was off-the-shelf technology that we could use,
and after those meetings in a variety of places, we found out
there was no off-the-shelf technology that could be used in a
city of our size.
In 1999, we got a violation order from EPA, and in 2000, we
hired Shepherd Miller of Fort Collins, CO, as our consultants,
and they began the chemical testing of the water. They have
gone through bench testing, they're at pilot testing now, as
well as looking for site selection at the same time, as well as
design. I think we're well on our way to being able to reach
the mandate that we've been given of September 2003. We've
expended an inordinate amount of money for a little town. Just
probably in the last year and a half, we've spent about
$400,000 with arsenic and its study and its treatment, as well
as expanding their work to include what's in our water that
could cause ALL, of which they have not found anything.
So a lot has been done, but it's not an issue to us
anymore. Actually in 1990, it wasn't an issue to us, because
the city signed an agreement that we would do this.
Politically, that might be a hard decision, because there are
lots of people in this community who would prefer that we not
do that, who feel that they're not being harmed by a hundred
parts per billion of pentavalent arsenic, but that's not the
decision we have to make. Our decision is to lower the arsenic
by September 2003, and that's what the city council said to do
and that's what we said to do, and we're going to do it. We're
just looking at you all to help us fund that, so we can do it.
There are some issues with an interim standard, because we
tried to seek out several funding sources, and with your help
and Senator Reid's, we've been able to get about $950,000 for
help with design and siting. We are trying to site that on
property we own, to save that money. We've been able to get,
through AB198, about $707,000. We have accrued about a million
dollars since 1990 to set aside for arsenic. But the bigger
problem is not just the building of the plant, but also the--
what some people lose sight of is, we spread those dollars over
2,800 hookups in the city of Fallon. This new standard of 10--
that's our goal to hit--really affects population sizes of
10,000 or less, as the Senator well knows from the recent
legislation of Senator Ensign, where there is probably limited
funds to do these sorts of thing. So this is an area where we--
even though out in Fallon, we like to be self-sufficient, we're
probably not going to be able to do that.
Senator Reid. Mayor, there's no question that's the reason
that Senator Ensign and I introduced the legislation 3 weeks
ago. There are a lot of Fallons around the country. I agree
with you. The standard has been set, and no matter what
standard we set, Fallon has a problem. So we have to get rid of
that. You were a sophomore in high school, I was a freshman in
the legislature when this problem came up in the 1969 session,
and we need to do something about it. If there is a thing that
will hurt Fallon and the surrounding areas, it's this arsenic
in the water, as far as growth. We've got to take care of that.
Whether it has any impact upon this cancer cluster at this
stage--we don't think so, but we certainly don't know--but
regardless of that, we're going to take care of the problem,
because, I repeat, there are a lot of Fallons around the
country, and we need to provide money to allow this water
system to be constructed. We're fortunate here in Fallon
because we have this great military installation here, and
there is simply no reason for the Navy to build a plant and
Fallon to build a plant, we're going to do one together.
Mayor Tedford. We're fully supportive of that.
Senator Reid. We hope sometime later this year to be able
to have more than just ``the check's in the mail.''
Mayor Tedford. I think you're absolutely right. I think the
cluster's heightened this and I think we've firmed our resolve
that we need to do this.
Senator Reid. We realize that Fallon is only a small part
of Churchill County, and we're going to have to make sure that
we provide some relief for the rest of the county, and that's
something we'll talk about later. It may not be done here.
We're not going to have a third treatment plant either. So
we're going to try to do something to remedy this problem for
the whole county.
One final question I have for you, Dr. Guinan. I don't want
to ask any questions about epidemiology. I understand over 50
percent of Nevada Health Division's budget comes from the
Federal Government. While the health division's total annual
budget increased in recent years, do you have sufficient
resources to devote to the cancer investigation and address all
the activities for which the division is responsible? In
effect, what I'm saying is, this must be a tremendous burden on
your budget. Is that a fair statement?
Dr. Guinan. Yes, it is a fair statement, Senator. The
Governor has given us carte blanche and said we will provide
resources to keep this a priority, but Dr. Todd has been taken
away from all his other epidemiologic duties and spends his
full time on the investigation, and he has an assistant who
also spends full-time on this, and that takes away from all of
our other--and I spend a great deal of my time also on it. We
have a very small health department and we're a small State.
This investigation takes a great deal of resources, and I can
only say, we couldn't have done it without the Centers for
Disease Control, who have been here since we knew about it,
helping us with the steps and finding out, getting the
resources that we need.
Senator Reid. It is a factor in your general budget. About
50 percent of it comes from the Federal Government, in some
form or fashion; is that true?
Dr. Guinan. I believe it's 85 percent.
Senator Clinton. Senator, could I just add one final
thought to what the mayor was saying? Because I really
appreciate what you said and the resolve that you've shown for
resolving this problem, and certainly both Senators Reid and
Ensign are going to stand behind you and try to figure out a
way to get some resources to you. But I just want to reiterate
what Senator Reid said, because our infrastructure needs for
clean drinking water around our country and for waste water
treatment are woefully underfunded, and part of the challenge
we face is providing help through Federal resources to
communities, such as you have here, so that you don't have to
go it alone.
It is a very big issue that is really on the horizon. It's
one of those issues that is not on the front pages of the
newspaper, but if we stop and look at what we need over the
next 25 to 50 years to make sure our drinking water is safe, to
deal with problems like arsenic, to set a standard and stick
with it, so that you can plan and know what you're supposed to
be doing, and to deal with, in more populated areas, like the
many that I represent, the waste water runoff that takes
pesticides and all other kinds of contaminants, as well as
sewage, into lakes and rivers and--I was, yesterday, on the
Long Island Sound--because beaches that people used to swim in
just 10 years ago are now closed permanently because of
pollution, because we don't have enough treatment for the
sewage that is flowing in.
So I think that what you said in your original statement,
Mayor, about Fallon being seen as maybe a model or a pilot
project is something that we ought to take seriously, and we
ought to find some other pilot projects around the country to
deal with these infrastructure needs. At the Federal budgetary
level, these are not issues that either individuals or
communities can handle on their own. They really do take all of
us to try to pull together to deal with problems that we know
we have. So I really want to thank you for your testimony and
for your response to the questions that have been asked today.
Senator Reid. Senator Ensign.
Senator Ensign. I want to discuss something about possible
areas of funding and getting more resources. I know we have
heard once or twice about the way that the water system of
Fallon water is a bit of an issue out here. We know that we
have a Superfund site upriver on the Carson River, between the
Truckee River and the Carson River since the beginning part of
the twentieth century. At least, we have those two rivers
coming together and dumping into Lahontan Reservoir. That was
fairly standard practice, I guess, kind of a ``flushing'' type
of, situation. We don't want to go into all the details of
what's happened in the last few years, but there has been a
change, in the way that the rivers flow. The question is: Is
there a change in the content of those rivers where they come
together? Can we maybe go after some of the Superfund money to
possibly investigate the possibility? Is that a place where we
could look for funding to investigate what's going on?
Dr. Guinan. Well, luckily, Senator Ensign, you have the
head of that agency who does the Superfund investigation, Dr.
Henry Falk from the Agency for Toxic Substance and Disease
Registry, on the next panel.
Senator Ensign. I guess we will ask that question to him.
Senator Reid. Congressman Gibbons.
Mr. Gibbons. Just one final brief comment here to the mayor
and the county commissioner. We're all aware that you have the
welfare of this community, the welfare of this county as your
No. 1 priority. The No. 1 priority would be the health and
safety of its individuals. The second priority, of course,
would be the economic welfare of this community. There've been
reports and people have called and said there's been an
economic impact, because of the adverse publicity that this
issue has given. We've heard testimony today, even
Assemblywoman de Braga has indicated, that the No. 1 issue
should be the welfare of these children. We all agree with
that, but since there are reports of that, since you've
probably heard the same statements, what can the community do,
in your opinions, both from the county and the city
perspective, with regard to dealing with the economic issues
that are addressed here?
Mayor Tedford. Well, you know, Congressman, I believe there
is an impact. There's no question. It just has not been, in the
City's view, the foremost issue right now. As you say, it has
been the families, but it is an issue that we know we need to
get to. I hear from people--like Mrs. de Braga said--realtors
that housing sales are down, contractors aren't building
houses. So you hear those concerns, and I think it is something
that we, as a city, are trying to develop now. We're trying to
gather information and knowledge and data from other places
that went through these things, like what we're going through.
We've even preliminarily planned to make site visits to some of
those places to ask, ``How did you handle your economy after
you, hopefully, were done worrying about your families?''
So I really don't have a hard answer as to what I think we
can do. I think we're probably going to need some sort of
economic development money to spur--if there is a lag here--to
spur growth back to where it was. But, in all honesty--and the
press have asked me that question many times--it is not an
issue I've spent a lot of time on, but that I plan on doing
very soon, because that's a critical issue. It's no different
than the families. I have four children under 10. So they're
all in Dr. Todd's factor of 0 to 19. I have to be worried about
every family.
Well, the same is true of business, and my responsibility
is to every business in this community. So that, indeed, is a
great responsibility that is going to take a lot of thought. I
think one thing that--if I was thinking of moving a company or
moving my family to a community, I would want to know, first
and foremost, this community had a problem, it addressed it, it
didn't deny it was there, and it helped those families that
were suffering, and, to me, that would go a long way as far as
easing some of the economic damage that's maybe being done.
Commissioner Washburn may have a different take on that than I
do, but I am hearing those same comments that I'm sure you're
hearing too.
Senator Reid. Commissioner Washburn, do you have anything
to add?
Ms. Washburn. Yes. I agree that there definitely is an
economic impact that has come with the notoriety that this
issue has brought to the community. One thing that I think
you'll find in my written portion here is that I've asked that
there should be some Federal funding to underwrite some low-
interest, maybe some longer term loans for the businesses that
are being proven to be hurt by this. That is one possibility.
We are attempting to help ourselves as much as we can. The
Churchill Economic Development Authority is working very hard,
and I've attended many meetings on this, on what we are calling
a visioning program at this point, but we're exploring ways to
put the community in a more positive light for people that are
looking to put their businesses and small industries in this
area, ways that we can attract those people and overcome this
problem and make it a positive place for them to be. We are
working with that. The other thing that comes to mind is just
basic cooperation between the city, the county, neighboring
counties, legislators on all levels. We just need that
cooperation, and if we can all talk to each other, I think we
can get through this and our business and industry can come
back the way it was.
Senator Reid. Thank you both very much. The whole panel has
been outstanding. We appreciate your being as candid and
forthright and informed as you are.
Senator Reid. We're now going to hear from Panel III, Dr.
Henry Falk, who is the assistant administrator for the Agency
for Toxic Substances and Disease Registry. We're going to hear
from Dr. Thomas Sinks, who's the associate director for the
National Center for Environmental Health, Centers for Disease
Control and Prevention. We're going to hear from Ms. Ramona
Trovato, who's the director for the Office of Children's Health
Protection, U.S. Environmental Protection Agency. Finally,
we're going to hear from Shelley Hearne, who's the executive
director of the Trust for America's Health.
Dr. Falk heads the Agency, as I've indicated, for Toxic
Substances and Disease Registry, serves under the director of
the Centers for Disease Control. This was established in 1980
under the Superfund law for the purpose of studying and
tracking the health effects of exposures to hazardous
substances at Superfund sites and other hazardous waste sites
and recommending interventions for public health.
Dr. Falk.
STATEMENT OF HENRY FALK, ASSISTANT ADMINISTRATOR, AGENCY FOR
TOXIC SUBSTANCE AND DISEASE REGISTRY, ATLANTA, GA
Dr. Falk. Thank you very much, Senator Reid. Good morning
to you, Senator Reid, and members of the committee. My name is
Henry Falk, and I'm the assistant administrator for the Agency
for Toxic Substances and Disease Registry, or ATSDR, as we've
shortened it. Dr. Aubrey Miller, unfortunately, was detained by
a snowstorm coming out of Denver and apparently will not be
able to make it here this morning. I have spoken to him in
advance of this session.
Thank you for inviting us to speak this morning. We share
your concerns about the health and well-being of children and
families in Fallon and across the country. Certainly, the
testimony this morning was very moving, and it must serve as a
spur to all of us in government to do our very best. We also
share your desire to adequately address the concerns expressed
about illness and disease that might be associated with the
environment.
As you noted, our agency was created by the Superfund
legislation. As such, we are an agency charged with determining
the nature and extent of health problems at Superfund sites,
including Federal Superfund sites, and advising the USEPA and
State health and environmental agencies on needed clean-up and
other actions to protect the public's health. ATSDR, of course,
works very closely with the EPA through our Superfund
responsibilities. We also work very closely with our DHHS
sister agency, the Centers for Disease Control and Prevention,
and, jointly, we will work with the Nevada Health Division to
assist in investigating the cancer cluster in Fallon. For our
part, ATSDR will assist in the investigation by reviewing all
relevant environmental data for toxic substances and assessing
whether people have been exposed to any of these contaminants
at levels of concern.
Unfortunately, the cancer cluster in Fallon is not a unique
situation. Increasingly, we at ATSDR are being asked by State
and local health departments to help respond to compelling
community concerns about apparent outbreaks of serious,
noninfectious diseases with unknown cause. We work closely and
collaborate with State health departments and have been funding
environmental public health activities in States since 1987. We
currently fund programs in 28 States to assist in carrying out
Superfund responsibilities, including cancer cluster
investigations and activities related to concerns about
hazardous waste and exposure to toxic substances.
The site work we do directly or through our State partners
has changed somewhat over time. Our original mandate under
Superfund called for public health assessments at all National
Priorities List sites, and these constituted the great majority
of our workload. While we still are heavily engaged at NPL
sites, increasingly our site work now is also occurring at
immediate removal sites, active waste sites, occasionally
Brownfield sites, and, like Fallon, sites where communities,
States, or congressional officials have asked or petitioned the
ATSDR to participate in the investigation.
I know you are familiar with some of our activities through
our work in Libby, MT, and Elko, NV, where individuals were
exposed to tremolite asbestos through vermiculite mining and
its effects, and I don't want to review all of that, but we
were very actively involved in the medical screening of over
6,000 people and providing information back to them. In
followup to remarks that were made on the last panel, we have
been working--particularly in the Libby area, but also
elsewhere--with local, State, and Federal health care providers
to address health care concerns that arise, specifically to
help local residents obtain medical care. We've worked closely
with the Department of Health and Human Services' regional
health administrator and other DHHS agencies, such as HRSA, to
ensure appropriate treatment is available.
Such partnerships are critical to providing needed health
services in such areas as Libby, Elko, and now Fallon.
Partnerships are also critical to fully assessing the true
existence and potential cause of disease clusters. ATSDR and
CDC, in this respect, are reviewing and responding to the Pew
Environmental Health Commission Report. The report recommends
strengthening Federal, State, and local public health capacity
to tackle environmental health problems and establishing a
nationwide health tracking network for chronic diseases and
related environmental hazards. We have made significant
progress at ATSDR in developing registries of individuals
exposed to specific substances, and we will work on the issues
raised by the Pew Commission as well.
In keeping with the Superfund mandate to establish and
maintain a national registry of serious diseases and illnesses,
we at ATSDR see ourselves as having a direct responsibility
under CERCLA to participate with CDC and others in developing
disease surveillance or tracking systems, particularly for
diseases with known or potential relationships to hazardous
waste and toxic substances. Because of our close working
relationship with EPA, we are particularly interested in the
ability to link health data sets with environmental data sets.
We recognize that more could be done. The public naturally
becomes concerned when they see situations such as half of a
class of third graders needing to bring asthma inhalers to
school or children suffering from cancer or other health
problems. We at ATSDR are committed to doing what we can to
address these very real concerns. We work every day at sites
around the country to address the concerns of communities
affected by toxic exposures. We work with our colleagues at CDC
to address the issue of health and disease tracking, and we
continue to strengthen our ongoing partnerships with Federal,
State, and local agencies.
On a personal note, just briefly, I started my professional
career at CDC as a pediatrician in 1972. My first investigation
in 1972 was of a leukemia cluster in Elmwood, WI. I did several
such investigations over the next 18 months, none of which
revealed an obvious cause for the clusters. However, my fourth
or fifth such investigation was of four cases of liver cancer
in a factory, which turned out to be the first reported cases
of vinyl chloride-induced liver angiosarcoma in polyvinyl
chloride polymerization workers. This subsequently led to much
improved and safer working conditions for the entire industry
worldwide. I have seen personally how agonizing and frustrating
this work can be, but I also feel that if we are in the mode of
carefully scrutinizing health data, then we will be positioned
correctly to detect new problems as they arise.
This concludes my testimony. Thank you very much.
Senator Reid. Doctor, I'm sure it's a comfort to the
parents of the children who are sick here to recognize someone
as well qualified as you doing the work that you're doing. So
I'm glad that you're here.
We're going to now hear from Dr. Thomas Sinks. Dr. Sinks is
a member of the State Health Division Expert Panel. He's
already been of great service to the State health division. He
represents other Federal agencies besides ATSDR. He's most
active in assisting cancer cluster investigations and
addressing environmentally-related community health concerns
with the Centers for Disease Control and Prevention.
Dr. Sinks.
STATEMENT OF THOMAS SINKS, ASSOCIATE DIRECTOR FOR SCIENCE,
NATIONAL CENTER FOR ENVIRONMENTAL HEALTH, CENTERS FOR DISEASE
CONTROL AND PREVENTION, ATLANTA, GA
Dr. Sinks. Good morning, Senator Reid, and other members of
the committee. I would like to say that I'm delighted to speak
before you on this issue. This is an issue which is very
important to many people, as can be seen by the media's
attention and all the people here from the community.
I want to begin by assuring the people of Fallon and the
parents whose children have been diagnosed with cancer that we
at CDC are committed to the health and well-being of children.
We are encouraged by the wonderful improvements in the clinical
treatment of childhood cancers. Still, as has been said before,
we need to identify the preventable causes of these diseases.
Let me assure you, chance has never caused one case of cancer.
CDC has been providing technical assistance to Nevada since
July 2000, and we will continue to do so, as you heard this
morning. I won't go into the details of that. It's in my
testimony. Perhaps someday we'll know how to prevent ALL, just
like we know today that folic acid prevents neural tube
defects. Whether or not we identify the cause of ALL, we need
to assure the families of Fallon about the safety of their
community.
I'd like to say a few words about cancer clusters in
general. Public health agencies are challenged by the large
number of public inquiries. Thousands of perceived cancer
clusters have been reported. More than 2000 published newspaper
articles from January 1990 to January 2000 contained the words
``cancer cluster.'' A survey of 41 State health departments
found that they registered about 1900 cancer inquiries in 1996
alone. Public health officials are expected to identify and
remove the cause of each cancer cluster. Yet, only 10 percent
to 15 percent of cancer clusters investigated actually find an
excess of cancer cases. Of these, only a handful have led to
discoveries of preventable causes of cancer.
Cancer clusters do provide an opportunity for cancer
prevention and control. Cancer education and screening programs
are important tools and can be used effectively in some cancer
cluster circumstances. Occasionally, scientific investigations
of clusters do lead to cancer prevention discoveries. I want to
point out that most of these have come from the observations of
clinicians working with patients. Another opportunity to
protect human health occurs when a cluster coexists with a
hazardous level of an environmental contaminant. In such
circumstances, removal of the health hazard is prudent, whether
or not it's related to the cluster. Cancer cluster activities
in the CDC have included field investigations, a conference on
clustering of health events, and technical assistance to health
departments.
In 1991, CDC published a set of standard investigation
procedures for investigating chronic disease clusters, and that
has been distributed to all States and is available on the CDC
website. CDC also funds State-based cancer registries, which
is, in my mind, the essential tool for evaluating inquiries
about too much disease. The Nevada Cancer Registry has received
more than $1.4 million from CDC from 1994 through 2000. CDC
also conducts exposure assessments and epidemiologic studies
that evaluate how people are exposed to hazards and identify
preventable causes of cancer.
I want to emphasize that State health departments are on
the front line of cancer cluster evaluations, and being
responsive to the public is the single most important element
to this. Three additional ingredients to enhancing responses
include infrastructure, scientific credibility, and
coordination between agencies. Essential infrastructure
elements are timely chronic and childhood disease registration
and linking health and environmental data bases,
recommendations supported by the Pew Environmental Health
Commission. One significant advance is taking place with the
creation of a national children's cancer registry through the
Children's Oncology Group and funded by the National Cancer
Institute. It will register all children with cancer at the
time of diagnosis and collect specimens at that time.
Last month, CDC released the first national report on human
exposure to environmental chemicals, providing baseline
concentrations of chemicals in the blood and the urine of
people in the United States. We plan to use this technology to
assist the investigation in Fallon.
Scientific credibility requires staff at the State level
having expertise not only in cancer, but also in epidemiology,
statistics, toxicology, and other matters. Independent review
by expert panels ensures the credibility of cluster
investigations. Scientific credibility and direction could be
further enhanced by directing priorities for future cancer
cluster investigations based upon hypotheses for why cancers
might cluster. A working group to establish such priorities is
sorely needed. The successful collaboration in Fallon has not
only included State health and environmental agencies, the CDC,
ATSDR, NCI, the Fallon Naval Air Station, and researchers from
the University of Berkeley and Minnesota, but also the
willingness and interest of the people of Fallon and their
appointed officials.
Thank you, Mr. Chairman and members of the committee, for
the opportunity to testify before you today, and I'll be happy
to answer any questions you might have.
Senator Reid. Thank you, Doctor.
We're now going to hear from the director of the Office of
Children's Health Protection, Environmental Protection Agency.
Ms. Ramona Trovato is the director and one of the office's most
experienced health officials. She will focus principally on
EPA's activities relating to the effects of environmental
pollution on children, including coordination with the Centers
for Disease Control, the National Institute of Health, and the
National Institute for Environmental Health Sciences.
Ms. Trovato.
STATEMENT OF E. RAMONA TROVATO, DIRECTOR, OFFICE OF CHILDREN'S
HEALTH PROTECTION, ENVIRONMENTAL PROTECTION AGENCY, WASHINGTON,
DC
Ms. Trovato. Good morning, and thank you.
I am Ramona Trovato, and I'm the director of the Office of
Children's Health Protection at the USEPA. I'd like to start by
saying it's very distressing to me that 12 children in this
community are suffering with leukemia, and my prayers certainly
go out to them and to their families.
EPA's mission is to protect human health and safeguard the
environment. We do this by controlling the amount of
contaminants that go into the air we breath, the water we
drink, and the food we eat. We can only do this in partnership
with the States. We partner with them on both public health
protection and environmental protection, and about half of our
budget is sent directly to the States for their efforts to
protect human health and the environment. This partnership is
absolutely necessary, we believe, to address human health
issues that are related to environmental factors, and it has to
be a partnership at local, State, and Federal levels.
Today, I'd like to discuss the governmental efforts to
protect children from environmental risks, I'll then give an
example of how we responded in the past to a community problem,
and, finally, I'd like to close by offering some thoughts about
how we can work together to help in Fallon.
Over the last 4 years, Federal agencies have joined
together to focus on three specific childhood illnesses that
have environmental links. These are asthma, developmental
disorders, and childhood cancer. Asthma affects about 5 million
children and is the leading cause of hospitalization of
children in the United States. Developmental disorders are the
leading cause of lifelong disability, and childhood cancer is
the leading cause of disease-related mortality in children.
Many of the factors that contribute to asthma, developmental
disorders, and childhood cancer are unknown. Therefore, the
Federal Government is focusing on research to better understand
how these environmental factors contribute to childhood
disease.
The EPA and HHS are funding eight centers for the first
time to investigate the effects of environmental factors on
children's health.
The National Cancer Institute is conducting a good deal of
research into environmental factors that influence childhood
cancer and is developing a national registry of children with
cancer.
Congress authorized the Child Health Act of 2000, requiring
a longitudinal cohort study, which is a long-term research
study to examine the impact of environmental pollutants on
children. As the Framingham study provided us most of what we
know about heart disease, this study could be the watershed in
understanding how environmental factors affect children's
health. Where we have sufficient knowledge to act we have
developed strategies to address environmental health concerns.
These strategies are primarily directed to reducing asthma and
lead poisoning in children in the United States. We're also
working directly with communities and States to respond to
their specific child-related health concerns. Currently,
government agencies work informally together to address cancer
clusters. State public health departments are the front line,
and they go out and investigate first. If they want additional
help, they contact CDC or ATSDR, and finally EPA may be
contacted if they want an environmental assessment done.
In 1996, due to public concerns about high rates of
childhood cancer in Tom's River, NJ, ATSDR and the State of New
Jersey conducted a study. They found a contaminant in drinking
water wells from a nearby Superfund site. This contaminant was
identified by EPA, and we required the company responsible for
that contaminant to put a carbon treatment system on the wells
that were contaminated. There is no detectable amount of this
contaminant in their wells at this time, and we are still
conducting and overseeing studies to determine if this
contaminant is a carcinogen and may have contributed to the
cancer cluster.
Through the Superfund program, we work closely with ATSDR
to respond to environmental hazards and associated health
risks. Communities petition ATSDR for a community health
assessment and they can request a preliminary assessment
through EPA of environmental conditions there. If the
environmental assessment indicates a problem, we can take steps
to address that problem. EPA also helps communities address
public health threats in drinking water through the Drinking
Water State Revolving Loan Fund. This fund provides money to
States for financing drinking water infrastructure projects.
The program recognizes and emphasizes the needs of small
systems, in particular, and those that serve fewer than 10,000
residents.
On a national level, I would like to suggest five actions
to make environmental health protection a priority. The first
is to formalize the cancer cluster response approach to address
cancer, as well as other environmental health problems. Second,
I'd like to see the State and local public health
infrastructure bolstered to respond to environmental health
threats. I'd like to see a strengthening of the relationship
between environment and health departments at all levels of
government. I strongly support a national tracking system of
chronic diseases. So we can understand where those diseases are
occurring and, if possible, look for associations with
contaminants in the environment. Finally, I think it's
absolutely necessary to conduct this longitudinal cohort study
to understand environmental factors that affect children's
health.
Finally, I'd like to address how we at EPA can support
efforts already underway in Fallon. We would like to work
closely with the city of Fallon, the ATSDR, the CDC, and the
State of Nevada to conduct environmental assessments. We can
sample, analyze, model, and cleanup environmental hazards. In
fact, EPA's Las Vegas laboratory has already offered to conduct
analyses of chemicals that are not typically found in drinking
water to help
understand what else may be here. ATSDR and EPA have also
established pediatric environmental health specialty units in
nine locations around the country. These are a first. These
units provide sources of information for doctors, nurses, and
parents about
environmental health threats and how they affect their
children. In addition, these units will actually see children
who have been affected. The closest one to Fallon is at the
University of California at San Francisco.
Thank you for allowing me to address this committee and the
community of Fallon. I hope that, together, we can make a
difference and prevent this in other communities. I'll be happy
to answer any questions.
Senator Reid. We will get to some questions in just a
minute. We're now going to hear from Dr. Shelley Hearne,
executive director of the Trust for America's Health. Dr.
Hearne has been involved with the Pew Environmental Health
Commission. Last year, this commission issued a comprehensive
report supporting enhanced tracking of chronic diseases in this
country and the coordinated and enhanced capacity of the
Federal Government to support cancer cluster investigations and
to respond to environmentally-related community health
concerns.
The most amazing thing I saw in your testimony is that
you've been doing this for more than 20 years. So I think we
should notify the Department of Labor for child labor
violations.
STATEMENT OF SHELLEY HEARNE, EXECUTIVE DIRECTOR, TRUST FOR
AMERICA'S HEALTH
Dr. Hearne. I appreciate that comment, thank you. Thank you
for this opportunity to come to Nevada and have a candid
conversation about our Nation's ability to respond to clusters.
I do serve as the executive director of the Trust for
America's Health, which is a new health advocacy organization
committed to protecting the health and safety of our
communities, and we are proud that several members of our
advisory council are former colleagues of yours--Senator Lowell
Weicker, Congressman John Porter, and also Congressman Louis
Stokes. They strictly told me not to use the word epidemiology,
you'll be happy to know.
Senator Reid. I'm more happy than you can imagine.
Dr. Hearne. I did recently serve as the executive director
of the Pew Environmental Health Commission at the Johns Hopkins
School of Public Health. It was a blue-ribbon panel charged
with developing recommendations to improve the Nation's health
defenses, and I appreciate all of my colleagues here from EPA,
ATSDR, and CDC for their comments and thoughtful consideration
of how to incorporate those recommendations in the agencies'
activities.
No child or community should suffer like this, and my heart
certainly goes out to the families of Fallon, but as a young
health scientist, I am growing actually quite angry watching
this story repeat itself across the Nation. As Henry Falk
noted, Fallon is not alone. In 1997, there were almost 1100
public requests to investigate suspected cancer clusters in
this Nation. My job as the last panelist, and I guess what
holds us all before lunch, is to actually deliver some of the
bad news, that our public health service is actually falling
short in its duty to watch the health of this Nation,
particularly when it comes to chronic diseases that may be
associated with environmental factors.
We are seeing this all across the country. Back in my home
State of New Jersey, parents in Brinck Township complained to
health officials about a feared autism cluster. It took almost
5 years for the health officials to confirm a cluster of 60
cases, because no one tracks autism in this country. In Elmira,
NY, 40 students have been diagnosed with cancer who attend a
local high school. I can go on and on with stories. Chronic
diseases account for 7 out of 10 deaths in this Nation, but we
still have no adequate system in place to detect these
diseases, nor the ability to effectively respond. Our health
agencies only coordinate tracking infectious diseases, such as
polio and typhoid, diseases that a national tracking and
response system helped to eradicate in the nineteenth century.
Over a hundred years later, we still have not updated our
public health system. Our health specialists remain in the dark
with no resources and unable to find the solutions to today's
health threats.
Let me give you a few examples of what's happening here in
Nevada. Birth defects are the No. 1 cause of infant mortality.
Yet, Nevada does not have a birth defects registry, nor does
Nevada track respiratory and neurological diseases, such as
asthma and Parkinson's. Nevada's cancer registry consistently
fails to meet national standards. Nevada is the only State that
charges its hospitals as the only forum of reporting cancer
cases. It's a perfect formula for poor performance.
See why I'm last?
The problem is, Nevada is not unusual. It's actually quite
close to the norm. To solve this problem, the Pew Commission
proposed a nationwide health tracking network. Here are a few
of the basic components: First, we need to build on the
existing infectious disease data systems that track priority
chronic diseases and related environmental factors. This would
include diseases such as childhood cancer, asthma, and multiple
sclerosis. Next, we need to develop an early warning system
that would alert communities to health crises, such as lead,
pesticide, and arsenic poisoning. Third, we need to improve our
response to identify disease clusters by coordinating health
officials into rapid response teams to quickly investigate
these health problems. Each State should have a chronic disease
investigator. Most States, like Nevada, do not.
This network is the key to developing prevention
strategies, which is the most effective way to reduce the $325
billion a year that we spend on chronic diseases. The estimated
cost of a network is about 275 million, less than a dollar per
person and about .01 percent of our expenditures on chronic
disease. The NIH budget is being doubled. Yet, most of those
dollars are not going to discover the most basic information
about why these diseases occur, where they strike, and how to
prevent future diseases. Ironically, the administration is
proposing cutting almost a quarter of CDC's chronic disease
program. Americans care immensely. Nine out of ten registered
voters support the creation of a nationwide health tracking
system, and even in today's economic climate, 63 percent feel
that public health spending is more important than getting your
money back, it's more important than cutting taxes.
Most local health departments have faced declining funding,
inadequate training, and limited laboratory access. In
addition, they receive minimal guidance from Federal agencies
on identifying and responding to clusters. CDC and ATSDR must
be directed to aggressively respond to communities like Fallon
with modern tracking systems and investigators who can take
action, and Congress must prioritize the real sources to make
this happen. Without this kind of commitment, we're going to
watch asthma, cancer, and other disease clusters grow and there
will be many more Fallons, and perhaps that's the greatest
tragedy.
Thank you.
Senator Reid. Dr. Hearne, thank you very much.
Dr. Falk, I'll direct this question to you, but perhaps the
other panelists could help. One of the things I'm concerned
about and I've heard from the community is that this disease
that has stricken these families leaves these families and the
rest of the community without any real help to work through
these problems. You know, if there's a suicide in a school, we
have people trained around the country that come forward and
help. Is there anything that we have on a national level to
help communities like Fallon to meet the emotional needs that
families have, in addition to their physical needs?
Dr. Falk. We at ATSDR do some of this around Superfund
sites. We have very active community education programs. We
work both with members of the community, as well as with
professionals in the community. We even have programs with
psychologists in the sense of stress management programs that
we can do, when indicated. So we try to actually do that, but
we don't do that beyond the Superfund program.
Senator Reid. You acknowledge, though, that these families
have a need in addition to making sure their kids get to a
physician and take care of their physical needs. I think it's
something that we have to keep in mind in this very complex
society, that we have some resource we can call upon for this.
Dr. Falk. I think there are several aspects to this.
Probably the most frequent question we see around hazardous
waste sites is, How will we provide for medical care for those
who are affected by toxic substances? As you know, as far as we
are concerned at ATSDR, our mandate relates to advising and
studying public health issues, but we have no mandate or no
authorization to provide actual medical care. What we are
trying to do at the moment is to creatively partner with other
HHS agencies to see whether existing Federal programs, whether
regional offices of other Federal agencies can be applied to
situations such as Fallon and elsewhere. So I think that we
would like to see existing programs be able to be developed so
they'll be applicable in situations such as this.
Senator Reid. Yes, Dr. Sinks, please.
Dr. Sinks. If I could just add a brief comment. The day
after I returned to Atlanta from the expert panel meeting, I
received from Dr. Mary Guinan a request to identify resources
to help the community deal with the mental health stress that
they were having in terms of dealing with this extraordinarily
difficult situation. I think it is a----
Senator Reid. Were you able to identify any?
Dr. Sinks. We tried to look at the National Institute of
Mental Health for resources. We do have a psychologist on our
staff who deals with refugee health issues in the Third World,
and Dr. Falk at ATSDR has a staff person who does help with
Superfund communities on these issues and we linked her into
the situation. I've not followed up to see where that is. I do
know that there are some mental health professionals in the
community working with members of the community.
Senator Reid. It's obvious from watching the movie ``Erin
Brockovich,'' which was based upon a true story--I spoke to the
lawyer who handled that case, and one of the big problems they
had after they identified there was a problem there is dealing
with the emotional problems of all the families that had, for
many, many years, thought that their disease just came out of
the sky someplace, when in fact it was Chromium 6 that was
afflicting them. So, anyway, that's a problem we have to
acknowledge.
I want to direct a question to you, Dr. Falk, or maybe Dr.
Sinks. I'm fascinated by the studies that we have as to this
maybe being a population mixing problem. There's no better
example of this in Nevada than in Fallon, unless, perhaps,
Nellis. We have people coming literally from all over the
world, we have people staying here for short periods of time
and leaving, and we have population exposures taking place
here. What we heard earlier is that there simply is no method
to do the tracking, and I'm wondering if you have a reaction to
this--in fact, anyone on the panel, other than Dr. Sinks and
Dr. Falk. Is there any way we could do a better job? I mean--
and we've got the parents over here--we should find out about
it, it shouldn't be too difficult to do. We should do it, if
it's possible to do the tracking. Can we do this?
Dr. Falk. One of the things that I have noted over the
years is that most clusters are identified by members of the
community. Occasionally by physicians, but very often the
people themselves recognize that a problem is occurring. We are
remiss in the sense that somehow the health care data systems,
or tracking systems, call it what you will, ought to be
identifying these kinds of situations proactively and arranging
to deal with them. I assume that many clusters are not even
brought to anybody's attention, because there is no system that
identifies them. So, yes, I think we could do a much more
organized effort to actually identify the distribution of
cases, look for clusters or uneven distribution of cases where
the rates are very high and actually explore those in a more
systematic way and in a more uniform way.
Dr. Sinks. Allow me to add to that.
The Kinley hypothesis you're referring to is
extraordinarily interesting. I view it as one of those
hypotheses that we ought to be searching for and targeting for
research. This theory is very interesting, but, we've not
really come up with a way to scientifically put it to the
test--prove it correct or false. Perhaps we might pull together
experts specifically to work at that hypothesis and come up
with a plan for testing. The second is that we fund extramural
research through the National Cancer Institute. I think there
is a role for extramural research in cancer clusters like this.
There are wonderful researchers out there in the academic
community, two of which are on our expert panel.
Senator Reid. Senator Ensign.
Senator Ensign. Dr. Sinks, when we talk about clusters,
statistically, what are we talking about here? What makes
something statistically significant to become a cluster?
Dr. Sinks. I'm always troubled by the word cluster. I get a
number of phone calls from the public, from the media, from
States, a variety of places--and let me say that I really enjoy
speaking to those people about their issues. The word
``cluster'' seems to be something that is defined differently
from one person to the next. In my mind, in the simplest sense,
it's the concept that we're observing more cases of some
disease than we would expect to see, given our baseline
information, which we hopefully have, and we do have that for
cancer. For many of the cancers, we do have population----
Senator Ensign. But that's what I'm saying. Then at what
level is it statistically significant?
Dr. Sinks. Well, this is the problem. Statistical
significance simply implies the likelihood of chance. The
likelihood of chance is very much influenced by the size of the
population and the number of cases, and it's not as relevant on
the likelihood of cause as other things. So I, myself, am not
so hung up on what the P value is in terms of, is the
probability one in a thousand or one in ten thousand? I'm more
concerned about, are there things that make biological sense
here in terms of a possible agent that people might be exposed
to?
Senator Ensign. Well, isn't the reason--if it's possible by
random chance--what Assemblywoman de Braga talked about, one in
a quadrillion? I don't know if that's an accurate number, but
certain parts are statistically impossible when you get to a
certain level of a number.
Dr. Sinks. Well, Senator Ensign, I think this is the
double-edged sword of looking at clusters. On the one hand, if
we simply go out and try to draw circles around the population
looking for events, we're going to find them. Whether the
chance is one in a thousand or the chance is one in ten
thousand, if we do a thousand searches, we'll find one. We have
to be a little cautious, when we start drawing circles, that we
have some fundamental understanding of why we're drawing the
circle, that there might be something that we're looking for.
I don't know if I'm answering your question.
Senator Ensign. Well, not really.
Maybe, Dr. Falk, you want to take a shot at this. Is this
random chance? Obviously, I think this one is a fairly extreme
case. We see such a small population, and the chances of this
being random, I think, are pretty slim. When we look at other
clusters as we're forming public policy, and we are not just
forming public policy for Fallon--when we're developing these
type of things, looking at other cases in the future, we need
to know what is significant in the future. We want to know when
to bring these resources to bear.
Dr. Falk. I think this is one of the hardest aspects of
dealing with problems like this. If you think of tens of
thousands or even hundreds of thousands of cases of cancer
across the United States, given the distribution that may
occur, even randomly, there would obviously be many occurrences
by chance that look like they're unusual but may not be, and
it's so very hard to know which ones to actually focus on.
Sometimes, as you pointed out, the statistics are so striking,
as here, that we say ``Oh, definitely, this is where we should
focus.'' But I think there's a huge gray area in between
something that looks like a perfectly normal distribution and a
situation such as we're discussing this morning, where there
will be only two or three cases or seemingly unusual
distributions, certainly ones that would seem so to people who
are concerned. I think, as Dr. Sinks points out, it will take a
lot of judgment to know where to focus and where the best
hypotheses are to pursue these leads.
Senator Ensign. I would just suggest to you that this seems
to be a fundamental question that we need to answer as we're
going forward. Resources are not unlimited. If we are going to
focus resources in the best possible manner, we are going to
have to deal with this question. If we're going to have a
national register or if we're going to have a focus, at what
point do we ask Federal, State, and local governments to work
together with private entities? You mentioned in your testimony
that 90 percent of them turn out not to be clusters. Well, what
do you mean by that? If you don't know what a cluster is, how
do you know that it's not a cluster? That seems to be a
fundamental question we need to have answered. I would
appreciate us giving some thought, as we go forward, to this,
and maybe the Pew Center will give this a great deal of thought
as well.
Senator Reid. Senator Clinton.
Senator Clinton. I'm clustered. I thought I was making
progress understanding all this, but now I feel like I've gone
10 steps back. I think that may be helpful, because, clearly,
we have a lot more questions than we do answers, and I think
it's very important for us to begin to put into place the
capacity to define the questions clearly and then to begin to
answer them. From what I understand with this panel, that seems
to be their recommendations.
Dr. Hearne, I really appreciate the work that the Pew
Foundation has done with the report and now following up with
the Trust for America's Health, and I am very pleased that you
got specific recommendations, that it's not just an analysis
that doesn't tell us what you think should be done, and they're
pretty hard hitting recommendations, I must say. Maybe, Harry,
the reason that Dr. Hearne is the front woman is because she
seems so much less hard than the recommendations.
Dr. Hearne. They're willing to sacrifice their young.
Senator Clinton. That's right, sacrifice their young for
this.
One thing that you said which really caught my attention is
that the proposed budget from the administration recommends
severe cuts for the Nation's chronic disease prevention
programs. Can you elaborate on which programs are slated to
receive cuts and how those cuts might impact on what we're
talking about today, which is to put into effect a health
tracking system nationwide that will assist people at all
levels of government?
Dr. Hearne. As you know, the budget from the administration
was just recently released. So we're still going through those
numbers, but currently the Center for Chronic Disease and
Prevention at CDC has been targeted with a 23-percent cut of
its budget. That is the sentinel spot in this country for work
on looking at the prevention opportunities of reducing the No.
1 cause of death in this country. I highlight that because I
think there has been a very strong bipartisan commitment in
this country to really move forward and advance our biomedical
research, and I cannot applaud that effort more as a health
scientist.
But I think it's also important--I think Dr. Prescott
actually noted this earlier on the first panel. We're at a
stage right now that we need to be starting to apply our
knowledge into the clinics, into the communities on how to
actually respond and prevent disease. We can't simply be
investing on the treatment side. We must stay with that front,
but we have the opportunity within our grasp for preventing
disease. I think one of the great examples--Dr. Sinks mentioned
folic acid and how our knowledge of that very simple vitamin or
nutritional addition to our diet has been reducing the cause of
neural tube defects, a key birth defect in this country that
was actually discovered from a birth defect registry in Texas.
Texas had a terrible birth defects crisis many years back and
couldn't answer the community's concerns, because they didn't
have a tracking system. Texas now has one of the best tracking
systems in the country for birth defects, and it was able to
put that information together, that by adding folic acid to the
diet, we can prevent birth defects. That's where this entire
concept of nationwide health tracking comes from, that we need
to have those investments.
Is there a line item for a nationwide health tracking
network? No. We hope, though, through leadership--and that was,
yes, the Pew Commission's recommendations. We made it as simple
but hard hitting as possible, and thanks to Governor Weicker,
Lou Stokes, and other thoughtful Members of Congress, they're
meant to be pragmatic, to deal with the concerns that
communities have, with the thoughts that the clinicians have,
the agencies. We heard from the State's own epidemiologist and
health officers--we need to track.
Senator Clinton. I hope that out of this hearing, which you
know certainly is receiving a lot of national attention, not
just attention here in Nevada, that we'll take another look at
that, because there has been a very strong push to increase and
double the NIH budget, but if we don't start applying what we
have learned to prevention, then we're going to be constantly
playing catch-up, and I don't think that's in our best
interest.
I also believe it's important, as you point out in your
report, that there are other diseases or conditions that seem
to be increasing without any real understanding, and you said
autism. I recently met with a group of experts on autism, and
it is just astonishing how much autism we now find among our
children. In fact, it seems to be down to about 1 out of 200 to
250 children who are being diagnosed with some form of the
autistic syndrome. We know we have an asthma epidemic in many
parts of our country. It's the leading cause of admission into
hospitals, and we haven't yet figured out what it is we're
doing in our homes and in our communities that is prompting so
much asthma.
So I really do hope that the recommendation that Dr. Hearne
is putting forth is going to be given some serious thought in
Washington and in the administration, as well as in Congress,
so that we can start to find out more about a lot.
I just had one question, perhaps, to Dr. Falk. Under the
toxic chemicals, the list and the myriad numbers of chemicals
that are out there that have an impact on our well-being and
our health, what predictability are we putting into some of our
effort with regard to these diseases that we're now seeing?
Where are we with regard to that level of predictability? Do we
have a high confidence in that predictability, or is it at an
evolving predictability level?
Dr. Falk. I think this is very much evolving. We know that
there are relationships between certain toxic substances and
disease, lead and lead poisoning and so on, but the great bulk
of diseases, in terms of chronic diseases, is really of unknown
etiology. We don't understand what causes most chronic
diseases. There are some--cigarette smoking, for example, and
lung cancer--where we have a pretty good understanding, but
many types of cancer, other types of disease, we don't
understand really all of the factors that cause those diseases.
I think one of the important aspects of doing better health
tracking would be to identify in a better way what are the
likely environmental inputs to disease, what are the
environmental factors that may relate to disease. I also think
that we could do a better job of coordinating the collection of
environmental data and the collection of health data. We have a
lot of environmental data bases. The EPA, State health
departments, and others have health data bases, but we probably
don't do a sufficient job of actually linking those data bases
to look for the connections that might help fill in some of the
blanks. So what Shelley Hearne and the Pew Commission have
espoused is a better collection of health data, but I think
part of that also is better linkage to environmental data to
explore the potential concerns.
Mr. Gibbons. Ms. Trovato, thank you for being here. It's
not often that we get the EPA with such a powerful individual.
I would like to put you on the spot. We do know that the EPA
does have a provision for their safe drinking water
infrastructure funding. Could we get a commitment from you for
this community here?
Ms. Trovato. We distribute that money to the States, and
then the States make the decisions, so we would have to begin
with a converstion with the State of Nevada.
Thank you, Mr. Chairman.
Senator Reid. Thank you, Congressman.
Dr. Falk, I want to thank you and your agency for
conducting the medical screening of approximately 70 people in
Elko who had worked in Montana and been exposed to asbestos-
related illnesses. That brought a sense of relief to those
people, some of whom got bad news, but the vast majority of
them got good news. So we're going to follow that, but I think
it's important to recognize that the work that has been done
there is extremely important and will have a long and lasting
impact on, I guess, a positive feeling of the people who have
been pulled out of the blue, so to speak, and told that they
need to have these tests conducted, and it was one example that
the Federal Government's here to help.
Dr. Falk. Thank you.
Senator Reid. I understand that Nevada's cancer registry is
currently not certified. What does this mean, Dr. Hearne?
Dr. Hearne. There is a national program with a long title,
NAACCR. I think epidemiology might be in there somewhere, so I
don't want to tackle that one. But it essentially sets a series
of criteria of expectations with minimal performance for a
cancer registry, to ensure its timeliness, its accuracy of
information, and the quality of analysis that is conducted with
that registry. In the last few years, that organization has
been announcing which States, which programs actually meet the
national standards of quality. It had been a very small number
back in 1995. It's been increasingly going up, partly a
reflection of the Federal commitment to invest in cancer
registries.
Nevada is probably one of the last States right now that
has failed to meet those national standards. In part, I believe
recognition--and I don't know the details on Nevada's system,
but I think it reflects that it has a limited ability to
collect all of the cancer cases in the State, because
information is limited by being generated from the hospitals.
Today, with increasing outpatient care, there may be many cases
that actually slip the radar screen, so that there would be
significant under-reporting in this State. In
addition, lack of resources prevent a timely analysis and
dissemination of that information, information that is critical
to the communities, to health workers, and many others involved
in doing investigative research.
Senator Reid. How does anyone on the panel recommend that
Federal and State agencies go about correlating exposure to
toxins in the environment? It seems to me that we have a lot of
things in the environment that we know aren't good for us, but
we don't have any way of correlating where they are and what
they do.
Dr. Sinks. I'm going to try to answer that by saying, I
think we've got a tremendous amount of work before us to truly
coordinate all of these data bases into something comprehensive
that can be used, and not only comprehensive but useful, in
terms of the type of information that exists.
From our side at the Centers for Disease Control and
Prevention, we're only beginning to launch into a new era where
we're collecting national data on levels of contaminants in
people, body burdens, if you will, of pesticides, of heavy
metals, of chemical contaminants that exist in people. We
believe that's one of the best ways to determine what's
actually getting into people. But we need to link that
information as well to the type of data that the States collect
on drinking water, air pollution releases, those things, and we
need to make those connections.
Senator Reid. My concern is that there was a period of time
when the State of Nevada was required to collect information
dealing with people who gamble. We did certain things and
collected all the information, which the Federal Government
just dumped in a warehouse, and no one ever looked at it. It
was just collected. For what reason, I've never learned. In
this instance, we not only don't collect information, but when
we do, it's not correlated.
Let me close by saying this: I know for the parents of
these children who are sick, we need some finality. I have
heard, during the time that we've heard these three panels--I
think there's an agreement that we could all have that would
give some consolation to these families. First of all, I think
there is a consensus among the panelists on the recommendations
of Dr. Hearne for a national system for tracking environmental
exposure and chronic diseases. All four of you agree there, do
you not?
Do we also have a consensus among this panel on the
recommendation of Dr. Hearne on the need for a coordinated
rapid response protocol within the Federal Government, who will
work in conjunction with State and local health officials to
address these clusters or other environmentally-related
illnesses. You would agree with that also. Is that fair?
[Nod in agreement.]
Last, do we have a consensus among the panelists on the
recommendation of Dr. Guinan for a Federal blueprint for State
investigation of clusters and for environmental monitoring, in
conjunction with the Federal Government?
[Nod in agreement.]
So I think those are three things that are very important.
Yes?
Dr. Sinks. Senator, just as a last particular point, I want
to emphasize as well the partnership of the States. Most of the
States do have protocols for dealing with these issues, and I
think that whatever we at the national level do, we need to
partner with the States and involve them in these discussions
and make sure that we are doing this together with the States.
Senator Reid. I think we've learned, in all things--I had a
hearing earlier this week dealing with the environment, and it
was clearly established by everybody that no matter how well-
meaning the Federal Government might be, unless the people on
the ground, locally, are involved in what we're trying to do,
it won't work. So the same applies here.
Senator Ensign.
Senator Ensign. Thank you, Senator Reid.
I think it's really been an excellent hearing, as far as
the information coming forward. It's really been terrific.
I want to address the three questions, because I want to
try to have an understanding of how to go forward. Senator
Reid, I'm glad you asked those questions, because that's
exactly where I wanted to go with my last line of questioning.
Dr. Guinan had said earlier, and you and Dr. Hearne have talked
about matters that seem to have somewhat to do with each other.
How do you structure this, and does money come from someplace
else? Does a new bureaucracy need to be set up, and which
agency or which entity is it to be set up in?
Dr. Hearne. This isn't rocket science. This is what public
health did with infectious disease back in the 1800's, and
we've won those battles. What we need to do is have CDC in
partnership with ATSDR and the State and local health
departments, modernize the public health system to deal with
chronic diseases. This effort must build on the existing
systems. They're antiquated systems and they've been starved
for a long time. It would take both an infusion of money--and
I'll answer that second part of your question--but it really is
about building on what we already have there, with a focus on
chronic disease and environmental exposures. It really just
takes the vision, as you've heard, from all of today's
panelists. We just now have to have the leadership to make it
happen.
We're not talking about a lot of money. I think the first
installment is getting a chronic disease investigator into
every State. There is already a system of EIS officers that
could be augmented to get that to happen. The tracking systems
will take an investment, but we're talking about a fraction of
money in comparison to many of our other investments on both
the health and environment side. I ideally would love to see
the health investments in this country increase, but I know
that that's more of a challenge, and I'll throw it back to
Congress in terms of where the money comes. But $275 million--
it's about 200 miles of highway roads--a fraction of one
environmental investigation into ambient air monitoring
programs, is what many people call ``dust'' in the budget
process. With a little creative thinking, that kind of small
investment could go a long way and really could modernize our
public health system.
Senator Ensign. Dr. Falk, you wanted to comment?
Dr. Falk. I certainly agree. You know, at ATSDR--the
original CERCLA legislation gave us the name of Agency for
Toxic Substances and Disease Registry--though I think that for
too long our agency never really actualized the last part of
the name, ``Disease Registry.'' So I see that as a direct
responsibility under our mandate, and certainly not one just
for us, but one that we would work on with the CDC and others.
So I think, for ATSDR, we would be very interested, willing,
and certainly eager to participate in thinking through these
issues and developing a better system.
Senator Ensign. I'm glad you said that.
Two other comments. One is that, in veterinarian medicine,
we actually focus on prevention. That's what our whole focus
is--diet, vaccinations, population, medicine. I've often said
and campaigned on many times that America has a sick care
system, not a health care system, and we need to change it more
to a preventive health care system. So I'm glad that--and the
families, I hope, take some comfort in--really, some good may
come out of this hearing today. Some profound changes in our
health-care system could come from this hearing today. I think
that that's very exciting. But I can't get away without letting
Dr. Falk answer a question that I asked of the last panel.
Regarding the issue of the Superfund site up on the Carson
River, are there funds available that we can possibly get to
use for this situation down here?
Dr. Falk. You know, our role is to advise EPA. We don't
disburse the clean-up funds, but, in our role of advising EPA,
we will take that question up with them and discuss it.
Senator Ensign. I appreciate that.
Dr. Sinks. Let me respond a little bit to the last
question, not in terms of the Superfund site, but in terms of
what we're doing with Fallon and the State. Everything
recommended by the expert panel, that is being asked of CDC and
ATSDR, we will find the resources in our budget to see that
it's done. We are not going to ask the State of Nevada to
provide us resources to help them in that work. I'm not sure
what additional resources we particularly need, we'll have to
wait to see the exact protocols. Every time I have asked for
help from EPA or ATSDR, it has been forthcoming. We will get
those resources and we will see that they're delivered to this
issue.
Senator Reid. Senator Clinton.
Senator Clinton. Yes.
Dr. Falk, would you mind submitting for the record what
ATSDR activities and ongoing studies are currently underway in
New York, just so that I have that information?
Dr. Falk. Sure.
Senator Clinton. I sure appreciate that.
Maybe we've got the makings of a Reid-Ensign-Clinton public
health bill that will be, of course, sponsored by Congressman
Gibbons in the house. I think that, like John, I am really
pleased at how much information came out, certainly information
I was not aware of, and some of the interactions among the
agencies that we can zero in on and try to create more support
for, as we do upgrade our public health system. One of the real
issues, I think, for the 21st century for our entire country is
how we build on the successes of the past, because I'm
certainly sure that every one of us want to live and continue
to live in a country where the water is safe to drink and the
air is safe to breathe and the food is safe to eat, and, yet, I
think we've fallen behind in dealing with some of the
challenges that we've now heard very eloquently addressed and
that we have an obligation to try to come up with solutions
for.
I appreciate the consensus among this panel and the
previous panelists about what needs to be done. I would just
point to, perhaps, some analogous situations. You know, we now
have a very good Federal emergency management assistance
program. We worked on it over the years, and it had to be
improved. We now not only deal with emergencies when they
occur, we've put in a lot more on the preventative side, and I
hope we continue to do that. You know, we help people deal with
earthquake issues after some terrible earthquakes, and we
really cut the amount of loss of life and damage from the
Seattle earthquakes. We have dealt with hurricanes and
tornadoes and other kinds of natural disasters. Certainly we
have had a good response to outbreaks of food poisonings, like
E. coli and the like, and I think we need to look at that
system. So I believe that we've got some good public, private,
and State, Federal, and local partnerships to look at as we
address the concerns that have been raised at this hearing, and
I anticipate there'll be a lot of work done in order to be able
to come up with some solutions.
So I really want to thank all of the panelists for coming
forward.
I join with the Senators up here in our compliments for the
panel and the testimony that they've presented to us today was
very enlightening. I do believe, as many of you do, that if we
are going to ever reach parity between treatment and
prevention, that we are going to have to make some significant
investments into this system. It is enlightening to hear the
testimony, but I also am reminded that over the last 20 years,
the evolution of information technology has made a contribution
to the macro side, which is where I believe each of you is
suggesting that we go--to look at the broad picture, as well as
the narrow choices that we have in making some predictability
to these diseases that we have affecting us today.
I just want to thank you again for your presence here
today.
Senator Reid. I want to thank everyone for being here
today. The audience has been considerate and polite and quiet,
for which we all up here acknowledge and extend our
appreciation.
We have here about 20 questions that have been submitted to
us. As you can see by the time, we're not going to be able to
answer those orally here today, but, as I indicated, everyone
here has their name and address, and we will in detail answer
these questions.
I want to extend my appreciation to the Environment and
Public Works staff. They have been working on this hearing for
several weeks. We've had people here on the ground. These are
your taxpayer dollars being spent to prepare this hearing. You
should be very proud of the work that each of these individuals
have done to allow us to arrive at this point. I want to extend
my appreciation to the staffs of Senator Ensign, Senator
Clinton, and Congressman Gibbons for also working to make this
hearing as good as it has been.
Let me say to the reason that we're here, the parents and
the children who are afflicted with this disease: This program
which has been conducted today has been helpful, and we are
going to do everything we can to find out if there is some
cause that we can find that has resulted in the illness of your
children, but also everyone within the sound of my voice should
understand that in the future we're going to do a better job
with these clusters. We're going to have the ability of the
Federal Government to respond in a way that we haven't
responded in the past. As it's been indicated, we're not going
to each time reinvent the wheel. Every time, for example, there
is an airplane crash in America, we have the National Air
Traffic Safety Board who responds immediately. They know
exactly what they're going to do when an accident occurs. We
also want to be able to respond that quickly and
scientifically.
I wish I could express to the panelists how much I
appreciate your time and expertise. From the first witness to
the last, it has just been a feast of information. Now we turn
this over, as we do so many times, to our very responsible
staffs and they're going to prepare a report based on the
testimony--every word has been taken--and they're going to
report to the committee and to the Congress and, hopefully,
come up with things that are going to be beneficial to our
country and certainly the community of Fallon.
This committee stands in adjournment.
[Whereupon, at 1:00 p.m., the committee was adjourned, to
reconvene at the call of the chair.]
[Additional statements submitted for the record follow:]
Statement of Nevada Assemblyman Marcia de Braga
Good morning. It's a great pleasure to welcome you to Fallon and we
want to thank you for convening these hearings.
In the fall of 1999 I read with sadness a story in our local
newspaper about a fund raiser for a 5-year old who had ALL (Acute
Lymphocytic Leukemia). Then there were a few more cases and more sad
stories.
I called the State Health Department and asked if they thought that
four cases of ALL in 3 months was an unusually high number in a small
community like ours. I was told it might just be an isolated cluster,
but they would look into it to be sure.
In less than a year eight more cases were discovered. The
statistical probability of this number of cases occurring in an area
with our population is one in ten quintillion. In other words, there is
almost zero possibility that this cluster happened by chance.
In mid-February, the Assembly Natural Resources, Agriculture and
Mining Committee, which I chair, held 3 days of legislative hearings.
The purpose of the hearings was to bring together the experts, data,
research, knowledge, funds and other resources in an effort to expedite
the search for any environmental causes or contributing factors.
The hearings also served to attract considerable media attention
and with it a great many offers and promises from individuals and
agencies as well as from local, State and national officials to work
together for a common--and urgent--purpose.
Others testifying will give you statistics and progress reports.
What I want to focus on is what I learned through the Legislative
hearings and through listening to the people whose lives have been
affected by this tragedy.
As a result of the hearings, we prepared a list of possible causes,
created from our research and the testimony we received. That entire
list is in your packet, along with the names of agencies and
individuals our recommendations have been forwarded to. It basically
asks those in authority to leave absolutely no stone unturned.
Our recommendations also include providing information to the
public and expanding the scope of the investigation to cover:
A longer period of time;
Other disease groupings;
The analyzing of water, soil and air, and
The testing of the blood, bone, tissue and hair of the
children.
I am happy to report that yesterday the Assembly Ways and Means
Committee approved $500,000 to be used specifically for those purposes.
In addition, the committee recommends cleaning up the things the
community is concerned about now and not waiting for science to catch
up or provide positive proof. We unanimously agreed that the cancer
registry and other data must be processed in a rapid manner so that
information is current and readily available to health and
environmental officials and to the general public.
This leukemia cluster may be only a part of the whole picture. An
eminent pediatric oncologist has advised us to investigate all marrow
diseases and to look for any increases in other forms of cancer among
children and adults.
We know that two additional ALL cases were diagnosed in 1992 and,
in 1991, a 5-year old died from Myelodysplastic Syndrome, a less common
form of leukemia. We know that earlier this year, a youngster was
diagnosed with aplastic anemia, another marrow disease. We know there
may be additional cases that are connected to Fallon but were not
diagnosed here. And, we know there are clusters of other diseases that
also are suspicious.
I think it is vitally important that everyone involved be proactive
and not rely on old data, that we look beyond the environmental
improvements that are already being done to what needs to be done next,
and that we approach our problems with the hope and optimism that,
through determination and perseverance, we can--if not find a
definitive answer--at the very least eliminate possible causes and add
to our information base.
Our legislative committee has sponsored a bill that would require
public and private entities, certified to do environmental testing, to
report to the Nevada Health Division or NDEP any findings of specific
values that exceed the established Maximum Contaminant Levels. Those
findings would have to be made public if a significant health risk was
posed.
I think it's imperative that we put these protections into law and
aggressively pursue our search for causes. That includes working to
eliminate known contaminants. In so doing, obviously we improve the
general health of our people and we very well may destroy some of the
ALL contributors.
Why do I feel so strongly that we have a responsibility to move
forward in every way possible?
Because this is about children--children whose lives have been
turned upside down by something terrible that's beyond their control.
This is about a beautiful, smiling little girl whose hair is gone. This
is about a promising young athlete whose energy now only lasts for
minutes. This is about a teenager whose HMO won't pay for a bone marrow
transplant.
This, as you well know, is about furthering what is known about
cancer so that other communities might be spared what's happened here.
I applaud your efforts to create a nationwide team to deal with these
situations if and when they arise.
Senator Clinton, I read that you said, ``There is no such thing as
other people's children.'' You, Senator Reid, and Senator Ensign have
clearly demonstrated that belief by coming to Fallon to hold these
hearings. We can't thank you enough for your concern and your
willingness to help our community and communities like this,
everywhere.
Thank you for the opportunity to testify. I would be happy to
answer any questions.
______
Report of the Leukemia Hearings, Fallon Leukemia Cluster, February 12-
14, 2001, Prepared by Linda, Eissmann, Senior Research Analyst,
Legislative Counsel Bureau
The Nevada State Assembly's Committee on Natural Resources,
Agriculture, and Mining, and its Committee on Health and Human
Services, held a series of hearings related to a cluster of leukemia
cases in Fallon, Nevada, on February 12, 13, and 14, 2001. They were
held in the Legislative Building in Carson City. This report provides a
brief overview of the cluster, testimony provided throughout the
hearings, and the recommendations adopted.
BACKGROUND
Acute Lymphocytic Leukemia
Childhood Acute Lymphocytic Leukemia (ALL) is a disease in which
underdeveloped lymphocytes (white blood cells) are found in unusually
high numbers in a child's blood and bone marrow. Under normal
conditions, the bone marrow makes cells known as blasts that mature
into several different types of blood cells, including red blood cells
that carry oxygen and platelets that help the blood to clot.
However, in ALL the developing lymphocytes become too numerous and
fail to mature. They crowd out the normally-occurring red blood cells
and platelets in the blood and bone marrow. As a result, the bone
marrow of children with ALL is unable to make sufficient red blood
cells to carry oxygen, and the child may develop anemia and tire
easily. In addition, without sufficient platelets, the child may bleed
or bruise easily.
Acute Lymphocytic Leukemia is the most common form of leukemia
found in children, and is the most common kind of childhood cancer
accounting for 85 percent of childhood acute leukemias. Thanks to
progress made over the last 50 years in the diagnosis and treatment of
leukemia, there is now an 80 percent survival rate.
Investigation of the Fallon ALL Cluster
A cluster of ALL patients all under the age of 19, has been
identified in Fallon, Nevada. The cluster has been defined by the
Health Division as ``medically confirmed diagnosis of ALL, in an
individual age 0 to 19 at the time of diagnosis, having resided in the
Fallon area prior to diagnosis.'' At the time of the hearings in the
Nevada State Assembly on February 12, 13, and 14, 2001, the State's
Health Division was investigating 11 confirmed cases of ALL in the
Fallon cluster. Of these, one was diagnosed in 1997, two in 1999, and
eight in 2000. Only a few weeks later, a 12th case was confirmed (2001)
and added to the cluster.
The expected rate of ALL cases statewide is calculated to be 2.78
per 100,000 population per year. With a population of only 7,850
people, the expected rate of ALL in Fallon would be 0.22 cases
annually. However, in the Fallon cluster, eight cases were diagnosed in
a single year (2000), representing a statistically significant event.
As such, the probability of the Fallon cluster being a random
occurrence was determined to be highly unlikely.
The epidemiologic study at the heart of the Health Division's
investigation involves a detailed questionnaire for each affected
family, a review of all laboratory and medical reports, environmental
sampling, and consultation with health and disease experts from around
the country, in an effort to find a common link between the cases.
TESTIMONY AT THE LEUKEMIA HEARINGS
Testimony at the leukemia hearings was provided by many State and
Federal agencies; local governments; experts in pediatric oncology,
childhood leukemia, arsenic research, and cluster investigations; a
leukemia patient's family; and members of the general public.
Attachment A contains the agendas and topics covered for each day of
the hearings.
For a complete overview of the testimony presented, please refer to
the minutes of the hearings, found in Attachment B of this report.
Although specific causes of ALL are not known, medical experts
testified that several environmental and demographic features (as well
as predisposing genetic syndromes) have been associated with an
increased risk for leukemias in children. Risk factors for the disease
may include (but are not necessarily limited to) ionizing radiation,
nonionizing radiation, chemical and toxic exposures, viral and
infectious agents, and parental occupational exposures. Overall,
childhood ALL has been classified by scientists as a heterogeneous
group of diseases, with varying immuno-phenotypes. Testimony also
revealed that most ALL cases have a genetic link.
Throughout the hearings, the committees heard a great deal of
testimony about a variety of suspected causal factors for the leukemia
cluster, including a number of potentially hazardous materials and
environmental contaminants. The possibility that the leukemia cases are
the result of a combination of factors was another common theme
throughout the hearings.
Due to the high levels of naturally-occurring arsenic known to
exist in the water supply of Fallon, arsenic was suggested as a
possible contributor. However, several expert witnesses testified that
while arsenic has been associated with some cancers (including lung,
bladder, skin, liver, kidney, and prostate cancers), research has not
revealed a clear link between arsenic and leukemia.
In addition to water quality concerns, other factors identified as
potential contributors to the ALL cluster were agriculture and domestic
chemical uses, military activities associated with the Naval Air
Station (NAS) in Fallon, and a variety of environmental contaminants.
The following is a summary of the concerns and possible health
risks identified during testimony:
Agriculture and Domestic Chemical Uses
Agricultural and other pesticides and herbicides used
throughout the region.
Possible effects of combined agricultural activities,
including chemicals and crop burning.
Overall inability to monitor uses of appropriate domestic
pesticides and herbicides.
Need to educate the public about reading label directions
for domestic chemical applications.
Water Quality Concerns
Implications of high levels of arsenic in the Churchill
County area water supply.
Insufficient water quality testing.
Inadequate laws to require water well testing.
Need to educate the public about the necessity of water
quality testing and possible mitigation activities.
Possible Implications of Military Activities
Potential contamination/use of hazardous substances at the
NAS Fallon, including jet fuel ``dumping'' or other emissions.
Stability of the jet fuel line to NAS Fallon.
Distribution and migration of chaff during military
training exercises.
Microwaves from radar systems.
Electromagnetic ground waves as a result of the Extremely
Low Frequency radio transmitting station installed in Churchill County
by the Navy.
Other Environmental Contamination
Surface, subsurface, and airborne radiation and other
contaminants as a result of Project Shoal weapon test conducted 28
miles southeast of Fallon in 1963.
Adequacy of industrial emissions monitoring (including
air, ground, and water contamination).
Possible implications of ionizing radiation, depleted
uranium, radon, nitrates, fluoride, MTBE, volatile organic compounds,
other industrial contaminants, and the possibility of other radio
nuclides in the Carson and Truckee Rivers.
Reported PCB contamination at the Fallon Freight Yard.
Flooding of the Carson and Truckee Rivers in 1997.
In addition to these potential risks to public health, suggestions
were also made to improve or expand the Health Division's investigation
of the Fallon leukemia cluster:
Cluster Investigation Issues
Expand the scope of the investigation to determine if
there are other leukemia cases or clusters that should be included in
the analysis, or any other related marrow diseases that have a bearing
on the investigation.
Determine if there has been an increase in adult cancers
over the last decade.
Consider any combinations of possible factors and the
potential involvement of past contaminations.
Test blood, bone, hair, and tissue samples from afflicted
children.
Occurrence of other possible disease clusters in the
Fallon area.
Possible implications of medical procedures including x-
rays, ultrasound, and immunizations.
Potential role of viral and bacterial infections as a
contributing factor.
Coordination with and guidance to local veterinarians for
possible/related animal diseases.
RECOMMENDATIONS
Following the hearings, and upon announcement of the 12th confirmed
case of childhood ALL, Assemblyman Marcia de Braga (Chairman of the
Committee on Natural Resources, Agriculture, and Mining) requested an
emergency appropriation to assist the investigation. Assembly Bill 359
would make $1 million available to the Health Division for expenses
relating to:
1. The testing of victims of leukemia;
2. The testing of the environment to determine what factors may be
contributing to this outbreak of leukemia;
3. The compilation of data from the results of such tests; and
4. The dissemination of factual information and health advice to
the residents of Fallon.
A copy of A.B. 359 is found in Attachment C.
A subcommittee was also formed to evaluate and finalize a list of
specific recommendations to enhance the sharing of resources among all
participants, and to assist the investigation in finding and addressing
the cause of this leukemia cluster as quickly and thoroughly as
possible.
Members of the subcommittee were:
Assemblyman Marcia de Braga, Chairman, Committee on Natural
Resources, Agriculture, and Mining (NRAM)
Assemblywoman Ellen M. Koivisto, Chairman, Committee on Health and
Human Services (HHS)
Assemblywoman Sharron E. Angle (HHS)
Assemblyman John C. Carpenter (NRAM)
Assemblywoman Sheila Leslie (HHS)
Assemblyman Harry Mortenson (NRAM)
Assemblyman P.M. ``Roy'' Neighbors (NRAM)
The subcommittee met twice, on March 6 and 8, 2001, and adopted a
formal list of recommendations. Immediately following adoption of this
list, the recommended Bill Draft Request (BDR) was made (and has
subsequently been introduced as Assembly Bill 630), and all recommended
letters were sent to the appropriate recipients.
Recommendations to Assist/Address the Leukemia Investigation
1. Committee BDR (40-1456, A.B. 630) should specifically include
the following:
a. If a public health risk is detected in an area, the overall
results should be made public; and
b. Require private or public entities certified to conduct
environmental testing (including air, ground, and water testing) to
report the results of these tests to the Health Division when specific
values exceed the established Maximum Contaminant Levels. The intent is
to make sure that the Health Division is able to track or detect any
public health risks by having information about contamination or
elevated risk levels reported to them.
2. Letter to the NAS Fallon urging it to:
a. Fully disclose to Nevada's Health Division all toxic and
hazardous materials historically or currently kept onsite, and all
instances of contamination with resulting clean-up measures;
b. Consider any and all other possible contaminates (including
those that may have been previously used) as possible contributors,
beyond those currently included in the investigation;
c. Evaluate medical histories of families formerly assigned to NAS
Fallon, insofar as there may be additional leukemia and other cancer
cases in families who have since been reassigned;
d. Compare results of the Navy's water testing of the wells on the
base, with the City's test results and any results of testing from the
Fallon Paiute-
Shoshone Tribe;
e. Address/confirm reports that benzene was found in one of the
Navy's wells, and if true, explain when and what corrective actions
were taken;
f. Address/confirm reports of jet fuel used in diesel trucks and as
weed spray;
g. Explain why Halon 1211 is listed on the NAS Fallon Section 311
``Emergency Planning and Community Right to Know Act'' for the 1999
Reporting Year, including how it has been used, is stored, and what
``maintenance activities'' involved the use of jet fuel; and
h. Consider any possibility that the general public might have come
into contact with any of the materials listed on the Section 311 report
of reportable materials.
3. Letter to Nevada's Health Division recommending it:
a. Expand the scope of the investigation to determine if there are
other leukemia cases or clusters that should be included in the
analysis, or any other related marrow diseases that have a bearing on
the investigation;
b. Determine if there has been an increase in adult cancers over
the last decade;
c. Consider any combinations of possible factors and the potential
involvement of past contaminations;
d. Test blood, bone, hair, and tissue samples from affected
children;
e. Continue to provide information to the general public and
coordinate education efforts about possible public health risks;
f. Continue to solicit input from the public regarding possible
causes; and
g. Address/consider the concerns and possible health risks
identified during testimony (as previously described on pages 3 and 4
of this report).
4. Letter to the Health Division encouraging it to act as the lead
agency to coordinate all educational, research, and investigative
efforts.
5. Letter to the Health Division requesting it to proceed with the
proposal provided by the University of Nevada, Reno, Department of
Civil Engineering, to perform the Ames test on air, water, and
``residue'' samples collected in the study area, and to work closely
with all parties in research sampling efforts with the primary goal
being to delineate any areas or sources of increased mutagenic
activity.
6. Letter to the Health Division requesting it to thoroughly
examine Nevada's Cancer Registry and the current abstraction process,
to determine ways in which it could be improved and ways in which the
lag time might be minimized. Letter will request the Health Division to
undertake necessary steps to improve the registry and report to the
Legislature no later than May 1, 2001, what it has learned.
7. Request the Health Division to provide regular updates to the
committee(s) about new developments and the progress of its
investigation and research, including any reports of its expert panel.
8. Letter to Nevada's Division of Environmental Protection; urging
it to:
a. Continue its participation with the Health Division in its
oversight capacity for environmental contamination (including air,
ground, and water contamination) in the Fallon area; and
b. Continue to monitor the progress of Project Shoal and the
migration of surface, subsurface, and airborne contaminates from the
initial project site.
9. Letter to Nevada's Department of Agriculture urging it to assist
the Health Division in the leukemia investigation, by providing
agricultural chemical use data and by collecting and analyzing
additional/necessary environmental samples (including air, ground, and
water samples) in an effort to help identify any problems resulting
from the use or combined uses of pesticides and herbicides in the
Fallon area.
10. Letter to Kinder-Morgan requesting information about the jet
fuel pipeline, including:
a. The frequency of inspection;
b. Reporting/inspection procedures;
c. Methods used to detect leakage;
d. Precautions used to avoid leakage;
e. History of repairs or upgrades; and
f. Potential to relocate the line if problems are detected.
11. Letter to the University of Nevada, Reno, asking it to assist
with the investigation, collaborate with the Health Division, and
participate with in-kind contributions to the extent possible.
12. Letters to the City of Fallon and Churchill County, indicating
the Legislature has undertaken hearings and held sequent meetings in an
effort to combine resources and expedite a solution to the leukemia
investigation. A copy of the recommendations will be enclosed. The
letters will further indicate that the committees wish to assist the
City and County in any way possible in their coordination activities
and educational efforts.
Recommendations to Assist/Address the Potential Public Health Risk of
Arsenic
13. Letter to City of Fallon urging it to:
a. Take whatever steps are necessary to adhere to the new EPA
standards for arsenic as soon as possible;
b. Evaluate opportunities for combining efforts of the City, NAS
Fallon, and the Fallon Paiute-Shoshone Tribe to reduce the overall cost
of a common filtration system; and
c. Compare its water testing results with those of NAS Fallon and
the Fallon Paiute-Shoshone Tribe.
14. Letter of support for Senate Concurrent Resolution No. 5 to the
Senate Committee on Legislative Affairs and Operations.
15. Investigate the cost of installing ``point of entry''
filtration systems at each of Fallon's eight schools.
(Note: Subsequent to adoption of this recommendation, staff learned
that the Churchill County School District has determined that ``point
of use'' systems are more cost effective, including 79 reverse osmosis
systems at water fountains and kitchen faucets throughout the district.
These systems are estimated to cost $70,000 to $80,000.)
Other Recommendations
16. Investigate whether community/public notification is made when
the Weed-Mosquito Abatement District undertakes its spraying
activities.
(Note: Subsequent to adoption of this recommendation, staff learned
that the Churchill County Weed-Mosquito Abatement District publishes an
article once per month in the local newspaper, informing residents
about mosquito and weed problems, general areas targeted, and chemicals
that will be used. However, representatives of the Abatement District
indicate that it is difficult to notify the public of the exact time
and place to be sprayed because of weather variability. Also, most
spraying takes place at the Carson Lake, 10 to 15 miles south of
Fallon.)
conclusion
The Committee on Natural Resources, Agriculture, and Mining, and
the Committee on Health and Human Services, expresses sincere
appreciation to the many witnesses who testified throughout the
leukemia hearings for their interest and participation in this unique
and compelling situation. Special appreciation is also extended to the
Health Division and members of its expert panel for their dedication
and the thoroughness of this investigation.
______
ATTACHMENT A
Assembly Agenda for the Committee on Natural Resources, Agriculture,
and Mining
Day: Monday
Date: February 12, 2001
Time: 1 p.m.
Room: 1214
special hearing on fallon leukemia cluster
Briefing.--Health Division.
Medical Overview.--Pediatric leukemia specialists; Local physicians
experienced in leukemia and immunology.
Environmental Overview.--Nevada Division of Environmental
Protection; Arsenic, Drinking Water Toxicologist, U.S. EPA.
Day: Tuesday
Date: February 13, 2001
Time: 1 p.m.
Room: 1214
Environmental Overview.--Jet fuel, NAS Fallon; Agriculture,
pesticides and crop spraying, Nevada Department of Agriculture,
Mosquito/Weed Abatement District; Other.
Impacts to the Community.--City of Fallon; Patient families.
Public Testimony.
Day: Wednesday
Date: February 14, 2001
Time: 1 p.m.
Room: 1214
Public testimony.
Medical and Environmental Overview.--Centers for Disease Control;
Arsenic research specialist; Oncologist.
Strategies, coordination, and recommendations of the committee.
______
ATTACHMENT B
Minutes of the Meeting of the Assembly Committee on Natural Resources,
Agriculture, and Mining, Seventy-First Session, February 12, 2001
The Committee on Natural Resources, Agriculture, and Mining was
called to order at 1 p.m., on Monday, February 12, 2001. Chairman
Marcia de Braga presided in room 1214 of the Legislative Building,
Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest
List. All exhibits are available and on file at the Research Library of
the Legislative Counsel Bureau.
Committee Members Present.--Mrs. Marcia de Braga, Chairman; Mr. Tom
Collins, Vice Chairman; Mr. Douglas Bache; Mr. David Brown; Mr. John
Carpenter; Mr. Jerry Claborn; Mr. David Humke; Mr. John J. Lee; Mr.
John Marvel; Mr. Harry Mortenson; Mr. Roy Neighbors.
Committee Members Absent.--Ms. Genie Ohrenschall (Excused)
Guest Legislators Present.--Assemblywoman Sharron Angle, District
29; Assemblywoman Merle Berman, District 2; Assemblywoman Vivian
Freeman, District 24; Assemblywoman Dawn Gibbons, District 25;
Assemblywoman Ellen Koivisto, District 14; Assemblywoman Sheila Leslie,
District 27; Assemblywoman Mark Manendo, District 18; Assemblywoman
Kathy McClain District 15; Assemblywoman Bonnie Parnell, District 40;
Assemblywoman Debbie Smith, District 30; Assemblywoman Sandy Tiffany,
District 21; Assemblyman Wendell Williams, District 6.
Staff Members Present.--Linda Eissmann, Committee Policy Analyst;
Marla McDade Williams, Committee Policy Analyst; June Rigsby, Committee
Secretary.
Others Present..--Yvonne Sylva, Administrator, Nevada State Health;
Division; Dr. Mary Guinan, Nevada State Health Officer, Dr. Randall
Todd, State Epidemiologist, Nevada State Health Division; Galen Denio,
Manager, Public Health Engineering, Nevada State Health Division; Dr.
Ronald Rosen, School of Medicine, University of Nevada, Reno; Dr.
Carolyn Hastings, Oncologist, Children's' Hospital of Oakland; Dr. Vera
Byers, Clinical Immunologist; Dr. Al Levin, Immunologist; Allan Biaggi,
Administrator, Division of Environmental Protection; Paul Liebendorfer,
Chief, Bureau of Federal Facilities; Dr. Bruce Macler, Regional
Toxicologist, EPA, San Francisco.
Chairman de Braga called the Assembly Natural Resources,
Agriculture, and Mining Committee to order. Roll was called and a
quorum was judged to be in place. All members were present except for
Assemblywoman Ohrenschall who was noted as an excused absence.
Chairman de Braga welcomed as guests the Assembly Committee on
Health and Human Services. Roll was called, and all members were
present, except for Assemblyman Tiffany who was noted as an excused
absence.
Chairman de Braga opened the meeting with a welcome to both
committees and an acknowledgement of the research and support that
contributed to the leukemia hearings. Chairman de Braga stated the
purpose of the 3-day special hearings was to gather information about
the recent Acute Lymphocytic Leukemia (ALL) cluster in Fallon and to
explore possible environmental causes. The hearings had been designed
to provide a forum for the pooling of research, data, experts,
community leaders, agencies, government officials, health and
environmental experts, and all other resources.
With the discovery of 11 cases of ALL in the Fallon area within a
short number of years, it had become imperative to address the expected
concerns of the residents as well as be aware of the welfare of the
community as a whole. With the extensive media coverage, Chairman de
Braga explained that publicity had served a positive purpose by
bringing attention and resources to the community.
The format for the 3 days was described as a balance of expert
testimony and public input. Following the testimony of witnesses,
questions by the two committees were slated. Guests were encouraged to
sign in and participate, and no questions would be judged as worthless.
At the conclusion of the 3 days, a panel would assemble recommendations
based on all of the testimony.
Chairman de Braga emphasized that, even if the specific cause of
the cluster was never identified, public concerns would be addressed
and environmental improvements made on behalf of the entire community.
Because of the pre-scheduled commitments of the two committees in
attendance, Chairman de Braga stated that, if at any time, a quorum
failed to be present, the hearings would continue uninterrupted under
the status of a subcommittee.
Chairman de Braga introduced the opening expert testimony from the
Nevada State Health Division. The committees received two handouts,
which were as follows:
A 6-page report entitled State of Nevada Health Division--
Leukemia Cluster Fact Sheet (Exhibit C).
A portfolio of reports which included leukemia fact
sheets, a summary of what constituted a cancer cluster, status reports,
an overview of Health Division actions, and other pertinent background
information compiled by the Nevada Health Division (Exhibit D).
Yvonne Sylva, Administrator of the State Health Division, outlined
their official action since being notified in July 2000 of the high
number of ALL cases in Fallon. Their role as the first line of response
was recognized. A complete investigation was initiated, with two
employees assigned full time, Dr. Mary Guinan, State Health Officer,
and Dr. Randall Todd, State Epidemiologist. By November 2000, it became
apparent that additional resources would be required. The calls from
the news media dictated the hiring of a full time media coordinator as
well as a bilingual research assistant to Dr. Todd.
Ms. Sylva summarized the multitude of State and Federal Government
agencies that were engaged for the fact-finding phase of their
investigation. These included the Center for Disease Control in
Atlanta, the National Institute of Cancer, EPA, Department of Energy,
the Nevada Department of Agriculture and Nevada Environmental
Protection. In January, an additional employee was assigned to field
requests from the public and the news media.
According to Ms. Sylva, the investigation had been designed as a
partnership with the community of Fallon and was evidenced by a
community presentation made to Fallon residents in January. A separate
community forum at the Naval Air Station followed, with attendance
estimated at 80 residents. A community meeting in early February
provided additional opportunity for more than 250 citizens to ask
questions and air their concerns. A community telephone hotline (1-888-
608-4623) was established, with a reported 56 inquiries to date. Ms.
Sylva welcomed additional recommendations for addressing public
concerns.
Scrutiny of the Health Division's investigative work had been
openly solicited, with requests made to Federal agencies across the
country. This peer review was designed to be an analytical critique of
the soundness of their investigative methods as well as their findings
to date. Recommendations on improvements to their methodology were
invited.
In response to Chairman de Braga's question regarding the nature of
hotline questions, Ms. Sylva replied that citizen concern centered on
the safety of continuing to live in Fallon, the chances of other
children developing leukemia, and the safety of drinking the water.
Assemblywoman Gibbons requested clarification of Fallon population
figures, the percentage of ethnic minority citizens, history of
residents who had requested testing of their private wells, and data on
other cancer cases that were linked to arsenic in well water in the
Fallon area. Ms. Sylva deferred to the upcoming testimony of Dr. Todd
and Galen Denio. Chairman de Braga clarified that the population of
Fallon was estimated at 8,300 within the city limits and 26,000 within
the county.
Dr. Mary Guinan, State Health Officer, resumed testimony for the
Nevada State Health Division. In July 2000 a call had been received
from Chairman de Braga regarding the alarming number of leukemia cases
at the Churchill Community Hospital. Following a review of the Nevada
State Cancer Registry, it became readily apparent that the rate of
current ALL cases in Fallon did represent a significant increase from
what would be expected statistically.
Phase 1 of their investigative work commenced with consultation
among experts from various schools of medicine and public health
agencies. All agreed that phase 1 had to be a thorough interview with
each of the affected families for purposes of determining common
exposures. Questionnaires from previously conducted epidemiological
studies were reviewed, which resulted in the development of a 32-page
questionnaire customized for the Fallon cluster. The time to conduct
each family interview was estimated at 2-3 hours. The participation by
affected families, voluntary in nature, was 100 percent. Scientific
methodology was closely followed in the gathering of the data.
Interviews of nine families were completed by November. The results
were analyzed and presented to the families in December by Dr. Todd.
In response to a question by Assemblywoman McClain regarding the
place of diagnosis of the nine cases, Dr. Guinan clarified that the
definitive diagnosis of leukemia was a bone marrow biopsy. This
specialized test had to be done at the hospital where the treatment
would occur.
Assemblywoman McClain requested clarification about the Health
Division's ability to track cases in other parts of the nation. Dr.
Guinan reported that the publicity did result in the addition of two
cases in individuals who were not residents of Fallon at the time of
diagnosis. Word-of-mouth reports from the citizens of Fallon
contributed to the identification of the first nine cases.
Assemblywoman Leslie inquired about whether the Health Division
investigation included the comparison of physical evidence (e.g., blood
test results) that might tie these cases together. Dr. Guinan explained
that questions did focus on discovering common experiences with the
goal of generating hypotheses that could be tested in the next phase of
the investigation. Environmental exposures were a principal focus.
Additionally, each family was invited to speculate about any theory
they had about cause or commonality with other families.
In response to Assemblywoman Leslie's request for clarification
regarding testing of the children and environment, Dr. Guinan explained
that no testing had been conducted. Phase one was descriptive in
nature, and additional testing would be premature until possible causal
agents could be identified. Testing of children (e.g., blood, hair
analysis) dictated a judicious approach.
Assemblywoman Angle raised the issue of the number of phases of the
investigation, any planned efforts to be proactive in uncovering new
cases of leukemia, and a timeline of when the results of the study
would be available.
Dr. Guinan explained that the number of phases of the investigation
was unknown. There had been hundreds of investigations of clusters,
with few resulting in identification of cause. The Woburn cluster, one
of the few with an identified cause, took 18 years. The Health Division
had planned to proceed step-wise. Assurance of public fears had to be
the first matter of importance.
In response to Assemblyman Neighbors, Dr. Guinan clarified that an
historic review of the health records had been conducted for purposes
of comparing the current cancer rate with historic rates. The rate for
Churchill County had been the same as the State average, with no
increase evidenced prior to this cluster. An essential piece of
information was described by Dr. Guinan as the population figures for
children up to the age of 9 years in the Fallon area.
Assemblyman Neighbors requested clarification on whether Fallon's
drinking water had been tested for substances besides arsenic. Dr.
Guinan reported that tests had included radioactive substances and
pesticide tests, with no evidence of significant levels. Jet fuel tests
of water had been negative as well. It was further noted that some of
the leukemia victims were served by the municipal water system while
others were on private wells.
In response to Assemblywoman Gibbons, Dr. Guinan outlined the
expected rate of cancer versus actual rates of cancer in Fallon. Dr.
Guinan reported that the same rate, 3 per 100,000 cases, would be
expected throughout the State of Nevada. Multiple comparisons had been
made with cancer registries across the nation, and the conclusion was
that we had a definite increase in Fallon.
Dr. Todd, State Epidemiologist, resumed testimony for the Nevada
State Health Division. Background information regarding communicable
disease and cancer reporting practices for Nevada was presented. Dr.
Todd referred the committees to his portfolio of handouts (Exhibit D).
Nevada Revised Statutes (NRS) 441 was cited as the guideline for their
tracking programs for 60 communicable diseases. NRS 457 contained the
regulations for tracking cancer. Since 1979, all invasive cancer had
been required to be reported by hospitals, with laboratories and
physician offices being added to reporting requirements in the late
1990's. It was noted that outpatient management of cancer had
interfered with the completeness of data in the cancer registry. This
had been compounded by an almost 2 year reporting lag in updating the
data of the cancer registry, a common problem nationwide.
Dr. Todd elaborated on the three principal uses of the registry
data, which included research, resource allocation, and program
evaluation. The value of the registry data was illustrated by its
application in cluster investigation.
The unusual number of ALL cases in a small community like Fallon
within a short timeframe grabbed the attention of the Nevada Health
Division. Using population figures of Nevada communities, mathematical
calculations of expected rates and actual rates were scrutinized.
Regardless of how the data was sliced, the probability of the Fallon
cluster being a random event was judged to be highly unlikely. For the
years 1995 to 1999, Churchill County had expected to see only one case
of childhood cancer. Statistical analyses were alarming and indicated
high probability of a non-random event.
The expected rate in Nevada for residents up to age 10 was
calculated at 2.78 cases of Acute Lymphocytic Leukemia (ALL) for a
population of 100,000. Churchill County, with eight actual cases, was
judged to be a statistically significant event given the expected 0.22
cases for its population of 7,850.
Dr. Todd elaborated on the epidemiological investigation,
specifically the 32-page questionnaire. Residential history was
examined starting with 2 years prior to the birth of each victim.
Occupational history of both parents, medical history of the index
child, prenatal history, environmental exposure data, types of pets,
activities, and hobbies, household products, types of appliances in the
home, and drinking water sources were all investigated.
A timeline was displayed which captured residency in the Fallon
area for all of the affected families. Data was charted on bar graphs
and then examined for overlapping of residency and other significant
marker events. The preponderance of overlapping points was identified
as November 1996 through June 1999. This became the timeframe of
interest and prompted research questions about coincidental
environmental events in Churchill County.
Scrutiny of water analyses received priority attention, especially
synthetic organic compounds (SOC) and volatile organic compounds (VOC).
None were detected in the municipal water supply that served
approximately half of the victim families. Data for private drinking
water wells was not complete. Mercury, arsenic, gross alpha radiation,
select components of jet fuel, benzene, and select pesticides and
herbicides were tested, and all were at or below the allowable limits.
Occupational history data included specific questions about
chemical, fume, and radiation exposures on the job. Although some
incidents of exposure were discovered, this was judged not to be a
common characteristic across all families. The medical history of each
index child was reviewed and revealed no common denominator. Maternal
pregnancy questions included many subjects such as alcohol and food
consumption, medications consumed, occupational exposures, and breast-
feeding habits. Questions related to family history of cancer revealed
no pattern.
The most prominent question fielded by Dr. Todd during his
investigation had been the possible link between leukemia and arsenic
in the drinking water. Research did not reveal a preponderance of
evidence that linked arsenic with leukemia. Arsenic had always been
present in Fallon, which begged the question of why the recent cluster
suddenly emerged. The pathway of exposure, as well as the biological
mechanism through which a suspected agent caused leukemia, were
described as essential elements of their epidemiological investigation.
Chairman de Braga requested clarification about the State cancer
registry, specifically at what point in time the registry would have
revealed a cluster of cancer. Dr. Todd explained that it would have
taken several years before he would have been confident to draw
conclusions about a cluster. The lag time between diagnosis and
reporting was reported to be common for most cancer registries across
the nation. Chairman de Braga urged the Nevada Health Division to
submit recommendations about methods for expediting the cancer
reporting process.
Assemblywoman Parnell inquired about substances tested in drinking
water, specifically hydrocarbons and chemicals similar to those
detected in Woburn. Dr. Todd explained that trichloroethylenes and
tetracholorethylenes were among the substances tested.
Assemblywoman Smith requested clarification on lag time,
specifically whether it was a lag between the initial reporting of the
cancer, the completeness, or both. Dr. Todd explained that lag time was
a multifaceted problem, with the first component of lag described as
the delay between diagnosis and compilation of the patient's medical
record. The second component of lag was related to the abstraction of
the information from the medical records, a problem that was evident
whether the abstraction was performed by the hospital or by a
representative of the Nevada Health Division. Dr. Todd estimated the
abstraction time for each medical record at 40 to 60 minutes. The
addition of laboratory reporting was anticipated to be a means to
expedite the process. By way of comparison, the Center for Disease
Control (CDC) standard was reported to be 90 percent at the 1-year
mark.
Assemblywoman Smith resumed questioning with a request for
clarification of dates of water testing, specifically the inconsistency
in the testing schedule and the reported 2-year gap. Dr. Todd deferred
to Galen Denio's upcoming testimony.
In response to Assemblywoman Smith's question about private well
testing, Dr. Todd clarified that private well testing had most often
occurred when the property changed ownership. The mortgage companies,
not the state, were the requestors of the water test and reportedly did
not routinely order detection of the more complex chemical substances.
Assemblywoman Smith inquired about the possibility of school
commonality. Dr. Todd reported no clustering or connection to any
school site.
Assemblywoman Koivisto pursued the issue of the amounts of
synthetic organic compounds (SOC) and volatile organic compounds (VOC)
detected in the water. Dr. Todd clarified that water analyses revealed
zero detection.
In response to Assemblywoman Leslie's question regarding high
levels of other diseases in the Fallon area, Dr. Todd explained that
his review of the cancer registry data through 1999 revealed only the
childhood ALL cases in Fallon.
Assemblywoman Gibbons inquired about the probability that the
Fallon cluster could be a statistical anomaly. Dr. Todd replied that it
was impossible to State with absolute certainty that it was not a
fluke. Despite the fact that most cluster investigations failed to
conclusively identify a causal link, public concerns dictated the need
to continue the investigation.
Assemblyman Mortenson shared his personal experience with recent
water testing and cited a line in his water report which stated that
radioactive substances were not included in the analysis. In response
to Assemblyman Mortenson's request for clarification, Dr. Todd added
that the municipal water data presented were historical in nature and
not connected to his current investigation.
Assemblyman Mortenson inquired about possible medical procedures
and diagnostic x-ray exposure that the leukemia victims may have
experienced. Dr. Todd clarified that those were precisely the types of
questions asked of the victims. No pattern of exposure, including
prenatal ultrasound testing, was revealed. In response to a question of
statistical probability, Dr. Todd stated that the projected statewide
probability rate of 0.84 per 100,000 residents had not held up in
Churchill County. Assemblyman Mortenson next requested if the
improbability of such events had been calculated, to which Dr. Todd
replied that it had not been determined.
Assemblywoman Berman cited an upcoming bill dealing with the
comprehensive cancer plan in Nevada. She specifically inquired whether
her bill should be amended to address the need for expeditious
identification and response to cancer clusters. Dr. Todd replied that
this would require additional thought and that his written response
would follow after consultation with his colleagues.
In response to Assemblyman Bache's question regarding the possible
connection with the 1997 flood, Dr. Todd explained that the flood had
been one of the most prominent events identified for the time period of
interest. Initial investigation had not revealed any evidence of
contamination of municipal water supplies. Aquifer contamination would
need further study.
Assemblyman Brown inquired about the geographic boundaries of the
investigation. Dr. Todd reported that the cases were distributed
throughout the city and surrounding area. Chairman de Braga called the
committees' attention to their information packets and to a copy of the
published map which pinpointed the 11 cases.
Galen Denio, Manager of Public Health Engineering, Bureau of Health
Protection Services resumed testimony for the Nevada State Health
Division. A handout (Exhibit E), which outlined the procedures for
protection of public water systems, was distributed. Mr. Denio
presented an overview of the principal functions of the Bureau, the
focus of which was ensuring compliance with drinking water regulations.
In response to earlier questions regarding water testing, Mr. Denio
clarified that the maximum contaminant levels (MCL) had been set by the
Environmental Protection Agency (EPA) and adopted by the State of
Nevada. The contaminant list was described as extensive. In regard to
private well water, Mr. Denio reported that the bureau did not test
these drinking water sources. In regard to the non-detects referenced
by Dr. Todd, current methodology did not allow for detection.
Chairman de Braga cautioned the committees of the need to maintain
open minds on the issues, especially given the extensive media coverage
and speculation about arsenic as a possible cause. Chairman de Braga
requested clarification about the policy and procedure for alerting the
public in cases of high level of contaminants in the drinking water.
She cited the recent case of private well contamination at Soda Lake
and inquired about the follow-up procedure.
Mr. Denio explained that, because it was not a public water system,
the Nevada Health Division had not been advised through formal
channels. Chairman de Braga emphasized that, although not a public
water supply covered by law, it was nonetheless a health threat to
residents in that area. She expressed concerns over the lack of a
system to alert the residents of the danger.
Mr. Denio clarified that the Federal mortgage lending agencies had
required well water testing when the property changed ownership. The
State did not have the responsibility with regard to private wells.
Chairman de Braga restated her concern that the quality of the drinking
water should be disclosed as part of the real estate transactions. This
breakdown in communication could be addressed in the final report of
recommendations.
Dr. Ronald Rosen, School of Medicine, University of Nevada, Reno
commenced testimony. Two handouts, a pamphlet entitled ``Epidemiology
of Childhood Leukemia'' and a one-page summary of comments (Exhibit F),
were distributed. Dr. Rosen reviewed the remarkable progress made
during the last 50 years in the diagnosis and treatment of leukemia,
with an estimated 85 percent survival rate. Children had accounted for
only 1 to 2 percent of all cancers, with Acute Lymphocytic Leukemia
(ALL) the most common malignancy. The projected ALL rate was described
as 3 per 100,000. At the point of diagnosis, ALL peaked at 2 to 5 years
of age. Gender and race had been discovered as significant, with a male
dominance of ALL and a prevalence in affluent white children.
Dr. Rosen explained the differences between the various forms of
leukemia. The childhood ALL had been classified as a heterogeneous
group of diseases, with varying immuno-phenotypes. He further
emphasized the point that 80 percent of all ALL revealed a genetic
link. These actual genetic abnormalities within the cells had the
promise of enabling scientists to understand how the genetic and
environmental factors linked together.
The trend, as described by Dr. Rosen, was one of increasing rates.
Trends also included striking differences in the international
statistics of cancer in children. Possible explanations were offered by
Dr. Rosen and included access to higher quality medical care, a finer
ability to diagnose cancer, and better cancer reporting systems.
Dr. Rosen summarized the risk to develop cancer as a complex
interplay of inherited predisposition, exogenous exposure to agents
with leukomogenic potential, and chance events. Despite impressive
advancements in the treatment of ALL, cause had evaded science and,
when discovered, was predicted to be complex. Dr. Rosen elaborated by
stating that ALL was a genetic disease, but rarely inherited as a
genetic syndrome. Of interest was the leukemia rate for children with
genetically-based Down's Syndrome, where the rate was 20 to 30 times
greater than the general population.
Dr. Rosen restated that little was known about epidemiology and
etiologic patterns in childhood cancers compared to adults. A strong
causal relationship had been established with prenatal radiation
exposure, albeit connected to a small percentage of ALL cases. Through
the decades, documentation from atomic bomb events had been thorough
and included occupational exposure of workers and their subsequent
deaths from cancer. The data for ionizing radiation, overall, had been
conflicting. High dose exposure had been correlated to the high
incidence of leukemia among survivors of atomic blasts, while age was
strongly correlated to the type of leukemia.
Non-ionizing radiation research had been extensive but
inconclusive. Finding a control, non-exposed population would be almost
impossible. EMF (electromagnetic fields) research had been largely
inconclusive and remained controversial. Research on chemical exposures
to herbicides and pesticides had been associated with certain forms of
leukemia.
Dr. Rosen described the unique population of interest, specifically
young children between the ages of two to five in developed countries.
Epidemiological evidence supported the view that childhood ALL occurred
in this age group due to a rare abnormal response brought on by unusual
timing in combination with individual genetic susceptibility to a
common infection.
This indirect evidence had been judged to be very compelling. The
etiologic role in this infection was described in the context of
population mixing. On the subject of population mixing and herd
immunity (e.g., polio virus), Dr. Rosen described an increased risk of
infection after population mixing and movement. Leukemia clusters
occurred when herd immunity was deregulated by population mixing.
In summary, Dr. Rosen highlighted that in the unique population
with ALL it was a delayed first exposure that had been considered to
contribute to pathogenesis of several diseases associated with socio-
economic affluence. Decreased breast-feeding practices in affluent
populations had been suggested as a factor and would need analysis in
the Fallon group. An abnormal immunologic response was emphasized as a
probable factor in the development of childhood leukemia.
Dr. Rosen highlighted the distinction between descriptive and
analytical statistics that resulted from epidemiological studies of
leukemia. Interpretation of data had been challenging, with conflicting
results between studies. A lack of prevalence of pediatric malignancies
plus confounding circumstances contributed to the chance of bias in
studies.
In closing, Dr. Rosen reiterated that the Fallon cases had great
significance and could contribute to the eventual link of
environmental-genetic interactions to the pathogenesis of the various
types and subtypes of childhood leukemia. Prevention would follow as a
realistic goal.
Chairman de Braga expressed her appreciation to Dr. Rosen. She
inquired as to whether the recommendations to which he alluded were in
the handouts. Dr. Rosen clarified that recommendations were not
included, however he would be happy to contribute input.
Dr. Carolyn Hastings, Pediatric Hematologist and Oncologist at the
Children's Hospital in Oakland, commenced testimony. Dr. Hastings had
practiced medicine for more than 10 years in northern Nevada and had
firsthand experience with the Fallon cluster. It was noted that,
because of the relative rareness of childhood leukemia (i.e., 3,000
cases per year), pediatric oncologists across the Nation networked for
purposes of sharing knowledge and experience.
The pooling of knowledge allowed for expansion of research and
hypothesis generation. Genetic mutation had been determined to be a
significant piece of the puzzle. One mutation that had developed in-
utero was thought to be complicated by a second mutation in early
childhood, probably due to some environmental exposure (e.g.,
infection). Establishment of the type and subtype of leukemia was
described by Dr. Hastings as essential to scientific comparisons.
Demographics were highlighted as the second essential component of
the research. Correlations with age, race, and gender had been
established. Children under the age of 5 years and Hispanic children
had been cited as having a higher incidence.
Assemblywoman Gibbons requested clarification of the role of socio-
economic factors and the possibility of the development of another type
of cancer. Dr. Hastings explained that it was impossible to determine
with certainty when the leukemia developed in a child.
In response to Assemblyman Carpenter's question regarding the
existence of a diagnostic blood test, Dr. Hastings explained that there
was no screening test available to predict the disease. The complete
blood count (CBC) was described as the most common screening tool.
There would be no predictive quality to the test, only diagnostic
value. A bone marrow test, described as highly invasive, would alert
the physician in advance of active symptoms. Acknowledged as the most
conclusive of all laboratory tests, Dr. Hastings added that bone marrow
testing would be done only after reasonable suspicion.
Chairman de Braga requested a comparison between suspected
environmental causes of lymphoma and leukemia. Dr. Hastings confirmed
the similarity. She elaborated on the two major hypotheses, genetics
and environmental exposures. Chairman de Braga expressed her gratitude
to Dr. Hastings and requested any recommendations.
Following a break, Chairman de Braga called the meeting to order
and stated that, because a quorum was not present, the hearings would
continue as a subcommittee. An introduction of Dr. Vera Byers and Dr.
Al Levin was made. An outline of their presentation (Exhibit G) was
distributed.
Dr. Vera Byers, a physician with a specialty in clinical
immunology, commenced testimony and described with her experiences with
the Woburn, Massachusetts cancer cluster case. Woburn was judged to be
the prototype for cluster investigation. Dr. Al Levin, a physician and
scientist, interjected with his description of the role he played in
the Woburn case.
Dr. Levin stated with certainty that he believed the Fallon case
would be a very easy case. There had been signature genetic lesions
evident in these diseases that could be connected to etiologic agents.
Examination of the siblings, parents and neighbors promised to be
revealing of any common environmental exposure. Dr. Levin expressed
confidence at discovering the disease process, the causal agent, and
perhaps the pathway.
Dr. Byers resumed testimony with an overview of the Woburn cancer
cluster. Woburn, a town with a significant industrial presence, saw the
development of 12 cases between the years 1969 to 1979. The cause was
determined to be well water contamination by tricholoethylene (TCE) and
percholoroethylene (PCE).
One of the outstanding features of the Woburn cluster was that the
community itself identified the increased number of cases (as did
Fallon) as well as the suspected source of contamination. The close
proximity of the affected homes was significant. Since 70 percent of
all cancers had been known to have a carcinogenic cause (as opposed to
genetic), water, soil and air sources were tested for chemicals.
Dr. Byers highlighted the value of testing family members and
neighbors to uncover similar abnormalities. In Woburn, immune
abnormalities were evident and correlated strongly with TCE
contamination. Sources of domestic exposure were scrutinized because it
was known that, increasingly, industrial chemicals were invading
households in alarming amounts. The significance was described as being
directly related to continuous low dose exposures within the contained
atmosphere in a home.
Dr. Byers reiterated the need to empower the community of Fallon.
Historically, it had been the community (e.g., Woburn) that not only
uncovered the cluster but the source of the environmental
contamination. The prolonged investigation over almost two decades was
attributed to the failure of the scientific and medical communities' to
believe the residents of Woburn.
Assemblyman Carpenter requested clarification of the map displaying
the location of cases in Woburn. Not all of the dots were included in
the Woburn cluster, highlighting the difficulty of cluster
identification. In terms of the genetic link, a prenatal exposure
compounded by a secondary environmental insult had been the leading
theory.
Dr. Levin interjected with an explanation of the role of genetics
in the development of all diseases. Disease was described as a function
of the individual as he responded to an etiologic agent.
Chairman de Braga asked if the findings in Woburn had been
conclusive. Dr. Byers replied that the findings were highly conclusive
and included the confirmation of autoimmune abnormalities among family
members of the leukemia victims. In response to a question regarding
the 20-year timeframe, Dr. Byers clarified that once the active
investigation was instigated and publicized, the answers were apparent
within 3 years. Woburn demonstrated conclusively that it was in-utero
exposure and that when the suspect water wells were closed, new cases
ceased within 10 years (i.e., latency period).
Chairman de Braga acknowledged the contribution of Dr. Byers and
Dr. Levin and requested submission of their recommendations for future
action.
Assemblywoman Gibbons summarized the factors that were known to be
correlated with leukemia, for example a virus. She also requested
clarification on the socio-economic status of the families in Woburn
and the role that Dr. Byers and Dr. Levin would play in the Fallon
investigation. Had they been invited to participate? Both responded
``no'' to the question of invitation.
Dr. Byers expanded her explanation of viral etiology by stating
that interaction with a chemical carcinogen was required to trigger the
cancer. In terms of socioeconomic class, Dr. Levin stated that all of
the Woburn families had great similarity as well as stability (i.e.,
long term residence in the area).
In response to Assemblyman Carpenter's question about the known
causes of up to 70 percent of cancers, Dr. Byers stated that triggers
such as smoking and tricholorethylene exposure had been well
established and documented. Assemblyman Carpenter observed that there
appeared to be more cases of cancer, despite the recent medical
discoveries. Dr. Byers shared her theory on the movement of industrial
chemicals into households and the significant increase in exposure. Dr.
Levin added his observation that pancreatic and brain cancers, once
rare, had become much more common today. Breast cancer appeared to be
epidemic.
Assemblyman Carpenter probed for a theory on the increase in
cancers. Dr. Levin explained that brain cancer had been tied
conclusively to maternal cigarette smoking and exposure to certain
pesticides.
Assemblywoman McClain requested a comparison between Fallon and
Woburn, specifically the compact number of years in the Fallon cluster.
Dr. Levin stated emphatically that the circumstances in Fallon
suggested an ideal case and great opportunity to learn. Chairman de
Braga expressed her hope of the continued involvement of Dr. Byers and
Dr. Levin.
Testimony resumed with Al Biaggi, Administrator of the Division of
Environmental Protection. A report entitled ``Environmental Conditions
Summary of the Fallon, Nevada Area'' (Exhibit H) was distributed to the
committees. Mr. Biaggi introduced his staff and then presented an
overview of the agency's principal activities.
Water quality issues received highest priority with Nevada
Environmental Protection. Issuance of permits, followed by quarterly
compliance reports were, reported to be the key elements of their water
monitoring programs. Periodic inspections had been conducted by the
agency to further ensure compliance with regulations. Mr. Biaggi
referred the committees to the handout, which contained summary tables
of caseload data.
In terms of Fallon, Mr. Biaggi described the area as not being a
heavily industrialized area. Fallon had a total of 64 permits, with 14
connected to industrial storm water and 19 assigned on a temporary
basis for cleanup of site contaminations. Waste management covered
solid waste (i.e., landfills), waste generation of hazardous waste, and
the oversight of facilities using highly hazardous materials. Mr.
Biaggi added that there were four facilities in Fallon designated as
hazardous waste facilities, one being a chrome-plating operation and
the remaining three being geothermal power plant operations. In regard
to solid waste management, there had been a steady decrease in the
number of landfills, with only one remaining in the Churchill area.
Mr. Biaggi outlined the air quality programs which operated in
concert with the permitting processes described above. For Fallon, only
two companies at three facilities had been subjected to reporting under
the EPA TRI--Toxic Release Regulations. Statistics for the two
companies had been unremarkable.
Strong inspection and enforcement programs ensured compliance with
regulations. In Fallon, there were permits issued for six geothermal
plaints, six mineral processing facilities, eight sand and gravel
operations, two industrial permits, four surface area disturbance
permits, and two NAS permits (e.g., boilers and power generators).
Data for spills and accidents revealed 86 sites in the Fallon area,
with 76 cases involving petroleum products. Ten cases were reported to
be still active.
Mr. Biaggi introduced Paul Liebendorfer, Chief of the Bureau of
Federal Facilities, who presented an overview of the Fallon Naval Air
Station activity. Mr. Liebendorfer stated that 26 sites were known at
the base and under current scrutiny. Principal contaminants included
fuel oil, paints, solvents, and industrial refuse materials. The upper
aquifer had been contaminated to a depth of 20 feet, however no
contaminant had migrated off the base. General ground water flow was
known to be to the southwest direction and away from the Fallon area.
Chairman de Braga requested clarification on the testing of soil
and air in addition to water testing. Mr. Leibendorfer explained that
all of the contamination had been determined as subsurface, therefore
no air tests were warranted. Chairman de Braga questioned the follow-up
procedures for fuel dumping. Mr. Biaggi interjected to explain that
fuel dumping in the air was considered a distinct activity and not
related to their responsibility to address soil and ground water
contamination.
In reply to Chairman de Braga's question about well contamination
with JP8 jet fuel, Mr. Biaggi acknowledged a problem with groundwater
contamination at the site with JP8.
Assemblywoman Gibbons asked for clarification on the scope of the
authority and the ability of the State Environmental Protection
Division to govern environmental events at the Fallon NAS. Mr. Biaggi
characterized the relationship as a cooperative agreement with the
Federal Government.
In response to Assemblyman Carpenter's question regarding detection
of jet fuel in well water, Mr. Biaggi stated that there had been no
indication of hydrocarbon contamination. Assemblyman Carpenter next
asked Mr. Biaggi if other tests had been conducted which might provide
insight to cancer. Mr. Biaggi reiterated that municipal wells were
tested frequently and that hydrocarbons had not been detected.
Chairman de Braga stated that it would be helpful to get a list of
recommendations which included what could go wrong. Mr. Biaggi
explained that there had to be an exposure pathway and that the mere
presence of a chemical contaminant would not be enough to cause harm.
Water would be suspected as a likely pathway, however there had been no
proof to date.
In response to a question about agricultural activities by
Assemblyman Carpenter, Mr. Biaggi acknowledged the testing of water for
agricultural contaminants. He referred the committees to the Nevada
Department of Agriculture.
Mr. Biaggi reintroduced Mr. Liebendorfer and the topic of the Shoal
Project, an underground nuclear detonation near Fallon in 1963. Through
the years, testing and remedial efforts were implemented, and Mr.
Liebendorfer described the site as contained today. Ground water wells
had been monitored through the years, with one well revealing traces of
a radionucleide. Any movement of ground water would be away from the
Fallon area.
In response to Chairman de Braga, Mr. Liebendorfer clarified that
the wells had been tested within the last 6 months. The Department of
Energy had hired the Desert Research Institute to conduct a full-scale
study of the groundwater movement at the site of Project Shoal.
Mr. Biaggi concluded his presentation with mention of Nevada's only
superfund site, the Carson River. With known high levels of mercury,
the Carson River had long flowed through the Fallon area, however,
links between mercury and cancer had not been established.
Assemblywoman Gibbons requested clarification of the flow of
groundwater to the east. Mr. Biaggi reiterated that the flow and any
potential contaminants from the navy base would be away from the Fallon
community. Mr. Biaggi expressed his appreciation for the opportunity to
participate and assist in the investigation.
Chairman de Braga introduced Dr. Bruce Macler, Regional
Toxicologist, EPA, San Francisco. Dr. Macler shared a handout of his
presentation (Exhibit 1). Dr. Macler stated that the focus of his
testimony was arsenic and its possible relation to the Fallon cluster.
Exposure routes to arsenic were described as varied. Dr. Macler
emphatically labeled arsenic a poison, regardless of ingestion route.
Arsenic had been conclusively linked to lung, bladder, skin, liver,
kidney, and prostate cancers, as well as diabetes and neurological
complications. Like other cancers, leukemia occurred when damaged genes
caused cells to reproduce uncontrollably.
Dr. Macler elaborated on the quantification of disease rates and
associated arsenic levels. Extrapolation downward from certainty to
uncertainty was voiced as a concern. Some cancer risks had been
quantified with confidence; however, information was not abundant on
the association with childhood leukemia. International studies (e.g.,
Bangladesh) did not reveal an increase in childhood leukemia cases. The
mechanism of arsenic damage appeared to be related to the repair
mechanisms of chromosomes. Acute Lymphocytic Leukemia (ALL) had been
linked to genetic damage in earlier testimony. Dr. Macler speculated
that arsenic did not initiate the leukemia but rather established a
toxic background so that the actual causal agent could trigger the
leukemia. Whatever agent triggered the leukemia was amplified by this
toxic background, asserted Dr. Macler.
The question persisted in scientific circles about why Fallon had
not witnessed increases in other cancers. Over a lifetime, with an
estimated 10,000 residents in Fallon, 100 people would be expected to
get cancers of all types from exposure to arsenic.
Detoxification of arsenic was described as a methylation process in
the human body and was said to offer some protection to the human.
Thinking had changed drastically in recent years, and the distinction
between safe and unsafe forms of arsenic was obliterated. In moving
from the known to the unknown in calculating risk, regulations
interfered with risk assessment. Dr. Macler emphasized that toxicology
and epidemiology and risk assessment were described as different
processes, but interrelated fields. Risk assessment was depicted as a
process that had been driven by regulatory needs.
Dr. Macler emphasized that there was no known threshold for arsenic
and corresponding adverse effects. It had the status of a nonthreshold
carcinogen. In summary, Dr. Macler stated that arsenic posed health
risks and regulatory challenges, however the risks could not be used to
link arsenic to the childhood leukemia cases. He further stated that
arsenic had the potential of being a contributing factor.
Chairman de Braga asked if 10 parts per billion was an unrealistic
level or excessively low. Dr. Macler replied that he did not agree, and
added that 10 was feasible and a good place to be. Costs were predicted
to go down for methods to treat arsenic in drinking water.
Assemblyman Carpenter referred back to an earlier comment made by
Dr. Macler and requested that he elaborate on any issues that caused
him concern during the day's testimony. Dr. Macler explained that the
nature of childhood leukemia and the associated chromosomal damage
caused him concern. The immunological steps employed by the body to
clean up damaged genes and systems needed more research to fully
understand the relationships, especially in relation to arsenic health
effects.
Assemblywoman Gibbons asked for clarification about the data that
indicated that methlylated arsenic compounds were as toxic as inorganic
arsenic. Dr. Macler explained that the source of the data would be
found in the Federal register, in the literature, and on their Web
site. Dr. Macler reiterated that because arsenic had long been present
in Fallon, it was likely to be a background amplifier rather than the
primary cause of the ALL.
In response to Assemblywoman Gibbons question regarding the role of
individual genetics and impaired immunity, Dr. Macler agreed that there
was a possibility of that association. He did not, however, agree that
it could be a fluke. He cautioned the committee members to remember
that everyone had been exposed to arsenic in Fallon water, but not
everyone got sick. Everyone could have been exposed to something else
in Fallon that might have initiated childhood leukemia. Testimony did
not indicate compact exposure among these 11 children in Fallon.
Variability in susceptibility had to be factored into the
investigation.
Assemblywoman Koivisto requested clarification about the
calculation of risk, for adults or for children or for both. Dr. Macler
stated that the risks were calculated for adults and therefore biased.
Risks were seldom quantified for childhood cancer.
Chairman de Braga expressed her appreciation for the testimony. The
meeting was adjourned at 5:19 p.m.
Respectfully submitted,
June Rigsby,
Committee Secretary.
______
February 13, 2001
The Committee on Natural Resources, Agriculture, and Mining was
called to order at 1:18 p.m., on Tuesday, February 13, 2001. Chairman
Marcia de Braga presided in room 1214 of the Legislative Building,
Carson City, Nevada. As there was no quorum present, Chairwoman de
Braga convened the meeting as a sub-committee of Natural Resources,
Agriculture and Mining, and Health and Human Services. Exhibit A is the
Agenda. Exhibit B is the Guest List. All exhibits are available and on
file at the Research Library of the Legislative Counsel Bureau.
Committee Members Present.--Mrs. Marcia de Braga, Chairman; Mr. Tom
Collins, Vice Chairman; Mr. Douglas Bache; Mr. David Brown; Mr. John
Carpenter; Mr. Jerry Claborn; Mr. David Humke; Mr. Harry Mortenson; Mr.
Roy Neighbors.
Committee Members Absent.--Mr. John J. Lee; Mr. John Marvel; Ms.
Genie Ohrenschall.
Guest Legislators Present.--Assemblywoman Sharon Angle, Assembly
District 29; Assemblywoman Dawn Gibbons, Assembly District 25;
Assemblywoman Ellen Koivisto, Assembly District 14; Assemblywoman
Sheila Leslie, Assembly District 27; Assemblywoman Kathy McClain,
Assembly District 15; Assemblywoman Bonnie Parnell, Assembly District
40; Assemblywoman Debbie Smith, Assembly District 30.
Staff Members Present.--Linda Eissmann, Committee Policy Analyst;
June Rigsby, Committee Secretary.
Others Present.--Captain D.A. ``Roy'' Rogers, Commanding Officer,
Naval Air Station Fallon; Charles Moses, Environmental Scientist,
Nevada Department of Agriculture; Mike Wargo, District Manager,
Churchill County Mosquito and Weed Abatement District; Ken Tedford,
Mayor, City of Fallon; Mike Mackedon, City Attorney, Fallon; Dr. Donald
D. Runnells, Senior Technical Adviser, Shepherd Miller, Inc.; H. Robert
Meyer, Senior Scientist, Shepherd Miller, Inc.; Bjorn P. Selinder,
County Manager, Churchill County; Norman Frey, Commissioner, Churchill
County; Gwen Washburn, County Commissioner; Dr. Bonnie Eberhardt Bob,
representing the Western Shoshone Nation; Leuren Moret, representing
Scientists for Indigenous People; Keith Weaver, a long-term resident of
Fallon.
This meeting continued the hearings from February 12, 2001, and was
the second part in a three-part series. Chairwoman de Braga requested
that committee members and agency representatives write down
recommendations to be included in the final report to the Congressional
committee hearings to be held at a future date. A work session was
planned for February 21 during which no testimony would be taken unless
an expert was available, but final recommendations for any legislation
would be made.
Captain David Rogers, Commanding Officer of Naval Air Station
(NAS), Fallon, Nevada, opened the hearing by reading a statement
(Exhibit C) that gave an overview of the history and operations of the
base since 1942, and issues which pertained to the investigation of the
leukemia cluster.
Chairwoman de Braga asked Captain Rogers to explain a little about
the pipeline that brought fuel to the base, the route it took, who
owned it and who was responsible for monitoring it.
Captain Rogers explained that the pipeline was owned and monitored
by Kinder Morgan Co. of Sparks, Nevada; specifically, it was tank 16. A
6-inch pipe ran 70 miles along 1-80, then through Churchill County to
the base. NAS assumed responsibility for the fuel when it was on the
base. Captain Rogers stated that Kinder Morgan had an extensive
monitoring program for leakage in the pipeline, which included pressure
differential testing in the pipe and testing of the soils around the
pipe. Kinder Morgan had not found any significant problems.
Additionally, air and water sampling done on the base had not indicated
any leakage problems.
Assemblywoman McClain asked if any planes came back to Fallon from
``Desert Storm'' and if there had been any way contaminants could have
come back with them. She wondered if the cause of the leukemia problems
could be airborne and asked if any investigations had been done to see
if that was a possibility.
Captain Rogers replied the airplanes that participated in ``Desert
Storm'' and ``Desert Shield'' action were not based at Fallon. There
was probably a 1\1/2\- to 2-year time lag before any of those aircraft
came to Fallon for training. The Navy had not investigated the
possibility of contamination and submitted that it probably was not
warranted.
Assemblywoman Smith inquired if the Navy was doing any follow-up
with families that had been in Fallon during this time period to
ascertain if they were included in this study.
According to Captain Rogers, the Navy medical community was
investigating whether any families which were no longer based at NAS
Fallon had cases of acute lymphocytic leukemia (ALL) occur since their
departure. This investigation would be completed by the beginning of
March. To date, the study was about 60 percent completed and none had
been found.
Assemblywoman Smith asked if the fuel-handling procedures included
the dumping of jet fuel, or if there had been a particular
precautionary measure that was covered in the fuel handling.
In response, Captain Rogers declared, generally fuel handling had
many aspects: refueling of aircraft, clean-up of fuel spills which
happened either as the airplanes were refueling or if the fuel
inadvertently was jettisoned overboard on the ground, and in-the-air
fuel dumping above 6000 feet of ground level.
There was an extensive spill containment program; the amount that
was spilled was handled in various ways based on the size of the spill.
If on concrete, it was cleaned with absorbent materials that were
disposed of in accordance with hazardous materials instructions. If the
spill was on soil, the soil was excavated and burned. The total number
of spills was insignificant in terms of the amount. Captain Rogers
offered to provide those figures if they were requested.
Captain Rogers continued, the only reason to jettison fuel over
land would be during an emergency when the plane must be reduced to
landing weight in order to land. The total number of times this had
occurred was perhaps 3 times in the past 15 years. In all three cases,
the fuel was jettisoned out to 1he east of the base. As evidenced in
the monitoring, the contaminants moved 10 the east out of the base
area.
Chairwoman de Braga stated that as she read the articles in the
newspaper, she noted a comment that ``they regularly see dumping'' and
asked what might have been seen.
Captain Rogers submitted that probably these were contrails, an
action between the exhaust product from the airplane and the water
vapor in the air which created a cloud that could appear like fuel. He
acknowledged the exhaust from the aircraft smelled like fuel.
Chairwoman de Braga asked if something had changed in recent years
regarding the dumping at 6,000 feet rather than the 6,000 meters
minimum standard of the Federal Government.
Captain Rogers replied-that the Department of Defense (DOD)
regulation is 6,000 feet above ground, unless it was a true emergency.
Chairwoman de Braga, to clarify, stated perhaps it was not a
requirement but that above 6,000 meters was estimated to be the proper
range above which fuel dissipated or evaporated before it hit the
ground.
Captain Rogers agreed but continued that there had been further
study. Six thousand feet was the DOD standard until the introduction of
JP8 jet fuel. JP8 did not disseminate as well as the JP4 and JP5 that
were previously used by the Navy. The Navy and the Air Force were
investigating a higher dump altitude. He affirmed that any fuel that
did not dissipate in the air would do so on the ground within 18 to 20
hours.
Assemblywoman Gibbons asked, as 1,800 people lived on base and
6,400 personnel resided off the base, were the two military children
diagnosed with ALL living on or off the base? And, was there data to
compare a base similar to Fallon, and were there any acute lymphocytic
leukemia cases on those bases?
Captain Rogers answered the first question by stating he was
unaware of where the children lived. Regardless, the water came from
the same aquifer. As for the second question, the Navy had done no
comparison of ALL rates in Fallon and other military areas. The
military medical community was ``all over this one'' and if there had
been another area with this same rate, that would show up in the
investigations.
Assemblywoman Gibbons asked how many of the 8,200 are children.
Captain Rogers offered to get the exact number, but estimated it was
around a thousand.
Assemblyman Neighbors said that he had seen much of the aluminum
foil chaff that was dropped out of the aircraft in the desert and asked
if everyone was comfortable that it was not a problem.
Captain Rogers defended that chaff was expended on the range
considerably east of the town and any chaff migration would tend to
drift further east with the prevailing wind. He explained that a select
panel of research scientists from eight universities studied the
harmful effects of chaff and concluded that there were none Chaff was a
litter issue, not a health issue. The total amount expended at Fallon
equated to one quarter of one ounce per acre per year. This was an
amount that the Navy was willing to use in the name of combat training.
Captain Rogers further affirmed that the combat training done with
chaff was essential because it was an end game maneuver that could save
a pilot's life if a missile was shot at him. Without that three-
dimensional training, people would die in combat.
Assemblywoman Parnell assumed that NAS Fallon had material safety
data sheets (MSDS) for toxic wastes and chemicals that they used, and
asked if the Health Division had seen them.
Captain Rogers acknowledged the base had that information but was
unaware if the Health Division had looked at it.
Ms. Parnell requested to know that the Health Division did have
that information in their possession. Ms. Parnell pointed out that in
her packet of information she had a 1999 article from the Las Vegas Sun
regarding the citation of the U.S. Navy by the U.S. EPA for
noncompliance and violations of hazardous chemicals that were noted 2
years prior to 1999. She requested to know the current status of
compliance.
Captain Rogers claimed the article, as it appeared in the paper,
was ``not exactly factual.'' He believed that Mr. Liebendorfer of the
State Division of Environmental Protection was aware of the situation
and testified on February 12 that the base was in compliance, and what
was reported on was a difference of opinion between the State and the
base regarding the interpretation of the regulation. That had been
resolved.
Assemblywoman Leslie questioned whether the live or spent ordinance
on bombing ranges Bravo 20 and Bravo 16 was swept up and discarded, and
did this debris have any possible connection to the problem? This range
scrap was extensive on the four ranges, Captain Rogers admitted. There
were times during the year when it was swept into large piles until
portions were removed. Scientists determined that contamination from
range scrap piled onsite in these dry alkaline lakebeds was not an
issue. Any migration of contaminants would tend to move eastwards.
Ms. Leslie asked if this was checked once or regularly every year.
According to Captain Rogers, the DOD Inspector General prepared a
report about this and regular testing of the environment was conducted.
Ms. Leslie's second question regarded the reaction of the families
of the military. She wished to know if they had asked the Navy for help
which had not been touched on in this hearing. The Captain replied this
was an emotional issue. The base had held town meetings. He affirmed
that the Navy did not feel that Fallon was an unsafe place to live nor
that this situation warranted moving families out of the area.
Ms. Leslie asked if the community accepted this or were some asking
for transfers out of the area. Captain Rogers believed that the
majority accepted this. Just a couple of people asked informally if
they could transfer but the Navy would not entertain that until they
had been convinced there was a problem. The San Diego-based Navy
Environmental Health Command was intimately involved with the
investigation and were as concerned as the local civilian community.
The Navy was doing everything possible to determine a solution. He
continued that if the DOD felt there was an immediate threat, ``they
would pull out.''
Assemblywoman Gibbons questioned whether he knew of any commonality
between the two cases with military children and the other nine cases
in the civilian community. The only answer Captain Rogers said he could
offer was there was nothing that was a common trait. The lifestyles and
activities were varied.
Assemblywoman de Braga returned to the pipeline issue asking if the
Navy could detect small leakages on the base. Captain Rogers guessed
that would depend on the definition of ``small'' leakages.
Ms. de Braga restated her question to inquire if the pipeline could
be leaking in such small amounts that it would not be detected anywhere
along its route. Captain Rogers acknowledged that a minute amount of
fuel would be detected in any water source. If fuel leaked from the
pipeline, he said, the ``very aggressive'' water testing program would
detect it. Ground testing was also done. The results of the testing
were reported to him and to State and Federal agencies that oversaw the
base water quality program. He further explained that Kinder Morgan Co.
was obligated to inform NAS Fallon if a problem was detected on the
pipeline anywhere off base. The base received the results of their
testing but Captain Rogers did not ``know specifically if there's a
requirement for them to do that or not.'' He would get that information
for Chairwoman de Braga.
Ms. de Braga stated that she wanted to be certain that enough
precautions were in place. She did not feel that there was ``a lot'' of
ground testing being done, but there was quite a bit of water testing.
She questioned again what the Navy was proactively doing differently to
help in this effort; e.g., studies, tests, or other possible
environmental causes.
Captain Rogers told the committee that the Navy was more sensitive
to the environmental issues on base. NAS Fallon, he said, had much
pride in the environmental programs he outlined previously (Exhibit C).
He felt the Navy had a good relationship with the State and Federal
agencies which monitored the activities. Captain Rogers revealed that
he had a task force on base that assisted with the investigation.
Ms. de Braga asked if the State had the authority to test on base.
The DOD and the Navy would give permission if necessary, Captain Rogers
replied. Assembly-
woman Koivisto asked Captain Rogers about the by-products in contrails
that people were breathing. He responded that the exhaust of a jet
airplane was similar to that of a motor vehicle. Contrails were
essentially water vapor, not a hazardous substance.
Ms. Koivisto stated that since automobile emissions were controlled
because of health effects on the population, she found it difficult to
believe that a jet airplane did not have as much exhaust as
automobiles. Captain Rogers replied that it had a similar composition
and offered to get that information for her. He continued that
obviously there is a larger amount than a car but State and Federal
regulations controlled their air permits.
The next speaker, Charles Moses, an Environmental Scientist of the
Nevada
Department of Agriculture (NDOA), stated that goals of the
Environmental Compliance Section (ECS) were to protect health and the
human environment from the adverse effects of pesticides and to assure
that pesticides remained available as valuable tools in an integrated
approach to pest management.
He stated that pesticides were used and regulated in a number of
applications, not just associated with agriculture: in ornamental lawns
and turf, golf fairways, household and domestic dwellings, fur- and
wool-bearing animals, even pets, wood protection, swimming pools and
hot tubs, airport landing fields, tennis courts, highway right-of-way,
mosquito abatement districts, and many more.
The challenge of regulating pesticides existed, he said, basically
because of the dual nature of the products. That is, they were a
tremendous benefit for the production of agricultural products and for
the protection of human health, but when they were used inappropriately
or inconsistently with label directions, they had adverse affects.
Mr. Moses indicated that the State of Nevada had a cooperative
agreement with the U.S. Environmental Protection Agency (EPA), that the
State received funding and oversight from the agency to regulate
pesticide use, manufacturing, sale, distribution and application.
Mr. Moses continued by giving an overview of the regulatory program
that enforced the EPA provisions in the state. This defined a pesticide
as any substance that made a claim of preventing, destroying or
repelling a pest or a substance or mixture of substances used for plant
regulators, defoliants and desiccants.
Since the creation of the EPA in 1972, it has been required that
all pesticides must be registered. The law was revised in 1996 to
eliminate the benefit factors on food crops and in areas where children
would be exposed. All pesticides, new and existing, were required to
conform to the standards.
Based on the data submitted for pesticide registration, the EPA
developed a label that addressed the hazards of using the products. Mr.
Moses emphasized that what set a pesticide label apart from other
hazardous chemical labels was that this label was the law. An
applicator must use this product in accordance with all information
that was printed on the label. A signal word ``CAUTION'' was used on
the label for the safest type product to give an indication of how
acutely toxic the pesticide was. In other words, with a large dose over
a small period of time, the ``CAUTION'' gave an indication of whether
the victim would experience health effects. For this type of product,
he claimed, it would take quite a bit to actually cause health effects.
However, the signal word would not say how chronically hazardous this
product was, used over an extended period of time.
Lastly, Mr. Moses continued, the EPA gave the State the
responsibility of enforcing the pesticide law and the State had to show
that it had similar State laws to regulate the sale, manufacturing and
use of pesticides (Chapters 555 and 586 of the Nevada Revised
Statutes). Commercial applicators and farmers were trained, tested and
regulated. The NDOA required all applicators submit reports of
customers, sites, products and quantities applied. These reports and
data have been acquired since 1970.
Mr. Moses said that the NDOA, as part of the agreement with the
EPA, did inspections on Federal property and had been to the NAS Fallon
airbase to inspect the pest control activities. In most cases, he
stated, they found that the Navy contracted with private individuals
and licensed companies to do the work. According to Mr. Moses, the Navy
asked the contractors ``to go above and beyond'' what NDOA required,
and concluded that they had been cooperative with the Nevada
inspectors.
Next, Mr. Moses showed a sample of a sales report which showed who
bought restricted-use products. All of this was public information and
was available upon request.
Mr. Moses then shifted gears and explained the ground water
monitoring program for pesticide residue. In 1988, the EPA found that
pesticides existed in low levels in a lot of different areas and in
some cases in public drinking supplies and shallow ground water wells.
Since then, the EPA has required every State that had a cooperative
agreement with them to have a regulatory program designed to protect
ground water from becoming more contaminated or becoming contaminated
from the applications and use of pesticides.
For a long time, Mr. Moses admitted, it was thought that pesticides
could not seep down 150 to 200 feet to water wells. But even with
proper application, he said, it had been found that pesticides had
properties that may allow them to leach down into ground water. Mr.
Moses showed that since the monitoring program was implemented, there
had been more detections in urban areas than in rural areas in the
ground water sampling.
Mr. Moses distributed a fact sheet (Exhibit D) done with the U.S.
Geological Survey (USGS) that explained the monitoring program. In most
cases, the wells were constructed by the NDOA to look at the shallowest
aquifer they could find. If pesticides were to show up in the shallow
wells, there would be time to implement regulatory measures before the
pesticides leached to the deeper aquifer.
In Churchill County last year, Mr. Moses further explained, water
samples from about 20 wells, many of which were put in by the USGS, but
some were irrigation wells, were examined for about 40 EPA-registered
products. The NDOA did not look for products that the EPA canceled due
to health risks because there would be no regulatory measures that NDOA
could take to try to keep the pesticide from getting worse because it
was no longer being used. No contamination was found in Churchill
County.
In one other item, Mr. Moses showed that the USGS did some studies
``in that area'' of ground water and surface water samples and did find
pesticide residues. The chart he used showed the levels were far below
what a health advisory would be for these products. Many of the
products leached into the ground water were a result of right-of-way
applications. These included Atrazine, Prometon and Simazine. He
summarized that most of the cases of leached pesticides were not from
agricultural products but from use around homes, lawns and right-of-
ways. But they were still quite low, far below health advisory levels.
Lastly, Mr. Moses stated that he had information about studies that
he had requested the EPA send him. He declared he would be glad to
submit them to the committee because there had been some links to
different types of uses where the mothers were working with the
chemicals when their children developed leukemia.
Chairwoman de Braga agreed she would very much like to see that
information because those gaps might lead the committee somewhere in
this investigation. She felt it helped them to know the extent to which
the NDOA went to protect people from chemicals. But, she questioned,
what could go wrong? The bottom line was that there was not complete
regulation because you could not know if a housewife mixed 409 and a
non-recommended agent which had fine print on the bottle that nobody
read. Maybe education would be the key to this. What she and the
committee wanted to know is not what was being done but rather what was
missed.
Mr. Moses agreed that one problem they had was assessing the use of
pesticides by homeowners. There was data in some of the studies that
suggested that there were links.
Mrs. de Braga added that even the people who aerial crop-sprayed,
who sprayed your house for spiders or whatever, were they taking the
proper precautions? And what about accidents? The problems might have
been entirely different from house to house.
Assemblyman Neighbors asked about the ground water level of the 20
wells that were tested in the Churchill County. Mr. Moses believed that
the monitoring wells averaged about 40 feet. Drinking water and
irrigation wells were much deeper.
Mr. Neighbors stated that, as he recalled, Nevada law said you may
put a well and a septic tank on one and a quarter acre. Correct? Mr.
Moses was uncertain. Mr. Neighbors ask about the percolation rate and
Mr. Moses replied that he did not know.
Ms. de Braga suggested that this was not really his area. Mr.
Neighbors said it would be interesting to know because there were areas
of Nevada where that had become a problem. Too many nitrates might be
in the water. Mr. Moses believed that the Health Division had that data
and it could easily be obtained from them.
Assemblywoman Gibbons mentioned that the members of the committee
were given maps of the Fallon area that showed where the children with
leukemia lived. She asked if there was a map that showed the areas
where pesticides were used. Could the rainfall or drought years have
had an effect on this? Mr. Moses answered that he could probably come
up with a map of the agricultural areas but it would be tougher to do
the residential usage areas. They did not know what homeowners were
using nor how much.
Ms. de Braga inquired about the types of complaints Mr. Moses had
received about pesticide use. They ranged from human health and
vegetation damage to possible adverse effects to animals, Mr. Moses
replied. He got from 10 to 50 of these serious investigations per year.
At conclusion, Mr. Moses distributed a list of Available Resources for
the Leukemia Task Force (Exhibit E).
The next speaker was Michael J. Wargo, District Manager, Churchill
County Mosquito and Weed Abatement District (MWAD). He distributed a
letter that outlined the activities of the Mosquito and Weed Abatement
District (Exhibit F). With this he also distributed material safety
data sheets for the pesticide used by the District (Exhibit G). Mr.
Wargo stated that he was a biologist more so than a chemist with a
degree in entomology, the study of insects.
Mr. Wargo briefly reviewed the information in the letter that
addressed the history of the MWAD, the chemicals they used to control
mosquitoes, and the weed activities. To control the mosquitoes, his
staff considered the site, the size of the colony, the impact on the
area and the population of the natural predators at the site. With the
mosquitoes in an early stage of development, natural agents such as a
bacteria or mosquito hormones were used for control. In a later stage,
a light petroleum oil was used in the water to suffocate the pupae. If
mosquitoes reached the flight stage, they were treated with pyrethrum,
a compound made from chrysanthemums, or with Dibrom aerially applied
over a large acreage. These latter two applications were not preferred
because of the expense and the difficulty of application. Mr. Wargo
added that most of the mosquito populations were not in Fallon but out
in the rural surroundings.
Next Mr. Wargo spoke about the weed control activities that began
in 1987. The chemicals used were listed on page 3 of his letter
(Exhibit F). In 1999 and in 2000, Pendulum was used as a preemergent
along the county roadsides. During the summer, Glyfos and Weedone were
used. Arsenal was used to create a bare zone that protects a road base
from emergent weeds that damaged asphalt. Roundup and 2-4-D were used
as needed to eliminate emerging weeds.
Mr. Wargo concluded by saying that, from 1998 to 2000, Tall
Whitetop control along the Carson River required the use of Weedar 64
and Rodeo. Some isolated patches of Tall Whitetop, Russian Knapweed and
African Rue were sprayed with Tordon.
Chairwoman de Braga asked Mr. Wargo if there had been any
substances used that were now considered unsafe.
Mr. Wargo replied that he was unaware of any. All the chemicals
they used, he said, were approved and were used extensively throughout
the United States by State and county health departments and by other
mosquito abatement districts.
Ms. de Braga stated that in the history of the area much was done
by aerial spraying, but if it were intended to kill insects, how could
it not be harmful to humans who breathed it?
In reply, Mr. Wargo referred to Mr. Moses' previous comments that
the EPA required tests to be done before the chemical was registered.
The end user had no input into that process.
Right, Ms. de Braga agreed, then mentioned that the committee was
back to not knowing what people were breathing in combination with this
chemical and what deleterious effect this might cause. She asked if Mr.
Wargo was aware of any use of jet fuel, or something with the same
components as JP8, for weed killer. She stated she had received a
report of this possibility in Churchill County. ``No,'' Mr. Wargo
replied.
Ken Tedford, Mayor of the city of Fallon, spoke next. He began his
testimony by stating that Fallon was a tight-knit community, taking
seriously the good and the bad that happened there. As the
investigation into the leukemia cases unfolded, more media attention
was paid to the children. He assured the committee that his focus was
not on the town's image but rather to put the care and comfort of the
children first while preserving their privacy. Mayor Tedford's goal was
to establish a single point of contact in the community, a place were
the families could go if they had needs that were not met, and a place
for those who wanted to give their time, money or talent to assist.
To avoid fear, rumor and lack of information, the city council
prepared fact sheets and answers to frequently asked questions (Exhibit
H) and other information for distribution throughout the community
(Exhibit I). He thanked Governor Guinn, the State Health Division
Administrator Yvonne Sylva, State Health Officer Dr. Mary Guinan and
State Epidemiologist Dr. Randall Todd for their efforts. He declared
that the city would continue to assist in the ongoing investigation.
Mayor Tedford then began to speak about the city water supply that
provided services to approximately 2,900 connections from four city
wells pumping water from the Basalt Aquifer. However, he clarified, not
all of the affected families were on city water--some used private
wells and some drank bottled water. He restated the belief that the
city water supply was not the common link in these cases.
He acknowledged that arsenic was present in the water of Lahontan
Valley. Many of the 4000 domestic wells, contained naturally occurring
arsenic, as did the water in the city and Navy wells. Fallon had known
of this arsenic for a long time and had struggled to deal with it. But,
there appeared to be no link between arsenic and leukemia, he held.
The city contracted with Shepherd Miller Inc. (SMI), an
environmental and engineering consulting firm, to conduct tests and
surveys for arsenic removal from the water. The public water system
would need to comply with the new Federal standards of 10 parts per
billion by the year 2006.
Mike Mackedon, Fallon City Attorney, next read from a brief
memorandum (Exhibit J) that stated that the city had engaged Shepherd
Miller, Inc. in April, 2000, to provide technical consultation. Within
the binder (Exhibit K) were some of the water reports ``in history''
that the city had provided to the State as part of its regular
reporting duties, under State or Federal law. Additionally, there were
numerous studies and analyses conducted by the city in excess of and
different from those required under any reporting requirement, and some
in direct response to the pattern of leukemia.
SMI had been asked to examine past data to determine the quality of
the data to the extent possible. They were further instructed to survey
the available or innovative technologies that would remove arsenic from
drinking water and select a suitable bent-scale test method, to perform
tests, to review and analyze the results, and evaluate the results; to
perform pilot-scale testing on the selected treatment technology,
evaluate those results, and recommend a final arsenic treatment
technology. The bent-scale tests were completed and pilot-scale testing
began on November 30, 2000.
Mr. Mackedon continued that SMI's work was expanded in July of 2000
when the city learned of the childhood leukemia cases and that the
pattern might have suggested an environmental cause. The mayor
instructed Shepherd Miller to: review the available literature and
research to confirm or not confirm a connection between arsenic and
childhood leukemia, to review the available literature and research to
confirm or not confirm a connection between the intake of radon and
childhood leukemia, to re-review the historical analysis of the water
chemistry of the city of Fallon, to proceed to develop a list of agents
known or suspected to cause leukemia, and to perform tests of agents
not previously analyzed.
Mr. Mackedon introduced SMI representatives Dr. Don Runnells,
Senior Technical Adviser, and Dr. H. Robert Meyers, Senior Scientist.
Don Runnells spoke first, introducing the company, its history and
himself, a water geochemist and professor at the University of
Colorado. He reiterated that SMI was hired in April of 2000 to
characterize the ground water supply and to provide recommendations on
water treatment technology to address the arsenic issue. From September
of 2000 through late January 2001, SMI reviewed and compiled data from
historic groundwater analyses of samples from the city of Fallon water
wells to determine if any regulated constituents were present in
concentrations above the Nevada drinking water standards maximum
contaminant limits (MCL).
With the exception of an elevated value of lead in 1989 and the
arsenic in all samples, the water had tested below the primary drinking
water standards. In the secondary standards, total dissolved solids in
the water had exceeded the secondary standard of 500 milligrams per
liter. It also exceeded the standard for PH that is 6.5 to 8.5, having
been around 9.
Based on a very recent literature review for potential leukemia
causing chemicals, Shepherd Miller, Inc. developed a list of chemicals
and analytes, some of which could potentially cause leukemia, for which
there had been no previous testing in Fallon. They excluded from the
list pharmaceuticals, analytes for which there were no analytical
methods for testing, chemicals used as part of the water treatment
system, and highly reactive chemicals that had a very short half-life
and were gone quickly when added to water. Those remaining of possible
concern included formaldehyde, lead 210, and radium 224. In early
February of 2001, the city of Fallon wells were sampled for these
additional chemicals. The results had not yet come in.
SMI also looked at the composition of fuels such as JP8 jet fuel,
to determine if historic water analyses might contain components that
could be related back to hydrocarbon fuels. No historic analyses showed
a presence of volatile organic chemicals or synthetic organic compounds
above detection limits. These were expected to be found if a fuel
supply was, in fact, contaminating the ground water. Dr. Runnells
remarked that the Fallon water was ``remarkably clean'' with the
exception of the arsenic. The binder (Exhibit K) summarized the
findings.
Assemblywoman Koivisto asked for clarification as to why so much
emphasis was placed on the water supply when the children who
contracted the leukemia did not all use the same water source. Dr.
Runnells affirmed that Ms. Koivisto's observation was correct. SMI was
brought in originally specifically for the arsenic issue. Subsequently,
with the community awareness of the leukemia cluster, the mayor and the
city council directed them to expand the scope of their work to include
a review of what was known about the relationship between arsenic and
leukemia and also to identify other chemicals that might be related to
leukemia. Dr. Runnells avowed that SMI did not believe that the city
water supply was the problem.
Assemblywoman Parnell stated that it appeared that most experts
agreed that the most direct link to childhood leukemia would be that of
radiation. She asked if it was possible to look for a radiation link in
the water supply or somewhere else.
Dr. Runnells affirmed that SMI was looking at the water
specifically for radionuclides. In the binder (Exhibit K), Table 4
listed the radionuclides and gave the values they found and the MCL.
Gross beta could be composed of a number of radionuclides. Therefore,
SMI also analyzed for lead-210 because it contributed to gross beta and
had a high risk factor.
Ms. Parnell asked whether anything on Table 4 alarmed Dr. Runnells,
especially the gross alpha of Wells 2 and 4. He deferred that answer to
Dr. Meyer as that was his field of specialty.
Assemblyman Mortenson asked if the lead-210 was a more energetic
beta to which Dr. Runnells replied that it was attracted to the surface
of the bone and therefore had a high risk factor. Mr. Mortenson also
asked about the short half-life of radium 224 and whether there were
products in the decay chain that were stable enough to analyze and then
infer back to the quantity of radium 224.
Dr. Runnells replied that radium 224 was a decay product of thorium
that normally was not found in the ground in a natural situation. But
SMI was analyzing specifically for radium 224 to be certain something
with a short half-life was not overlooked. The half-life of radium 224
is about 48 hours.
Mr. Mortenson asked if lead-210 was not a product in the decay
chain of radium 224. Dr. Runnells believed that lead-210 came from
uranium decay chain not the thorium decay chain.
Assemblyman Claborn requested to know if any studies were conducted
on small aquatic animals (frogs, fish, even birds). Dr. Runnells
responded that he did not have that knowledge but that perhaps someone
from the city or county knew. Mr. Claborn continued that generally when
something happened [in the environment] it was noticed lower down in
the chain of life. Dr. Runnells agreed stating he made an excellent
point.
Robert Meyer, a Senior Scientist (radiation biologist) with
Shepherd Miller, Inc. testified next. He summarized the materials in
the handout (Exhibit K). In late July of 2000, SMI began studies on the
potential causes of childhood leukemia. They arranged for Dr. Glyn
Caldwell, an epidemiologist, to participate in the health risk reviews.
Mr. Meyer reiterated that SMI reached the conclusion that no
obvious link existed between the Fallon water supply and the leukemia
cases identified in the area, but the issue was not closed. The
literature review summaries were provided in the binder (Exhibit K). A
clear link between arsenic and leukemia was not revealed in the
literature. As it had always been present in the water supply, arsenic
did not seem to explain the recent appearance of childhood leukemia.
One factor could be other sources of radiation, a known cause of
leukemia.
There were a number of possible sources of radiation to which
everyone was exposed. Levels of radiation seen in communities were low
with respect to the recognized standards for radiation protection. He
explained there were different types of radiation that could impact a
human. One would be an external source of radiation, such as cosmic
radiation, gamma rays and other radiation sources from outer space, and
from natural deposits of radioactive materials of the sort analyzed in
the Fallon water supply. These natural deposits were also present,
typically in low levels, in surface soils and rocks. Exposure from
these sources included direct exposure and wind-blown exposure.
Mr. Meyer went on to say that the ``Nevada experience is unique, of
course, given the presence of the test site and the test that was
conducted much closer to the city of Fallon.'' He had not studied the
results of the test nor the weather patterns at the time, but he knew
there were cases in which the circulation of radioactive materials was
in other directions.
There were also other possible sources of radioactivity in the
environment that could have influenced this situation. It was not
clear, he acknowledged, how an exposure from the 1950's or 1960's could
impact a cancer that was rapidly developing. It would be good idea to
examine the possibility of other sources of radiation in the area.
Chairwoman de Braga asked if Mr. Meyers and SMI had compared their
studies with those done at the base vis-a-vis the water system. Mr.
Meyer replied that they were aware of the findings on the base but had
not made comparisons.
Assemblywoman Koivisto asked if the historic levels of arsenic
remained the same or were there spikes and, were there studies of the
effects of arsenic on children rather than just adults? Dr. Runnells
answered that the concentrations of arsenic have been remarkably
constant. Mr. Meyer stated that he was not aware of toxicological
models that might extrapolate from adult leukemogenesis to childhood
leukemogenesis.
Assemblyman Mortenson related to Mr. Meyer that he recalled reading
that minor earthquakes could produce fissures. As thorium was all over
Nevada, he queried, could a minor tremor release a pulse of radon-224
into the water. Mr. Meyer submitted that radon-222 and radon-220 were
produced as a natural decay of uranium and thorium. He had read, too,
that one of the ways to identify the potential for an earthquake
occurrence would be to measure radon. The release of radon gas then was
possible. The total exposure over a period of time would be a major
factor in whether or not cancer might result. He speculated that the
release of this gas prior to or during an earthquake might be quite
brief, yet the damage done to a human body normally accrued over a
period of time. A short low-level exposure would be unlikely to
increase risk. Risk was proportional to dose.
Mr. Mortenson apologized that he had meant to say radium-224 to
which Mr. Meyer stated that he was unaware of particulate materials
released during moderate earthquakes.
Mr. Mortenson continued that he had read recently that with
volatile organic compounds in drinking water, the ``body burden'' was
via three methods: drinking the water, bathing with it, and through
inhalation (steam of showers or cooking). Even though someone might
have consumed bottled water, that was a fraction of the way the body
absorbed water.
Mayor Tedford of Fallon again testified the city began looking at
the water first (Exhibit L) because it was something they had control
over. The city had also begun looking at their landfills, utilities,
airport and other lands that they own. He closed by saying that he
hoped the committee would be vigilant in supporting the executive
branch that had made this investigation a priority. Funds and staff
were important to complete the mission. He thanked the committee for
the opportunity to speak.
Assemblywoman Leslie thanked the mayor for his testimony and asked
him to briefly describe the plans for the resource center. She hoped
that the Fallon Family Resource Center would be included. Mayor Tedford
said this was to be a clearinghouse for assistance that would allow the
families to maintain some anonymity. The hospital would assist and the
Family Resource Center was a good idea.
Bjorn Selinder, Churchill County Manager, with Gwen Washburn,
Churchill County Commission Chairman, and Norm Frey, Churchill County
Commissioner, read the following statement from Commissioner Washburn
(Exhibit L):
The Churchill County officials are very concerned about the
welfare of the citizens. We want to explore all possible
avenues that may attribute to the cause of leukemia but none of
us is willing to point to any one cause. We are leaving that to
the health experts.
Ask 10 people on the street and we'll get 10 different
opinions as to the cause of the cluster. I will attempt to
address what the county is doing about some of the causes.
In Churchill County, the first thought is always water. We
have been very concerned about how the reallocation of
irrigation water that historically came into the valley is
affecting the quality of the water being pumped from domestic
wells, especially since the passage of Public Law 106-18 known
as the Negotiated Settlement.
Churchill County began cooperating with the U.S.G.S. on a
ground water monitoring project in 1994. In 1999, the data
collection network included water level measurements at 19
wells monthly, 39 wells quarterly, and annually at 18 wells.
Quality sampling and testing on five wells was done twice
during the year, once during the irrigation season and once
during the winter. The water was sampled for major ions,
arsenic and nutrients. In the year 2000, four more wells were
installed in an area slated for development where septic tanks
would be used for sewage disposal to provide background data on
the effect of development on water quantity and quality. Also
in the year 2000, one isotope sample was obtained and analyzed
at each of the five water quality wells. There's an attachment
that describes some of that activity.
Realizing the potential for growth and the need to supply the
community with a safe and assured water supply in the future,
we have for the last several years been in the process of
developing a plan for a community-wide water system. The plan
is very tentative at this point and the economic feasibility
study is not yet complete. We are looking at every possible
source to supply this system, including Dixie Valley and the
Stillwater Mountain Range. In cooperation with U.S.G.S. and
Carson Water Subconservancy District, an injection and recovery
experiment storing water for municipal and industrial use from
Lahontan Reservoir in the Dead Camel Mountain alluvial fan will
begin soon. Every aspect of the proposed water system is in the
planning and study stage at this time. For all practical
purposes, the water system is many years away. At this point,
the cost to install the system, well over $200 million, is
prohibitive for a small community. Obviously, funding is the
huge hurdle for the county even after the water source is
identified and developed.
In the interim we are faced with the problems here and now.
Churchill Economic Development Authority, known as CEDA, is in
the process of developing a vision for Fallon and Churchill
County. In this process, CEDA has held three public workshops
and one meeting of a committee made up of citizens from all
business sectors. Water quantity and quality have been
identified in every session as the top priority issue.
There is little that Churchill County can do at this juncture
to improve the quantity and the quality of the water but [what]
we can do, and are prepared to do, is to educate citizens about
how they can help themselves. It has been suggested that we,
the county, test the well water. That is not something that we
can do. At our best estimate there are over 4,000 domestic
wells in the county and it would be not only cost prohibitive
and time prohibitive, but there are private property issues
involved as well. What we are doing is telling private well
owners how they can have their water tested.
We are actively encouraging the University of Nevada
Extension Service to reinstate the Guard Our Local Drinking
Water program known as Nevada GOLD. This is a group of
volunteers dedicated to educating homeowners about their water
supply. It is funded through the agricultural extension budget
but has been inactive since the local water specialist became
ill more than 3 years ago. At this point it is imperative that
the University Extension Service reactivate this water
education program. Many people move into the area and purchase
their ``dream'' country home and they have no idea that the
water comes from their own private well and they have the sole
responsibility for that well. We will begin dispensing
information about water safety and possible health related
issues and testing labs at the local library, extension office,
county administrative office, planning office, doctors'
offices, and so forth.
Operations of certain businesses and industries have been
blamed. Businesses and industries including agriculture,
pesticide operators and dairies that locate in the area must
have Churchill County business licenses and meet all the local
zoning criteria as well the Nevada Bureau of Health
requirements, and have all necessary permits from the Nevada
Department of Environmental Protection. We are looking at ways
to make the issuance of a business license contingent upon the
company showing current permits from the State of Nevada.
Naval Air Station and jet fuel in particular are suspect.
Even though we have a good relationship with the Navy, we have
no control over the Federal facility and depend upon the Navy
to protect its personnel and its neighbors from any harmful
effects of their operation. We must leave investigations of the
operations of the Navy in Churchill County to the experts.
The Churchill County commissioners are as concerned as any
one about this leukemia cluster and will work closely with the
local hospital to assist the health care professionals in the
investigation to best of our ability.
Now, I would like to comment as an individual. I know that
many people are quick to point to the water and water quality
in the Lahontan Valley as the culprit in the present leukemia
scare. I am not an expert on the water nor in the medical
field, so I will not say that water is or is not the cause. I
just would like to point out that I began using bottled water
service at my home in 1995. This is because I felt that there
was a definite deterioration in the quantity, quality and taste
of my well water that like most in the valley comes from the
shallow aquifer. I subscribed to the water service feeling that
it was an inexpensive health insurance. At the time, I was more
concerned about water-borne bacteria than heavy metals or
minerals. Now, under the changing conditions in the valley, my
concern about the quality of my well water encompasses more
than just bacteria. At this time I can honestly say that I do
not advocate anyone in the valley drinking water from their
domestic well unless they have had that well tested recently
and that it tested as safe to use.
The deterioration of our water quantity and quality has been
significant since water right buy-out began. The safety of our
water supply must remain the top priority of the community.
Personally and professionally, I thank you members of the
Assembly for adding your support to our community at this
especially difficult time.
This concluded the reading of Ms. Washburn's statement (Exhibit M).
Norman Frey, Churchill County Commissioner, spoke next, and was
very concerned about the negative press that the investigation was
generating and stressed that the study must be kept to a scientific and
professional level. He felt that the general public had not separated
the presence of arsenic in the water and the leukemia cluster.
Mr. Frey stated the government must deal with the people's
perceptions in order to ease their tensions. He claimed the county
might need assistance from the State to make well testing easier and
more affordable for some 4,500 well owners. The county might need to
set up low interest loans to purchase approved types of filtration
systems for individual homes. He concluded by stressing that Churchill
County is a very healthy place to live. Thousands had grown up and
grown old there free of hideous disease.
Chairwoman de Braga stated that she and the committee would do
whatever they could to reinstate the Nevada GOLD program at the
Agricultural Extension Service. She also requested that the
commissioners would present the committee with recommendations for
educating the public, especially those in the Soda Lake area, where the
arsenic rates were very much higher.
Assemblyman Neighbors requested to know the size of the area that
contained the 4,500 wells. About 95 percent of the total population of
Churchill County resided in the Lahontan Valley, which constituted
Basin 101, the largest groundwater basin in the state.
Mr. Neighbors inquired, what was the current cost of testing a
well? The cost appeared to be roughly $15 per item for each item on the
test, less than $100 per resident. Each property sale required a
complete test that cost $120.
In response to Mr. Claborn's question about increased abnormalities
in animals in the county, Mr. Selinder responded that a veterinarian
who had practiced in the county for many years had seen none.
Testimony came next from Dr. Bonnie Eberhardt Bob and Leuren Moret,
representing Scientists for Indigenous People. Ms. Moret revealed that
she had worked at the Lawrence Livermore Laboratory in California
(Exhibit N) and had done research on the Yucca Mountain project
(Exhibit O) and ran the sampling lab for the superfund project. She
felt these hearings had been good but that air pathways and sampling of
the upper dust layer in Fallon had been overlooked. She stated other
items to investigate included: the incineration of out-dated munitions
(some depleted uranium) at Honey Lake Depot that had sent a smoke plume
over Nevada; planes returned to NAS from the Gulf War which might have
had radioactive metal; the increased toxicity of highly complex and
mixed compounds such as radionucleides mixed with hydrocarbons; and,
burns in the fallout areas of Nevada (from the testing of the 1950's)
which remobilized the radionucleides in the upper dust levels thus
recontaminating some populations. Constant exposure to low-level
radiation, she testified, was more dangerous than a flash exposure such
as was at Hiroshima. She concluded by stating that the water in Fallon
had not been tested for tritium (radioactive hydrogen), and that the
city should test surface ditches and drainage for airborne
radionucleides.
Dr. Bonnie Eberhardt Bob, a psycho-biologist, answered
Assemblywoman Gibbons' earlier question saying yes, there was at least
one Shoshone child who was quite young and has contracted leukemia.
Dr. Bob related a story of gathering pine nuts with the Shoshone
last Fall in an area indicated to be ``experimental tree plots'' and in
which the trees had been dying from the top down. After some research,
Dr. Bob found that the BLM had planned to bum 870,000 acres of pinion
trees in Nevada. The chemical that killed the trees, she claimed, was
probably tebuthiuron, a ground sterilizing agent.
Another chemical, picloram, also known as Agent White, was one of
the defoliants used in Vietnam and was now used by the U.S. government
in the war against drugs in Columbia. Picloram was used to make Tordon
which when mixed equally with 2-4-D plus 245T (Weedar) was Agent
Orange. She concluded that, in effect, ``we'' are making Agent Orange
again, except perhaps with the dioxins removed. Furthermore, in the Ely
district where there were fires, the fields were sprayed with Garlon,
which when burned ``mimics estrogens and hormones of women and it ruins
the reproductive system.''
Dr. Bob continued her testimony and described the level of picloram
in Nevada's water and wondered what the reaction was when this chemical
was mixed with others and used for weed or insect control. She
expressed her concern for: the burning of parts of Nevada that would
release radionuclides into the air; tritium that was in the tree
cellulose and was released into the air from a burning tree; and
plutonium that would be released into the air when burning occurred.
Dr. Bob gave the committee a letter she wrote to the Bureau of Land
Management (Exhibit P).
Ms. Moret added that the smoke plume from the burning at the Fallon
Naval Air Station should be investigated as well.
Dr. Bob ended her testimony by reading a statement from Corbin
Harney, Shoshone Nation, which emphasized the importance of cleaning
the earth.
Keith Weaver, a long term Fallon resident and a member of the de
Braga family, delivered the final testimony. Mr. Weaver felt that the
link between arsenic and leukemia should not be eliminated from
examination at this point, based on a recent article he had read in the
Journal of Epidemiology. Chairwoman de Braga agreed that the committee
did not wish to rule out anything at this point.
The hearing closed at 5:23 p.m. to be resumed February 15 at 1 p.m.
Respectfully submitted,
June Rigsby,
Committee Secretary.
______
February 14, 2001
The Committee on Natural Resources, Agriculture, and Mining was
called to order at 1 p.m., on Wednesday, February 14, 2001. Chairman
Marcia de Braga presided in room 1214 of the Legislative Building,
Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest
List. All exhibits are available and on file at the Research Library of
the Legislative Counsel Bureau.
Committee Members Present.--Mrs. Marcia de Braga, Chairman; Mr. Tom
Collins, Vice Chairman; Mr. Douglas Bache; Mr. David Brown; Mr. John
Carpenter; Mr. Jerry Claborn; Mr. David Humke; Mr. John J. Lee; Mr.
John Marvel; Mr. Harry Mortenson; Mr. Roy Neighbors.
Committee Members Absent.--Ms. Genie Ohrenschall.
Guest Legislators Present.--Assemblywoman Sharron Angle, District
29; Assemblywoman Merle Berman, District 2; Assemblywoman Vivian
Freeman, District 24; Assemblywoman Dawn Gibbons, District 25;
Assemblywoman Ellen Koivisto, District 14; Assemblywoman Sheila Leslie,
District 27; Assemblyman Mark Manendo, District 18; Assemblywoman Kathy
McClain, District 15; Assemblywoman Bonnie Parnell, District 40;
Assemblywoman Debbie Smith, District 30; Assemblywoman Sandra Tiffany,
District 21; Assemblyman Wendell Williams, District 6.
Staff Members Present.--Linda Eissmann, Committee Policy Analyst;
Marla McDade Williams, Committee Policy Analyst; June Rigsby, Committee
Secretary.
Others Present.--Glen Anderson, Policy Specialist, National
Conference of State Legislators; Dr. Thomas Sinks, Epidemiologist,
Center for Disease Control; Dr. Allan Smith, arsenic specialist,
University of California, Berkeley; Brenda Gross, Fallon parent of a
leukemia victim; Dr. James Forsythe, Medical Oncologist, Reno; Dr. Gary
Ridenour, Fallon Physician; Diane Hansen, Fallon citizen; Peter
Washburn, Attorney, Senator Harry Reid's Office; Jerry Buk, University
of Nevada, Reno, Cooperative Extension; Juanita Cox, Citizen Lobbyist;
Robert Sonderfan, Citizen Lobbyist.
Chairman de Braga called the Assembly Natural Resources,
Agriculture, and Mining Committee to order. Roll was called, and a
quorum was judged to be in place. All members were present except for
Assemblywoman Ohrenschall who was noted as an excused absence. Chairman
de Braga welcomed as guests the Assembly Committee on Health and Human
Services. Roll was called, and all members were present.
Chairman de Braga, in her opening statements, remarked that this
was the third and final day of hearings on the Fallon leukemia cluster.
As with the previous 2 days, a balance of expert testimony and public
input was scheduled.
Expert testimony commenced with the introduction of Glen Anderson,
Policy Specialist, National Conference of State Legislators (NCSL). The
role of the NCSL was described as providing assistance to State
legislators on environmental health issues. Mr. Anderson distributed
two handouts that outlined a list of environmental disease registry
legislation by State (Exhibit C) and NCSL environmental projects
(Exhibit D).
Mr. Anderson commenced his testimony with an overview of what was
known about the link between environmental agents and cancer.
Scientific investigation of childhood cancer was complicated by the
relative rarity of cases as well as by the difficulty of estimating
past exposure levels for young victims after they developed cancer.
What had been established was that children had less developed
immune systems and were therefore more susceptible to the effects of
toxic exposure (e.g., mercury, lead, pesticide). Childhood cancer was
described as the second leading cause of death in children under age
14, with leukemia the most common type of cancer.
Human research on the link between the environment and cancer
lagged behind animal research. To date, clear causes had evaded
scientists in cancer cluster investigations. An extensive list of
variables under investigation included long latency periods between
exposure and onset of disease, the plethora of potential chemical
agents, and the tendency of families to change residency often.
Disease tracking registries were described as offering the greatest
hope for closing the information gap between exposure data and the
cancer data. Nationwide, State disease registry information would be
combined with background data on environmental exposure to promote
understanding of cancer causes.
Mr. Anderson reviewed innovations made in other States. Geographic
mapping was described as a significant enhancement to some State
registries and promised to aid in more expeditious detection of future
cancer clusters. Some States had taken a preventative approach through
the introduction of children's environmental health legislation.
Because most law had been designed around protection of adult health,
Maryland and California were cited as two States that enacted specific
health guidelines for children.
Federal efforts in the areas of children's health, the environment,
and disease tracking (e.g. Center for Disease Control) had paralleled
and supported the States' disease registry efforts. The Food Quality
and Protection Act of 1996 resulted in the restriction of pesticide use
that might cause childhood disease.
The Children's Health Act of 2000 addressed childhood cancer
through the requirement of the study of environmental and other risk
factors for diseases such as leukemia. A uniform reporting system to
track epidemiological data was described as an essential success
factor.
Mr. Anderson added that the clean up of identified environmental
hazards would always be a positive side benefit to all cancer cluster
investigations, even when a definitive cause for the cluster had never
been found.
Chairman de Braga requested recommendations on methods for
facilitating the sharing of registry data between the States. Mr.
Anderson explained that there had not been a lot of work done to
connect cancer cluster data. He was unsure of how a streamlined system
would be designed. Chairman de Braga posed a question on the prevalence
of backlog in State registries across the nation. Mr. Anderson
clarified that all States had registries in place, however it was
unknown about how vigilant each State was in monitoring their registry
data. The scrutiny of data by any State, including the integration of
geographical mapping information, would take a much greater investment
of time and resources.
Mr. Anderson reassured Chairman de Braga that his agency did track
the research on registry efforts in each State. Most States had not
done a lot to make connections between a cancer cluster and
environmental exposures. Legislative bills had been introduced, however
few had been passed. On a positive note, Mr. Anderson added that
awareness of the need was increasing.
Chairman de Braga expressed her appreciation to Mr. Anderson for
his testimony. Before introducing the next expert, Chairman de Braga
made several announcements to the committees. Senator Harry Reid's
Office let it be known that a $500,000 Federal fund would be available
to help enhance the cancer registry data gathering. The second
announcement was regarding the Nevada GOLD (Guarding Our Local Drinking
Water) program. Jerry Buck would address a positive breakthrough on the
future of this program later in the hearings.
Dr. Thomas Sinks, an Epidemiologist with the Center for Disease
Control (CDC), distributed a 6-page handout (Exhibit E) that contained
his testimony on the epidemiology of Acute Lymphocytic Leukemia (ALL)
and the work of the CDC and their sister agency, the Agency for Toxic
Substances and Disease Registry (ATSDR). Dr. Sinks commenced testimony
with his assurance to the residents of Fallon of the CDC's deep concern
over the leukemia cluster. Although causes had rarely been identified
in cluster studies, the survival rate for ALL of 80 percent was judged
to be a significant milestone in the cancer battle.
Dr. Sinks emphasized that the highest priorities remained the need
to identify causes and prevent future occurrences. Although described
as a relatively rare diagnosis in children, the national rate was known
to be one case of ALL per 6,600 children. This translated to an
estimated 2,400 new cases of ALL each year in the United States.
Gender, age, race, and socio-economic status were highlighted as
significant factors in the profile of a leukemia victim. The peak age
was reported for children between the age of 2 and 5 years, with boys
known to be 30 percent more likely to develop ALL. Genetic and
environmental factors were judged to play a significant, but
unexplained role, in the development of ALL.
Dr. Sinks continued with a list of suspected cancer-inducing
factors, which included ionizing radiation, certain medical conditions
(e.g., Down's Syndrome), high birth weight, maternal history of fetal
loss, and birth order. Other inconsistent evidence included parental
smoking, parental occupation exposure, and postnatal infection. In-
utero exposure to ultrasound examinations had not been associated with
ALL.
In terms of cancer prevention and control programs at CDC, support
of population-based cancer registries and cancer screening efforts were
described as in place across the country. The compilation of the
various State registries enabled some longitudinal oversight
capabilities by the CDC. Federal support in Nevada was further
illustrated by $1.4 million of funding of the Nevada Cancer Registry
between 1994 and 2000.
Dr. Sinks reported that CDC had participated in 108 cancer cluster
field investigations, convened a national conference on the clustering
of health events, published recommendations, and provided technical
assistance to health departments nationwide. He expressed his concern
over the tremendous amount of time and money required to conduct field
investigations, with most studies revealing no conclusive findings.
Positive remedial steps, however, were reported as implemented in most
cases.
Chairman de Braga requested clarification of the definition of a
cluster and the number of years typically involved. Dr. Sinks explained
that the word cluster, from an epidemiological point, was defined as
being a greater number of cases than expected statistically. The word
cluster did not necessarily imply that there would be a unifying cause.
He further emphasized that statistical tests looked only at
probabilities of chance occurrence and did not address the likelihood
of cause. CDC treated each suspected cluster as a unique situation.
Assemblywoman Berman requested clarification of the term ``panel of
experts'' on page 6 of the handout (Exhibit E) and why the Federal
Government was not involved in the testing. Dr. Sinks defended the
practice of assembling a wide variety of medical, academic, and
scientific experts for purposes of peer review. In response to the
issue of Federal involvement, Dr. Sinks explained that the CDC
responded to numerous requests by the invitation of States facing a
public health problem. The CDC role was described as being supportive,
but was not one of assuming ownership of the problem.
Assemblywoman Leslie expressed her concern that there was no formal
national tracking system in place for cancer clusters. Dr. Sinks agreed
that there was need for a national tracking system, but it would
require higher review and authority. Additionally, it would be a
difficult process to implement because of the variability of defining
and identifying clusters. In response to Assemblywoman Leslie's
question about a cluster being simply one of a high number of cases in
a specific geographic area, Dr. Sinks explained that defining a cluster
would only be the first step. It would be followed by the challenge of
establishing the corrective steps needed to deal with the problem.
Dr. Sinks elaborated that, unlike breast cancer screening programs,
there was no health screening program for childhood ALL. He stated that
requests for cancer cluster investigations were predominantly for the
more common, screenable cancers and, therefore, targeted the adult
population.
To Assemblywoman Leslie's inquiry about the role of arsenic, Dr.
Sinks stated that it would be impossible to say definitively that it
would be associated with the Fallon cluster. It had been established
that the levels exceeded acceptable amounts and that arsenic was known
to be a human carcinogen. He encouraged the investigative team to
pursue the examination of other agents, such as volatile organic
chemicals and ionizing radiation.
Assemblywoman Gibbons expressed concern as to whether everything
was being done to minimize risk and exposure. She also asked for
clarification on the 20 percent mortality rate among ALL victims and
the significance of the demographics (e.g., age, gender). Dr. Sinks
responded that it was unknown if all preventative and remedial steps
were in place. It had been established that the 20 percent mortality
was seen in older victims where chemotherapy was less effective. Late
diagnosis was also a negative for survival.
Clarification was requested by Assemblywoman McClain on whether the
$500,000 Federal fund would be enough to bring the Nevada Cancer
Registry up to date. She also expressed concern over the reported 2-
year lag in the registry data and the possibility that there could be
other undetected clusters. Dr. Sinks stated that the Nevada registry
was average for reporting lag in comparison to other States. There were
some state-of-the-art systems developed in other States. Dr. Sinks
cautioned that having up-to-date cancer registries would not
necessarily be the answer to early detection of cancer clusters. It
would likely result in a multitude of unnecessary investigations.
Generally, the registry data had been judged most useful after
attention had been drawn to a suspected cluster.
Assemblywoman McClain commented on the fact that the current ALL
cluster in Fallon had been identified by the smallness of the community
and not by the cancer registry. Dr. Sinks concurred and added that the
current study would likely spur the Nevada Health Division to look at
the occurrence of ALL across the entire State. The most difficult
challenge was described as being able to take data from the cancer
registry and tie it directly to environmental agents.
In response to Assemblywoman Berman's question regarding
statistical chance, Dr. Sinks clarified that nobody ever developed
cancer because of chances. There was always a cause, and the challenge
in Fallon would be to discover the common denominator among the 11
children. The unifying cause was not yet known, but eventually science
would identify the commonality. The probability of the Fallon cluster
being a chance event was described by Dr. Sinks as being unlikely .
Chairman de Braga raised a question about ALL cases that occurred
outside of the identified cluster timeframe of 1995-1999. She requested
clarification about the upcoming assignments of the panel of experts
and whether two 1992 cases would be considered for inclusion in the
panel's discussions. Dr. Sinks explained that the panel of experts had
been assembled by the Nevada Health Division. As such, the Nevada
Health Division would charge the panel with direction and
recommendations for action. Dr. Sinks did agree that it would be
reasonable to look at the 1992 cases to determine if inclusion would be
appropriate. He referred the Chairman to Dr. Guinan for specific
answers.
Assemblyman Collins posed a question about the thoroughness of the
health division's investigation. In response, Dr. Sinks stated that it
would be virtually impossible to look at all suspected agents. The
accepted process was to narrow the list of hypotheses to a testable
number and then prioritize them based on probability of involvement.
Assemblyman Collins, using the example of PCB contamination
cleanup, reiterated his concern that limiting the investigation could
limit the answers. Dr. Sinks stated that it would be imperative to
separate the things that had been known to be hazardous but had
remedial solutions versus the need to answer scientific questions that
could not be answered. Preventing the next case of leukemia would
remain the primary goal.
Dr. Allan Smith, an arsenic specialist with University of
California, Berkeley, commenced testimony with a review of various
domestic and international arsenic research programs. Dr. Smith
reported on his 8-year research project in Nevada, which included a
bladder cancer study. The Nevada Tumor Registry was utilized in this
study as well as in a childhood cancer study.
Dr. Smith explained that most of his cancer research had been with
adults and included cluster investigative work. A leukemia cluster in
North Carolina was determined to be related to solvents in a tire
producing plant. Most of his cluster investigations did not, however,
result in the discovery of a definitive agent.
In his review of the Nevada tumor registry data for Churchill
County for the years 1979 to 1999, Dr. Smith detected only two cases of
leukemia. With those statistics in mind, Dr. Smith characterized the
current cluster as ``remarkable.'' Armed with the knowledge of Fallon's
levels of arsenic for decades, Dr. Smith stated emphatically that it
would be highly unlikely that arsenic would be the cause of the
leukemia cluster.
In response to a question about handouts, Dr. Smith replied that he
had not prepared written testimony, and he referred the committees to
his Web site www.socrates.berkeley.edu/-asrg/.
Chairman de Braga inquired about Dr. Smith's choice of Fallon for
his research studies on bladder cancer. Dr. Smith explained that Fallon
was selected because the area was known to have some of the highest
arsenic levels in the nation. The Fallon population was judged to be a
highly exposed group. His researchers looked for genetic damage in
bladder cells associated with high cancer rates.
Chairman de Braga asked if his research included the effects of
arsenic on the immune system. Dr. Smith replied that it did not. His
research instead focused on the end result of the cancer. He added that
if he had judged it to be a high priority research question, it would
have been done. The evidence was not there to support arsenic and an
adverse effect on the immune system. In response to Assemblyman
Collins' question regarding the difficulty of discovering combinations
of causal agents, Dr. Smith acknowledged that this was a significant
challenge. The synergy between two agents had been investigated, an
example being the combination of smoking and arsenic. He made the
distinction, however that the sudden onset of a cancer cluster was
different and did not fit the classic profile of long-term synergistic
effects. The sudden introduction of an environmental co-factor
suggested an infectious agent, for example.
Assemblywoman Gibbons requested clarification of the list of
suggested questions that was included in their information packet.
Chairman de Braga explained that these were supplied as a guideline to
the committee members.
Assemblywoman Gibbons posed a question about the levels of arsenic,
bladder cancer rates, and cure rates in Churchill County compared with
other areas. Dr. Smith clarified that typical arsenic levels in the
United States were 2 micrograms per liter. Fallon, Lyon County, and
Kings County, California had always tested at 90 to 100 micrograms per
liter. The private wells in Churchill County revealed some of the
highest arsenic levels in the world.
In response to the subject of bladder cancer incidence and cure
rates, Dr. Smith described his long-term study as still in the analysis
phase. A proposal for the study of lung cancer in Nevada had recently
been submitted to the National Institutes for Health (NIH). Using a
method called ``rapid case ascertainment'' with data from the Nevada
Tumor Registry, Dr. Smith was optimistic of a more rapid identification
of lung cancer.
Assemblywoman Gibbons requested clarification on the extremely high
levels of arsenic in Fallon's private wells and the interplay between
dosage and individual immunity. Dr. Smith explained that he had
deliberately studied wells with the highest levels of arsenic,
selecting 11 families whose wells exceeded 1,000 micrograms per liter.
Chairman de Braga added that a recurring question among the
committees was the threshold amount at which arsenic became a problem.
Dr. Smith elaborated that in their risk assessment studies, at 50
micrograms per liter, there was an estimated probability of 1 in 100
people dying of cancer. He concluded that it was an acceptable fact
that consumption of water with 90 to 100 micrograms of arsenic was
detrimental to public health.
Brenda Gross, a Fallon resident and mother of one of the leukemia
victims, commenced testimony. Mrs. Gross shared the heartbreak and
stress of dealing with a devastating illness in the family. She
acknowledged the involvement of the Nevada Health Division and their
sharing of information. Her specific concerns were centered on the
difficulty of making treatment choices for her son, constantly having
to weigh the side effects of treatment against the chances of death.
Mrs. Gross addressed a further concern regarding the tendency to
dismiss a cause, such as arsenic. She emphasized that investigation
into combination agents (e.g., arsenic plus another environmental
agent) would be imperative.
Mrs. Gross expressed her certainty that there was a definitive
cause in Fallon, and she hoped that the Nevada Health Division would be
aggressive in their pursuit of common denominators. She concluded by
saying that, with only one of her four children affected, she was
baffled by what would be so unique about her one son (e.g., genetic).
On behalf of both committees, Chairman de Braga expressed her
sincere appreciation to Mrs. Gross for sharing her personal story.
Assemblywoman Leslie reiterated her appreciation and asked Mrs. Gross
if, in her judgment, the State of Nevada could be doing more for the
families and the community. Mrs. Gross added that testing of private
well water, soil testing, jet fuel studies and air quality studies in
surrounding areas might be helpful.
Assemblywoman Leslie added that, as a minimum, establishing a
central place for questions would be warranted for the community. It
was emphasized that recommendations would be most welcome from the
families of Churchill County.
In response to Assemblywoman Gibbons, Mrs. Gross explained that her
son's chemotherapy was being done in Fallon on a weekly basis and at
the University of California, Davis on a monthly basis.
Dr. James Forsythe, Reno Oncologist, was introduced as the next
presenter. He distributed a handout (Exhibit F), a 1979 newspaper
article which described a suspected cancer cluster in northern Nevada.
At that time, Dr. Forsythe was one of only two oncologists in the area,
the significance being that he had firsthand knowledge of every cancer
case in the area. This lead to his discovery of what he considered to
be a cancer cluster in the Fallon area. His concern was amplified by
the Veteran's Hospital in Reno.
In 1979, an investigative study was initiated by the University of
California, Berkeley, Public Health Service. Their statistical analyses
revealed significant increases in brain and testicular cancer in the
Fallon area. The report was delivered to the chairman of the Northern
Nevada Cancer Council, Dr. John Shields, and the matter was not
pursued.
Dr. Forsythe described his ongoing involvement in the diagnosis and
treatment of Fallon cancer patients. He had long speculated on the
commonality of the drinking water as the source of the problem, with
arsenic levels at 20 times the national average. Today, Dr. Forsythe
stated that his focus was diverted to contamination of water supplies
by petroleum products originating in industries or perhaps the naval
base.
Dr. Forsythe next shared anecdotal stories from various sources
which he believed could have significance. The first point he
highlighted was the high water table in Fallon (i.e., less than 50
feet) in combination with poor water quality. Second, Dr. Forsythe
commented on the reported practice at the Fallon NAS of routinely
spraying weeds with jet fuel. His third point centered on reports from
utility inspectors excavating soil on the naval base and their
observations of a petroleum stench at the 4 to 6 foot soil level. In
1995, there was an unofficial report of a large spill of petroleum
products on the base. Although not revealed in the news media, the EPA
did respond with remedial efforts.
Other risk factors included the atomic blast in 1963 (i.e., Shoal
Project) and electromagnetic field radiation. Dr. Forsythe stated that,
of all of the risk factors on a long list, childhood Acute Lymphocytic
Leukemia (ALL) had been known to be induced, in part, by petroleum
byproducts such as benzene and other gasoline substances. Lymphocyte
assays of family members, through an analysis called ELISA, had proven
to be revealing. More than 400 chemicals would be detected with ELISA
methodology. Hair and urine analyses for heavy metals were also
recommended by Dr. Forsythe.
Dr. Forsythe encouraged the expansion of testing by the Nevada
Health Division to include the victims and families. He stated with
reasonable certainty that petroleum byproducts had leached through the
earth and had contaminated the high aquifers of the Churchill area. In
his judgment, this would prove to be significant in the cluster
investigation.
Chairman de Braga requested clarification on the 1979 cluster,
specifically regarding the reaction of the medical community. Dr.
Forsythe described the event as being ``clinically suspicious'' and was
not noticed until Berkeley released their report. Chairman de Braga
shared her own experience with inquiring about the cancer levels in
Fallon. In reply, Dr. Forsythe expressed his disappointment in the
apparent inaccuracy of the Nevada Tumor Board records. This was
compounded by the fact that, in a small town like Fallon, many cancer
patients left the area for treatment and were not tracked by the
registry. Reporting lag time was also cited as a significant factor in
the inaccuracy.
Chairman de Braga inquired about the costs and the process to test
families and neighbors. Dr. Forsythe judged that it would be reasonable
if a sampling of families was used and not the entire population. Hair
testing would be non-invasive, and costs were estimated at $50 to $80.
Urine testing for heavy metals was reported to be approximately $200.
The ELISA testing for multiple chemical exposure was described as $300
to $400 per sample, but was the most diagnostic method. The latter test
was based on the detection of antibodies produced by the body in
reaction to various foreign substances.
In response to Chairman de Braga's question about herbicides and
pesticides, Dr. Forsythe acknowledged that these substances would need
to be considered, given the extensive agricultural activity in the
valley. Chairman de Braga requested recommendations for how to proceed
with the cluster investigation. Dr. Forsythe summarized his
recommendations as: the testing of the victims for chemicals in the
hair and urine, testing a control group of friends or neighbors, and
thoroughly analyzing the drinking water for all possible pollutants.
Dr. Forsythe clarified that he was not familiar with the list of
previously tested substances in drinking water.
Dr. Forsythe reviewed the types of cancers he had handled during
the last 10 years in the Churchill County area; 40 cases of breast
cancer, 30 cases of colon cancer, 35 cases of lung cancer, 15 cases of
Hodgkins/Lymphoma/leukemia, 25 cases of prostate cancer, 20 cases of
skin cancer, 8 cases of brain cancer, 5 cases of ovarian cancer, and 8
cases of head/neck cancers. It was notable that these were just the
cases handled by Dr. Forsythe and did not include the cancer statistics
from 10 other oncologists in Reno.
Assemblywoman Koivisto asked for elaboration on the microwaves from
radar systems at the Fallon Naval Air Station (NAS). Dr. Forsythe
stated that electromagnetic fields (EMF) must be considered, however
EMF research to date was inconclusive.
Chairman de Braga introduced Dr. Gary Ridenour, a Fallon physician.
He commenced testimony with the topic of jet fuel, in particular JP8.
It was introduced to Fallon in 1991, and shortly after that, Dr.
Ridenour noticed an immediate change in the liver function tests (e.g.,
liver damage) in patients. Dr. Ridenour shared his extensive research
on incidents of jet fuel leakage on the base. He further stated that he
had not observed intentional malice on the part of the Navy regarding
the subject of jet fuel. What they know was described by Dr. Ridenour
as what they were told by the Department of Defense.
Often dismissed by the military as similar to kerosene, the high
toxicity of jet fuel, even in minute quantities, had been demonstrated
in multiple studies and was known to provoke serious health effects
including skin penetration, decreased immune system response, increase
in lung permeability, and headaches, to name a few. During the 1990's,
medical articles abounded on the subject of the toxicity of JP8.
In terms of fuel dumping and evaporation, the jet fuel would still
exist in some form when it made contact with the earth. Dr. Ridenour
cited a recent example of a cloud sighting near the base, described as
a large brown vapor emitted from the startup of jets. He added that one
of the biggest problems with JP8 was the low cost of 80 cents per
gallon, approximately half of the cost of its predecessor fuel JP5.
JP8 had so far not been allowed on aircraft carriers, a point which
Dr. Ridenour considered significant. It was utilized extensively during
the Gulf War, which suggested the need to connect the fuel with the
highly publicized health problems among the military personnel. Even
brief contact with JPB fumes resulted in the immediate detectable
presence of fuel in the breath of the person. Dr. Ridenour cited
several recent research articles about the negative health effects of
exposure to jet fuel.
In regard to the 6-inch fuel line that delivered jet fuel to the
Fallon NAS, Dr. Ridenour described it as more than 30 years old, made
of steel, and highly susceptible to corrosion and seismic activity in
the desert. The integrity of the pipeline would be highly questionable.
A map of Fallon displayed the path of the pipeline, described as
running within 10 feet of schools in Fallon and crossing the parking
lot of the new Baptist Church. The pipeline was further described as
coming in contact with the Carson River and every ditch and irrigation
channel across the town. In retrospect, it should have been routed
around the city of Fallon, and not through it. Vents, located along the
route, were visibly damaged in certain areas.
Dr. Ridenour expressed his alarm that, despite the plethora of
reports and warnings about the hazards of the jet fuel, nothing was
done about it. Morgan Kinder, the operators of the fuel pipeline, had
some checks on the integrity of the system. Dr. Ridenour described a
photo of one of the pipeline test locations. It was covered with spider
webs, indicating that it had not been disturbed by personnel assigned
to monitor the pipeline. Morgan Kinder supposedly used pressurization
tests to detect leaks, with the problem being the unknown amount of
pressure used during the test. In Dr. Ridenour's judgment, given the
300-mile length of the pipeline, it would have to be a sizable leak
before it would be detected as a pressure drop. At a leakage rate of
one drop per second, the soil contamination in 1 year would be 300
gallons.
Dr. Ridenour summarized by saying it generally would take 8-10
years after introduction of a toxic material before the onset of
disease. In terms of what had changed in Fallon during the last 10
years, Dr. Ridenour summarized that insecticide spraying had actually
declined due to fewer fields. He added there had been no increase in
radar nor had there been a change in water quality. Whereas literature
searches on the topics of arsenic and leukemia yielded no matches, the
topics of bone marrow and JP8 fuel revealed multiple references.
Despite the military's comparison of JP8 fuel to kerosene, Dr.
Ridenour cautioned the committees that it would be akin to comparing
plastic explosives to play dough. He encouraged the committees to
consider requesting that JP5 be pumped through the pipeline from
Benecia for an interim period in order to complete testing of JP8. A
determination of the complete integrity of the line was also
recommended by Dr. Ridenour. Finally, the aerosol effects of the fuel
should be studied in greater depth. Air currents in the desert, below
18,000 feet of altitude, were described as highly unpredictable, and
jet fuel particles would be very capable of making contact with people
and soil.
Dr. Ridenour reemphasized that the change in jet fuels had to be
considered as one of the most significant new events during the last 10
years in Churchill County. He once again stated that the Navy itself
would not necessarily be at fault if they had also been ``sold a bill
of goods'' on the merits of JP8. Morgan Kinder should be made to
reroute the pipeline around the town.
Assemblyman Carpenter inquired about the type of fuel used on
commercial jets. Dr. Ridenour stated that it was Jet A, a fuel that was
closer to JP4 in composition. He cautioned that, because of its
economical cost, some airlines were considering switching to JP8.
In response to Assemblyman Claborn's comment about the fuel
pipeline in Las Vegas, Dr. Ridenour cited the distinction between the
two as being one of age, namely that the northern Nevada line was much
older. The Fallon line also pumped a greater volume, estimated at more
than 400,000 gallons per month.
Assemblyman Neighbors shared his confusion regarding the Helm's Pit
in Reno, once the site of serious ground contamination and now a family
recreational area for boating and fishing. Dr. Ridenour agreed that it
was both suspicious and confusing, and it seemed highly unlikely that
the fuel oil would be cleaned up in such a short amount of time.
Chairman de Braga introduced Diane Hansen, a Fallon resident. Ms.
Hansen sought reassurance from the committees that a systematic and
thorough cluster investigation would continue. She spoke candidly and
shared her concerns that the next stage of the Nevada Health Division's
investigation would not happen. Ms. Hansen expressed her expectations
that a team of experts would be assembled and that this investigative
team would receive specific direction and adequate manpower and funding
to do the job right. She further emphasized the need for the team to
ask the right questions and to be forthright in their communication
with the residents of Churchill County.
Making reference to a 1996 newspaper article, Ms. Hansen shared her
specific concerns about an industrial plant 12 miles north of Fallon.
The New American Tec Corporation arrived in Nevada after having been
cited for severe environmental contamination in Kentucky. Their
chemical process, a nickel and chrome plating operation, was known to
utilize known carcinogens. Ms. Hansen was especially concerned that
there had been no followup publicity on this hazardous industry.
In an effort to get answers to her questions, Ms. Hansen conducted
her own research and called various agencies, including NDEP, EPA in
San Francisco, the Lahontan Valley News, the Reno Gazette, and the
Churchill County Planning Commission. She was surprised to hear that
she had been the only person to request followup information on New
American Tec. What she learned was that Fallon was the only location in
the Nation that utilized a vaporization process to plate copper using
nickel carbonyl, a known carcinogen. There was evidence that New
American Tec had not been totally forthcoming about their history in
Kentucky in applying for a permit in Nevada.
Her inquiries to Nevada Department of Environmental Protection
revealed that New American Tec was permitted to emit 2 pounds of nickel
components per hour into the air. Neither the State nor the county
required air monitoring on a regularly scheduled basis. Any air
emission results were self-issued by the corporation. The possible
significance of the New American Tec production startup of November
1996 should not be ignored.
In closing, Ms. Hansen asked for assurance that the investigation
would include these small pieces of the puzzle, for example New
American Tec.
Chairman de Braga acknowledged that Ms. Hansen represented
widespread community concern and that the serious nature of the cluster
dictated a very serious and thorough approach. It was explained that
the role of the legislators would be to make recommendations. The
expert panel, comprised of a variety of medical and scientific experts,
would also make recommendations. Ms. Hansen was reassured that the
Nevada Health Division was committed to doing as much as possible.
Congressional, State, and community interest would propel the
investigation in the right direction.
Ms. Hansen requested clarification on the issue of NDEP writing a
requirement for monitoring into their permitting process. The New
American Tec permit was up for renewal at the current time, and NDEP
was said to be in negotiation with the attorney for the company to
require monitoring activities. Ms. Hansen emphasized the sincere
interest on the part of the Fallon residents to do what ever they could
to help.
Assemblywoman de Braga echoed the words of Ms. Hansen and agreed
that Fallon was, indeed, a wonderful community for families. She
gratefully acknowledged the testimony of Ms. Hansen.
The next expert witness called was Peter Washburn, Attorney for
Senator Reid's office in Washington, DC. Mr. Washburn distributed a
copy of his written statements (Exhibit G). He commenced his testimony
by highlighting Senator Reid's senior membership with the Senate
Environment and Public Works Committee. Mr. Washburn assured the
committees of Senator Reid's deep concern over the Fallon cluster. He
commended Chairman de Braga on her foresight in scheduling the special
legislative hearings and acknowledged the dedication of the two
committees and Dr. Mary Guinan for their participation.
Because of Senator Reid's dual membership in both the
Appropriations and Environmental Committees, he was described as being
in a unique position to leverage Federal resources to aid the
investigative work. Senator Reid's first priority was described as in
the areas of communication, participation, and coordination. Because of
the multitude of experts and citizens involved in the process, these
hearings were said to set the stage for the essential communication and
coordination of information sharing.
Mr. Washburn described Senator Reid's second priority as pointing
to the issue of what could and should be done now to reduce
environmental risk to the citizens of Fallon. Because investigative
work would likely take years, remedial steps should be implemented
regardless of conclusions about causal agents. He cited the example of
arsenic and stated that Federal grants were forthcoming. The Small
Community Safe Drinking Water Safety Act was slotted for introduction
by Senator Reid. This bill would make Federal grants, not loans,
available to small public water systems for purposes of improving the
quality of the water.
Mr. Washburn explained that Senator Reid was planning to schedule
hearings in Nevada for purposes of addressing the leukemia cluster and
public health concerns. Dates and agenda would be announced. Chairman
de Braga expressed her thanks to Senator Reid for his early and on-
going involvement in the matter.
Chairman de Braga introduced Jerry Buk, Regional Director for the
University of Nevada Cooperative Extension Service in northern Nevada.
Mr. Buk addressed the Nevada Gold (Guarding Our Local Drinking Water)
project in Fallon. This program was designed by a water specialist in
Fallon, Mary Reed. The model employed was a ``train the trainer'' in
which volunteers from the community were trained to share water safety
information with the residents, especially those served by private
wells.
Due to an unexpected illness of the project leader, the Nevada Gold
project atrophied and ceased to function by May 2000. Mr. Buk explained
that the program would be reinstated immediately. The first order of
business was described as a compilation of all Nevada Gold information
and dissemination of the data to all agencies and businesses that dealt
with residents served by private wells.
Mr. Buk concluded by saying that the program was being reviewed and
streamlined for implementation in March 2001. The new program would be
tailored to include the leukemia cluster issue and would focus on
educating citizens on the need to have water tested, as well as how and
where to procure testing services.
In response to Chairman de Braga's question regarding the expansion
of testing, Mr. Buk shared his knowledge of some grant money connected
to a Ph.D. dissertation. This was described as a possible source of
funds for actual water testing for residents. Mr. Buk cautioned that
the breadth of water testing (i.e., number of substances) was
overwhelming. The Nevada Gold program had looked specifically at
nitrates in water, a relatively cheap and easy analysis. This was
contrasted to the complexity and higher cost of testing newer
substances.
The next experts to testify were Juanita Cox and Robert Sonderfan,
representatives of People To Protect America and Citizens In Action.
Self-described lobbyists, researchers, and investigative journalists,
Ms. Cox and Mr. Sonderfan displayed a stack of articles and research
information (no handouts). Ms. Cox expressed concern over the lack of
discussion of the water contaminant MTBE. Added to gasoline in the late
1970's, it had now been known to cause three types of cancer in
laboratory animals, including leukemia. The amount of contamination of
drinking water and recreational water was described as extensive, and
therefore, should be added to the Fallon testing agenda, according to
Ms. Cox.
Internet literature searches revealed the 2001 military
construction program for Fallon NAS, specifically the plan to replace
military fuel tanks. Underground fuel tanks were described by the
military as being 45 years old and having known leakage problems. The
immersion of the tanks in the area's saltwater aquifer caused corrosive
effects on the metal. Because contamination by various substances could
be through ingestion, inhalation, or skin contact, Ms. Cox urged the
expansion of testing. Fluoride was cited as an example.
Ms. Cox concluded her testimony with her observations of the 3-day
hearings, described as ``CYA'' and damage control. Because of economic
reasons or the threat of legal ramifications, some answers would never
be disclosed. Massive denials and subsequent legal actions were
predicted by Ms. Cox to be unavoidable.
Mr. Sonderfan commenced his testimony with a review of Project
Shoal and Project Faultless. He described the hurdles and red tape he
faced in researching these topics. Project Faultless was a 13-megaton
detonation of a classified military warhead near Fallon. In his
judgment, the military had not been forthcoming in revealing harmful
practices, such as burying trash for more than 40 years. Nellis Air
Force Base was described as having 30 tons of depleted uranium, with a
half-life of more than four billion years.
Ms. Cox elaborated on the subject of depleted uranium and stated
that the Pentagon knew in 1995 about the environmental threats posed by
nuclear weapon waste. The question needed to be asked of the Fallon NAS
about their use of plutonium, one of the most toxic substances known to
man.
Ms. Cox concluded her testimony with an overview of other agents
for investigation and testing, which included electromagnetic radiation
(i.e., EMF), Agent White (i.e., Tordon), DDT, nuclear fallout, fuel
dumping from jets, manganese, ethylene dibromide, and bovine leukemia
viruses. Research indicated that veterinarians and dairy farmers had
elevated leukemia rates. Production of milk was reportedly greater in
cows infected with bovine leukemia.
Due to the lateness of the hour, Chairman de Braga interjected with
a request of Ms. Cox to leave one copy of her testimony for
distribution to the committees. Ms. Cox concurred and added that having
her testimony cutoff would be expected especially since the topic was
milk.
Mr. Sonderfan interjected with a plea for the Fallon NAS to come
forward with a report of chemicals used and stored on the base. His
research revealed leaking storage tanks. Arsenic, according to Mr.
Sonderfan, was just a smokescreen. Leukemia was described as resulting
from a one-two punch, the first being the lowering of the immune system
and the second punch some exposure to a trigger agent. Bovine leukemia
virus in raw milk had the capability of being transmitted to humans.
Ms. Cox interjected with comments about the synergistic effects of
chemicals and environmental toxins. She further cautioned that, even if
causes were suggested by a citizen, it would invite legal entanglement
for years. She urged the cessation of cover-ups and human
experimentation. She urged the committees to empower the community
because it was most likely that the answers would come from the people.
The public needed a civilian investigative board and a hotline for
public input that would facilitate the reporting of environmental
hazards.
Chairman de Braga explained that there was a hotline in place for
citizen input. In response to Ms. Cox's concern about reporting an
incidence of environmental dumping, Chairman de Braga assured the
witness that the health department in each community was there to
respond to these concerns.
Assemblyman Mortensen inquired if anybody in the room knew with
certainty that the Fallon NAS practiced with depleted uranium shells.
Chairman de Braga elaborated that this had been suggested in several
letters from other concerned constituents. It would be included in the
list of recommendations. A handout (Exhibit H) was received from the
Department of Energy.
Chairman de Braga adjourned the meeting at 5:46 p.m.
Respectfully submitted,
June Rigsby,
Committee Secretary.
__________
April, 19, 2001.
Committee on Environment and Public Works,
Washington, DC.
Subject: Fallon Leukemia Cluster
Dear Committee Members: I am writing in response to a request for
public testimony concerning factors to consider connection with the
Fallon Leukemia cluster. I would like to see this committee carefully
consider the role of fire in the disbursal of hazardous materials
through the environment, including fire's role in remobilized
radioactive isotopes and other contaminates deposited in Nevada as a
result of weapons testing. I would request the committee to consider
the dangers associated with fire as a remobilizing agent of
radionuclides from the Nevada Test Site and other testing ranges in the
State.
During the period of above ground testing from 1951 to 1963,
radioactive releases from the Nevada Test Site emitted over 12 billion
curies of radioactive material into the atmosphere, 148 times as much
as the nuclear disaster at Chernobyl. Other pre-1971 nuclear tests
released 25,300,000 curies, and from 1971-1988, 54,000 curies were
released, including the 36,000 curies from the Mighty Oak accident,
which was itself 2000 times greater than the release at Three Mile
Island. Over half of all underground tests have leaked radiation into
the atmosphere (DOE Report on Radioactive Effluents, 1988). DOE has
been out of compliance with Federal and State permit requirements in
the areas of air emissions, water releases, and solid waste disposal
(DOE Nevada Operations Office Five Year Plan, 1989).
There is contamination in soil, air, ground and surface water.
Strong winds, common to this area of Nevada, can carry plutonium-
contaminated dust across a large area. Fallout from above ground
nuclear tests in the United States and other countries has
radioactively contaminated the atmosphere around the Earth. Project
Faultless in Hot Creek Valley was found to have caused radioactive
contamination in groundwater. According to EPA Publication 520/4-77-
016, cumulative deposits of plutonium (Pu-239 and Pu-240) have been
found in soil over 100 miles north of the NTS at levels of 790 mg per
acre. Plutonium has a half-life of 26,000 years, and plutonium
contaminants ingested in microscopic amounts are capable of causing
cancer for 200,000 years. There is no cost-effective technology for
decontaminating such sites. No surveys have been conducted to determine
health effects on Native American or other residents from Nevada Test
Site (NTS) releases. Currently the Nuclear Risk Management for Native
Communities project is working to answer some of these questions.
It is known that plutonium translocates to specific radiosensitive
organs, especially reproductive organs.
During the years of 1999 and 2000, almost 3,000,000 acres of Public
Lands in the State of Nevada were subjected to fires, both wild fire
and prescribed burns. Fire remobilizes contaminants. Particles are
lifted from the ground into the air, then mobilized through environment
on wind currents. The particles are resuspended for an indefinite time
period, finally redeposit onto the earth. This process creates fallout.
As a result of this process, fire can carry containments across the
globe.
We understand that the Nevada BLM oversees management of 1,722,330
acres of public lands considered contaminated with UXO, (unexploded
military ordinances). BLM lands border NTS (Nevada Test Site), Nellis
Bombing and Gunnery Range, Tonopha Air Force Base, together with the
Fallon Range. No one knows the amount or extent of nuclear
contamination in the area surrounding the NTS and Nellis Air Force Base
which tests depleted uranium (DU) bombs. In 1997 it was estimated that
30 tons of DU had already been deposited in the target area (Draft
Environmental Assessment Resumption of Use of Depleted Uranium Rounds
at Nellis Air Force Range Target 63-10), a total of 9,500 combat mix
rounds (7,900 DU rounds) being expended annually, there.
Depleted uranium or U-238 has an atomic mass of 238. Its half-life
is 4.468 billion years (Rokke, 2001). It's natural occurrence is 2.1
parts per million. Uranium is silver white, lustrous, malleable,
ductile, and pyrophoric. This makes DU an ideal metal for use as
kinetic energy penetrators, counterweights, and shielding or armor.
High density and pyrophoric (catches fire) nature are the two most
significant physical properties that guided its selection for use as a
kinetic energy penetrator.
A study performed at Yucca Proving Grounds found DU residues in all
components of the environment, that environmental concentrations varied
widely, that corroded DU residues are soluble and mobile in water, that
wind dispersal during testing is the prevalent means of dispersal of DU
particles, and that an unknown degree of risk was posed to human health
by DU in the environment. Moreover, there appears to be no insight into
the issue of long-term (100 to 1,000 years and longer). DU forms of
both soluble and insoluble oxides. The inhalation of the insoluble
oxides presents an internal hazard from radiation if retained in the
lungs.
The long-term effects of internalized depleted uranium are not
fully known, but the Army has admitted that ``if DU enters the body, it
has the potential to generate significant medical consequences.''
Inhaled DU particles or respirable size may become permanently trapped
in the lungs. Inhaled DU particles larger than respirable size may be
expelled from the lungs and ingested. DU may also be ingested via hand-
to-mouth transfer or contamination of water or food supplies. DU, which
is ingested, or enters the body through wind contamination, will enter
the bloodstream and migrate throughout the body, with most of it
eventually concentrating in the kidney, bone, or liver. The kidney is
the organ most sensitive to DU toxicity.
More testing of soil and plants needs to be done to determine what
radionuclides might be released into the air in a fire, since a fire
and its relationship to the resuspension of contaminants has not been
the subject of study. Plutonium and radionuclides concentrate in dust,
thus higher concentrations are found in the dust sampling than in
regular soil sampling. The standard air monitors and surface water
samplers usually used are not sufficient to measure submicroscopic
particles of plutonium. Further, plutonium contamination is not
homogeneous, so simplistic sampling methods are inadequate (John Till,
President, Risk Assessment Corp; 2000). Wind-blown particulates must be
considered. Debris and gas will go somewhere, but where? Into the water
or the soil?
Radiation detection devices that detect and measure alpha
particles, beta particles, x-rays, and gamma rays emissions at
appropriate levels from 20 dpm up to 100,000 dpm and from .1 mrem/hour
to 75 mrem/hour must be acquired to assess the distribution of
particles. Standard rad-meters or Geiger counters do not measure these
levels.
In order to assess the health risks and damage due to exposure to
tritium (radioactive hydrogen), three blood tests must be done. White
blood cells must be tested for the presence of micronuclei, indicating
the loss of DNA repair processes and leading to increased cancer risk.
Red blood cells must be examined for genetic modification of surface
glycophorin-A molecules, also indicating DNA damage. A study of
Japanese nuclear bombing victims forty years from the time of the
blasts showed DNA codes were still unrepaired. In addition, chromosome
painting allows chromosomes to be stained for identification of
structural and sequential or numerical abnormalities linked to
radiation and chemical exposure, cancer, and inherited diseases.
In addition to the redistribution of containments, we need to
consider the effects of fire upon other substances. For example, we
must consider chemical reactions which may take place when multiple
herbicides are burned together. For instance, one chemical being most
often utilized on public lands is Tordon. But Tordon is also called
Grazon, and the active ingredient is picloram, better known as Agent
White, similar to Agent Orange, and one of several defoliants used in
Vietnam. In fact, Agent White (picloram) appeared in 5 of the 15
defoliants used there. Agent White is currently being sprayed by the
U.S. on the coca fields in Columbia as part of the drug war. In 1998,
Dow Chemical, manufacturer of Agent White (picloram) tried to halt its
use, warning that it does not bind well with soil, easily washes into
the groundwater and could cause irreparable damage to the Amazon
Rainforest. Yet, U.S.G.S. Pesticide 1992 Annual Use Map showed
estimated annual agricultural use of Agent White to be less than 0.370
pounds per square mile per year. The map shows the entire State of
Nevada has been exposed. This is a lot, and has probably increased
since that time. If it's dangerous to the water and forest areas of
Colombia, it is dangerous here in the U.S. The use of Tordon is banned
in some countries.
Also commonly used are 2, 4-D which forms poisonous gas in fire. It
is on the Hazardous Substance List because it is regulated by OSHA. The
chemical is a mutagen (changes the genetic structure), a teratogen
causing birth defects, and a carcinogen particularly related to breast
cancer. Short term effects of its use include the death of animals,
birds, fish, and plants within 2-4 days after exposure. About 91.7
percent of 2, 4-D will eventually end up in water. In 1990, the Clean
Air Act announced 2, 4-D as a hazardous air pollutant. Run off vapors
can kill non-target plants. Agent Orange was a mix of 2, 4-D and 2, 4,
5-T. Another name for 2, 4, 5-T is Weedar. And both of these chemicals
appear on the recommended list of chemicals used on public lands.
Garlon is also known as triclopyr (both names appear separately on
the recommended treatment list as if they are different herbicides).
Triclopyr's chemical structure is very similar to 2, 4, 5-T. The MSDS
sheet includes the following data: Nitrogen oxides, hydrogen chloride,
and phosgene may result under fire conditions and NIOSH/MSHA requires
approved SCBA and full protective equipment for firefighters. Garlon-
treated wood that is burned during forest fires, or in wood stoves at
home produces a dioxin, one of the most damaging compounds to living
organisms. Garlon is an endocrine disrupter.
It mimics a plant hormone, acting systematically to kill the plant
or tree. The hormone that Garlon mimics is perceived by the human body
to be estrogen. In women, this may result in breast cancer,
miscarriages, infertility, birth defects, and possibly ovarian cancer.
In men, it can cause prostate or testicular cancer and reduction of
sperm count. It also may aggravate liver and kidney disease. We do not
know what the effects of burning multiple pesticides and the full
extent of the risk to public health from such events.
I suggest that a more appropriate methodology for determining
causation of the Fallon leukemia clusters would use a multidimensional
model for analysis. In other words, rather considering singular
etiologies, as suggested by Prescott from CDC at the hearings, a more
complex multi-factor dynamic process may be in operation. We might
hypothesize very generally that exposure to radionuclides such as
tritium, plutonium, or DU, might cause mitochondrial damage to cells.
In addition to other functions, mitochondria contribute to a sort of
``programmed cell-suicide''. For example, in certain stages of fetal
development, humans have webbed fingers. The mitochondria detect this,
and at the appropriate time, seek to destroy the web cells, leaving
humans with fully formed fingers. This cell-suicide is necessary.
However, when exposed to an error or to toxins or radionuclides,
the mitochondria engage in a process of ``unprogrammed cell suicide.''
Thus, healthy cells are destroyed. Such suicides may lead to
destruction of critical elements of immune system function, resulting
in cancers, leukemia, and the inability to fight the effects of various
viruses and bacteria. The cells may be more vulnerable to effects of
exposure to chemicals or pesticides. In addition, adequate production
of certain neurotransmitters and hormones might be disrupted leading to
diabetes or neurological damage. These medical conditions have been
reported as increasing in the general population, and though differing
in appearance, may be reflecting a basic underlying cellular assault
caused by radiation exposure. I refer you to the work of Guy Brown.
Thank you for your thoughtful consideration.
Sincerely,
Bonnie Eberhardt Bobb,
Shundahai Network.
__________
Statement of General Accounting Office, Health, Education, and Human
Services Division, Washington, DC.
Toxic Chemicals--Long-Term Coordinated Strategy Needed to Measure
Exposures in Humans
State and local officials report continuing public concern over the
health risks posed by exposures to toxic chemicals, ranging from heavy
metals such as arsenic found at national hazardous waste sites to
common pesticides used in and around the home. For example, increasing
rates of cancer in various communities have prompted questions about
the potential link to residues from pesticides, indoor air pollutants,
and other toxic chemicals. Historically, estimates of human exposure to
toxic chemicals have been based on the concentration of these chemicals
in environmental media--such as air, water, and food--along with
assumptions about how people are exposed. Federal monitoring efforts
have primarily focused on this type of measurement. However, according
to public health experts, measurements of internal doses of exposure--
actual levels of chemicals or their metabolites\1\ in human tissues
such as blood or urine--can be a more useful measure of exposure for
some purposes.
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\1\ Metabolites result from the interaction of the chemicals with
enzymes or other chemicals inside the body.
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Over the past decade, advances in laboratory technology have
provided new tools for measuring a broad range of chemicals in human
tissues--tools that can help researchers and health officials assess'
how much of a chemical has been absorbed in the body and provide more
accurate measurements of exposure to relate to potential health risks.
When gathered for the U.S. population, such data can help identify new
or previously unrecognized hazards related to chemical substances found
in the environment, monitor changes in exposures over time, and
establish the distribution of exposure levels among the general
population. These data can also help identify subpopulations--such as
children, low-income groups, or ethnic minorities--that might be at
increased risk because they face particularly high levels of exposure.
State and local health officials can use information on typical
exposures in the general population to help assess environmental health
risks for specific sites or populations within their borders and to
keep local residents informed. For example, local officials in one
community collected exposure measurements before, during, and after the
burning of arsenic-contaminated soil and found that no excess
exposure--as compared to typical levels found in the population--had
occurred.
In light of the potential benefits offered by these new
technologies, you asked us to review efforts to collect and use such
information at both the State and Federal levels. Specifically, you
asked us to (1) determine the extent to which State and Federal
agencies--in particular, the Department of Health and Human Services
(HHS) and the Environmental Protection Agency (EPA)--collect human
exposure data\2\ on potentially harmful chemicals, including data to
identify at-risk populations, and (2) identify the main barriers
hindering further progress in such efforts.
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\2\ The scientific community uses varying terminology when
referring to human exposures. Often, external contacts with chemicals
are defined as ``exposures,'' and internal measurements of exposure are
referred to as ``doses.'' Doses are also considered a measure of
exposure. Our review focused primarily on efforts to gather internal
exposure measurements through human tissue in the non-occupationally-
exposed population. To simplify reporting, we are referring to such
internal exposure measurements as ``human exposure'' data.
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We compiled a list of more than 1,400 naturally occurring and
manmade chemicals considered by HHS, EPA, and other entities to pose a
potential threat to human health. These included chemicals prioritized
for safety testing (based on EPA's findings that the chemicals may
present unreasonable health risks), chemicals linked to cancer, toxic
chemicals frequently found at Superfund sites, and certain pesticides
monitored in foods or thought to be potentially harmful to humans. For
these chemicals, we assessed the extent to which major HHS and EPA
survey efforts--specifically HHS' National Health and Nutrition
Examination Survey (NHANES) and EPA's National Human Exposure
Assessment Survey (NHEXAS) phase I (pilot surveys)--were collecting
human exposure data. We also surveyed 93 environmental health officials
in 50 States and the District of Columbia, receiving responses from 81
officials in 48 States for a response rate of 87 percent. At the
Federal level, we focused on survey data collected for the general
(non-occupationally exposed) population. We excluded federally
sponsored academic and private sector research. Appendix I explains our
scope and methodology in more detail. We conducted our work from March
1999 through March 2000 in accordance with generally accepted
government auditing standards.
RESULTS IN BRIEF
Federal and State efforts to collect human exposure data are
limited, despite some recent expansions. HHS and EPA have been able to
take advantage of improved technology to measure exposures for more
people and for a broader range of chemicals. Still, with existing
resources, HHS and EPA surveys together measure in the general
population only about 6 percent of the more than 1,400 toxic chemicals
in our review. For those toxic chemicals that we reviewed, the portion
measured ranged from 2 percent of chemicals prioritized for safety
testing to about 23 percent of those chemicals most often found at
Superfund sites and considered to pose a significant threat to human
health. Even for those chemicals that are measured, information is
often insufficient to identify smaller population groups at high risk,
such as children in inner cities and people living in polluted
locations who may have particularly high exposures. At the State level,
efforts are similarly limited. Almost all State officials who we
surveyed said they highly valued human exposure data for populations
within their borders, and many provided specific examples of how such
data have provided useful information for interpreting citizens' health
risks and guiding public health actions. For example, State officials
in nine States used human samples not only to identify who was exposed
to a toxic pesticide illegally sprayed in citizens' homes, but to
identify houses most in need of clean-up. Despite this perceived value,
most officials reported that they were unable to collect or use human
exposure data in most of the cases where they thought it was important
to do so.
Three main barriers limit Federal and State agencies' abilities to
make more progress. First, Federal and State laboratories often lack
the capacity to conduct measurements needed to collect human exposure
data; additionally, for most of the chemicals on our list, no
laboratory method has been developed for measuring the chemical levels
in human tissues. The second barrier, particularly voiced by State
officials, relates to the lack of information to help set test results
in context. Public health officials said they need more information on
typical exposures in the general population so that they can compare
this information with people's levels at specific sites or with
specific populations in their States. They also said they needed more
research to relate exposure levels to health effects for the chemicals
of concern in their States. The third barrier, of particular concern at
the Federal level, is that coordinated, long-term planning among
Federal agencies has been lacking, partly because of sporadic agency
commitments to human exposure measurement and monitoring. HHS and EPA
officials indicated that they have been discussing the merits of
establishing a coordinated interagency human exposure program, but they
have not yet formalized or agreed upon a long-term strategy. A long-
term coordinated strategy should also ensure adequate linkages between
collection efforts and agency goals, provide a framework for
coordinating data collection efforts that considers individual
agencies' needs and expertise, provide a framework for identifying at-
risk populations, and consider States' needs for information. To
address these needs, we are recommending that the Secretary of HHS and
the Administrator of EPA develop a coordinated Federal strategy for the
short- and long-term monitoring and reporting of human exposures to
potentially toxic chemicals.
BACKGROUND
EPA projects a continuing upward trend in environmental compliance
costs for pollution control measures, amounting to an estimated $148
billion this year. Hundreds of millions of dollars are spent monitoring
levels of toxic chemicals in the environment--for example,
approximately $139 million of Federal funding supported national air-
quality monitoring networks in the United States in fiscal year
1999.\3\ Despite these expenditures, what often is not known is the
extent to which people are exposed to potentially harmful chemicals in
their daily lives, the chemicals to which they are most often exposed,
the levels of such exposure, how exposures change over time in relation
to regulatory policies, and the sources of exposure. Policymakers,
regulators, researchers, and public health officials must often rely on
estimates of human exposure levels for the general population or for
smaller groups thought to be at risk. Such estimates are often derived
from data showing the extent the chemicals are found in the air, water,
food, or other environmental media and assumptions about how and at
what rate the body absorbs the chemicals it contacts. A variety of
methods for measuring exposures are considered to be more direct than
those that measure chemicals in the ambient environment. These methods
measure exposures in people's more immediate environments and include
tools such as personal air monitors, which measure chemicals that may
be inhaled. For several chemicals and purposes, measuring internal
exposure levels in human tissues is considered the most useful and
accurate measure and an important piece of the information needed to
link contaminants in the environment with adverse health effects.
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\3\ The Role of Monitoring Networks in the Management of the
Nation's Air Quality, National Science and Technology Council,
Committee on Environment and Natural Resources, Air Quality Research
Subcommittee (Mar. 1999).
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While officials may be able to collect internal exposure levels at
a local level, the results are difficult to interpret without
information such as comparative data to show what exposure levels might
be considered high or research findings linking exposure levels to
specific health effects. Because of the need for improved data on
actual human exposures found in the general population, the National
Research Council (NRC), an arm of the National Academy of Sciences,
recommended in 1991 that the Nation adopt a new program to monitor
chemical residues in human tissues, such as blood. NRC noted that
determining the concentrations of specific chemicals in human tissues
could serve to integrate many kinds of human exposures across media
such as air, water, or food and over time. As one component of an
effort to manage environmental quality and protect public health, NRC
reported that a well-designed national program for monitoring toxic
chemicals in human tissues was needed.\4\ NRC pointed out that human
exposure data could be used to help monitor changes in the population's
exposure to chemicals and identify population groups--by factors such
as age or geographic location--that might be at increased risk because
they face higher levels of exposure.
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\4\ According to NRC, human monitoring data alone can signal the
need to conduct studies on specific environmental chemicals, but these
data are best viewed as one component of a comprehensive environmental
monitoring program. Human measurements are best supplemented with
knowledge of contaminant sources, environmental pathways, environmental
concentrations, time patterns and locations of exposure, routes of
entry into the body, material toxicity, and latency. See NRC,
Commission on Life Sciences, Monitoring Human Tissues for Toxic
Substances (Washington, DC.: National Academy Press, 1991) .
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Direct biological monitoring of human exposure to chemicals has
been made increasingly possible by recent advancements in analytical
chemistry and molecular biology. Methods have been developed to measure
smaller levels of toxicants in body tissues and to do so with smaller
sample amounts.\5\ For example, a few years ago a laboratory would need
100 milliliters of blood to detect dioxins in the part-
per-billion range. New test methods use less than 10 milliliters and
are capable of detecting concentrations in the parts-per-trillion
range. Single samples can also now be used to detect low concentrations
of multiple chemicals. Since 1995, for example, laboratory methods have
been developed to detect polycyclic aromatic hydrocarbons, a group of
more than 100 chemicals formed during the incomplete burning of coal,
oil, gas, garbage, tobacco, and other substances.
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\5\ Other human biological tissues that might be used for
measurements of chemical concentrations include fat tissue, breast
milk, semen, urine, liver specimens, hair, fingernails, or saliva.
Human breath has also been used to measure exposure to certain
chemicals.
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Lead is an example of a chemical that has been monitored
extensively by measuring absorption into human tissues--specifically,
lead levels in the blood. Elevated levels of lead in the blood can
cause learning problems and, at extreme levels, result in serious brain
or kidney damage. Data on blood lead levels have been collected for the
national population since 1976. Public health officials, researchers,
and others have used lead exposure data from large- and small-scale
studies in many ways to identify at-risk populations, evaluate
regulatory actions, improve the models used to estimate exposure, and
identify significant sources of preventable exposure, as shown in the
following examples.
Identifying at-risk populations: National blood lead data
revealed that low-
income children living in houses built before 1946 had a prevalence of
elevated blood lead levels of 16.4 percent as compared to 4.4 percent
for all children ages 1 through 5; non-Hispanic black children in
similar housing had a prevalence of 21.9 percent--the highest risk of
elevated blood lead levels of any demographic group. Using this
information, State and local health of officials can more effectively
target screening and treatment efforts.
Establishing and evaluating public health-related
policies: In the 1980's, EPA was considering whether or not to make
permanent a temporary ban on lead in gasoline. National data on lead
exposure showed a decline in average blood lead levels that
corresponded to the declining amounts of lead in gasoline. Based on
this and other information, EPA strengthened its restrictions on lead
in gasoline and required a more rapid removal of lead from gasoline.
Improving models used to estimate exposure: Experts
indicate that an increasingly important use of human exposure data has
been as a ``reality check'' on other indexes of exposure, such as
questionnaires about activities or work histories, to ascertain whether
exposures may have occurred. For example, prior to the decision to
phaseout lead in gasoline, exposure models suggested that eliminating
lead in gasoline would have only a slight effect on blood lead levels,
while actual testing showed a more dramatic effect.
Identifying key sources of exposure: When combined with
other exposure data, exposure measurements can help reveal the source
of the exposure--an essential step in developing and monitoring
intervention strategies designed to reduce or eliminate harmful
exposures. For example, when no evidence of lead paint--the most common
source of lead contamination--was found in the home of a child whose
blood showed abnormal levels of lead, public health officials were
baffled. Observational data on how and where the child spent time and
environmental data from the surfaces most often encountered revealed
that lead-contaminated stuffing in a toy the child chewed likely
accounted for the high exposure. The child's blood lead level declined
when the contaminated toy was removed.
While lead is unique among chemicals in that it has been
extensively studied--decades of research has shown its harmful effects
at increasingly lower levels--such research has been possible in part
because of laboratory advances in measurement technology. Over the
years, as technology improved the ability to measure smaller and
smaller amounts of lead in the bloodstream, researchers have been able
to identify increasingly subtle adverse effects by linking blood lead
levels and changes in neurobehavioral functioning.
CURRENT MEASUREMENT EFFORTS COVER FEW CHEMICALS AND SITUATIONS
Although HHS and EPA each are expanding their survey efforts to use
new technologies and measure a broader range of exposures in the
national population, their measurement efforts cover a limited portion
of the more than 1,400 potentially harmful chemicals we reviewed. These
surveys also remain of limited value for identifying at-risk
populations, because in the case of their survey efforts, sample sizes
to date have been insufficient--and, for most chemicals, not
representative of the general population. In addition, Federal efforts
to help assess potential disproportionate exposures by collecting data
on communities living near Superfund sites have been limited to few
locations. State agencies reported that their efforts are also limited,
despite the importance they place on using such data in their studies
of population- or site-specific situations within their borders.
According to State environmental health officials, they are often
unable to collect these data.
Federal Efforts Are Expanding
In our examination of the HHS and EPA surveys, we found that the
types of chemicals measured have recently increased. For the past 40
years, HHS' Centers for Disease Control and Prevention (CDC) has
collected through a survey nationally representative data on the health
and nutrition of the U.S. population. Exposure measurements are one
component of this survey. In the mid-1990s, EPA's Office of Research
and Development initiated a human exposure survey, which is currently
in its pilot phase in three locations across the country. A third more
recent effort to monitor human exposures to select chemicals was
initiated in 1996 by HHS' National Institute of Environmental Health
Sciences (NIEHS) of the National Institutes of Health (NIH). For each
of these Federal efforts, laboratory measurements are largely conducted
by the laboratory at CDC's National Center for Environmental Health,
which also developed many of the methods for performing these
measurements.
CDC's National Health and Nutrition Examination Survey
CDC collects human exposure data as part of NHANES, which has been
conducted periodically since 1960 and, beginning in 1999, has been
conducted annually. NHANES monitors trends in health status by
conducting interviews and physical assessments on a nationally
representative sample of about 5,000 people per year. NHANES collects
blood and urine samples for many purposes, such as assessing
cholesterol levels and the prevalence of diabetes. Since 1976, these
samples have also been used to measure exposure to selected chemicals,
and excess samples are banked for future research. In the past, CDC's
human exposure monitoring efforts have focused largely on lead,
cadmium, and a few pesticides and volatile organic compounds--chemical
compounds which include a number of animal and known or suspected human
carcinogens found in tobacco smoke, building supplies, and consumer
products.\6\ Starting with the 1999 NHANES, CDC proposed to measure up
to 210 chemicals in human tissues as staff and other resources
permitted. These chemicals include metals such as mercury, which at
high levels may damage the brain, kidneys, and developing fetus;
polyaromatic hydrocarbons (a group of compounds found in sources such
as foods that have been grilled); and volatile organic compounds, such
as benzene. At the time of our review, a CDC official indicated that
resources allowed them to include about 74 chemicals for 1999 and 2000.
The estimated marginal costs for the environmental exposure-related
components of the NHANES 1999 survey were about $5 million.
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\6\ Special reference studies supported by the Agency for Toxic
Substances and Disease Registry were also conducted on
nonrepresentative samples of a portion of the people participating in
the most recently completed segment of NHANES (conducted from 1991
through 1994). These special studies assessed exposure to 45 pesticides
and volatile organic compounds.
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EPA's National Human Exposure Assessment Survey
To expand upon and replace its National Human Adipose Tissue Survey
(NHATS)--a tissue monitoring program, which ended in 1992-EPA initiated
in 1993 pilot surveys for NHEXAS in three regions of the country.\7\ A
goal of the NHEXAS pilots is to obtain knowledge on the population's
distribution of total exposure to several classes of chemicals and to
test the feasibility of collecting representative survey data on
people's total exposures. NHATS focused on monitoring human fat tissues
for persistent organochlorine pesticides and polychlorinated biphenyls
(PCB); NHEXAS has broadened this focus in two ways. First, in addition
to measuring chemical levels in samples such as blood or urine, the
NHEXAS pilot surveys included measurements of chemicals in air, foods
and beverages, water, and dust in individuals' personal external and
internal environments. To conduct these measurements, the pilot surveys
used tools such as questionnaires, activity diaries, air-monitoring
badges worn by the individual or other air-monitoring devices, and tap
and drinking water and food samples. Such data are important for
purposes such as identifying the most important sources or routes of
exposure and for taking actions to reduce or prevent exposures. Second,
the NHEXAS pilot surveys included more types of chemicals than
pesticides, such as lead and other heavy metals. The NHEXAS pilots,
however, included fewer chemicals than its predecessor--which measured
about 130 pesticides and PCBs in human fat tissue--in part because
monitoring levels of any given chemical in personal environments and in
human tissues requires significantly more laboratory measurements for
the same chemical. EPA's NHEXAS pilot surveys, which have tested
biological samples from about 460 participants, have collectively
measured up to 46 chemicals, including pesticides, heavy metals, and
volatile organic compounds in blood, urine, or hair. Once data from
these pilot surveys have been further analyzed, EPA intends to assess
the feasibility and cost of conducting a national effort to collect
total exposure data. To date, EPA has invested about $20 million to
support the pilot surveys. Very preliminary estimates by EPA for a
national survey range from $20 million to $30 million per year over 10
years or more.
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\7\ Specifically, pilot surveys were conducted in Arizona,
Maryland, and, EPA's region 5 (Illinois, Indiana, Michigan, Minnesota,
Ohio, and Wisconsin).
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National Institute Environmental Health Sciences' Human Exposure
Initiative
In 1996, NIEHS began an initiative to collect human exposure data.
This initiative was started as a collaboration between NIEHS and CDC to
improve understanding of human exposures to hormonally active agents--
also called ``environmental endocrine disrupters''--for the national
population.\8\ The effort was intended to build upon the chemical
monitoring in NHANES by supporting the development of laboratory
methods and measurement of previously unmeasured chemicals in human
tissues collected from NHANES and other studies. NIEHS and CDC signed
an interagency agreement, under which CDC will develop methods for
measuring and will measure in blood, urine, or both up to 80 chemicals
thought to be hormonally active agents. For this effort, CDC obtained
samples of about 200 people--most of whom are from the ongoing sampling
of the general population under NHANES.
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\8\ The concern about endocrine disrupters originated from the
finding that some synthetic chemicals in the environment are associated
with adverse reproductive and developmental effects in wildlife and
mimic the actions of female hormones. According to NRC, although it is
clear that exposures to hormonally active agents at high concentrations
can affect wildlife and human health, the extent of harm caused by
exposure to these compounds in concentrations that are common in the
environment is debated. See NRC, Commission on Life Sciences,
Hormonally Active Agents in the Environment (Washington, DC: National
Academy Press, July 1999).
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In 1999, officials of NIEHS and the National Toxicology Program
(NTP)--an interagency effort to coordinate toxicological research and
testing activities of HHS, which is administratively housed at NIEHS--
proposed to expand upon the initial collaboration and formalized the
undertaking as the Human Exposure Initiative. Specifically, they
proposed a broader interagency effort to quantify human internal
exposures to chemicals released into the environment and workplace. One
significant purpose of this effort was to help prioritize those
chemicals and chemical mixtures to be studied by NTP, recognizing the
limited resources available for toxicological testing and the need for
better information to prioritize which chemicals should be tested.
According to NTP officials, although NTP is the nation's largest
Federal toxicology testing program, it can initiate only 10 long-term
cancer studies and 10 reproductive studies per year.\9\ NIEHS provided
a list of 131 chemicals it hoped would be measured through this
expanded effort. At the time of our review, however, program officials
told us that NIEHS had not published data from the chemicals CDC had
measured under this agreement, and CDC was developing the laboratory
methods needed to measure many of the chemicals identified by NIEHS as
needed.\10\ (For more information on NHANES, NHATS, NHEXAS, and NIEHS'
Human Exposure Initiative, see app. II.)
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\9\ According to NTP officials, chemicals are tested for cancer and
noncancer endpoints--including effects on reproduction, development,
nervous system, and immune systems--using traditional bioassays as well
as newly validated tests. Validation of new tests is achieved through
an NTP interagency center involving 15 Federal agencies or institutes.
\10\ CDC officials indicated that, by the end of 1999, it had
developed laboratory methods to measure more than half of the chemicals
under the agreement with NIEHS.
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Despite Expansion, Chemicals Covered in Exposure Measurements Remains
Limited
Despite these expanded efforts, NHANES and the NHEXAS pilot surveys
cover only about 6 percent (or 81) of the 1,456 potentially harmful
chemicals in our review. We compared the chemicals measured by these
surveys to eight selected lists of chemicals of concern.\11\ Our
selection was based, in part, on our assessment and input from experts
that these lists contained chemicals of higher concern to human
health.\12\ However, the listed chemicals represent a small portion of
those that are regulated or are of potential public health importance.
For example, there are over 7,000 lists of chemical substances and
classes that are regulated under the Toxic Substances Control Act and
the Emergency Planning and Community Right-to-Know Act.
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\11\ ``We excluded NHATS and Human Exposure Initiative chemical
lists from our analysis. NRC's 1991 review of the NHATS program raised
questions about the representativeness of the results and the methods
used to handle the tissue specimens, among other questions. The Human
Exposure Initiative measurements were not available at the time of our
review and, thus, which chemicals had been or are currently being
measured was not known.
\12\ We selected these lists based on input from program officials
and experts at EPA, HHS, the Association of Public Health Laboratories,
and the Pew Commission on Environmental Health and our assessment that
the criteria for listing a chemical demonstrated that exposure could
potentially be harmful to humans. There are many toxic chemical lists
maintained by different programs and agencies for different purposes
that we did not include in our review and, as such, the ones we
reviewed do not necessarily individually or collectively represent the
chemicals of highest concern to human health.
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For those individual lists that we reviewed, the portion of toxic
chemicals measured ranged from 2 percent of chemicals prioritized for
safety testing (based on EPA's findings that the chemicals may present
unreasonable risks) to about 23 percent of chemicals most often found
at the nation's Superfund sites and identified as posing the most
significant threat to human health. See table 1 for each of the lists
reviewed and the extent to which NHANES or the NHEXAS pilots are
measuring these chemicals, and appendix I for a discussion of each list
included in our review.
Table 1.--Extent to Which Human Exposure Data Are Collected for
Potentially Harmful Chemicals Through NHANES or the NHEXAS Pilot Surveys
------------------------------------------------------------------------
Priority chemicals Chemicals
------------------------------------------------------- measured or
being measured
Description of list No. in -----------------
list No. Percent
------------------------------------------------------------------------
Chemicals found most often at the national 275 62 23%
Superfund sites and of most potential threat
to human health.............................
EPA's list of toxics of concern in air....... 168 27 16
Chemicals harmful because of their 368 52 14
persistence in the environment, tendency to
bioaccumulate in plant or animal tissues and
toxicity....................................
Pesticides of potential concern as listed by 243 32 13
EPA's Office of Pesticide Programs and the
U.S. Department of Agriculture's Pesticide
Data Program................................
Chemicals that are reported in the Toxic 579 50 9
Release Inventory; are considered toxic; and
are used, manufactured, treated,
transported, or released into the
environment.................................
Chemicals that are known or probable 234 17 7
carcinogens as listed in HHS' Report on
Carcinogens a...............................
Chemicals most in need of testing under the 476 10 2
Toxic Substances Control Act (Master Testing
list).......................................
------------------------------------------------------------------------
Note: Our analysis was based on human exposure data collected through
NHANES or the NHEXAS pilot surveys through 2000.
a The Report on Carcinogens list may also include pharmaceutical agents,
substances of primarily occupational concern, and banned substances.
According to NIEHS officials, this may account for their lower
inclusion in NHANES or the NHEXAS pilots. NIEHS and NTP officials
indicated that, in addition to these chemicals, NTP reports results of
its chronic bioassays for cancer in its technical report series. There
are now approximately 500 reports, which collectively include nearly
250 chemicals found to cause cancer in rodents. Officials indicated
that another useful evaluation would assess the proportion of rodent
carcinogens for which human exposure data are collected and that NTP
is planning to conduct such an evaluation.
While many potentially harmful chemicals in these lists are not
measured in the population, NHANES or the NHEXAS pilot surveys contain
a greater portion of chemicals considered of higher priority. Two toxic
chemical lists we reviewed--one ranking chemicals frequently found at
Superfund sites and one ranking selected chemicals compiled by EPA--
prioritized chemicals based on their potential to harm human health We
examined the highest-ranked chemicals on these lists and found that
higher proportions of these chemicals were or will be measured compared
to the overall list. A CDC laboratory official also indicated CDG was
in the process of developing methods to measure a number of the
chemicals on these lists and planned to measure other chemicals in
future efforts if they have adequate resources to do so.
Ranking of chemicals frequently found at Superfund sites:
Developed by EPA and HHS' Agency for Toxic Substances and Disease
Registry (ATSDR), which conducts public health assessments or other
health investigations for populations living around national Superfund
sites, this list ranks substances that are most commonly found at
Superfund sites and pose the most significant potential threat to human
health due to their known or suspected toxicity and potential for human
exposure. Of the top 40 chemicals on this list, CDC indicated that 9
were currently being measured in NHANES. CDC hopes to include an
additional 30 of the top 40 in future efforts; 11 of these 30
chemicals, however, were included in the NHEXAS pilot surveys.
Ranking of selected toxic chemicals compiled by EPA: These
rankings are based on a chemical's persistence, tendency to accumulate
in plants and animals, and toxicity. CDC indicated 4 of the top 22
chemicals on this list based on their health hazard\13\ were currently
being measured in NHANES. CDC hopes to include the remaining 18 in
future efforts; 6 of the 18 chemicals were included in the NHEXAS pilot
surveys.
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\13\ EPA's prioritized chemical list ranks chemicals based on the
length of time to break down, the degree to which they accumulate in
plants and animals, and their toxicity. Both ecological and health risk
scores are calculated. We used only the health risk scores in our
analysis.
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Federal Efforts Are Limited for Identifying At-Risk Subpopulations
In recent years, Federal agencies have been charged with
identifying whether certain populations--including minorities, people
with low incomes, and children--disproportionately face greater health
risks because they have greater exposure to environmental hazards.\14\
Researchers increasingly recognize that the scarcity of adequate and
appropriate data, especially for exposures and related health effects,
hinders efforts to more systematically identify groups that may be at
risk.\15\ Lacking such data, past efforts to identify the exposures of
certain demographic groups have often relied on measures of chemical
levels in the surrounding environment. For example, some studies around
hazardous waste sites and industrial plants have shown that minorities
and low-income subpopulations are disproportionately represented within
the geographic area around the sites. Such studies are limited in
identifying the actual health risk because they must make assumptions
about how these substitute measures, such as how close one lives to a
hazardous waste site, relate to actual exposures experienced by people.
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\14\ Executive Order 12898 requires that each agency identify and
address as appropriate disproportionately high and adverse human health
or environmental effects of its programs, policies, and activities on
minority populations and low-income populations in the United States
and its territories and possessions. Executive Order 13045 established
similar requirements with respect to children.
\15\ S. Perlin, K. Sexton, and D. Wong, ``An Examination of Race
and Poverty for Populations Living Near Industrial Sources of Air
Pollution,'' Journal of Exposure Analysis and Environmental
Epidemiology, Vol. 9, No. 1 (1999), pp. 29-48.
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To identify groups whose exposure is disproportionately greater
than that experienced by the remainder of the population--and thereby
provide more definitive assessments of whether certain groups
potentially face greater health risks--health officials and researchers
might measure exposure levels for (1) a representative sample and
analyze the characteristics of subpopulations with the highest
exposures or (2) a population thought to be at high risk and compare it
to measurements from a reference population.\16\ We examined the extent
to which Federal survey data on human exposures collected to date could
be used to assess characteristics of those groups most exposed. We also
examined the extent to which human exposure data was collected on a
population considered to be at higher risk--specifically, those living
around national priority hazardous waste sites. In each effort, the
information collected has been limited, as discussed below.
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\16\ D. Wagener, D. Williams, and P. Wilson, ``Equity in
Environmental Health: Data Collection and Interpretation Issues,''
Toxicology and Industrial Health, Vol. 9, No. 5 (1993), pp. 775-95.
---------------------------------------------------------------------------
Sampling Not Sufficient to Identify Many Highly Exposed Groups
Representative sampling is required to identify at-risk
subpopulations in a non-biased way--that is, without presupposing that
a certain group is at higher risk. The sample must also be large enough
to ensure highly exposed subpopulations can be objectively
identified.\17\ For nearly all chemicals except lead, however, past
Federal collection of human exposure data in NHANES and the NHEXAS
pilot surveys has been insufficient to identify whether
disproportionate exposures are occurring in many demographic groups. In
the case of NHANES, the sample is generally drawn to reflect the
national population as a whole.\18\ Consequently, the sample of the
group of interest may be too small to draw meaningful conclusions about
characteristics, such as exposures, of the group. In the past, most
NHANES exposure measurements were conducted among non-randomly-selected
samples and from only a portion of the surveyed participants, thus
limiting the ability to identify highly exposed groups. Lead was an
exception. Data for blood lead levels in children have been the most
comprehensively collected, and certain characteristics have been
clearly associated with a higher prevalence of blood lead levels. EPA
has concluded that the evidence is unambiguous: children of color have
a higher prevalence of elevated blood lead levels than white children
do, and children in lower-income families have a higher prevalence than
children in higher income families. See table 2 for the most recent
NHANES analysis.
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\17\ The feasibility of using a representative survey to identify
at-risk subpopulations based on individual characteristics (such as
age, race, or income level) or location (such as a city, county, or
State) depends on sample design and size--that is, on how the
participants are selected and how many participants are included.
Generally, the lower the percentage of the population in question in
the sample, the less the data can be used to develop precise estimates
of exposure or to distinguish exposure levels between subgroups.
\18\ Certain groups may be included at a higher rate or oversampled
to ensure a greater level of accuracy. For example, between 1988 and
1994, children ages 2 months through 5 years surveyed in NHANES were
oversampled.
Table 2.--Prevalence of Elevated Blood Lead Levels in Children Ages 1
Through 5, by Selected Demographic Characteristics (NHANES, 1991 Through
1994)
------------------------------------------------------------------------
Percentage
with
Characteristic of children in sample elevated
blood lead
levels
------------------------------------------------------------------------
Race/ethnicity:
Black, non-Hispanic....................................... 11.2%
Mexican-American.......................................... 4.0
White, non-Hispanic....................................... 2.3
Income level:
Low....................................................... 8.0
Middle.................................................... 1.9
High...................................................... 1.0
Age group:
1 through 2............................................... 5.9
3 through 5............................................... 3.5
-----------
Total age 1 through 5................................... 4.4%
------------------------------------------------------------------------
Source: CDC, ``Update: Blood Lead Levels--United States, 1991-1994,''
``Morbidity and Mortality Weekly Report, Vol. 46, No. 7 (1997), pp.
141-5.
CDC officials told us that representative data, such as that
collected for lead, would be collected for a larger number of chemicals
starting in 1999. However, CDC plans indicated that for most chemicals
monitored, only a portion of NHANES survey participants--generally one-
third or fewer, depending on the type of chemical--would be tested. For
some chemicals, only certain groups thought to be at higher risk may be
tested. For example, NHANES will include measurement of certain
persistent pesticides known as organochlorines in one-third of the
survey participants ages 12 through 19. Children under 12 will not be
assessed.\19\ CDC officials indicated that people over 19 may be
assessed if adequate resources are available to do so. Although most
organochlorines are banned in the United States, some are still used in
home and garden products, such as products for treating lice and
controlling agricultural and structural pests and flame retardants used
in synthetic fabrics.\20\ NHANES data from a one-third subsample will
be useful for establishing reference ranges within the population and
illuminating exposure levels nationally; they will also be useful for
identifying exposures of broad demographic groups, such as males and
females. But these data are not enough to enable researchers to assess
exposure levels of or characterize many potentially at-risk groups,
such as the exposures of inner-city children in low-income
families.\21\ According to a CDC laboratory official, targeted studies
should be considered for groups that represent a small portion of the
population.
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\19\ According to CDC officials, children under 12 will not be
assessed because the volume of tissue samples needed to perform the
measurement will not be available. Other measurements--such as those
for lead, mercury, and cotinine (a metabolite of nicotine illustrating
exposure to cigarette smoke)--will be performed for many in this age
group.
\20\ According to CDC laboratory officials, other NHANES exposure
measurements planned for 1999 and 2000 for a subsample of participants
includes volatile organic compounds, mercury, nonpersistent pesticides,
phthalates, and trace metals. Air toxic exposures to selected volatile
organic compounds will be measured in personal measurements--such as
chemical levels in the air, measured through badges, and chemicals in
water samples--and in blood samples from a subsample of people ages 20
through 59. Mercury will be measured in the hair and blood of
participants ages 1 through 5 and women ages 16 through 49.
Nonpersistent pesticides or their metabolites are planned for
measurement in one-half of participants ages 6 through 11 and one-third
of participants ages 12 and over. Surveys and focused research indicate
that household use of certain pesticides may be extensive, but little
information is available concerning residential or household exposures
among the general population. Phthalates are planned for measurement in
one-third of the participant ages 6 and older. Seventeen trace metals
will be measured in one-third of participants ages 6 and older. Trace
metals such as barium and beryllium have been associated with adverse
health effects in occupational or laboratory studies but have not been
monitored in the general population.
\21\ The current design of NHANES samples allows several years of
data to be combined. If exposure for chemicals is measured consistently
over several years, then assessing risk factors may be increasingly
possible over time. CDC officials indicated that for any annual NHANES
full sample, a limited number of estimates for broad population
subgroups can be developed. More detailed measures for smaller
subgroups (for example, analyses by age, gender, and race and
ethnicity) will require more years of data, generally 3 through 6
years--and even longer if a subsample is used--of data collected for
all participants. Based on an annual sample of one-third of the
participants, CDC indicated that estimates may be possible for very
broad subgroups, such as males or females; participants ages 6 through
19 or over 20; or a few major race and ethnicity groups, depending on
the prevalence of the condition examined.
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Similarly, the NHEXAS pilot surveys included representative samples
of participants in the three geographic locations covered. However,
because of the smaller sample sizes, the work to date has also been too
limited for much analysis of at-risk populations.\22\ The pilot surveys
included biological measurements for about 200 people in six Midwestern
States, about 180 people in Arizona,\23\ and about 80 people in
Baltimore.
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\22\ One assessment of the data from Midwestern States provided
some indication of potential differences in personal exposures between
age groups, races, income segments, and house construction dates.
Researchers cautioned that the data for some categories examined were
small. This assessment did not report on exposure measurements from
biological sampling in this survey. (See E.D. Pellizzari, R.L. Perritt,
and C.A. Clayton, ``National Human Exposure Assessment Survey:
Exploratory Survey of Exposure Among Population Subgroups in EPA Region
V,'' ``Journal of Exposure Analysis and Environmental Epidemiology,''
Vol. 9 (1999), pp. 49-55.
\23\ These participants provided biological samples, such as blood
and urine. Larger participant groups in the study areas provided
environmental and food monitoring samples and responded to
questionnaires. This excludes a related but separate study done in
Minnesota reviewing pesticide exposures that was not one of the three
formal pilot surveys.
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Federal Efforts to Identify Communities of Concern Valuable, but Human
Exposure Data Are Limited
A second method to identify a subpopulation disproportionately at
risk of adverse health effects is to compare exposure levels for a
group thought to be at high risk with baseline measurements from a
reference population.\24\ This method can be used to determine, for
example, the extent to which people in a neighborhood, community, or
geographic location are exposed relative to others. In cases where
exposure levels have been identified as high compared to reference
populations but potential health effects associated with those levels
have not been researched, public health actions can help prevent
further or increasing exposures, and these groups can be assessed for
any subsequent health outcomes.
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\24\ Determining the distribution of chemical exposure among a non-
occupationally-exposed population establishes a ``reference range''
that shows what can be considered background exposure and what can be
considered high. With reference range information, officials concerned
about exposures of groups can compare the groups' exposures to those of
the general population and determine whether public health action is
warranted to prevent or reduce high levels of exposure.
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One Federal effort, conducted by ATSDR, analyzes risks faced by
communities near hazardous waste sites. ATSDR estimates that 12.5
million people live within 1 mile of the nation's 1,300 Superfund
sites. The agency can collect biological samples through exposure
investigations as part of the public health assessment process or in
response to requests from the public.\25\ ATSDR officials said that
human exposure data collected at Superfund sites have been useful in
deciding on actions such as stopping or reducing exposures, relocating
residents, referring residents for medical follow-up, reducing
community anxiety, influencing priorities on site-specific clean-up,
making referrals to researchers for assessing health links, and
educating community and other health providers. As evidence, they
pointed to the conclusions of an expert review panel, which stated in
March 1997 that human exposure data were as important to exposure
investigations and public health assessments as environmental
monitoring results at the sites of concern.\26\ However, the number of
investigations that included human exposure data has been limited.
Between 1995 and July 1999, ATSDR had gathered biological samples at
only about 47 of the more than 1,300 Superfund sites. At least 34 of
these investigations detected contaminants in people and 16 found
elevated levels.
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\25\ ATSDR conducts exposure investigations when (1) people have
likely been exposed to a contaminant, (2) more information is needed on
the exposure, (3) an exposure investigation will provide that
information, and (4) that investigation will affect public health
decisions.
\26\ In its report, panel members suggested many improvements to
ATSDR's exposure investigations, including creating a technical
planning group to review emerging and innovative technologies and
establishing a national clearinghouse of collected data. ATSDR
officials indicated that they had not been able to act on some of the
panel's suggestions because of limited staff and resources and other
barriers to collecting data, such as the lack of laboratory methods for
testing chemicals of interest ATSDR has nine staff to conduct exposure
assessments for sites across the nation and can only respond to
requests from communities or State or local officials for assistance
rather than conducting such assessments as part of every new
investigation.
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Other federally conducted efforts designed to monitor or collect
data on the exposures of populations within selected communities or
geographic regions have also been infrequent.\27\ One such regional-
scale effort under way is collecting data on exposures within selected
communities along the border between Texas and Mexico. Officials from
Mexico and Federal and State agencies in the United States are
comparing exposures of people in the border area with those in areas
away from the border. Another study examined the exposures of people
along the Arizona border compared to the exposures of people elsewhere
in the State. This study collected environmental samples for
pesticides, metals, and volatile organic chemicals. Blood and urine
samples were also tested to relate the environmental measurements to
the measurements in human tissues for these chemicals.
---------------------------------------------------------------------------
\27\ Federal agencies also might fund academic research that is
designed to identify communities of concern. Assessing the extent that
federally supported academic research included or focused on human
exposure data to identify at-risk population was beyond the scope of
our review.
---------------------------------------------------------------------------
State Officials Value Human Exposure Data for Studies and
Investigations but Do Not Often Include Them
Most State officials who we surveyed highly valued human exposure
data. However, most could not include it in their exposure-related
health studies, investigations of concerns such as disease clusters, or
surveillance efforts. Almost half of the officials responding to our
survey estimated that they had participated in 10 or more exposure-
related studies or investigations since 1996, with about 16 percent
estimating they participated in 50 or more. However, about half of the
officials indicated they could seldom if ever collect exposure data
through human samples in their efforts. When data were developed,
officials listed five main uses: (1) environmental health epidemiologic
studies, (2) surveillance of diseases or conditions with suspected
environmental causes, (3) investigations of citizen concerns, (4)
planned or accidental chemical releases, and (5) disease clusters (see
table 3).\28\ State officials we spoke with noted that human exposure
data are often the most valid and persuasive evidence available to
demonstrate whether, and to what extent, exposure has occurred or
changed over time. In highly charged situations, where community trust
has eroded, such data may be the only evidence acceptable to area
residents.
---------------------------------------------------------------------------
\28\ Since most States conduct surveillance for lead exposure, we
asked officials to not include these efforts in their responses. See
app. III for a copy of our survey.
Table 3.--Examples of How State Officials Use Human Exposure Data
------------------------------------------------------------------------
Purpose Example
------------------------------------------------------------------------
Environmental health epidemiologic Using blood and urine samples
studies. from people who ate sport fish
and were concerned about undue
exposure to dioxins,
pesticides, and other
chemicals, health officials
determined these people had
exposure to some chemicals
from 2 to 10 times higher than
levels in a reference
population. Based on these
results, officials will focus
a larger health effects study
on exposure to those
chemicals.
Surveillance of diseases or conditions Virtually all States collect
with suspected environmental causes. information on blood lead
levels in children to monitor
and prevent lead poisoning.
Some also monitor exposure to
pesticides and other chemicals
such as mercury and arsenic.
Investigation of citizen concerns...... Health officials used human
tissue measurements and
citizens' reports of illnesses
to demonstrate that the
combined effect of chemicals
released into the environment
posed a health hazard severe
enough to warrant evacuating
nearby residents. State and
Federal officials subsequently
closed a manufacturing plant
because of the harmful health
effects of its chemical
releases.
Investigation of planned or accidental Officials in nine States asked
chemical releases. CDC to test tissue samples
from almost 17,000 individuals
thought to have been exposed
to methyl parathion, a deadly
pesticide. CDC's ability to
measure the pesticide in human
tissue and compare exposures
across States was critical to
identifying individuals with
high exposures and houses most
in need of clean-up. Because
relocating residents and
removing the pesticide from
homes cost up to $250 000 per
household, the exposure data
helped officials avoid
spending limited funds on
houses that did not pose a
health risk to the people
living in them. One State
official said the exposure
results reduced the number of
houses needing pesticide
removal from hundreds to fewer
than 10.
Investigation of disease clusters...... State health officials reviewed
data on individual cases of
cancer in one community and
for the entire State. When
available data on known risk
factors did not account for
the increased incidence of
breast cancer, officials began
a more detailed study that
included human tissue
analysis. Blood samples were
obtained from women before and
after treatment began and from
women in a control group.
Results will be compared to
reference range data developed
by CDC. One goal of such
studies is to help identify
environmental factors that
contribute to breast cancer
risk.
------------------------------------------------------------------------
While mercury, arsenic, and pesticides were most often reported as
being studied in human samples, some State officials reported using
human exposure data for chemicals that CDC has since 1991 developed
methods to measure. For example, about 15 percent of officials
conducted studies of human exposure to volatile organic compounds, and
almost 30 percent reported studies of exposure to PCBs using data from
tissue analysis.
Regardless of whether State officials had collected or used human
exposure data in the past 4 years, about 90 percent of those officials
responding to our survey said human exposure data from tissue samples
was extremely or very important for addressing environmental health
concerns. Despite the perceived value of such data, almost two-thirds
of officials said they could include human exposure data in fewer than
half of the exposure-related studies, investigations, and surveillance
efforts where they considered it important. More than one-third said
they seldom could include such data.
Several State health and laboratory officials whom we interviewed
expressed frustration at the missed opportunities for collecting
biological samples as part of their studies and investigations for
reasons such as limited laboratory capacity. For example, health
officials in one State could not examine the role played by methyl t-
butyl ether (MTBE)--an additive designed to promote more efficient
burning of gasoline--in a major respiratory disease outbreak because
State staff lacked the expertise and CDC staff lacked the time to
conduct the needed tests. In 1995, after MTBE was added to gasoline and
thousands of citizens reported becoming ill, State officials wanted to
measure MTBE or its by-products in blood from samples of individuals
with and without symptoms to determine whether MTBE exposure might be
the cause or a contributing factor. Objective measures of individual
exposure might have allowed public health officials to conclusively
demonstrate or rule out a link between the outbreak and exposure,
something that was not possible with environmental data and
epidemiologic surveys. The chemicals officials most often cited as
wanting to study using human exposure data, but could not, were
pesticides and volatile organic compounds.
SIGNIFICANT INFORMATION AND INFRASTRUCTURE GAPS POINT TO NEED FOR
STRATEGIC PLANNING AND COORDINATION
As part of our survey and interviews, we asked public health
experts and State and Federal officials to identify barriers they
considered significant to structure their efforts to collect and use
human exposure data. Officials cited two primary barriers: the lack of
laboratory capacity or methods to analyze tissue samples and the lack
of information to help set exposure test results in context. Addressing
these barriers takes time and resources. In that regard, we identified
a third barrier to more effective use of existing resources: HHS and
EPA lack a long-term strategic plan to address infrastructure and
science barriers, coordinate efforts to meet Federal and State needs,
and address the many questions about how to set priorities given their
limited resources.
Laboratory Capacity and Methods to Measure More Chemicals Needed
State officials frequently said insufficient laboratory capacity in
their States and at the Federal level hindered their ability to obtain
human exposure data in cases where they thought such data were
important. Over half of the officials said their States lacked
sufficient numbers of trained laboratory staff, sufficient laboratory
capacity to analyze samples, or sufficient laboratory equipment. Many
officials attribute such capacity limitations to funding constraints
because tissue analyses can be time-consuming and expensive to perform.
For example, according to a CDC official, each test to measure dioxins
in a sample requires (1) a laboratory free from chemicals that could
compromise test results, (2) specialized equipment that costs about
$500,000, and (3) highly trained and experienced staff to complete.
Officials of a professional organization representing public health
laboratories told us that, although many State laboratories perceive
they have a role in conducting tests to detect toxic substances in
humans, very few currently have such capacity.\29\
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\29\ This organization actively supports expanding State and local
laboratory capacity to participate in a human biomonitoring program to
provide human exposure data that would enhance the effectiveness of
environmental policy and regulatory decisions. In addition this group
helped States apply for the four grants CDC offered to increase State
and local laboratory capacity to detect in human fluids and issues
chemicals that could be used in a terrorist attack. Illustrating their
interest in developing such laboratory capacity, 31 State and 2 local
health departments applied for the four grants.
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State and Federal officials we interviewed told us that because few
State laboratories have the necessary equipment and expertise, they
often rely on CDC's environmental health laboratory staff to analyze
tissue samples. Given the specialized laboratory requirements, CDC's
environmental health laboratory is generally considered the best-suited
to analyze tissue samples for a range of chemicals and has, in fact,
developed many of the methods to do so, according to Federal and State
officials. CDC's laboratory performs measurements for most Federal and
many State efforts to gather human exposure data. Many officials said
CDC's laboratory capacity is essential to their efforts and needs to
expand to meet growing needs. A few State officials said CDC's
laboratory consistently returned test results when people's lives were
at risk but was less able to help States assess health risks more
generally. An official in one State said that, while CDC's assistance
is invaluable, the State's laboratory capacity allowed public health
officials to obtain human exposure data and investigate citizen's
concerns more frequently than they could if they had to rely soley on
CDC's laboratory capacity.
Another significant issue is the lack of analytical laboratory
methods to measure chemicals of concern. Despite advances over the past
2 decades in analytic chemistry and molecular biology, laboratory
methods have not been developed to measure about 88 percent of the
1,456 chemicals in our review, according to information provided by CDC
and EPA officials. Although laboratory staff at CDC have quickly
applied scientific and technological advances to develop new and more
efficient laboratory methods, they are concerned about the lack of
methods to test a single human sample for several related toxics. For
example, a method exists to measure arsenic in blood but not to measure
arsenic and other heavy metals at the same time. Such methods make more
efficient use of the samples that are gathered and greatly reduce the
time and money needed to test large numbers of samples. While CDC's
laboratory continuously develops new chemical testing methods, current
resources limit the number to about 10 annually.
Even when analytical methods exist, efforts to gather human
exposure data are sometimes limited by problems with the methods used
to gather the samples. This is especially true for young children, a
group thought to be particularly susceptible to harmful effects from
exposure. In some cases, existing laboratory methods require sample
volumes that can only be obtained through invasive techniques. That is,
blood samples must be obtained by puncturing a vein rather than by
pricking a finger. Many people will not allow their children to
participate in studies that require such techniques. Similarly, urine
samples can be difficult to obtain from children who wear diapers. For
example, substances in the diapers can compromise test results.
Information Needed to Interpret Human Exposure Measurements
To help interpret the results of laboratory analysis and determine
what actions, if any, are needed to protect the public's health, State
and Federal officials cited the need for two types of context-setting
data: comparative (or reference range) information that shows exposure
levels among the general population and research that links exposure to
adverse health effects. At the State level, where many of the specific
actions regarding at-risk situations are taken, almost three-fourths of
responding officials cited the lack of such information as a problem.
State officials said that reference range data, when available,
allowed them to determine whether exposures are sufficiently high to
merit action to reduce or prevent further exposure. For example, in one
State, public health officials, with help from CDC, responded to
citizens' reports of foul odors from leaking tanks at a waste cleanup
site by gathering and analyzing blood samples from those living nearby.
CDC's analysis of the blood samples showed that residents near the site
had exposure levels at the high end of a CDC-developed reference range.
State and Federal officials ordered the contractor to move the cleanup
operations to another location. Over 60 percent of State officials
responding to our survey said the lack of reference range data
prevented them from using human exposure data in their work. State
officials said the problem for research about adverse health effects
was similar. Much of the data linking exposure to health effects
concerns high-level occupational exposures or higher doses administered
to laboratory animals. Consequently, translating the results of such
research to lower-level exposures of people and determining how best to
advise people about potential effects is problematic.
Federal health officials and researchers also cited a need for both
types of information in their investigations, particularly for
federally supported work in specific geographic areas. ATSDR officials
said the lack of reference ranges was a particular reason they could
not generate human exposure data more often in public health
assessments and exposure investigations. When data allow officials to
put exposure into context, concerns can be investigated and addressed.
For example, in one community, where citizens were concerned about
exposure to dioxins from nearby chemical manufacturing plants, ATSDR
officials had CDC's laboratory analyze blood samples and found that
some residents had levels of several dioxins above the highest levels
in a CDC-ATSDR-developed reference range. In response, ATSDR helped
residents obtain assistance from medical professionals expert in
dioxins and, working with State and Federal environmental agencies,
began environmental testing to locate the exposure source.
Stronger Interagency Efforts Needed for Strategic Planning and
Coordination
The barriers outlined above present daunting challenges to State
and Federal agencies. The number of chemicals that remain to be
investigated and the kinds of information needed are substantial, the
research is often expensive, and progress is often slow. At the same
time, the level of resources available for dealing with the issue is
limited, and responsibilities are fragmented among many State and
Federal agencies. Many studies have pointed to the need for better
coordination. While HHS and EPA efforts have been coordinated through,
for example, participation on advisory committees and the use of CDC's
laboratory for performing the actual measurements, such coordination
falls short of what is needed for long term planning. This need is
illustrated by the growing convergence of interest in the planned
expansions of NHANES and NHEXAS. To ensure as much progress as possible
with available resources, HHS and EPA need a strategic planning effort
that reflects a clear set of priorities, a framework for coordinating
data collection and reporting efforts, and a tie to performance goals.
Agreement About Need for Better Planning and Coordination of Efforts Is
Widespread
In 1991, NRC reported that ``although a successful monitoring
program must be highly relevant to regulatory needs, it could and
should serve a wide range of client programs and must not be dominated
by any one of them.'' NRC reported that the approaches of EPA, CDC, and
ATSDR are each important in the identification and control of
environmental hazards to human health and that coordination among the
programs would enhance Federal monitoring efforts and benefit
researchers, health professionals, and the public.\30\
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\30\ While NRC found EPA in the best position to house a human
exposure monitoring program, it also found that the ambivalence within
EPA about the National Human Monitoring program's future indicated that
the match of program goals, potential benefits, and EPA mandates was
not perfect.
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Officials and experts agree that interagency interaction is needed
to take advantage of all approaches and information available to
develop the most cost-effective, least burdensome approach for
collecting needed exposure data. Toward this end, HHS agencies and EPA
have at various times attempted to collaborate in their respective
exposure monitoring efforts. For example, EPA solicited broad
interagency input into the design of NHEXAS and established interagency
agreements with CDC and others to assist in performing laboratory
measurements, quality control, and other support functions. Also
through interagency agreements, CDC has broadened the exposure
monitoring component of NHANES to incorporate the needs of EPA
researchers.
Outside reviews and involved researchers and officials indicate
that even with recent efforts, coordination has fallen short in
ensuring adequate interaction and linkages between agencies. For
example, EPA's scientific advisers reviewed the NHEXAS pilot surveys
and concluded that, while NHEXAS was an excellent project and highly
relevant for providing needed information, a strategic plan was needed
for follow-up studies. They also urged that EPA link NHEXAS exposure
data with biological data from NHANES, where possible, and develop a
more collaborative process for gathering input for chemical selection.
Attendees at a September 1999 NIEHS conference on the Role of Human
Exposure Assessment in the Prevention of Environmental Disease also
called for a coordinated interagency effort in assessing human
exposure.\31\ One theme and recommendation from the discussions was the
need to bridge scientific disciplines and agency missions to address
knowledge gaps in assessing human exposure.
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\31\ The NIEHS-supported conference addressed many opportunities
and challenges in exposure assessment research including exposure-
analysis methodology, exposure-disease relationships, regulatory and
legislative issues, gene-environment interactions, disease prevention
and intervention and some current Federal initiatives related to
exposure assessment. One area of discussion was the need for and
limitations of biological measures of exposure.
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State officials and others have also indicated that better linkages
and partnering are needed between Federal, State, and local agencies.
For example, an official of the Association of Public Health
Laboratories told us that one way to improve States' involvement in a
national exposure monitoring program would be to further their
capability to assess levels of toxic chemicals in their own populations
relative to national levels. This would require, in this official's
view, the transfer of new monitoring technology to State public health
laboratories, along with the resources necessary to support that
technology. Improved capacity at the State level would allow Federal
laboratories to concentrate on developing more and faster analytical
methods for measuring chemicals in tissues and on responding to crisis
situations. Other experts have also called for better linkages between
Federal efforts and communities and community concerns. For example,
the NHEXAS reviewers recommended that EPA improve communication between
NHEXAS investigators and State and local health officials. Another
theme of the conference on human exposure assessment was that efforts
to assess human exposure be in line with public health goals and
community concerns.
Individual Priorities Contribute to Difficulties in Coordinating
Efforts
The challenges Federal and State agencies face in setting
priorities for which chemicals to assess in their individual programs
likely contribute to the difficulties they have in collaborating with
one another. The expense of conducting exposure measurements in ongoing
surveys--especially for the number of samples required to establish
national or regional trends and levels--necessitates that priorities be
set. However, agreeing on priorities--or even agreeing on the process
for setting priorities--is challenging and resource-intensive. For
example, to identify chemicals to measure in NHEXAS, EPA undertook an
extensive selection process, soliciting input from regional and program
offices.\32\ EPA's scientific advisers, while supportive of the
program, cited the criteria for selecting target chemicals as a
weakness. NHANES is even less formal in this regard, with no documented
priority-setting process for chemicals to be measured. Chemicals
measured are largely determined by CDC's laboratory scientists based on
such factors as the availability of analytical methods for measuring
the chemical and the laboratory's capacity to perform the
measurements.\33\ According to a CDC official, CDC's limited staff and
laboratory resources cannot develop the administrative infrastructure
to establish a scientific review process for selecting priority
chemicals.
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\32\ Because of its emphasis on evaluating total human exposure,
NHEXAS emphasized those chemicals that can be measured In multiple
environmental media (for example in air, water, and food) as well as
human tissues.
\33\ CDC's laboratory officials indicated that their choice of
chemicals is determined by the availability of high-quality analytical
methods with adequate throughput, whether the chemical is a known or
suspected cause of health problems, whether the chemical is on EPA and
ATSDR priority lists, the number of persons likely exposed, and the
availability of funding from collaborators.
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Another challenge in setting priorities, according to some
officials, is the appropriate balance between gathering exposure
information on chemicals about which little is known and gathering
information on those already considered to be toxic. NHANES and NHEXAS,
for example, focus largely on chemicals that are considered to be toxic
at some level. By contrast, the National Toxicology Program's Human
Exposure Initiative is intended to help set priorities for chemical
toxicological testing and might gather baseline information on
chemicals and chemical mixtures occurring in the population that are
not necessarily already known as harmful.
Officials we interviewed raised many other concerns that would need
to be addressed when trying to coordinate efforts among multiple
Federal and State agencies and programs:
For what specific purpose(s) will these data be collected?
What chemicals should be measured, in what order, how
frequently, and in what specific tissues?\34\
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\34\ Several officials pointed to the importance of developing a
breast milk monitoring program. Many environmental agents are fat
soluble and are released into breast milk at significant
concentrations. Examples include dioxins and PCBs. According to NIEHS
researchers, 6 months of nursing could result in dioxin or PCB
concentrations in infants which are 10 times higher than in the mother.
Breast milk monitoring programs operate in several European countries
including Sweden, Germany, and the Netherlands.
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What chemicals should be measured concurrently with or
only through personal environmental measurements?
What is the best way to identify populations that might be
at higher risk of exposure?
What chemicals should be monitored in humans nationally,
versus regionally or locally?\35\
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\35\ EPA's scientific advisers' review of the NHEXAS pilot surveys
illustrates some of the trade-offs in determining the appropriate
balance between large population surveys and more targeted follow-up
surveys. The advisers reported that population studies are the only
means for collecting baseline information for such uses as trend
analysis. NHANES is an example of such a probability study. On the
other hand, more targeted special studies tend to assess high-end
exposure groups more precisely. Additionally, the review illustrated
how total exposure data may be unnecessary to collect for chemicals at
a national level, depending on the chemical. The advisers pointed out
that targeted special studies can be used to identify sources and
factors associated with high-end exposures. While identification of
major sources, media and pathways for populations experiencing high
exposures are essential to reduce unacceptably high risks, if the
majority of the national population is exposed to pollutants at levels
under health-related benchmarks, source identification for such
exposures is not a priority from a health standpoint.
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How can exposure data be coupled with our increasing
knowledge about the effect genetic factors have on risk from exposure
to improve the understanding about an individual's risk from chemical
contaminants?
What role should State agencies have in conducting human
exposure measurements and in planning Federal efforts?
The fragmentation of responsibilities and efforts for assessing
human exposure reflect larger issues in the fragmentation of
responsibility for environmental health. For over a decade, a number of
studies have pointed to the need for improved coordination between
regulatory and health agencies (see table 4).
Table 4.--Examples of Reports Calling for Coordination in Environmental
Health
------------------------------------------------------------------------
Report Description
------------------------------------------------------------------------
Environmental Health Data Needs: An Called for the Federal
Action Plan for Federal Public Health Government to facilitate
Agencies (Public Health Foundation, stronger ties between
1997). environmental protection and
public health agencies,
perhaps by strengthening
organizational links and
coordinating funding for
Federal (EPA and HHS)
programs. Also indicated that
priority environmental health
information needs included
more complete exposure data,
including laboratory data such
as biological measurements.
Burke, Shalauta, and Tran, The Found that progress in
Environmental Web: Impact of Federal understanding the relationship
Statutes on State Environmental Health between human health and the
and Protection (Public Health Service, environment will require,
Jan. 1995). among other actions, improved
cooperation between the many
health and environmental
agendas at the Federal, State,
and local levels.
Researching Health Risks (Office of Reported that although agendas
Technology Assessment, 1993). are expanding their research
efforts, few incentives exist
for them to collaborate, and
the lack of collaboration can
only hinder progress in
applying newly developed
techniques and knowledge to
understanding the potential
links between exposure and
adverse health effects.
The Potential for Linking Environmental Reported that linkage of
and Health Data (National Governors' environmental and health data
Association, 1990). to investigate possible
connections between exposure
and adverse health effects
cannot occur without
interagency communication and
cooperation, which rarely
evolves naturally.
The Future of Public Health (Institute Found that separating
of Medicine, 1988). environmental health from
public health programs impeded
desirable coordination and
could limit the depth of
analyses given to the health
implications of environmental
hazards.
------------------------------------------------------------------------
Potential for Convergence of Effort Is Increasing
The importance of planning and coordination is magnified by the
possible overlap in current plans to expand human exposure monitoring
efforts. This potential can be seen in HHS' and EPA's plans for NHANES
and proposed expansions of the NHEXAS pilots. Although nearly two-
thirds of the chemicals measured in the NHEXAS pilot surveys are
currently measured or planned for NHANES, the two efforts have taken
differing approaches in the past to monitoring the population's
exposure to these chemicals.\36\ The NHEXAS pilots have focused on
``total'' exposure, which entailed measurements in human tissues,
water, air, food, dust, and other potential sources in participants'
living environments, and data-gathering has focused on three selected
regions of the country. Total exposure measurements can help identify
those sources that most contribute to exposure--a critical part of
determining how to take action to reduce or prevent exposures. However,
measuring total exposure requires several types of laboratory
measurements and is thus more expensive. By contrast, NHANES has
focused its exposure monitoring on human biological measurements and on
a sample that is generally representative of the Nation as a whole.
Biological monitoring data demonstrate exposure from all sources, but
determining exposure sources usually requires additional environmental
measurements. Other than the few chemicals it covered, NHANES has
historically been considered an awkward vehicle for including exposure
monitoring--in large part because of its wide range of competing goals
and lack of a primary commitment to monitoring tissues for exposures.
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\36\ The follow-up to the NHEXAS pilots has not been planned, so
the identity of the chemicals to be measured is not known.
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Changes to the 1999 NHANES, such as the following, show a greater
emphasis in environmental health. These changes along with EPAs plans
to expand NHEXAS suggest a convergence of the two approaches and a
growing and overlapping interest among agencies in exposure measurement
and monitoring.
NHANES now has a goal of monitoring exposures. Starting
with NHANES 1999, CDC formalized its commitment to monitoring trends in
the nation's environmental exposures by establishing this as a Stated
goal of NHANES.\37\ In line with this goal, CDC's laboratory plans to
issue this year a ``National Exposure Report Card'' using NHANES
samples.\38\ This goal is similar to EPA's goal as proposed for NHEXAS'
follow-up survey--to document the status and trends of the national
distributions of human exposure to potentially high-risk chemicals.
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\37\ At this writing, NHANES' goals are to (1) estimate the number
and percentage of persons in the United States and designated subgroups
with selected diseases and risk factors: (2) monitor trends in the
prevalence, awareness, treatment, and control of selected diseases; (3)
monitor trends in risk behaviors and environmental exposures; (4)
analyze risk factors for selected diseases; (5) study the relationship
between diet, nutrition, and health; (6) explore emerging public health
issues and new technologies; and (7) establish a national probability
sample of genetic material for future genetic research. CDC official
told us that the emerging focus in NHANES on environmental health
issues reflects advances in technology as well as the public's
increasing priority for understanding the impacts of environment on
health. Part of CDC's responsibility is to report on environmental
hazards and determinants of health. Section 306 of the Public Health
Service Act (42 U.S. C. 242k) directs the National Center for Health
Statistics, the CDC agency that conducts NHANES, to collect statistics
on subjects such as the extent and nature of illness and disability of
the population; environmental, social, and other health hazards;
determinants of health; health resources; and utilization of health
care.
\38\ According to CDC laboratory officials, the first report card
will provide data on exposure levels of the population to 25 chemicals
that have not yet been determined. These might include selected heavy
metals, indoor air pollutants, nonpersistant pesticides, and
phthalates.
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NHANES will include selected environmental measurements.
Starting with NHANES 1999, environmental measurements, such as
contaminant levels in water and house dust, and levels measured through
personal air monitors worn by participants will be included in the
survey to help identify potential sources of exposure.\39\
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\39\ Because of the wide range of other health and nutrition
questions addressed in NHANES, environmental measurements currently
included are less extensive than those included in NHEXAS because, for
example, food and beverage samples are not conducted.
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NHANES will be conducted continuously rather than
periodically, allowing for more flexibility in the measurements it
includes. According to CDC officials, the new annual sampling design
will enable them to include emerging and changing priorities in the
data collected through the survey and thus allow for a broader
collection of data than in previous surveys, including exposure and
measurements in people's personal environments.
Other planned changes to NHANES and NHEXAS also indicate a growing
overlap in approaches and interests. For example, pending analysis and
evaluation of its pilot surveys, EPA is proposing to expand NHEXAS
beyond the regional focus of its pilot to include a nationally
representative sample similar to the framework of NHANES. Also, both
CDC and EPA would like to eventually include a component in NHANES and
NHEXAS to monitor special populations. EPA's proposed expansion of
NHEXAS would eventually include ``special studies'' to examine high-end
exposures in more detail and with greater precision Small populations
for further study would be identified through the national survey. CDC
also plans to add a component to NHANES that will gather selected
NHANES health and nutrition data, possibly including exposure
measurements, on specific subpopulations in geographic areas of
interest or among specific racial or ethnic minority populations. This
effort to add a subpopulation component to NHANES was initiated in
response to the needs of State health officials and others for local
level data.
Funding Is Sporadic, and Funding Priorities Change
Part of the difficulty in collaborating and in planning human
exposure monitoring efforts to meet longer-term needs may also arise
from issues of sporadic funding and resources to support these efforts.
As compared to the hundreds of millions spent on monitoring
contaminants in environmental media, we estimate that less than $7
million was spent collectively by CDC (including ATSDR) and EPA on
their respective human exposure efforts in 1999.\40\
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\40\ NIEHS-CDC interagency agreements document that NIEHS had
provided about $3.3 million to CDC between fiscal years 1996 and 2000
for performing environmental exposure measurements for its Human
Exposure Initiative. No funding was provided in fiscal year 1999.
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Neither CDC nor EPA has provided a dedicated funding stream for
their exposure measurement efforts. Funding for efforts has, to a large
extent, depended on priorities established year to year. For example,
funding for the exposure and other environmental components of NHANES
depends to some extent on the interests of other Federal agencies and
their willingness to pay for related data gathering and analysis.\41\
CDC estimated it would spend about $4.7 million for laboratory
measurements and laboratory staff costs in 1999 for NHANES-related
exposure measurements such as lead, mercury, cotinine, heavy metals,
pesticides, volatile organic compounds, and other chemical classes.
Interagency agreements document the receipt of about $1.2 million from
collaborators for some of those laboratory measurements. If other
agencies do not pay CDC to conduct laboratory tests--with the exception
of some ``core'' measurements, such as lead--CDC performs tests as time
and laboratory resources allow. For example, although CDC initially
proposed for the survey starting in 1999 to measure up to 210 chemicals
in tissues of a subset of NHANES survey participants, CDC officials
indicated that those chemicals could be measured only as resources
allowed.\42\ At the time of our review, a CDC laboratory official
indicated that resources might allow them to include about 74 chemicals
in 1999 and 2000.
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\41\ NHANES 1999, for example, received $15.9 million in
appropriated funding and, according to CDC officials, an additional
$6.8 million from collaborating institutions. Interagency agreements
related to environmental measurements performed in conjunction with
NHANES document the receipt of about $1.4 million from collaborators at
EPA and other agencies for environmental exposure measurements. In
addition to EPA's support for measurement of certain chemicals in human
tissues, an estimated $125,000 was received from the Department of
Housing and Urban Development for performing dust sampling and an
estimated $30,000 from the Mickey Leland National Urban Air Toxics for
personal measurements of volatile organic compounds. CDC laboratory
officials indicated that the increase to their fiscal year 2000 funding
for the environmental health laboratory has improved their ability to
support needed laboratory measurements for NHANES and other efforts.
This funding increased by about $5 million between fiscal years 1999
and 2000.
\42\ According to CDC officials, uncertain funding may limit their
ability to perform NHANES measurements for dioxins, furans,
coplanercoplanar PCBs, phytoestrogens, certain heavy metals,
phthalates, and polyaromatic hydrocarbons.
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EPA's commitment to funding NHEXAS also remains uncertain. EPA
officials estimated that approximately $20 million was spent on NHEXAS
from 1993 through 1999--with a decreasing amount designated to the
project in 1999 and 2000. While EPA's independent scientific advisers
commended the design for NHEXAS and said it could be the basis for an
effective national program, they expressed concerns about the limited
resources allocated to analyze the data gathered in the pilot
projects.\43\ At national level, EPA has dedicated approximately three
full-time positions to evaluate the data from the NHEXAS pilots and
design future expansions.
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\43\ EPA officials indicated that at the individual study level,
approximately $250,000 was allocated for analyses of the NHEXAS pilot
data in fiscal year 1999; EPA plans to spend approximately $170,000 in
fiscal year 2000.
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Better Linkages to Program Goals and Performance Monitoring Needed
The Government Performance and Results Act of 1993 (Results Act)
provides Federal agencies a structured frameswork to coordinate efforts
in crosscutting programs when agency missions overlap. The Results Act
requires Federal agencies, as part of their mandated responsibilities,
to prepare annual performance plans that discuss agency goals and
performance measures. Past reviews have shown that EPA, HHS, and other
Federal agencies have not fully used the Results Act planning process
to explain how each would coordinate crosscutting efforts with other
agencies. Few agency plans attempt the challenging task of discussing
planned strategies for coordination and establishing complementary
performance goals and common or complementary performance measures.
A major weakness of EPA's fiscal year 2000 Annual Performance Plan
was the lack of sufficient detail describing crosscutting goals and
activities or how EPA planned to coordinate with other Federal agencies
on related strategic or performance goals.\44\ For example, under its
plan's ``safe food'' objective, EPA discusses coordinating with HHS and
other agencies to reduce health risks from pesticides. However, it did
not outline specific projects and strategies, responsibilities, and
products that must be coordinated for EPA to accomplish its goals.
Similarly, HHS' performance plan lacked details regarding how
crosscutting activities and goals would be coordinated with other
agencies.
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\44\ See Observations on the Environmental Protection Agency's
Fiscal Year 2000 Performance Plan (GAO/RCED-99-237R) July 20, 1999.
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In their fiscal year 2001 performance plans, EPA and CDC make
limited use of human exposure data to measure or validate performance,
and neither agency describes how data collection efforts relate to
complementary goals of other Federal agencies. For example, EPA and CDC
have the common goal of reducing childhood lead poisoning, but only CDC
uses data on blood lead levels to validate progress toward this goal.
Although EPA has goals that are clearly related to reducing human
exposure to other toxic chemicals, the human exposure data collected by
EPA and CDC have largely not been linked with or used to measure
progress. Such data show potential for helping elucidate Federal
progress in environmental efforts, but EPA has not yet acted to fully
realize such potential. For example, NHEXAS data are used to help
assess children's exposure to pesticides. However, a related goal to
reduce public exposure to pesticides does not use human exposure data;
instead, it relies on the number of activities to educate agricultural
workers and the public. The effectiveness of these efforts could be
assessed, in part, through measured reductions in actual human exposure
to specific pesticides. During 1999, CDC maintained a goal to develop
methods to measure toxic substances in humans and added a goal to
measure and report on human exposure to toxic substances. However,
neither goal discusses how CDC will coordinate with EPA and other
Federal programs in meeting these goals and ensuring that newly
developed methods and measured substances meet priority data needs.
Successful Models for Planning and Coordination Point to the Need for
High-Level Mandate, Process for Inclusion, and Mechanism for
Reporting
Program officials at HHS and EPA told us in early 2000 that they
were discussing the merits of establishing a new interagency program in
human exposure monitoring.\45\ At the time of our review, the proposal
was in early stages of discussion and officials had not clarified how a
new program would consider States' information needs, differ from or
relate to NHANES and the NHEXAS pilot surveys, or resolve past issues
about differing agency goals and priorities.
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\45\ This effort was coordinated through the White House Office of
Science and Technology Policy.
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Several experts and agency officials have pointed to successful
models of interagency collaboration in environmental health issues that
could help shape an HHS-EPA interagency effort. One such model is the
collaboration on children's environmental health issues. In this case,
Executive Order 13045, signed by the President on April 21, 1997,
established a Task Force on Environmental Health Risks and Safety Risks
to Children to develop and recommend Federal strategies for children's
environmental health and safety. Among the elements that have been
cited as contributing to success were a clear mandate to collaborate
and a process to respond to the input and data needs of different
stakeholders. According to involved officials, a high-level interagency
work group has worked closely to address its charges. These charges
include developing general policy and annual priorities; a coordinated
Federal research agenda; recommendations for partnerships among
Federal, State, local, and tribal governments and the private,
academic, and nonprofit sectors; and identifying high-priority
initiatives to advance protection of children's environmental
health.\46\
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\46\ Executive Order 13045 also indicates such strategies are to
include proposals to enhance public outreach and communication and a
statement regarding the desirability of new legislation to fulfill or
promote the purposes of the order.
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A second model with a top-down mandate and a process to respond to
stakeholders is NTP, established in 1978 as an HHS-wide effort to
provide regulatory and research agencies needed information about
potentially toxic and hazardous chemicals nationwide and to strengthen
the science base in toxicology. According to officials, part of NTP's
success in fostering collaboration are an inclusive executive committee
and an established process for decisionmaking. The NTP Executive
Committee, which provides policy oversight of NTP, includes agencies
outside of HHS, such as EPA and the Consumer Product Safety Commission.
The NTP Executive Committee also serves as a decisionmaking body, in
that members cast votes on key issues, such as prioritization of
chemicals for study and for listing in NTP's Report on Carcinogens.\47\
Involved officials believe the voting requirement helps move key issues
forward and provides an effective means of resolving disagreements. NTP
also has an inclusive process for identifying chemicals to be
considered by the Executive Committee. NTP's chemical testing
nominations are solicited from sources in academia, Federal and State
regulatory and health agencies, industry, and unions, as well as
environmental groups and the general public.
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\47\ The Director of NTP issues the Report on Carcinogens pursuant
to a 1978 amendment, section 301 (B) (4) of the Public Health Services
Act. which requires the Secretary of HHS to publish a list of all
substances that are either known to be human carcinogens or may
reasonably be anticipated to be human carcinogens and to which a
significant number of persons residing in the United States are
exposed. NTP issues a revised Report on Carcinogens every 2 years.
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Several officials indicated that reports on exposures in the
national population to toxic chemicals are needed to help inform
policymakers, researchers, and the public. Specifically, such reports
can help identify serious human health risks, help officials link
exposures to sources, determine appropriate interventions to help
reduce these risks, and document the effectiveness of interventions in
reducing exposures. Moreover, agencies could use such reports to
validate or measure progress in meeting goals established under the
Results Act. A key element of NTP is its biennial reports. As
informational scientific and public health documents, these reports are
not only used by Federal and State agencies but are considered an
important medium for informing the public and policymakers on the
status of substances considered likely to be carcinogenic for humans.
CONCLUSIONS
The Nation has a long way to go in measuring human exposures to
potentially harmful chemicals. While Federal efforts are increasingly
covering chemicals of
potential concern, there are substantial gaps in current information on
exposure
levels, the health risks that result, and those who may be most at
risk. Recent advances in laboratory technology show promise for
improving the collection and analysis of some of the information needed
to understand and measure human exposures. However, a more long-term
and concerted effort to address infrastructure and scientific
limitations in measuring exposure will be required if substantive
progress is to be made. Applying and continually improving upon these
advances to cover an increasing number of chemicals and issues will
require both time and resources. CDC's laboratory to date has been able
to meet many demands for human exposure data for Federal and State
measurement and monitoring efforts. However, its capacity, given
current resources, will continue to limit progress to develop new
methods and include more people and chemicals in Federal and State
efforts.
Federal agencies are currently planning whether and how they can
expand existing programs to meet the significant needs for human
exposure data. Collaboration in such planning is essential, because
agencies have different capacities and skills, and separate attempts
have fallen short of supporting the large efforts that are needed. So
far, no clear strategy has emerged for how to carry out this major
task, particularly given the growing and overlapping interests among
many agencies for understanding and measuring human exposures to
potentially harmful chemicals. In our view, developing such a strategy
is a challenging but necessary first step.
In the meantime, State and local health officials must try to
understand and communicate the risks from environmental contaminants to
concerned citizens--a difficult, if not impossible, task when
information is unavailable to help them interpret the risks from the
exposures citizens face in their daily environments. State officials
indicate they need more of the information that is collected through
Federal efforts to help interpret those levels faced by citizens in
their States. And to collect measurements for their studies and
investigations, State officials are faced with finding laboratories
that have the equipment and capacity to perform the complex
measurements. Federal capacity, largely centered at CDC, cannot meet
States' needs in many situations, and laboratory capacity is lacking in
most States.
To help meet the gaps in environmental exposure data at all levels
of government, EPA and the various HHS agencies with environmental
health responsibilities need to work closely together to forge a
strategic plan laying out the necessary next steps for addressing human
exposure information and concerns. In addition to considering States'
needs and capacities for collecting human exposure data, such a plan
could:
provide long-term structure to human exposure monitoring
as an interagency effort,
establish a mechanism for setting program priorities in
line with agency goals and performance measures,
clarify agency roles and minimize duplication, and
help agencies share expertise.
Policymakers, agencies, and the public seek many types of
information on exposure trends and levels in the national population as
well as for groups considered potentially at risk of disproportionate
exposures. Resolution is also needed on what information should be
reported on national trends and levels of exposure. A strategic plan
could help agencies resolve the many different informational needs to
determine what exposure information should be reported and how agencies
can work together to report such information.
RECOMMENDATIONS TO THE SECRETARY OF HHS AND THE ADMINISTRATOR OF EPA
We recommend that the Secretary of HHS and the Administrator of EPA
develop a coordinated Federal strategy for the short- and long-term
monitoring of human exposures to potentially toxic chemicals. In and
the Administrator developing such a strategy, the Secretary and the
Administrator should of EPA assess the need for an interagency program
to collect and report data on human exposures, the extent current
surveys and agency efforts can be used as part of such an effort, and
the funding needs and sources to sustain a viable program for
monitoring human exposures to toxic substances.
Such a strategy should:
address individual agency needs and expertise,
provide a framework for coordinating efforts to gather
data needed to improve understanding of human exposures,
assess needed Federal and State laboratory capacity,
establish research priorities for laboratory methods
development and a mechanism or process for setting chemical monitoring
priorities,
develop a framework for identifying at-risk populations,
and
consider States' informational needs.
We further recommend that the agencies identify common or
complementary performance goals or measures to reduce, monitor, or
develop methods for measuring human exposures to toxic chemicals. Such
goals or measures can be a basis for structuring and supporting
interagency collaborations to collect and use human exposure data.
As part of this coordinated strategy, we recommend that the
Secretary of HHS and Administrator of EPA periodically publish a report
on levels and trends in the national population of exposures to
selected toxic substances.
AGENCY COMMENTS
We provided HHS and EPA an opportunity to comment on a draft of
this report. Both agencies generally concurred with our conclusions and
recommendations--that a long-term coordinated Federal strategy was
needed for monitoring human exposures to potentially toxic chemicals
and that such efforts could be linked through common or complementary
performance goals--and indicated that they would work together to
implement our recommendations. (See apps. IV and V respectively.) HHS
and EPA also both stressed the importance, as discussed in our report,
of expanding the scope of their efforts to monitor and measure human
exposures to toxic chemicals beyond the limited number of chemicals
covered today. To support such expansions, HHS noted the importance of
additional resources for improving laboratory capacity and methods.
HHS and EPA provided several other comments raising points that one
or both agencies consider important to monitoring human exposures to
toxic chemicals. These included the need to: (1) coordinate any
exposure monitoring in the general population with monitoring of
occupational exposures; (2) consider adding the monitoring of breast
milk in a national program; (3) depending on the chemical and the
purpose for the data collection, consider measures of human exposure
other than the concentration in human tissues for collection; and (4)
consider the option of expanding the scope of NHANES as a means of
improving data needed to identify potentially at-risk subgroups. We
agree that the points raised in these comments are important and that
they should be considered during development of any coordinated Federal
strategy.
EPA also said that additional Federal partners, including the
Departments of Defense, Transportation, and Energy should participate
in developing and supporting a coordinated Federal strategy. We agree
that it would be appropriate to obtain input from all involved and
interested agencies. HHS and EPA also provided a number of clarifying
and technical comments, which we incorporated where appropriate.
We are sending copies of this report to the Honorable Donna E.
Shalala, Secretary of HHS, and the Honorable Carol M. Browner,
Administrator, EPA. We are also sending copies to Jeffrey P. Koplan,
Director, CDC, and Administrator, ATSDR; Ruth Kirschstein, Acting
Director; NIH; Kenneth Olden, Director, NIEHS; Richard J. Jackson,
Director, National Center for Environmental Health; Edward J. Sondik,
National Center for Health Statistics; Norine Noonan, Assistant
Administrator for Research and Development, EPA; and other interested
parties. We will make copies available to others upon request.
If you or your staff have any questions, please contact me at (202)
512-7119. Other major contributors are included in appendix VI.
Janet Heinrich,
Associate Director, Health Financing and Public Health Issues.
__________
Appendix I
Objectives, Scope, and Methodology
Nine Members of the Congress asked us to study the nation's data
collected to assess human exposure to potentially toxic chemicals in
the environment. As agreed with our requesters, we focused our work
primarily on efforts to measure chemical exposures in human tissue
samples, such as blood, hair, and urine. This report discusses (1) the
extent to which State and Federal agencies--specifically, HHS and EPA--
collect human exposure data on potentially harmful chemicals, including
data to identify at-risk populations, and (2) the main barriers
hindering further progress in such efforts.
SCOPE OF OUR REVIEW
Although laboratory measurements of chemical exposure are only one
part of the data collected to address environmental health concerns,
they merit attention because new technology makes it increasingly easy
to measure the degree to which a chemical has been absorbed into human
tissues. Such measurements are often a more accurate and useful
approach to assessing exposure than environmental measurements,
according to public health experts.
Because Federal agencies that collect human exposure data collect
these data for different purposes, we were not able to assess the
overall adequacy of the nation's efforts to address environmental
health concerns. Therefore, we focused our work at the Federal level on
the efforts of two agencies--HHS and EPA--and the subcomponents of
these agencies involved in exposure measurement and monitoring in the
U.S. population:
EPA's Office of Research and Development,
HHS' National Center for Environmental Health (NCEH),
HHS' National Center for Health Statistics (NCHS),
HHS' Agency for Toxic Substances and Disease Registry
(ATSDR), and
HHS' National Institute of Environmental Health Sciences
(NIEHS).
We focused our work mainly on nonoccupational environmental
exposure to chemical agents known or thought to pose a health hazard by
one or more of these agencies.
To gather information about activities of State officials, we
surveyed environmental health officials in State public health agencies
and conducted site visits to six States.
METHODOLOGY OF OUR REVIEW
To assess the extent to which the Federal agencies we reviewed have
collected human exposure data, we met with key officials responsible
for efforts intended to collect human exposure data at each agency. We
focused on what we identified as being the most significant Federal
efforts in human exposure assessment at EPA and HHS related to
nonoccupational human exposure to environmental contaminants. We
reviewed four major activities: EPA's National Human Exposure
Assessment Survey (NHEXAS), CDC's National Health and Nutrition
Examination Survey (NHANES), NIEHS' Human Exposure Initiative, and
ATSDR's exposure investigation activities around hazardous waste and
other sites. We also obtained information on EPA's National Human
Adipose Tissue Survey (NHATS), which ended in 1992.
We also interviewed officials and obtained documentation on how
these various programs were planned and organized and to assess the
extent data were collected in a manner that allows the identification
of at-risk subpopulations by such factors as income, race and
ethnicity, age, and geographic location. We obtained relevant budget
information for 1999 and reviewed related agency performance plans.
To assess barriers to progress in collecting or using human
exposure data, we interviewed Federal officials involved in such
efforts about past and current views on such barriers. In addition, we
reviewed the general literature on human exposure to environmental
chemicals and interviewed officials from organizations representing
State epidemiologists, State public health laboratory directors, local
public health officials, the chemical industry, environmental
advocates, and public health experts.
To gather nationwide data on the views of State public health
officials, we surveyed officials with environmental health
responsibilities related to chemical exposure in State public health
agencies. We identified 93 officials in each of the 50 States and the
District of Columbia--referred to collectively as States--with
assistance from the Council of State and Territorial Epidemiologists
and officials in each of the 51 States.
We also conducted onsite work at EPA, CDC agencies, and NIEHS and
in six States--California, Louisiana, Massachusetts, North Carolina,
Oregon, and Washington. These six States were selected to represent
diverse geographic areas and environmental health programs. In the six
States, we interviewed State public health officials. We also
interviewed officials in State environmental protection and agriculture
agencies, academic and independent researchers, and representatives of
community advocacy organizations.
We excluded efforts to collect human exposure data within
occupational settings from the scope of our review. Similarly, we
excluded federally supported academic and private sector research
efforts.
Our work was conducted from March 1999 through March 2000 in
accordance with generally accepted government auditing standards.
Methodology for Chemical List Analyses
To assess the extent to which human exposure data are available for
chemicals of high concern to human health, we analyzed a number of
chemical lists maintained by HHS and EPA agencies. We also identified
chemicals measured through HHS and EPA representative surveys. Chemical
data were gathered from various sources, including EPAs Offices of
Pesticide Programs, Air and Radiation, Pollution Prevention and Toxics,
and Research and Development; the National Toxicology Program (NTP)
headquartered at NIEHS; CDC's ATSDR; and NCEH and NCHS within ATSDR.
Several toxic chemical lists were identified through a review of
related reports and literature on environmental exposure issues. To
narrow the scope, we also contacted staff in relevant offices within
these agencies and asked them to identify key lists of chemicals of
concern. We consulted experts and public health laboratory officials at
the Pew Commission for Environmental Health and the Association for
Public Health Laboratories.
From the many available chemical lists, we judgmentally selected
eight based on our assessment that each list contained chemicals
thought to have a high potential for causing harm to human health and
input and recommendations from experts. These eight lists, which
contained more than 1,400 unique chemicals, provide a conservative
number of the chemicals agency officials consider a concern for human
health. To ensure that chemicals with more than one name were not
included more than once, we used Chemical Abstract Service numbers, a
unique identifier. These lists, whether singly or combined, do not
necessarily reflect the highest priorities of the Federal Government or
the agencies or programs we contacted. The lists we reviewed are
described below.
Chemicals found most often at the nation's Superfund
sites: HHS' ATSDR, which conducts public health assessments or other
health investigations for populations living around national priority
hazardous waste sites, and EPA prepare a list, in order of priority, of
hazardous substances. This list contains substances that are most
commonly found at facilities on the National Priorities List
(Superfund) and pose the most significant potential threat to human
health due to their known or suspected toxicity and potential for human
exposure.
EPA's list of toxics of concern in air: The Congress
established the original list of 188 hazardous air pollutants that EPA
would regulate through the Clean Air Act. EPA periodically must revise
the list to add or, when warranted, remove substances. EPA adds
substances that it determines to be air pollutants that are known to
cause or may reasonably be anticipated to cause adverse effects to
human health or adverse environmental effects.
Chemicals harmful because of their persistence in the
environment, tendency to bioaccumulate in plant or animal tissues, and
toxicity: EPA's Office of Solid Waste and Office of Pollution
Prevention and Toxics created this list of persistent, bioaccumulative,
and toxic (PBT) chemicals. PBT chemicals do not readily break down or
decrease in potency after they are released into the environment, even
if released in quantities that are very small and legally permitted.
Over time, these chemicals are likely to accumulate in soils or other
environmental media, be absorbed or ingested by animals and plants,
accumulate in animal and plant tissue, pass through the food chain, and
potentially cause long-term human health or ecological problems.
Priority pesticides of potential concern: We combined two
lists of potentially harmful chemicals to develop this list. EPA's
Office of Pesticides Programs provided a list of pesticides of concern
that were classified as organophosphates; carbamates; or group B1, B2,
or C carcinogens. According to a program official, these classes of
pesticides are generally considered among the most potentially harmful
to human health. We combined this list with the U.S. Department of
Agriculture's Pesticide Data Program list of pesticides that are
measured in selected commodities or foods. Pesticides monitored by the
program in 1997 included insecticides, herbicides, fungicides, and
growth regulators in fresh and processed fruit and vegetables, whole
milk, and grains.
Chemicals that are known or probable carcinogens: HHS'
Report on Carcinogens includes substances known or reasonably thought
to be cancer-causing based on evaluations of substances performed by
scientists from NTP, other Federal health research and regulatory
agencies, and nongovernment institutions. The list of substances in the
report represents an initial step in hazard identification. Substances
listed as ``known to be human carcinogens'' are those for which there
is sufficient evidence of carcinogenicity (cancer-causing potential) in
humans to indicate a causal relationship between exposure to the agent,
substance, or mixture and human cancer. Substances listed as
``reasonably anticipated to be human carcinogens'' are those for which
there is limited evidence of carcinogenicity in humans, insufficient
evidence of carcinogenicity in experimental animals, or both.
Chemicals that are considered toxic and used,
manufactured, treated, transported, or released into the environment:
EPA publishes the Toxics Release Inventory containing information on
the release and other waste management activities of toxic chemicals by
facilities that manufacture, process, or otherwise use them. This data
base is made available to the public and is considered useful to
citizens, businesses, and governments for purposes of working together
to protect the quality of their land, air, and water and for evaluating
the probability that chemical releases could impact human health in
communities.
Chemicals most in need of testing required by the Toxic Substances
Control Act: The Master Testing list contains those chemicals that are
prioritized for safety testing based on EPA's finding that (1) a
chemical may present an unreasonable risk of injury to human health or
the environment and/or the chemical is produced in substantial
quantities that could result in significant or substantial human or
environmental exposure, (2) the available data to evaluate the chemical
are inadequate, and (3) testing is needed to develop the required data.
We compared the combined list of these chemicals, totaling 1,456,
and each individual list with those chemicals identified by EPA and CDC
officials as measured in the NHEXAS and NHANES human exposure efforts
through 2000. We excluded NHATS' and the Human Exposure Initiative's
chemical lists from our analysis. NRC's 1991 review of the NHATS
program raised questions about, for example, the representativeness of
the results and the methods used to handle the tissue specimens. NIEHS'
Human Exposure Initiative measurements were not complete at the time of
our review and thus it was not known which chemicals had been or are
currently being measured.
Survey Development and Distribution and Analysis
To develop survey questions, we reviewed documentation on
environmental health programs prepared by HHS and EPA agencies,
professional organizations representing State epidemiology and public
health laboratory officials, and public health experts. We also spoke
with officials and representatives from each of these groups.
We pretested our survey in person with State environmental health
officials in two States and in teleconferences with officials in two
additional States. We asked knowledgeable people in EPA and CDC and in
the environmental and public health fields to review the survey
instrument. We refined the questionnaire in response to their comments
to help ensure that potential respondents could provide the information
requested and that our questions were fair, relevant, answerable with
readily available information, and relatively free of design flaws that
could introduce bias or error into our study results. We mailed
questionnaires to the 93 officials in August 1999. We sent at least one
follow-up mailing and conducted telephone follow-ups to nonrespondents.
We ended data collection in December 1999; had received responses from
81 officials in 48 States for a response rate of 87 percent.
In preparing for our analysis, we reviewed and edited the completed
questionnaires and checked the data for consistency. We tested the
validity of the respondents' answers and comments by comparing them
with data we gathered through interviews with public health experts and
other public health officials and with documentation obtained at
Federal agencies and in case study States.
The survey and survey results are presented in appendix III.
Appendix II
Reported Gaps in Human Exposure Data and History of Federal Efforts
Since the 1980's, reports reviewing environmental health data needs
have recommended the broader collection of human data showing actual
human exposures to chemical contaminants in the environment. Various
Federal agencies have collected such human exposure data for a number
of purposes; historically, these collection efforts have been limited
to selected chemicals, subpopulations, and time periods.
VARIOUS REPORTS DISCUSS THE GAPS IN HUMAN DATA SHOWING MEASURED
EXPOSURE TO CHEMICAL CONTAMINANTS
Data on actual levels of chemicals in humans has been a
longstanding gap in the information needed to establish human health
risks from exposures to environmental contaminants. While data on the
concentration of chemicals in environmental media--such as air, water,
and food--have historically been used to estimate human exposure to
harmful chemicals, this approach to detect or define human health risks
has limitations. According to the NRC, there are too many chemicals,
too many sources, and too many routes of exposure to rely solely on
environmental monitoring. Measurements of internal doses of exposure--
actual levels of chemicals or their metabolites found in human tissues,
such as blood or urine--are generally considered an accurate measure of
human exposure. Such measurements can reflect exposures from all routes
and that may be accumulated over time, modified by individual
differences in physiology, and difficult or impossible to assess by
environmental measurements (such as hand-to-mouth ingestion in young
children). In 1991, NRC reported that a program of human tissue
monitoring is critical to the continued improvement of understanding of
exposure to toxic chemicals and recommended that such a program be
given high priority for funds and other resources.\1\
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\1\ NRC, Commission on Life Sciences, Monitoring Human Tissues for
Toxic Substances.
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Several other Federal reviews have pointed to information needs in
this area. An interagency assessment of federally supported data bases
conducted in the early 1990's concluded that Federal data systems
generally lacked data on actual human exposures, including information
about contact between the chemical and the human body (personal
exposures) and the amount of the chemical absorbed (internal doses).
The review also found substantial value in collecting and analyzing
these data in a comprehensive and systematic manner and that the costs
associated with establishing and maintaining appropriate data bases
were justified.\2\ A discussion of some of these reviews follow.
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\2\ See K. Sexton and others, ``Estimating Human Exposures to
Environmental Pollutants: Availability and Utility of Existing Data
bases,'' ``Archives of Environmental Health, Vol. 47, No. 6 (1992), pp.
398-407.
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HHS, NCHS, Environmental Health: A Plan for Collecting and
Coordinating Statistical and Epidemiologic Data (Washington, DC:
Government Printing Office, 1980): This report found that ``acceptable
ranges of physiologic measurements and normal levels of trace elements
must be determined before any attempt can be made to associate health
outcomes with environmental exposures. Many of these baseline data do
not exist for particular populations of interest or for specific
pollutants. In addition, early indicators and symptoms of disease that
might be environmentally related are not dearly understood.'' The
report identified a number of research directions to help define the
association between health effects and specific environmental
exposures, including the establishment of baseline data on
physiological measurements of trace elements in tissue and blood for
the population.
HHS, NIEHS, Issues and Challenges in Environmental Health
(Washington, DC: National Institutes of Environmental Sciences, 1987):
This report found that due to ``gaps in data systems established for
monitoring and surveillance of environmental exposure, effort should be
made to foster better linkage among existing systems . . . Existing
data systems should be expanded to include biochemical and cellular
indicators of early stages of disease. . . . The group found there is a
need for more research and more systematic collection of data on the
exposure of human populations to harmful substances. Reliable exposure
data are necessary for assessing the probability that exposed
populations will develop adverse health effects and the likelihood of
success in intervening to reduce those risks.''
K. Sexton and others, ``Estimating Human Exposures to
Environmental Pollutants: Availability and Utility of Existing Data
bases'': This report found that while ``the evidence suggests that
existing data systems contain a substantial amount of information that
is relevant to exposure estimation . . . the quality of the data is
inconsistent and difficult to assess and that understanding and
accessing the information is often difficult. Furthermore, these
systems demonstrate a striking absence of data on actual human
exposures, including a lack of information about contact between the
agent and the human body (exposure) and about the amount of the agent
or its metabolites that enters the body (dose).''
NRC, Hormonally Active Agents in the Environment: This
report found that
``determining the risk of environmental hormonally active agents to
humans and wildlife is difficult because exposure to these agents has
not been routinely monitored. . . . Background concentrations of
hormonally active agents in humans, particularly in adipose (fat)
tissue and blood, and other biota need to be established. In
particular, routes of exposure and the effects of diet need to be
assessed to provide a framework for examining the effects of these
compounds in the general population and in highly exposed
subpopulations.''
HISTORY OF FEDERAL EFFORTS TO COLLECT HUMAN EXPOSURE DATA
Since 1967, HHS and EPA have conducted Federal surveys to assess
the U.S. population's exposures to toxic chemicals from the analysis of
human tissue samples. While their efforts measured some of the same
exposures and covered some of the same time periods, their goals
differed and most did not include a nationally representative sample of
citizens. EPA's efforts first monitored exposure to pesticides and,
more recently, have attempted to link human exposure data to specific
routes of exposure. CDC's periodic surveys are intended to monitor
trends in the health and nutrition status of the population but, over
time, have included exposures to environmental toxics as one component
of the general survey. NIEHS' Human Exposure Initiative, established in
the late 1990's, is intended to help the agency prioritize chemicals
for further toxicology and carcinogenicity testing. Within these
studies, various subgroups have been used to develop human exposure
estimates, but in most cases, sampling has not been for all participant
groups or random. Consequently, the results cannot be projected to the
U.S. population as a whole for most chemicals. See table 5 for the
timeframes and numbers of chemicals covered for major Federal efforts.
Table 5.--Number of Chemicals and Time Frames for Select Federal Efforts
----------------------------------------------------------------------------------------------------------------
No. of
No. of chemicals
chemicals measured for
Duration No. of participants providing measured for all
biological samples any participants
participations (ages 1 and
older)
----------------------------------------------------------------------------------------------------------------
Second National Health and Nutrition
Examination Survey (NHANES II):
1976-1980.................................... 20,000 examined a................ 36 1
Third National Health and Nutrition Examination
Survey (NHANES III)
1988-1994.................................... 30,000 examined a................ 47 1
National Health and Nutrition Examination
Survey, 1999 (NHANES)
1999-ongoing................................. 5,000 per year b................. 74 c 2 d
National Human Adipose Tissue Survey (NHATS):
1967-1992.................................... 14,000........................... 128 20 e
National Human Exposure Assessment Survey
(NHEXAS) Pilot Study:
1995-1999.................................... 460 f............................ 46 c 6
----------------------------------------------------------------------------------------------------------------
a The number of participants in NHANES II and NHANES III who received physical examinations is used as a proxy
for the number providing biological samples, as the latter number was not readily available.
b The number of persons examined in a calendar year is planned to be about 5,000.
c For NHANES, the list of potentially toxic chemicals covered was provided by CDC laboratory officials. For
NHEXAS, the list of potentially toxic chemicals covered was provided by EPA NHEXAS officials.
d According to a CDC laboratory official, lead and cadmium are measured in all participants. Cotinine will also
be measured in many participants--specifically, those ages 4 and older.
e Chemicals analyzed by NHATS varied over time. NHATS collected data on 20 pesticides between 1970 and 1981.
NIEHS chemicals are not included because data were not available at the time of our review.
f Excludes a related but separate study done in Minnesota reviewing pesticide exposures that was not one of the
three formal pilot surveys.
A description of these Federal efforts to collect human exposure
data follows.
CDC's National Health and Nutrition Examination Surveys:
NHANES, conducted multiple times since 1960 by NCHS, is designed to
provide national estimates of the health and nutrition status of the
noninstitutionalized civilian population of the United States.
Estimates are obtained by examining randomly selected participants in a
manner that accurately reflects the demographic characteristics of the
U.S. population. Participants are given comprehensive physical
examinations (including tissue samples) and are interviewed on issues
such as their nutritional habits, health conditions, and housing
characteristics. NHANES data are used for a number of purposes. For
example, in addition to monitoring changes in blood lead levels, uses
of NHANES include development of national standards for blood pressure
and cholesterol levels and for determining infection rates for
diseases. CDC's laboratory housed at NCEH performs the measurements of
chemicals in human tissues for NHANES.
Second National Health and Nutrition Examination Survey:
NHANES II was designed to provide national estimates of the health and
nutritional status of the civilian noninstitutionalized population of
the United States for persons aged 6 months to 74 years. Children, the
elderly and people classified as living at or below the poverty level
were oversampled in order to increase the reliability of the estimates
for these groups. Measurements of pesticide residues were taken from
participants who were between the ages of 12 and 74 years of age.\3\
Blood lead measurements were taken from participants in all age groups
in the survey.
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\3\ Data were not publicly available, as CDC is resolving some
methodological issues associated with data collection.
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Third National Health and Nutrition Examination Survey: NHANES III
was designed to provide national estimates of health and nutritional
status of the civilian noninstitutionalized population of the United
States ages 2 months and older. Children ages 2 months through 5 years,
blacks, Mexican-Americans, and persons ages 60 or older were
oversampled to increase the reliability of the estimates for these
groups. Blood lead measurements were taken from all particiapants ages
1 year or older. Cadmium measurements were taken from all participants
ages 6 years or older. In addition, some participants ages 20 through
59 years had measurements taken for volatile organic compounds and
pesticides. Participants volunteered for these additional measurements,
so the results cannot be projected to the population as a whole.
However, the results still serve as the reference ranges for these
chemicals.
National Health and Nutrition Examination Survey, 1999: In 1999,
NCHS changed the design of NHANES so that it will now be conducted as a
continuous survey of about 5,000 participants annually. Like the
previous surveys, NHANES will yield nationally representative results
for the civilian noninstitutionalized population. The NHANES design
will allow for oversampling to vary between years; persons aged 12 to
19, persons aged 60 and over, blacks, and Mexican-Americans are being
oversampled. It will be tied to related Federal government data
collections conducted on the general U.S. population, in particular,
the National Health Interview Survey.\4\ NCHS also plans to release
results from the survey every year after the first 3 years of data
collection. More than 1 year of data will be required for many
estimates, particularly among detailed subgroups of the population.
While lead and cadmium will be the only potentially toxic chemicals
measured for all participants ages 1 and older (although cotinine, a
metabolite which illustrates exposure to environmental tobacco smoke,
will be measured for most age groups--those ages 4 and over), NCHS and
NCEH plan to get nationally representative data for specific chemicals
for persons in specific demographic groups, such as mercury
measurements in women ages 16 through 49. NCHS will also measure
household lead dust, drinking water contaminants, and exposure to
volatile organic compounds for selected participants. In addition to
conducting an annual national survey, NCHS is developing a smaller,
more targeted health survey--the Defined Population Health and
Nutrition Examination Survey (DP-HANES). NCHS recognizes that NHANES
cannot collect information that would be directly useful at the local
or State level or for small populations. DP-HANES is intended to
address this issue through the use of small mobile examination centers
that would visit areas of interest and examine 2,000 to 3,000
participants for each special study. DP-HANES participants would not
receive the full range of tests given under NHANES; rather, the DP-
HANES examination would be tailored to the specific needs of the
population under study.
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\4\ The sampling will be conducted on different people, but some
questions asked in each survey will be the same.
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EPA's National Human Adipose Tissue Survey: NHATS was
intended to be a continuously operating survey that would collect,
store, and analyze samples of autopsy and surgical specimens of human
adipose tissue from major metropolitan areas of the country. It was
established by HHS in 1967 and was transferred to EPA in 1970. During
its existence, NHATS data documented the widespread and significant
prevalence of pesticide exposures in the general population. NHATS data
also showed that reduced use of polychlorinated biphenyls (PCB) and DDT
and dieldrin (common insecticides) resulted in lower tissue
concentrations of these compounds. A trend analysis for 1970 through
1981 of NHATS data showed a dramatic decline in PCB concentrations
after the regulation of PCBs in 1976. During the 1980's, problems with
NHATS' survey design, management, and goals were compounded by
insufficient financial support and caused the usefulness and quality of
NHATS to deteriorate. In 1991, NRC conducted a study to review and
evaluate the effectiveness and potential applications of NHATS.\5\ The
study concluded that a more comprehensive national program of human
tissue monitoring was a critical need for understanding human exposures
to environmental toxics. In addition, EPA needed a human tissue
monitoring program in order to evaluate the need and effectiveness of
EPA's regulatory programs. The study recommended that NHATS be
completely redesigned to provide more useful data based on probability
samples of the whole U.S. population and that funding be increased to
permit the program to fulfill its mission. EPA ended the NHATS in 1992
and replaced it with the NHEXAS pilot surveys.
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\5\ NRC, Commission on Life Sciences, Monitoring Human Tissues for
Toxic Substances.
---------------------------------------------------------------------------
EPA's National Human Exposure Assessment Survey Pilot
Surveys: The NHEXAS pilot surveys were designed to obtain knowledge on
the multiple pathways and media population distribution of exposures to
several classes of chemicals and to test the feasibility of conducting
a national survey to provide estimates on the status of human exposure
to potentially high-risk chemicals. NHEXAS was also designed to measure
``total exposure''--the levels of chemicals participants take in
through the air they breathe; the food, drinking water, and other
beverages they consume; and in the soil and dust around their homes.
Measurements have also been made of chemicals in biological samples
(such as blood and urine) provided by some participants. Participants
completed questionnaires to help identify possible sources of exposure
to chemicals. As designed, NHEXAS has three phases. Phase I is intended
to develop and validate NHEXAS methods, phase II is designed to obtain
nationally representative exposure data in a manner similar to that
used by NHANES to get health data, and phase III is designed to follow
up on information developed from phase II and will study selected
subpopulations. EPA conducted NHEXAS phase I (pilot) surveys in
Arizona, Maryland, and EPA's region 5 (Illinois, Indiana, Michigan,
Minnesota, Ohio, and Wisconsin). About 460 participants in the pilot
surveys provided biological samples; examinations measured a variety of
chemicals, such as volatile organic compounds, heavy metals, and
pesticides. Human tissue measurements were performed under interagency
agreement by CDC's environmental health laboratory. EPA has completed
most of the fieldwork for the NHEXAS phase I surveys and is now
analyzing the results. Based on these results, EPA will finalize the
scope and methods for NHEXAS phases II and III.
ATSDR's Exposure Investigations: As part of its health assessment
process or in response to requests, ATSDR may conduct limited
biological monitoring at hazardous waste sites or other locations
through a process called exposure investigations. In response to the
recognition that the conclusions drawn from indirect methods of
measuring exposures were often not accurate and not reliable for
assessing potential health impacts and the need for more direct
measures of exposures, ATSDR formally established an exposure
investigation unit within its Division of Health Assessments and
Consultation. The Exposure Investigation Section was established in
1995 and is comprised of nine staff members who respond to requests to
conduct exposure investigations around hazardous waste sites. These
investigations involve gathering biological samples, conducting
personal monitoring for site-related contaminants and their byproducts,
and analyzing environmental data using computational tools.
In 1996, ATSDR convened an expert review panel to comment on
ATSDR's exposure investigation program, including whether ATSDR was on
the right track in providing exposure information to improve public
health decisionmaking intended to address environmental releases from
hazardous waste sites. The panelists endorsed many aspects of ATSDR's
investigative process, including the following:
Conducting exposure investigations prior to preparing
public health assessments, which makes agency responsibilities easier
because information is provided that enables Federal agencies to take
action and respond to community concerns in a timely manner.
Considering exposure determinations to be as important as
obtaining environmental monitoring results.
Emphasizing the human element of exposure investigations,
which illustrates that the Federal Government responds to community
concerns.
The panel also made several suggested improvements to the process,
including establishing a national clearinghouse of exposure
investigation data and results and developing site criteria and a
protocol for identifying who will decide onsites to target for exposure
investigation.
ATSDR's exposure investigations have been valuable but limited in
scope. ATSDR used biological monitoring in conducting 47 exposure
investigations between 1995 and July 1999. Of these investigations, 17
were done in support of the 460 health assessments done at that time.
Unlike NHANES and the NHEXAS pilot surveys, exposure investigations
usually have a small number of participants (less than 100) who
volunteer to participate in the study. While the exposure
investigations are not intended to be used for generalizations about
larger populations, the studies have proven very useful in ATSDR's
community outreach and intervention activities.
NIEHS' Human Exposure Initiative: In 1996, this
initiative, a collaboration between NIEHS and CDC, was started to
improve understanding of human exposures to hormonally active agents--
also called ``environmental endocrine disrupters''--for the national
population. CDC's environmental health laboratory under an interagency
agreement is developing methods for and measuring up to 80 chemicals
thought to be hormonally active agents in blood, urine, or both. Human
tissue samples used for these measurements are largely obtained from
the ongoing sampling of the general population under NHANES and total
about 200 in number.
In 1999, NIEHS and NTP officials proposed to expand the initial
collaboration between NEHS and CDC by quantifying human internal
exposures to selected chemicals that are released into the environment
and workplace. NTP officials indicated this information would benefit
public health and priority-setting in a number of ways. First, it would
strengthen the scientific foundation for risk assessments by allowing
(1) the development of more credible relationships between exposure and
response in people thereby improving cross-species extrapolation, (2)
the development of biologically based dose-response models, and (3) the
identification of sensitive subpopulations and for estimates of risk
based on ``margin of exposure.'' Second, it would provide the kind of
information necessary for deciding which chemicals should be studied
with the limited resources available for toxicological testing. For
example, there are 85,000 chemicals in commerce today, and NTP can
provide toxicological evaluations on 10 to 20 per year. Third, the
information could be used to identify and help focus research on those
mixtures of chemicals that are actually present in people's bodies.
Fourth, the types and amount of chemicals in children and other
potentially sensitive subpopulations would be identified.
Determinations of whether additional safety factors need to be applied
to children must rest in part upon comparative exposure analyses
between children and adults. Fifth, this initiative, taken together
with the environmental genome initiative, will provide the science base
essential for meaningful studies on gene and environment interactions,
particularly for strengthening the evaluation of epidemiology studies.
Finally, efficacy of public health policies aimed at reducing human
exposure to chemical agents could be evaluated in a more meaningful way
if human exposure data were available over time, including remediation
around Superfund sites and efforts to achieve environmental equity.
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__________
Statement of Stephen M. Prescott, M.D., Executive Director, Huntsman
Cancer Institute
This year, approximately 2,400 children in the United States will
be diagnosed with acute lymphoblastic leukemia (ALL), the most common
form of childhood cancer. Their chances for cure are significantly
better than they were three decades ago. Due to breathtaking progress
in research, close to 75 percent of these children will grow up to lead
healthy productive lives. The results are improving each year and
childhood ALL is one of the most curable forms of human cancer.
Despite this success, many challenges remain and the first is
obvious--the cure rate isn't 100 percent. And, until it is we must work
toward this goal. A second goal is to develop treatments with fewer
side effects. To achieve these goals we must discover the root causes
of childhood leukemia. In this regard, the future is bright. We are
beginning to unravel the events that cause a single cell to become
cancerous. These results can be attributed to significant advances in
basic research, especially in the area of genetics. When we talk about
cancer genetics we mean two different things. The first, which is
readily understood, means inheriting a high risk of cancer from one's
parents. This is only a small minority of all cancer cases and is very
rarely the cause of childhood cancer. The second meaning of genetic is
that the cancer cell has acquired damage to its genes, while the rest
of the body's cells have a perfectly normal genetic make-up.
In the case of ALL, we know that a single normal cell, destined to
become a normal white blood cell called a lymphocyte, develops a
mistake in the genetic code. In the case of leukemia, this is a swap of
genetic material between two chromosomes and is called a translocation.
These translocations occur in genes that control growth under normal
circumstances. When such growth-promoting genes are damaged, the cell
will continue to grow even when the body is trying to send a message to
tell it to stop growing. Through the development of powerful techniques
we now know the location of many of these defects and researchers at
many centers are working to unravel the complexity of the cancer cell
to understand specifically changes that allows the cancer to grow.
Perhaps the most difficult questions for a physician to answer are,
``Doctor, why did my child get leukemia? And, was there anything I
could have done to prevent it''? The answer to the second is a
resounding ``no.'' The answer to ``why'' is that we don't yet know the
fundamental cause of ALL.
When clusters, or dramatic increases in cancer cases in small
geographic areas, occur, we always revisit the issue of whether a
cancer-causing agent from the environment or an infection resulted in
the increased number of cases. Unfortunately, this approach has not
identified any causes for ALL. But it is possible that we are missing
subtle relationships if an environmental or infectious cause is present
but only affects individuals with a certain genetic makeup and not all
members of the population.
The recent sequencing of the human genome provides us with
unprecedented opportunities to understand cancer and to use that
knowledge to develop new treatment and prevention. The major focus of
the Huntsman Cancer Institute (HCI) is to understand this genetic
blueprint of cancer. Using a new technology called ``DNA chips''
investigators in our childhood cancer program have uncovered genetic
pathways that are active in cancer cells but not normal blood cells.
Using this information it may be possible to develop drugs that could
interfere with these active pathways. Since these changes are limited
to the cancer, new drugs targeted to these pathways might avoid the
side effects seen with conventional drugs.
We also now know that certain pathways are unique to groups of
patients that have a greater risk of relapse after treatment. It may be
possible to use the genetic ``fingerprint'' of the leukemia someday to
``tailor'' therapy so that patients with a high likelihood of cure can
be treated without exposing them to unnecessary more toxic therapy,
while patients with high risk disease can be more effectively treated
before the leukemia comes back. This approach is still experimental and
leukemia samples from children treated at children's hospitals
throughout the United States will be sent to us to test further this
genetic approach to classifying leukemia. We believe that the same
approach could be applied to studies of clusters of ALL to try to
understand why they occur. For example, is there a specific genetic
pathway damaged in children from Fallon who have ALL. If so, this would
suggest that an infection or environmental agent initiated a common
form of damage.
The Children's Oncology Group, a consortium of all major children's
hospitals in North America, is embarking on a massive effort to
identify a subset of patients who might be especially vulnerable to
environmental risks because of inherent susceptibility to damage from
chemicals. This effort will use the approach I've described and will be
led by Dr. Bill Carroll, the deputy director of the Huntsman Cancer
Institute.
Although these projects are just underway, progress is being
achieved at a remarkable rate. By combining sophisticated genetic
analysis of patients and their tumors with the best treatments
available, we hope to reach that goal of uniform cancer cure and
ultimately, prevention.
Environmental Exposures and Childhood Cancer: Our Best May Not Be Good
Enough
Childhood cancer ranks high among public concerns, evoking the
public's fear of cancer as well as the special emotional attention that
is focused on children. Although it is rare, its priority is elevated
on the basis of years of life lost and its prominence among life-
threatening diseases of children. Despite great success in the
treatment of childhood cancers such as Wilms' tumor and leukemia,
cancer continues to be life threatening in children.
For several decades, clusters of childhood leukemia have been
investigated, in a search first for an infectious etiology and then for
an environmental etiology,1 both without success. Childhood
cancer clusters continue to generate public concern and consume health
department resources, but there has been little progress in
understanding the etiology or identifying preventive measures. The
focus often turns to the role of environmental pollutants such as
pesticides, electromagnetic fields, and chemicals found in hazardous
wastes. The rationale for seeking exogenous, modifiable causes of
childhood cancer that can be avoided leading to a reduction in the risk
of disease, is compelling. The negative consequence of such public
demand and support for epidemiologic research is the temptation to
overinterpret every shred of fallible evidence that emerges. The public
and media tend to place much more faith than is warranted in isolated
findings, to the detriment of sound policy and the credibility of
researchers.
Epidemiologic research into potential environmental contributors to
the etiology of childhood leukemia, brain cancer, and other pediatric
malignancies has been pursued intensively for over 20 years. Motivated
by scientific interest and public concern, a number of studies have
evaluated the role of pesticides,2 ionizing
radiation,3 nonionizing radiation,4-5 and a wide
range of occupational and environmental exposures.6-7 Dozens
of epidemiologic studies have been conducted on these topics, some with
sophisticated designs, large populations, and attention to exposure
assessment, such as the report in this issue by Freedman et
al.8 on solvent exposure and childhood acute lymphoblastic
leukemia.
SCIENTIFIC CHALLENGES TO IDENTIFYING CAUSES OF CHILDHOOD CANCER
The scientific challenges to identifying environmental contributors
to the etiology of childhood cancer are daunting. We are uncertain
about the relative importance of exposures of the mother, father, and
child in disease etiology. Although the time frame is narrower than the
half century of potential relevance in the etiology of adult cancer,
the origins of childhood cancer may lie anywhere between conception and
diagnosis. The appropriate disease entities for study cannot be defined
with confidence, so histology, age of onset, and tumor biology are all
potential markers of etiologic heterogeneity. The goal of creating
ever-finer case subgroups must be reconciled with the overall variety
of cancers in children. The trade-off is between potential gains in
validity achieved by creating more homogeneous case groups and a
definite loss of precision as the group size is reduced.
Because childhood cancers are so rare, true prospective studies are
virtually impossible, necessitating continued reliance on case-control
studies. As noted by Freedman et al.,8 the 2 key challenges
associated with that design are control selection and exposure
assessment. Except in locations with complete birth registries or
population rosters (mostly in northern Europe), identifying and
recruiting a sample of the case-generating study base pose great
challenges.
Hospital-based studies make it impossible to define the source of
cases, particularly for diseases that result in referrals from a wide
geographic area. Because few children are hospitalized for any reason,
finding ``exposure-neutral'' diagnostic groups of children as a source
of controls is even more challenging than it is for adults. In
population-based studies, nonresponse is inevitable, often reaching
levels of 20 percent to 40 percent of the eligible population. As a
reminder that this nonresponse is capable of distorting measures of
association, virtually all case-control studies of childhood leukemia
in the United States, including the study by Freedman et al., have
found higher risk in the lower social classes, despite there being an
established, though modest, positive correlation between higher social
class and risk for child cancer on the basis of registry information.
The overrepresentation of upper-social-class controls, stronger than
the corresponding trend among cases, appears to be the source of this
effect, replicated across studies. Adjustment for social class can be
made, but this consistent observation suggests that other aspects of
nonresponse (particularly among controls) may well have more insidious
effects.
The second consequence of conducting case-control studies is the
loss of information associated with retrospective exposure assessment.
Until the cancer is identified (or the control child reaches the
equivalent age), we can not ascertain exposure and are thus faced with
reconstructing exposure throughout the potential etiologic period.
Studies that identify the cases as they are diagnosed, as was done by
Freedman et al.,8 avoid the additional time delay associated
with recruiting cases diagnosed before the initiation of data
collection, but there is still a limit to the accuracy of exposure
assessment for periods extending back as far as 15 years. Biological
markers of exposure are clearly not applicable, and direct measurement
of environmental agents in the physical locations of interest is of
uncertain relevance owing to the passage of time. We are forced to
relay on memory, which itself is limited in accuracy and objectivity
with regard to the important details about workplaces and the home
environment that can affect exposure.
SOLVENTS AND CHILDHOOD LEUKEMIA
Recognizing all these limitations, the report by Freedman et al.
reflects the ``state of the art'' in childhood cancer epidemiology with
regard to study size (640 cases included in the analysis), homogeneity
of disease classification (all acute lymphoblastic leukemia), method of
control selection (random-digit dialing), and approach to exposure
assessment (structured questionnaire addressing frequency and duration
of exposure). As would be predicted, the greatest concerns with bias
arise from nonresponse and exposure misclassification. Only 64 percent
of eligible controls were enrolled, and despite some evidence against
the available measures of social class being associated with solvent
exposure, that level of nonparticipation leaves open the possibility of
distorted results. Relative to an ideal measure of actual solvent
exposure, as might be obtained through personal monitoring, the
effectiveness of the exposure assessment questions is uncertain. The
investigators focus on differential error, which could contribute to
elevated measures of association, but nondifferential misclassification
is more certain to be present and can be invoked as an argument that
observed associations are more likely to be underestimates of any
underlying causal association.
This study advances the hypothesis that solvent exposure may
contribute to the etiology of childhood leukemia, moving it from a
plausible hypothesis with no direct epidemiologic support to one with
very limited epidemiologic support. The total evidence supporting the
hypothesis that household solvent exposures cause childhood leukemia
nevertheless remains weak but deserving of further study. Perhaps the
most disconcerting challenge posed by the study is how to make progress
in evaluating the hypothesis further. The very strengths of the study
by Freedman et al. make it difficult to suggest improvements.
Certainly, pure replication, assessing whether the same study design
generates the same results in other settings, would be welcome. There
is clearly some room for refinements in the approach to exposure
assessment, with more detailed query pertaining to exposure
determinants. Those who are already engaged in such studies would do
well to include pertinent questions regarding household solvent
exposure. However, given the rarity of the disease and the expense
associated with studies of this size, it is difficult to advocate
initiating new studies with household solvent exposure as a primary
justification.
Even though the epidemiologic studies directly tackle the exposure
and disease of interest, more insight may be generated by strong
findings of indirect relevance than by more weak findings of direct
relevance. Research that addresses the impact of self-reported
activities on measured solvent exposure would be highly beneficial to
interpreting this study and could lead to improved methods of
retrospective exposure assessment. Toxicologic studies of implicated
agents, such as methylene chloride and benzene, focusing on animal
models of childhood leukemia may help in the interpretation of these
results. For a possible paternally mediated pathway linking solvent
exposure to childhood leukemia, further work on sperm-mediated genetic
alterations associated with solvent exposures could be contributory.
With regard to childhood exposure, focus might shift to endpoints that
can measured prospectively in modest populations, ideally, biomarkers
of early effect such as cytogenetic damage. If we are to attain the
conclusive results pertaining to solvent exposure (or pesticides,
nonionizing radiation, etc.) and leukemia (or other childhood
cancers)--an elusive goal so far--it is very unlikely to come through
sheer weight of replicated findings from conventional epidemiologic
studies.
David A. Savitz, PhD.
ACKNOWLEDGMENTS
I would like to thank Dr. Andrew Olshan for his review and helpful
comments on the manuscript.
references
1. Alexander FE. Clusters and clustering of childhood cancer: A
review, Eur J. Epidemiol. 1999; 15:847-852.
2. Daniels JL, Olshan AF, Savitz DA. Pesticides and childhood
cancers. Environ Health Perspect. 1997; 105:1068-1077.
3. Laurier D, Bard D. Epidemiologic studies of leukemia among
persons under 25 years of age living near nuclear sites. Epidemiol Rev.
1999; 21:188-206.
4. Ahlboin A, Day N, Feychting M. et al. A pooled analysis of
magnetic fields and childhood leukemia. Br J. Cancer. 2000; 83:692-698.
5. Little J. Epidemiology of Childhood Cancer. Lyons, France:
International Agency for Research on Cancer; 1999. LARC Scientific
Publication 149.
6. McBride ML. Childhood cancer and environmental contaminants. Can
J. Public Health. 1998; 89:S53-S62.
7. Colt JS, Blair A. Parental occupational exposures and risk of
childhood cancer. Environ Health Perspect. 1998; 106:909-926.
8. Freedman DM, Stewart P, Kleinerman RA, et al. Household solvent
exposures and childhood acute lymphoblastic leukemia. Am J Public
Health. 2001; 91:564-567.
______
Household Solvent Exposures and Childhood Acute
Lymphoblastic Leukemia
ABSTRACT
Objectives.--This study explored the risk of childhood acute
lymphoblastic leukemia (ALL) associated with participation by household
members in hobbies or other home projects involving organic solvents.
Methods.--Participants in this case--control study were 640
subjects with ALL and 640 matched controls.
Results.--Childhood ALL was associated with frequent (>4 times/
month) exposure to model building (odds ratio [OR]=1.9; 95 percent
confidence interval [95 percent CI]=0.7, 5.8) and artwork using
solvents (OR=4.1; 95 percent CI=1.1, 15.1). We also found elevated risk
(OR=1.7; 95 percent CI=1.1, 2.7) among children whose mothers lived in
homes painted extensively (>4 rooms) in the year before the children's
birth.
Conclusions. In this exploratory study, substantial participation
by household members in some common household activities that involve
organic solvents was associated with elevated risks of childhood ALL.
(Am J Public Health. 2001;91:564-567)
Little is known about the role of environmental exposures in
childhood leukemia.1 Several epidemiologic studies have
described elevated risks of childhood leukemia associated with parents'
exposure to occupational chemicals, 2-10 including solvents
3,6,8,9 and paints.3,5,7,10 Children may also be
exposed to solvents and paints at home through their own or their
parents' hobbies and household maintenance activities. To our
knowledge, few studies \10\ have examined the risks of childhood
leukemia associated with exposures to solvents in the home other than
pesticides.
As part of a large comprehensive case-control study of potential
risk factors for childhood acute lymphoblastic leukemia (ALL) conducted
by the Children's Cancer Group, we undertook an exploratory study to
examine the relationship between childhood leukemia and exposure to
selected household chemicals during childhood, as well as indoor house
painting during preconception, pregnancy, and childhood. We focused on
common home activities likely to result in exposures to
solvents.11-14
METHODS
Case subjects were children, aged birth to 14 years, who were newly
diagnosed with ALL between 1989 and 1993, resident in any of 9
midwestern and mid-Atlantic States, and enrolled through the Children's
Cancer Group, a cooperative clinical trials group.15,16
Eligibility criteria included a residential telephone and an English-
speaking biological mother available for an in-person interview.
Control subjects were selected through random-digit dialing and were
individually matched to the case subjects by age (within 25 percent of
the case's age at diagnosis), the first 8 digits of the telephone
number, and race.17 The overall participation rates were 88
percent for case subjects and 64 percent for control subjects. After
exclusion of patients with Down syndrome, which has been associated
with a high risk of ALL,18 there were 640 matched case-
control pairs.
For each of 3 hobbies (model building, artwork using solvents, and
furniture stripping) and 2 household maintenance activities (motor
vehicle and electronic equipment repair), interviewers asked mothers
whether household members engaged in any of the 5 activities in and
around their home. Because pretesting revealed that many mothers could
not remember early activities or gave identical answers for each year
of the child's life, the interview focused on activities during the
reference year (the year preceding the date of diagnosis for the case
and its matched control). Interviewers asked the mother about which
household members participated in the activities, as well as the
frequency and duration of each episode. Interviewers also asked
questions about painting inside the subjects' homes within 3 months of
conception, during the pregnancy, and after the subjects' birth,
including the specific rooms painted, the frequency of the painting,
who painted (mother or others), and whether members of the family
remained at home overnight during the house painting.
For each hobby or household activity other than house painting, we
analyzed 2 measures of exposure: frequency (defined as the number of
times engaged in the activity per month) and cumulative exposure
(defined as the product of the frequency of the activity and its
duration per episode). Because fewer control than case mothers provided
information about duration, our analysis emphasized frequency as a more
unbiased exposure measure. Before any analysis, we arbitrarily
classified frequency and cumulative exposure into common time
categories. We categorized frequency of exposure as low (<1 time/
month), medium (1-4 times/month), and high (>4 times/month); we
categorized cumulative exposure as low (<10 minutes over a month),
medium (10 minutes-1 hour over a month), and high (>1 hour over a
month). For house painting, exposure was classified by the total number
of rooms painted (1-2, 3-4, >4 rooms), as well as the frequency (1-2,
3-5, >5 times since birth) among those painting after the child's
birth.
We computed odds ratios by unconditional logistic regression so as
to maximize the number of cases and controls included in this
exploratory analysis. We confirmed our main findings by conditional
logistic regression. Odds ratios were adjusted for age at the reference
date, sex, mother's education level, and family income. We compared
subjects by whether they ever or never participated in a given activity
and by the 2 measures of exposure. We analyzed the total population, as
well as 2 age strata: younger than 5 years (the peak ages are 2-4 years
for ALL) and 5 years and older. Except for model building, there was an
insufficient number of children participating in the various activities
to assess the risk of ALL among child participants. For house painting,
we investigated the timing of painting before and after birth.
We also examined 2 strata based on length of time between diagnosis
and interview (24 months vs >24 months). We explored trends
in risk by entering exposure variables ordinally into the models.
RESULTS
Case subjects and control subjects were demographically similar,
except that the former came from families with lower income and had
mothers with less formal education. Both groups were predominantly
White (Table 1).
Exposures From Hobbies, Vehicle Maintenance, and Electronic Repair
No significant excess risk of childhood ALL was observed with ever
vs never participation in any of the activities by a household member
(Table 2). Moreover, neither automotive and truck maintenance nor
electronic repairs reflected a pattern of risk with increasing
exposure.
Elevated risks of childhood ALL, however, were associated with the
highest levels of participation in some activities (Table 2). Risks
were elevated for model building in the highest-frequency category
(odds ratio [OR] = 1.9; 95 percent confidence interval [CI]=0.7, 5.8)
but did not vary by age group or the child's involvement. Artwork
requiring solvents was linked with significantly elevated risks of
childhood ALL in the highest-frequency exposure category (OR=4.1; 95
percent CI=1.1, 15.1), and risks increased as exposure rose (P
trend=.07). Although the numbers were small, similar risks were
observed in both age groups (data not shown). The associations with
high cumulative exposure were similar to those with frequent exposures
for both model building and artwork (data not shown).
For furniture stripping, risk was not elevated among children in
families with the highest frequency of exposure. Risk was, however,
significantly elevated among children in those families with the
highest cumulative exposures (OR=2.9; 95 percent CI=1.1, 9.1).
In general, when the subjects were stratified by time between
diagnosis and interview dates, the odds ratios among those interviewed
close to the diagnosis date were about the same as or stronger than the
unstratified odds ratios.
TABLE 1.--Characteristics of 840 Children With Acute Lymphoblastic
Leukemia and 640 Matched Controls,a From Interview Data on Use of
Household Solvent Exposures
------------------------------------------------------------------------
Cases N Controls
Characteristics (%) N (%)
------------------------------------------------------------------------
Sex:
Male.......................................... 333 (52.0) 337 (52.7)
Female........................................ 307 (48.0) 303 (47.3)
Age at diagnosis/reference date, y:
<2............................................ 68 (10.6) 85 (13.3)
2-4........................................... 312 (48.8) 289 (45.2)
5-9........................................... 179 (28.0) 185 (28.9)
510........................................... 81 (12.7) 81 (12.7)
Race:
White......................................... 585 (91.4) 612 (95.8)
Black......................................... 20 (3.1) 16 (2.5)
Other......................................... 35 (5.5) 12 (1.9)
Household income during reference year, $:
<20,000....................................... 113 (17.7) 77 (12.0)
20,000-29,999................................. 122 (19.1) 86 (13.4)
30,000-39,999................................. 133 (20.8) 112 (17.5)
40,000-49,999................................. 98 (15.3) 105 (16.4)
50,000........................................ 168 (26.2) 255 (39.8)
Missing....................................... 6 (0.9) 5 (0.8)
Mother's education:
a Excludes 11 pairs in which 1 member of the air had Down syndrome.
TABLE 2.--Distribution of Cases and Controls by Frequency a of Hobby and
Household Maintenance Activity During Year of Diagnosis, With Odds
Ratios b (ORs) and 95% Confidence Intervals (Cls)
------------------------------------------------------------------------
Cases Controls OR(95% CI)
------------------------------------------------------------------------
Hobbies
Model building:
Never c........................... 549 555 1.0
Ever d............................ 90 83 1.1 (0.8, 1.5)
Low............................... 51 60 0.9 (0.6, 1.3)
Medium............................ 29 18 1.5 (.08, 2.8)
High.............................. 10 5 1.9 (0.7, 5.8)
P trend........................... ...... .......... .21
Artwork (using solvents):
Never c........................... 566 571 1.0
Ever d............................ 73 65 1.3 (0.9, 1.8)
Low............................... 34 35 1.1 (0.7, 1.8)
Medium............................ 28 27 1.2 (0.7, 2.0)
High.............................. 11 3 4.1 (1.1,
15.1)
P trend........................... ...... .......... .07
Furniture stripping:
Never c........................... 574 579 1.0
Ever d............................ 65 59 1.1 (0.8, 1.6)
Low............................... 32 35 0.9 (0.6, 1.5)
Medium............................ 24 14 1.8 (0.9, 3.6)
High.............................. 8 8 1.0 (0.4, 2.7)
P trend........................... ...... .......... .33
Household maintenance
Auto/truck maintenance:
Never c........................... 378 383 1.0
Ever d............................ 260 255 0.9 (0.7, 1.2)
Low............................... 121 129 0.9 (0.7, 1.2)
Medium............................ 107 107 0.9 (0.6, 1.2
High.............................. 31 19 1.5 (0.8, 2.7)
P trend........................... ...... .......... .91
Electronic repair:
Never c........................... 604 612 1.0
Ever d............................ 35 25 1.4 (0.8, 2.4)
Low............................... 20 14 1.5 (0.7, 3.0)
Medium............................ 13 5 2.7 (1.0, 7.7)
High.............................. 2 6 0.3 (0.1, 1.5)
P trend........................... ...... .......... .50
------------------------------------------------------------------------
a Frequency refers to occasions per moth: ``low'' is less than once a
month, ``medium'' is 1 to 4 times a month, and ``high'' is more than 4
times a month.
b Adjusted for child's age at the reference date, sex, household income
at the reference date, and maternal education.
c Referent category.
d Not all respondents reporting participation specified frequency.
TABLE 3.--Distribution of Cases and Controls by Indoor House Painting in Subject's Home During Year Before
Birth, With Odds Ratiosa (ORs) and 95% Confidence Intervals (CIs)
----------------------------------------------------------------------------------------------------------------
Cases Controls OR 95% CI
----------------------------------------------------------------------------------------------------------------
Ever painted:
No............................................................ 346 359 1.0
Yes........................................................... 289 278 1.2 0.9, 1.5
No. of rooms painted:
Never painted................................................. 346 359 1.0
1-2........................................................... 161 188 1.0 0.8, 1.3
3-4........................................................... 62 48 1.4 0.9, 2.1
>4............................................................ 64 40 1.7 1.1, 2.7
P trend....................................................... .......... .......... .01
Family stayed at home overnight:b
Never painted................................................. 346 359 1.0
Not at home................................................... 25 17 2.3 0.6, 8.9
At home....................................................... 102 109 1.9 0.6, 6.4
Painter:
Never painted................................................. 346 359 1.0
Mother........................................................ 160 152 1.1 0.9, 1.5
Other......................................................... 128 124 1.3 0.9, 1.7
----------------------------------------------------------------------------------------------------------------
Note. Not all respondents who reported painting provided information about the number of rooms painted, whether
family stayed at home overnight, or who performed the painting.
a Adjusted for child's age at the reference date, sex, household income at the reference date, maternal
education, and painting during other periods.
b Also adjusted for number of rooms painted.
Exposure From Household Painting
We observed no significant overall increase in risk (OR=1.2; 95
percent CI=0.9, 1.5) of childhood ALL associated with interior house
painting during the 12 months before the subject's birth, although the
risk was elevated among children whose mothers lived in homes in which
more than 4 rooms were painted during this period (Table 3). Risk of
ALL was not higher among children whose mothers, rather than other
people, did the painting (Table 3).
When risk was analyzed by 3-month periods in the year before birth,
we also found no significant risk during each period except for a small
borderline risk in the 3 months before conception (data not shown).
However, when the study population was analyzed by length of time from
diagnosis to interview, this association appeared to be due to
responses from those interviewed at a more distant time from the
reference date.
Among children residing in homes painted after the subject's birth,
a small, but borderline significant, excess risk was seen (OR=1.3; 95
percent CI=1.0, 1.6). Risk was elevated for painting more rooms (for >4
rooms, OR= 1.6; 95 percent CI=1.2,2.2) and painting more frequently
(for >5 times, OR=1.8; 95 percent CI=1.1, 2.8). When the associations
among those interviewed close to the diagnosis date were examined, risk
remained about the same, but those associations disappeared among
subjects interviewed later.
DISCUSSION
This study found elevated risks for childhood ALL associated with
substantial postnatal exposure to some household activities and
prebirth and postnatal exposure to indoor house painting. There are,
however, several limitations to this study. As in any retrospective
interview study, exposures are likely to be misclassified owing both to
imperfect respondent recollections and to the crudeness of the
information requested. The questionnaire obtained only limited
information on the child's proximity to the activity and none on other
activities that may involve solvents, particularly home renovation,
such as floor refinishing. Moreover, little is known about the relevant
time frame for exposure--whether exposures occurred before conception
(germ cell mutations), during pregnancy (transplacental fetal
exposure), or after birth. With the exception of house painting, the
survey was restricted to postnatal exposures.
Our greatest concern in interpreting the findings is the
possibility that differential reporting errors by case and control
mothers exaggerated estimates of effect.12 The weaker
association with house painting before conception among mothers
interviewed near the reference date substantially weakens the
credibility of an association with preconception painting. However, the
consistency between the other odds ratios and those limited to mothers
interviewed close to the reference date supports the findings.
Unfortunately, the disproportionate delay in interviewing control
mothers limited our ability to check the consistency of associations at
interview times very close to the events in question.
Selection bias due to differential socioeconomic status potentially
could have resulted from use of random-digit dialing for control
selection. Family income, however, was not associated with substantial
participation in model building, artwork using solvents, or furniture
stripping. Moreover, indoor house painting was more common among high-
income controls, which suggests that a selection bias could have
underestimated the association with house painting. Finally,
socioeconomic factors do not appear to have confounded the relationship
between ALL and the activities assessed, because controlling for family
income and maternal education did not appreciably affect the results.
Despite the study limitations, there are several arguments for the
plausibility of the findings. Some epidemiologic studies have shown an
association between paternal occupational exposure to organic solvents
and childhood leukemia in the postnatal period.2,3,10
Exposure of children could occur through inhalation of solvents used at
home or brought home from the workplace on the parents'
breath.19 Previous epidemiologic studies have found positive
associations between childhood leukemia and painting on the job during
the prenatal 7,10,20 and postnatal \10\ periods.
Each of the activities associated with an elevated risk of
childhood ALL involves exposure to organic solvents, some of which are
known or possible human carcinogens. Benzene, a typical constituent in
hobby glues in model building\11\ and in paints,\12\ is an established
adult leukemogenic solvent.\21\ There is a case report of childhood
leukemia following intense exposure to toluene-containing glues used in
model building.\22\ Methylene chloride, the main constituent of
furniture strippers,\13\ is also a possible carcinogen,\23\ and
trichloroethylene, which may be found in paints and varnishes,\24\ has
been found to cause cancer in animals.\23\
As the first large case--control study of childhood ALL evaluating
associations with hobbies and household activities that may involve
carcinogenic solvent exposures, our study is primarily exploratory.
Because of the number of exposures examined, confirmation is required
to rule out false-positive results. Further study is also warranted of
additional household activities involving solvents, with exposure
information for individual chemicals and levels and better delineation
of specific time frames of exposure (prenatal vs. exclusively
postnatal) to illuminate the relevant biological pathways.
ACKNOWLEDGMENTS
This study was supported in part by grants from the National Cancer
Institute (R0I CA 48051 and U01 CA 13539) and by the University of
Minnesota Children's Cancer Research Fund.
The authors gratefully acknowledge Dr. Robert Hoover of the
National Cancer Institute for his thoughtful comments on the
manuscript.
The study was approved by the National Cancer Institute Special
Studies Institutional Review Board and obtained the consent of
participants.
REFERENCES
1. Chow W-H, Linet MS, Liff JM, Greenberg RS. Cancers in children.
In: Schottenfeld D, Fraumeni JF Jr, eds. Cancer Epidemiology and
Prevention. New York, NY: Oxford University Press; 1996:1331-1369.
2. Colt JS, Blair A. Parental occupational exposures and risk of
childhood cancer. Environ Health Perspect 1998; 106:909-926.
3. Buckley JD, Robison LL, Swotinsky R, et al. Occupational
exposures of parents of children with acute nonlymphocytic leukemia: a
report from the Children's Cancer Study Group. Cancer Res.
1989;49:4030-4037.
4. Fabia J, Thuy TD. Occupation of father at time of birth of
children dying of malignant diseases. Br J Prev Soc Med. 1974;28:98-
100.
5. Hemminki K, Saloniemi I, Salonen T, Partanen T, Vainio H.
Childhood cancer and parental occupation in Finland. J Epidemiol
Community Health. 1981;35:11-15.
6. Cocco P, Rapallo M, Turghetta R, Biddau PF, Fadda D. Analysis of
risk factors in a cluster of childhood acute lymphoblastic leukemia.
Arch Environ Health. 1996;51:242-244.
7. Van Steensel-Moll HA, Valkenburg HA, Van Zanen GE. Childhood
leukemia and parental occupation, a register-based case-control study.
Am J Epidemiol. 1985;121:216-224.
8. McKinney PA, Alexander FE, Cartwright RA, Parker L. Parental
occupations and children with leukaemia in west Cumbria, north
Humberside, and Gateshead. BMJ 1991;302:681-687.
9. Feingold L, Savitz DA, John EM. Use of a job-exposure matrix to
evaluate parental occupation and childhood cancer. Cancer Causes
Control. 1992;3:161-169.
10. Lowengart RA, Peters JM, Cicioni C, et al. Childhood leukemia
and parents' occupational and home exposures. J Natl Cancer Inst. 1987;
79:39-46.
11. Rastogi SC. Organic solvent levels in model and hobby glues.
Bull Environ Contam Toxicol. 1993;51:501-507.
12. Wallace LA. Comparison of risks from outdoor and indoor
exposure to toxic chemicals. Environ Health Perspect. 1991;95:7-13.
13. Stewart RD, Hake CL. Paint-remover hazard. JAMA. 1976;235:398-
401.
14. Thomas TL, Stolley PD, Stemhagen A, et al. Brain tumor
mortality risk among men with electrical and electronics jobs: a case-
control study. J Natl Cancer Inst. 1987;79:233-238.
15. Kleinerman RA, Linet MS, Hatch EE, et al. Magnetic field
exposure assessment in a casecontrol study of childhood leukemia.
Epidemiology. 1997;8:575-583.
16. Hatch EE, Linet MS, Kleinerman RA, et al. Association between
childhood acute lymphoblastic leukemia and use of electrical appliances
during pregnancy and childhood. Epidemiology. 1998;9:234-245.
17. Robison LL, Daigle A. Control selection using random digit
dialing for cases of childhood cancer. Am J Epidemiol. 1984;120:164-
166.
18. Robison LL, Neglia JP. Epidemiology of Down syndrome and
childhood acute leukemia. In: McCoy EE, Epstein CJ, eds. Oncology and
Immunology of Down Syndrome. New York, NY: Alan R Liss; 1987:19-32.
19. Monster A, Regouin-Peeters W, van Schijndel A, van der Tuin J.
Biological monitoring of occupational exposure to tetrachloroethene.
Scand J Work Health. 1983;9:273-281.
20. Shu XO, Stewart P, Wen W-Q, et al. Parental occupational
exposure to hydrocarbons and risk of acute lymphoblastic leukemia in
offspring. Cancer Epidemiol Biomarkers Prev. 1999;8: 783-791.
21. Linet MS, Cartwright RA. The leukemias. In: Schottenfeld D,
Fraumeni JF Jr, eds. Cancer Epidemiology and Prevention. New York, NY:
Oxford University Press; 1996:841-892.
22. Caligiuri MA, Early AP, Marinello MJ, Preisler HD. Acute
nonlymphocytic leukemia in a glue sniffer. Am J Hematol. 1985;20:89-90.
23. Lynge E, Anttila A, Hemminki K. Organic solvents and cancer.
Cancer Causes Control. 1997; 8:406-419.
24. Tas S, Lauwerys R, Lison D. Occupational hazards for the male
reproductive system. Crit Rev Toxicol. 1996;26:261-307.
______
AUTHOR NOTE
D. Michal Freedman, PhD, Patricia Stewart, PhD, Ruth A. Kleinerman,
MPH, Sholom Wacholder PhD, Elizabeth E. Hatch, PhD, Robert E. Tarone,
PhD, Leslie L. Robison, PhD, and Martha S. Linet, MD.
D. Michal Freedman, Patricia Stewart, Ruth A. Kleinerman, Sholom
Wacholder, Elizabeth E. Hatch, Robert E. Tarone, and Martha S. Linet
are with the Division of Cancer Epidemiology and Genetics, National
Cancer Institute, Bethesda, Md. Leslie L. Robison is with the Division
of Pediatric Epidemiology and Clinical Research, Department of
Pediatrics, University of Minnesota, Minneapolis.
Requests for reprints should be sent to D. Michal Freedman, PhD,
Radiation Epidemiology Branch, Division of Cancer Epidemiology and
Genetics, National Cancer Institute, Executive Plaza--South, Room 7087,
6120 Executive Blvd, Bethesda, MD 20892-7238 (e-mail: [email protected]).
This brief was accepted July 18, 2000.
CONTRIBUTORS
D.M. Freedman was principal author and analyst of the paper. P
Stewart and R. E. Tarone were involved in interpretation of data,
analysis, and revisions of the paper. R.A. Kleinerman was involved in
data collection, interpretation of data, analysis, and revisions of the
paper. S. Wacholder was involved in the design of the entire study of
which this study is a part, interpretation of data, and revision of the
paper. E.E. Hatch was involved in data collection, the design of the
study--including selection of cases and controls--interpretation of
data, and revisions of the paper. L.L. Robison and M.S. Linet were
involved in the design of the entire study of which this study is a
part, data collection, interpretation of data, and revisions of the
paper.
Reproduced with permission of the copyright owner. Further
reproduction or distribution is prohibited without permission.
__________
Statement of Mary Guinan, MD., Ph.D., Nevada State Health Officer
INTRODUCTION
I am Dr. Mary Guinan, Nevada State Health Officer. I have been
asked to speak today on the status of the continuing investigation and
Federal agency roles in the investigation of cancer clusters.
Status of Investigation
An Expert Panel was convened on February 15, 2001 to guide the next
steps of the investigation. The panel made the following
recommendations:
1. Expand case-finding efforts.--In progress with Navy. Health
Division continues to review cases of leukemia, cancer and other bone
marrow diseases reported to us. All reports are kept on file. Expansion
of search through the Children's Oncology group and California Cancer
Registry will proceed when funding becomes available. (Chronic disease
epidemiologist, part time pediatric oncologist).
2. Categorize the Acute Lymphocytic Leukemia (ALL) cases by
clinically relevant biomarkers.--Need services of pediatric oncologist
and funding for locating tissue and determining what phenotypic and
genetic tests need to be done and identify laboratory to do testing.
3. Identify potential excess environmental exposures unique to the
community.--Test the drinking water of case families whose water supply
is from private wells. Health Division is in process of testing. Nevada
State Health Division has requested assistance from the Centers for
Disease Control and Prevention and the Agency for Toxic Substances and
Disease Registry Human. Representatives of these Agencies will be
coming to Nevada during the week of April 16th to review next steps on
the following issues: (a) Collection of blood and urine samples from
cases and family members for testing for environmental chemicals, (b)
Advisability of dust studies from homes of affected families for
environmental chemicals, (c) Environmental pathways assessment, (d)
Radiologic assessment of milk produced in Churchill County.
4. Collect and Bank Biologic Samples for Future Study.--On hold
until funding is made available and storage sites located.
5. Determine time course and characteristics of population movement
into the Fallon area.--This is part of a bigger picture to provide
evidence for population mixing theory. Although some efforts have
begun, this is much larger research study than State can support.
Federal funding should be made available for this research.
6. Maintain Expert Panel.--Panel members have agreed to continue in
an advisory role.
In addition the State Health Division has: (a) Enhanced access to
public information about the ALL cluster and environmental concerns
through multiple public community meetings in Fallon, the Health
Division website (health2K.state.nv.us) and a dedicated call-in
telephone line. (b) Developed with the Division of Mental Health a
mental health crises counseling and community assistance initiative.
This has received funding from the Nevada Emergency Management Division
and the first steps have been implemented.
LESSONS LEARNED FROM INVESTIGATION OF CLUSTER OF ALL WITH REGARD TO
FEDERAL AGENCIES ROLE
1. Investigation of Cancer Clusters.--Although hundreds of cancer
clusters have been recognized and investigated during the past 30 years
by State and local health departments and Federal agencies, little
information is available on appropriate scientific methods of study
especially with regard to determining causative factors or associated
risk factors. Well over 90 percent of these investigations have found
no associated suspect causative factor. No Federal agency wants to
expend scarce resources in investigation of cancer clusters that are
likely to show nothing. However State (or local) health departments
must investigate clusters to ensure that a dangerous environmental
agent is not present in the community contributing to the increase in
cancer cases.
While several Federal agencies have expertise in some part of
cancer cluster investigations, no one agency has a comprehensive
mandate. We have identified gaps in information available to States as
follows:
1. No repository of information exists on the occurrence of cancer
clusters (i.e., surveillance of cancer of clusters) or to record the
results of these investigations.
2. Lack of a standard or a ``best-practices guidance'' for the
investigation of cancer clusters.
3. No information to identify characteristics of clusters that
might be most productive to investigate.
4. No resources available to State to implement investigations of
clusters with the most promise of advancing the science of cancer
causation.
Bringing together all the relevant Federal Public Health Agencies
(National Cancer Institute, Centers for Disease Control and Prevention,
Agency for Toxic Substances and Disease Registry) and Environmental
agencies to develop a comprehensive approach to the study of cancer
clusters (which would include at minimum the 4 activities listed above)
would greatly enhance the speed, efficiency and scientific validity of
cluster investigations. A guidance for best practices for investigation
of clusters would reassure the community that standards do exist for
these investigations and that health departments efforts can be
evaluated in comparison to the standard. Recognition of clusters that
may be most productive in finding evidence for causation of cancer and
providing resources for the appropriate study of such clusters would
prevent lost opportunities and maximize the probability of advancing
the science of cancer causation.
2. Environmental Factors.--The cause or causes of acute lymphocytic
leukemia are largely unknown. Theories of causation have focused on two
main theories, (a) environmental agents such as chemicals or radiation
or (b) infection with a virus or bacteria that results in genetic
damage that eventually causes leukemia. Studies of suspect infectious
and environmental agents for the most part have not been fruitful.
What the environmental factors should be monitored by health
departments in a systematic way? No consensus exists on the minimum
standards for environmental surveillance. It would be of immense value
to the States if all the involved Federal agencies could be brought
together (perhaps by ASTHO, an organization of State health officials
or another non-governmental agency) and come to consensus on what
constitutes the minimum standard for environmental surveillance for
State health departments.
The Environmental Protection Agency is often in conflict with
Federal Public Health Agencies on assessment of risks to health of
environmental contaminants. This results in a bizarre mixture of
conflicting standards for which States are held accountable. EPA should
be required to work with Federal Public Health agencies to resolve
conflicts on interpretation of scientific data before implementing
regulations for the States.
In the Churchill County area many environmental agents are present
that may constitute a risk for health, including excess arsenic in the
drinking water supply. A great deal of information is available about
arsenic in the water and steps have been taken by the city of Fallon to
reduce the arsenic in the municipal drinking water. However, community
concerns have surfaced about other agents in the environment for which
we have much less information. These include jet fuel from Naval Air
Station, radioactive substances that may resulted from nuclear testing
that was done in 1963 about 20 miles away from Fallon (Project Shoal
conducted by Department of Energy), pesticides used for insect control
and agriculture, chemical pollutants from industries in the area and
air contamination with radioactive or chemical debris from the Sierra
Army Depot in California which is about 3 miles from the Nevada border.
One of the requirements for the explosion or burning of munitions at
this depot is that the wind is blowing toward Nevada at a certain speed
before the explosions can take place. There has been no monitoring of
the contamination of the air that blows into Nevada from the depot.
Therefore no data are available on this potential source of
environmental contamination. Despite numerous requests the
Environmental Protection Agency has not required California to be
accountable to Nevada to ensure that toxic substances are not blown
into Nevada from the operation of this depot.
Like all States Nevada does not have jurisdiction over private well
water used for drinking water, nor does any Federal agency. The safety
of drinking water from these wells is unknown. Churchill County has
many households whose water supply comes from private wells. How to
ensure the safety of drinking water from private wells is a critical
issue for all States. Federal agencies may have a role in providing
guidance on solutions to this public health issue.
3. Community Mental Health.--Recognition of a cancer cluster in a
community is associated with increased stress for the community. The
need for preventive mental health services must be assessed. The Nevada
Health Division and Mental Health Division have partnered to begin a
community mental health initiative in Fallon to assess the need for and
to provide the necessary mental health services for the affected
families and the community at-large.
It would be of great value to have a model for providing such
services for communities experiencing cancer clusters. The National
Institute for Mental Health and other Public Health agencies have a
role in providing guidance for determining mental health needs and
providing resources for these services during crises.
______
ATTACHMENT
Review and Recommendations of the Expert Panel
The expert panel was convened on February 15, 2001 in Reno, Nevada
by Dr. Mary Guinan, Nevada State Health Officer. The panel reviewed the
State health department's investigation of acute lymphoblastic leukemia
(ALL) cases that had been diagnosed in Churchill County, Nevada. The
panel considered possible followup actions and priorities by the Nevada
Health Division. The meeting of the expert panel was attended by panel
members and staff from the Nevada Health Division, University of Nevada
School of Medicine, Nevada Governor's Office, U.S. Senate (Senator John
Ensign's Office and Senator Reid's staff on U.S. Senate Committee on
Environment and Natural Resources), and the Fallon Naval Air Base. This
report summarizes the panel's review and recommendations.
The expert panel recognized the difficulty in evaluating and
investigating excess occurrences of ALL. The panel members acknowledged
that the cause(s) of ALL are insufficiently understood to single out a
specific factor as explaining the observed excess in Fallon, Nevada.
The panel members were familiar with previous investigations of ALL
clusters, all of which had failed to uncover an explanation of the
cause of these excesses. At the same time, the panel members confirmed
that the excess occurrence of ALL in Fallon, Nevada is unusual; not
only because of it's large number of observed cases among so small a
population-at-risk over a short time period, but also because further
observed ALL cases had been diagnosed after the initial recognition of
the ALL excess. The members of the expert panel acknowledged the
excellent work of the staff of the Nevada Health Division on this
investigation.
Scientific understanding of the biology of ALL prevented the
committee members from predicting the cause of the observed excess of
cases in Fallon. The committee is aware of at least three distinct sets
of possibilities. The first set of theories collectively point toward a
cancer causing chemical contaminant (e.g., human carcinogen) as the
causal agent for the ALL epidemic. Theories about a chemical in the
environment have received the greatest amount of public attention and
community concern. The expert panel recognizes the need to address
community concern regarding the presence of a hazardous chemical
contaminant. However, the absence of cases of acute myeloid leukemia,
the type of leukemia most commonly associated with toxic chemical
exposure (1-3), argues against the Fallon cases being the result of
toxic exposures. The panel members were skeptical that a chemical
exposure could explain the excess cases of ALL in Fallon, Nevada. A
second possible explanation relates to the theory of what is called
population mixing in which clusters of ALL have been reported
associated with unusual mixing of people, often in relatively isolated
rural areas (4-11). The population mixing theory initially focused on
the possibility of an unidentified infectious agent (i.e., a virus).
However, the current consensus is that exposure to a variety of
infectious agents (i.e., viral and bacterial) may trigger an unusual
and rare reaction that affects a very small number of children within
the susceptible population. The hypothesis suggests that ALL is not
infectious, spreading from one person to another; but an unusual
complication to a common infection within a susceptible population. The
population-mixing theory is supported by the observation that excesses
of ALL eventually subside, presumably because of increased population
immunity. This theory requires further examination. The panel believes
it reasonable to test this hypothesis by calculating rates of ALL in
other rural areas of the U.S. having significant population mixing.
However, such an effort falls outside the mandate of the Nevada Health
Division. Finally, the possibility that the excess of ALL cases is due
to random chance cannot be totally excluded as an explanation. The
panel acknowledges, however, that the excess of ALL cases in Fallon,
Nevada is not likely to represent a ``chance'' occurrence.
The expert panel recommends to the Nevada Health Division six
followup steps in the investigation of the excess occurrence of ALL in
Fallon, Nevada (see Table 1).
The purpose of these next steps are to: (1) efficiently expand
case-finding efforts, (2) categorize the observed ALL cases by
clinically relevant disease biomarkers, (3) identify potential excess
environmental exposures unique to the community by a cross-sectional
exposure assessment of selective contaminants and an evaluation of
contaminant releases into the local environment with assessment of
completed pathways for the case families, (4) collect and bank biologic
specimens for future scientific investigations, (5) determine the time
course and characteristics of population movements into the Fallon area
for the period 1990 to 2000, and (6) maintain an expert panel to peer
review investigative protocols and study results, consider future use
of banked specimens, and provide ongoing consultation to the Nevada
Health Division.
The expert panel also discussed the importance of high
concentrations of arsenic in municipal and private drinking water
supplies. The panel members expressed doubt that arsenic consumption in
drinking water, by itself, could explain the observed ALL excess for
several reasons: (1) The excess occurrence of ALL began in 1999,
whereas the arsenic concentrations in drinking water have been
consistently elevated for many years. (2) The case children who make-up
the excess occurrence of ALL differ in respect to their consumption of
arsenic contaminated drinking water. (3) Epidemiologic studies of
arsenic exposed populations have not linked arsenic exposure with adult
or childhood leukemia. One recent article suggests a weak association
between childhood leukemia risk and exposure to low levels of arsenic
in drinking water (12). The panel has reviewed the article and believes
that the study is inadequate to support a conclusion that ALL is
related to arsenic in drinking water. Each panel members expressed
concern that the ongoing exposure to excess levels of arsenic in
drinking water was a human health hazard, regardless of its
relationship to the excess of ALL. The Fallon municipal water supply is
contaminated with arsenic (As) at a level 10 times the EPA recommended
standard for arsenic in drinking water. The panel was also aware that
an unknown proportion of Churchill County drinking water wells,
unregulated by the Federal Safe Drinking Water Act (SDWA), are at least
as contaminated as the Fallon municipal water supply. Arsenic is
recognized by the Report on Carcinogens of the National Toxicology
Program as a known human carcinogen on the basis of epidemiologic
studies that have linked arsenic exposure with an excess of skin,
bladder, and lung cancers in exposed human populations.
The expert panel recommends that arsenic concentrations in the
Fallon municipal drinking water be reduced to a level no more than that
currently recommended by EPA (e.g.; 10 g/L) as soon as
possible. The panel strongly encourages the Nevada Health Division, and
other State agencies, to proceed with recommendations for testing
arsenic in all drinking water wells in Churchill County that are
unregulated by the SDWA. The State health division should work to
create a process providing this service when necessary and develop a
set of recommendations for preventing arsenic exposure based on
reported test results. The State health division should consider
maintaining a listing of wells that have been tested along with test
results.
Table 1: Investigating the excess occurrence of Acute Lymphoblastic
Leukemia in Fallon, Nevada: Phase II Recommendations of the Expert
Panel (February 15, 2001)
Priority Task/Timeframe/Collaborators
1. Efficiently expand case-finding efforts. The panel members
encourage the Nevada Health Division to continue limited case-finding
strategies. The panel members recommended limited expansion of case-
finding by linking to:
A. The national Childhood Oncology Group (COG) data bases(s) to
identify all children with ALL having a residence at time of diagnosis
in the State of Nevada. The purpose of this would be to evaluate
completeness of the Nevada tumor registry and identify additional ALL
cases from Churchill County.
B. An ongoing case-control study of ALL being conducted in
California to review residential history of cases for previous
residence in Churchill County, Nevada.
C. The California State Tumor Registry to identify any children
with ALL with a Nevada residence at time of diagnosis.
Timeframe.--These additional steps could be done within 2 months
after satisfactory negotiations regarding patient confidentiality are
completed.
Potential Collaborators.--Clinical Oncology Group, California Tumor
Registry, California ALL research team.
2. Categorize the observed ALL cases by clinically relevant disease
biomarkers. Cancer cells from each case-child have probably been
collected and undergone immunophenotyping and cytogenetic testing. The
health division should collect this information. If testing has not
been done and tumor cells have been stored, the health division should
secure samples and have them tested. These materials could be reviewed
or tested at two independent laboratories. The distribution of these
results among the case-children from Fallon can be compared against
other children with ALL to determine if these distributions are similar
or if the distribution among the Fallon case-series is unique.
Timeframe.--The health division should proceed to determine
availability of data or tumor cells as soon as possible.
Potential Collaborators.--Pediatric oncologists, Childhood Oncology
Group, National Cancer Institute.
3. Identify potential excess environmental exposures unique to the
community. The health division should conduct limited testing for
current exposures in environmental media or human samples as well as
evaluate contaminant releases into the local environment and assess the
potential for human exposure to such contaminants. This analysis would
be used to identify chemicals that are (and are not) elevated in the
community and to consider if additional data collection is required.
A. A cross-sectional exposure assessment of selective contaminants
would include examination of drinking water, human blood and urine of
family members, and possibly dust collected from homes where case-
children did and did not live. Testing should be limited to compounds
for which normative data are available. The expert panel recommended
testing for volatile organic compounds in drinking water and human
tissues; radioactive isotopes in drinking water; selected heavy metals
in drinking water, household dust, and human tissues; and pesticides in
human tissues and in household dust.
B. An evaluation of contaminant releases into the local environment
with assessment of completed pathways for the case families. The expert
panel recommends collecting environmental release data, including that
from local industry and the Fallon Naval Air Station. An assessment of
the potential for environmentally released chemicals to result in human
exposure should also be conducted, including potential for case-
children to have been exposed.
Timeframe.--These activities will require development of survey and
sampling protocols and appropriate review of consent forms and
confidentiality agreements. The committee anticipates startup of these
activities during the months of March or April and available results
within 1 year.
Potential Collaborators.--National Center for Environmental Health,
Centers for Disease Control and Prevention; Agency for Toxic Substances
and Disease Registries; Jonathan Buckley (University of Southern
California) for input on measuring housedust for pesticide residues,
heavy metals, PAHs. .
4. Collect and bank biologic specimens for future scientific
investigations. The members of the panel recognize how limited our
knowledge is of the cause(s) of ALL and the difficulty investigators
have had in identifying the causes of similar ALL excesses. The panel
members believe that collection of biologic specimens from case-
children and family members may be useful for future research
investigations into the cause(s) of ALL. A small amount of blood and
urine, and perhaps buccal cells, should be collected, maintained, and
made available for future research.
Timeframe.--Collection of specimens could occur simultaneously with
the exposure assessment (see 3A) or include samples taken during
clinical care. A protocol for collection, storage, and access to
samples must be developed and reviewed by an Institutional Review Board
for compliance with human subject research.
Potential Collaborators.--Nevada Public Health Laboratory, National
Center for Environmental Health, Centers for Disease Control and
Prevention, National Cancer Institute as possible repositories for the
tissue bank.
5. Determine the time course and characteristics of population
movement into the Fallon area for the period 1990-2000. The expert
panel recommends collecting demographic data concerning changes in the
population of Fallon, specifically looking for evidence of large
migration of new long-term residents into the community during this
time period. The appended table illustrates the kind of first-level
information that is relevant to this issue.
Timeframe.--Initial data collection within 2 months.
Potential Collaborators.--Public school systems and Fallon Naval
Airbase (for information concerning migration patterns), Drs. Les
Robison and Malcolm Smith (for consultation to identify the specific
data required).
6. Maintain the expert panel to peer review investigative protocols
and study results, review proposals for future use of banked specimens,
and provide ongoing consultation to the Nevada Health Division.
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__________
Statement of Randall Todd, State Epidemiologist, Nevada State
Health Division
Good morning Mr. Chairman and members of the committee. For the
record my name is Dr. Randall Todd. I am the Nevada State
Epidemiologist and work for the Nevada State Health Division. I would
like to briefly describe the Health Division's investigation into the
cluster of childhood leukemia in Churchill County and discuss the role
of Nevada's Central Cancer Registry.
The initial phase of our investigation consisted of confirming the
diagnosis of each reported case and conducting an interview with each
case family to identify any potentially common characteristics or
environmental exposures that might point to a preventable cause. We are
indebted to the Centers for Disease Control and Prevention as well as
the Massachusetts Department of Public Health for their assistance in
providing us with model interview instruments.
The case family interviews were conducted face-to-face with each
family. This involved a detailed review of the family's residential
history from the date of diagnosis back to a point in time 2 years
prior to conception of the ill child. For each residence we inquired as
to the source of water, in-home treatment of water, and uses of water.
We also inquired about known exposures to chemicals from agricultural
or home use of herbicides and pesticides as well as indoor uses of
chemicals and solvents. For each parent, we also inquired about
occupation and occupation-related exposures to chemicals, fumes, dust,
or radiation. We conducted a detailed review of the child's medical
history and the mother's pregnancy and breast-feeding histories.
Finally, we asked case families about any hobbies, sports activities,
or typical travel destinations that might have brought them into
contact with chemicals, fumes, dust, or radiation.
From this interview process we learned that half of the case
families had spent 2 years or more in the Fallon/Churchill County area.
The others had resided in the area for shorter periods of time. The 12
case families had resided in a total of 88 different homes over their
respective time periods of interest. Of these, 22 were located within
Churchill County. Of these 22 local residences, half were served by
public water systems while the others obtained their water from
domestic wells.
Our initial analysis of the occupational, medical, environmental,
and other historical information provided by the case families has not
suggested any particular common denominator that would link these cases
together. We recognize, however, that some of our data is subject to
recall limitations on the part of the families. Specifically, they may
not have known of an environmental exposure that did, in fact, exist,
or may have forgotten about it. For this reason we are currently taking
steps to obtain additional data through objective environmental
sampling. This constitutes a second phase of the investigation.
We are now in the process of obtaining water samples from those
current and former case residences in Churchill County that are served
by domestic wells. These samples are being subjected to the analyses
that are routinely done for public water systems. In other words, any
test required by the safe drinking water act for public water systems
is also being conducted on the water samples obtained from the wells of
residences where case families have lived. The results of these
analyses are pending at this time.
We have also invited the Centers for Disease Control and Prevention
as well as the Agency for Toxic Substances and Disease Registry to
assist us in identifying and analyzing completed pathways for other
sources of environmental contamination. This would include industrial,
agricultural, military, or other sources.
On a parallel tract with these environmental studies we are also
collecting data on the overall population dynamics in Churchill County.
This includes looking at size of various age cohorts over the last 10
years, school enrollment information, and military populations. This
analysis will help to determine if Churchill County matches the profile
of other communities around the world where population mixing has been
suggested as a possible explanation for increased rates of childhood
leukemia.
In closing, I would like to make some brief comments as to the
importance of cancer registries in the conduct of cancer cluster
investigations. Nevada has maintained a population-based cancer
registry since 1979. This activity has been funded, in part, through a
grant from the Centers for Disease Control and Prevention since 1995.
All disease reporting systems, including cancer registries,
experience a lag in time between the diagnosis of a case and the
reporting of that case. With a disease such as cancer, the patient
record may not be complete enough to warrant abstracting information
until about 6 months from the date of diagnosis. Additional delays in
obtaining information beyond this 6-month time period relate to work
load and staffing. In the more rural parts of Nevada, this situation is
made even more difficult due to the distances involved and the
relatively low number of acute hospital beds in each facility making it
a costly and time consuming process to collect rural data. For these
reasons, if a cancer cluster is identified through a cancer registry it
is likely to have been going on for some time.
The increased incidence of childhood leukemia in Churchill County
was not identified through analysis of cancer registry data. The local
hospital, physicians, and community leaders noted the cases and
perceived the numbers to be unusually high. Nevertheless, Nevada's
cancer registry has been invaluable in helping to place the observed
number of childhood leukemia cases in historical and geographic
context. Only through analysis of cancer registry data have we been
able to calculate the usual rate of childhood leukemia and determine
that the local cases represent a significant excess over the expected.
I hope this overview of our investigation to date and the role of
cancer registries has been helpful. I would be happy to answer any
questions the committee may have.
__________
Statement of Rear Admiral Richard J. Naughton, U.S. Navy, Commander,
Naval Strike and Air Warfare Center
Good Morning. My name is RADM Richard J. Naughton and I am the
Commander of the Naval Strike and Air Warfare Center located at Naval
Air Station, Fallon, NV. Here with me this morning is CAPT David A.
Rogers, the Base Commander. We welcome the opportunity to testify
before the Environmental and Public Works Committee on military
activity in the Fallon area, particularly as it may pertain to
Churchill County's recent childhood Leukemia cluster situation.
I will begin with a short discussion of the mission and operations
at Fallon followed by some remarks on items I know are of special
interest to the committee members. I will then be happy to entertain
questions. Let me assure the committee members that the United States
Navy is committed to public health and assisting this continuing
investigation in any way possible. One of the cases in question is the
child of a military member stationed at Fallon and three fourths of our
base population of 7200 personnel and their family members live off
base. The Navy's Bureau of Medicine has just completed an extensive
screen of Naval Cancer cases which might be related to being stationed
at Fallon. Their review of over 12 million records from 1997 to the
present revealed just the one Navy case already identified. The Navy is
also committed to exploring the Expert Panel's Population Mixing Theory
and has shared data on transient activity at NAS Fallon with the State.
While further examination of similar demographic data in other military
locales (i.e. small isolated communities near military bases with large
numbers of transients in training) would appear prudent, it will take a
coordinated effort by the entire Department of Defense to conduct such
a study.
As many of you know, NAS Fallon has been in operation since 1942.
The focus of the base was squadron level air-to-ground combat training
until 1984, when the Navy established the Naval Strike Warfare Center
(``Strike University'') and began focusing on training entire air wings
(1500 personnel and 70 aircraft) in an integrated fashion. The mid-
eighties also saw the development of the Fallon Range Complex--an
instrumented Military Operating Area flown over 6.5 million acres East
of Fallon. The majority of the land we fly over is managed by the
Bureau of Land Management, as the Navy only directly controls 204,000
acres. The third major change in the mid-eighties was the outsourcing
of many of the functions on the base, which is reflected in our current
percentage of contractors (55 percent). 1996 saw the consolidation of
all graduate level aviation flight programs at Fallon with the arrival
of ``Topgun'' and ``Topdome'' from Southern California and the
establishment of a senior two-star Flag officer on the base as Naval
Strike and Air Warfare Center, or NSAWC. As NSAWC, I report directly to
the Chief of Naval Operations and provide oversight for training of
approximately 55,000 sailors a year. The base has conducted an average
of 40,000 flights a year for the past 5 years, with a 4 to 5 percent
increase over that time. The investment in NAS Fallon since 1984 has
been almost $300 million dollars.
I would like to discuss some of our specific operating issues as
they might pertain to this investigation. First, the consolidation of
all of our training here in 1996 did not appreciably change the way we
conduct operations. We fly the same aircraft and the number of flights
has only increased by 4 to 5 percent. In fact, our two biggest years in
terms of flight generation at NAS Fallon occurred in 1990 and 1991 in
preparation for Operation's Desert Shield/Storm. The type of flight
training NSAWC conducts has remained unchanged, particularly from an
environmental perspective.
Second, NAS Fallon's Environmental, Safety, Operations and Weapons
Departments are responsible for the administration of all of our
environmentally sensitive materials. For anything we use, there's a
program for safely handling and disposing of it where applicable. We
follow guidelines established by Federal, State, Department of Defense
and the U.S. Navy and arguably more heavily regulated than the private
sector. Programs such as Fuel Handling, Air Emissions, Hazardous
Materials Disposal, Electromagnetic Radiation Effects and Installation
Restoration are all inspected on a regular basis and have received high
marks for compliance. We have shared the details of each program with
the State Health Division and Expert Panel and are prepared to do the
same with the Agency for Toxic Substances and Disease Registry when
they visit next week.
Third, NAS Fallon's drinking water supply services the 3000
personnel who work on the base and up to 2000 transients at any one
time. It is separate from the city of Fallon's but taps the same Basalt
Aquifer with the resultant water chemistry being identical. The base
tests our water supply routinely and also monitors for contamination of
the 8000 acres of base property through the use of 218 environmental
monitoring wells. No DoD activity-related contaminants have ever been
detected in the Basalt aquifer or leaving base property. While the
State and Select Panel investigations have not established a link
between Fallon water arsenic levels and the Leukemia cluster, these
levels are a matter of concern to the Navy. We are working on a joint
DoD/city of Fallon water treatment facility.
My detailed written statement previously submitted for the record
contains further information on NAS Fallon activity as it might relate
to this investigation. It also lists points of contact for additional
information if required. Thank you for your attention. I will now
entertain any questions.
______
Statement of RADM Richard J. Naughton, USN Commander, Naval Strike and
Air Warfare Center and CAPT David A. Rogers, USN Commanding Officer,
NAS Fallon 12
The following paragraphs are designed to provide the reader with
background on operational activity at NAS Fallon, NV as it relates to
the environment in general and the leukemia cluster in specific. The
Navy is committed to public health and will assist the State-led
investigation in any way desired. Specific points of contact are listed
for further detail if required.
1. MILITARY TRAINING ACTIVITY AT FALLON WITH POSSIBLE
ENVIRONMENTAL CONSEQUENCES
A. Fuels
1. NAS Fallon's fuel is supplied by the Kinder-Morgan Company of
Sparks, NV, through a 70-mile pipeline. The pipeline is cathodically
protected with induced current and monitored. It is also visually
inspected by air weekly, visually inspected by truck bi-weekly and kept
under pressure even when fuel is not being pumped so as to monitor for
leakage. No leaks have ever been detected. The point of contact at
Kinder-Morgan is Mr. Girard Gonyeau at 775-358-6971.
2. Spills.--The Nevada Division of Environmental Protection
strictly regulates fuel spills. There are reporting requirements for
spills over 25 gallons, spills that contaminate three cubic yards of
soil, or spills of any amount that contaminate surface water.
3. More than 95 percent of fuel spills are confined to paved areas
on the flightline, runways or taxiways. The average spill is about 15
gallons, and there have been an average of 60 of those per year over
the last 10 years. Spills on paved areas are cleaned-up immediately
using absorbent pads or absorbent media. Spills on soil are cleaned by
excavating and subsequent proper disposal of the contaminated soil.
These procedures and amount of spillage are similar to procedures and
amounts at any commercial airport with a similar operating tempo.
4. The largest spill in the last 5 years was approximately 400
gallons. The spill resulted from a break in an underground fuel
delivery pipeline. All soil contaminated by the spill was excavated and
transported to an authorized treatment facility near Mustang, NV.
5. Fuel venting.--This is also heavily regulated. We must report
all incidents and must vent fuel above 6000 feet above ground level.
Above 6000 feet, 99 percent of fuel is vaporized. Fuel may be vented/
jettisoned below 6000 feet only in an actual aircraft emergency. The
last 15 years worth of data show an average yearly vent of 3.5
occurrences above 6000 feet (1500 gallons total). There have been three
occurrences in 15 years where fuel was vented below 6000 feet (800
gallons total)--each was east of the base on BLM property and nowhere
near population centers (the nearest settlement East/Southeast of the
base is Middlegate Station located 32 miles East/Southeast.
6. Aircraft mishaps (crashes).--Of the 12 mishaps in the last 15
years, nine were in the operating area on BLM land or on Navy property,
the remaining three were on private property. Ten of 12 had fire
associated with the crash that consumed residual fuel. State Health
department personnel have determined that there were no long term
environmental impacts from any of those events.
B. Air Emissions
(1) NAS Fallon has just completed an extensive modeling effort for
base air emissions endorsed by the State Environmental Division. The
modeling shows that NAS Fallon meets all Nevada ambient air quality
standards.
(2) The base has many detailed reports on the composition of jet
exhaust, which varies by type of aircraft. Each of these is monitored
by the Nevada Division of Environmental Protection and United States
Environmental Protection Agency to assure public safety. While the
quantities of materials released into the atmosphere vary according to
aircraft type, they essentially involve a mix of the following five:
Carbon Monoxide, Nitrogen Oxide, Sulfur Oxide, Hydrocarbons and
Particulate Matter, each of which are relatively common at most
industrial sites, particularly airports. The total amount of all
contaminants released into the atmosphere equates to 1500 parts per
million per day at an average operating tempo (115 flights per day).
This equates to approximately half that of the Reno-Tahoe International
Airport. Commercial ``Jet-A'' fuel is composed of the same basic
materials and burns in an almost identical fashion to that of military
``JP-8'', the primary difference being the addition of an anti-icing
agent in JP-8.
(3) The fire department open burns approximately 30,000 gallons of
jet fuel per year in training permitted under the Nevada Division of
Environmental Protection Bureau of Air Quality. The fuel is burned no
more than four times per month and/or two times in any week. When it
occurs it is also dependent on the winds, which must be blowing at
least five knots from the West to avoid blowing the smoke toward the
community. The chemicals contained in fire smoke are roughly twice that
contained in jet engine exhausts. The total amount released into the
atmosphere equates to 1/1000th of that released by the jet traffic at
the airfield. Other fire departments around the country routinely burn
fuel for training.
C. Other Hazardous Materials (HAZMAT)
Other HAZMATs (cleaning solvents, paints, pesticides, photo
processing, vehicle fluids, etc.) are routinely used on base. An
extensive HAZMAT handling facility and program is managed by the NAS
Fallon Supply Department with oversight from the Industrial Hygiene
Office, the Safety Office, the Environmental Office and the Weapons
Department. All hazardous waste generated by station operations is sent
to permitted treatment, storage and disposal facilities. Details are
available from the NAS Fallon Supply Officer, CDR Troy Brannon, 426-
2750, or NAS Fallon Environmental Division Head, Mr. Doug Bonham at
426-2772.
D. Electromagnetic Radiation (EMR) Hazards
(1) A survey of electromagnetic radiation hazard for NAS Fallon is
conducted approximately every 3 years by the Department of Defense
Inspector General Office. No significant hazards of electromagnetic
radiation to personnel situations were detected on the Naval Air
Station. The systems used at NAS Fallon include aircraft navigational
aids, radar for aircraft and weather, radios, cell phones, electronic
warfare (EW) equipment and aircraft. Equipment used at NAS Fallon
adhere to the DOD radio frequency safety standards and the Institute of
Electrical and Electronics Engineers recommended practice for the
measurement of potentially hazardous electromagnetic fields and
microwave. (The standard developed by representatives of industry,
government agencies, scientific communities and the public.)
(2) Standard operating procedures are used to protect Navy
personnel and the public from EMR hazards. These procedures include
setting the height and angle of transmission to avoid direct exposure,
posting warning signs, activating warning lights when the radar are
operational, and/or securing sites with fencing. EMR from EW systems is
the same type as emitted by cell phones, hand-held radios, walkie-
talkies, commercial radio, and television stations. EMR from a typical
EW site averages less and 0.325 milliwatts per square centimeter; EMR
from a cell phone is 1.19 milliwatts per square centimeter. Other
sources of EMR include navigation aids and radar. These systems are the
same or similar to civilian navigation aids and radars at airports, TV
weather stations, and aircraft navigation aids throughout the United
States. All systems have safety limits to prevent potential hazard.
Measures are also in place to prevent hazards from EMR emitted by
military aircraft. The majority of EMR is emitted in the training
airspace east of the Naval Air Station.
E. Depleted Uranium (DU) Ammunition.
Depleted uranium is the inert, low-radioactivity uranium which
remains after more-radioactive isotopes have been separated from
natural uranium or spent reactor fuel. DU is used globally in private
industry as radiation shielding, ballast and counterweights in
commercial and military aircraft. The U.S. Military continues to use DU
projectiles because of their extraordinary effectiveness as anti-armor
munitions. Chemically and toxically, DU is no different than the
natural uranium found in air, soil and water everywhere on earth. DU
ammunition has never been used, nor is it authorized for any of the
Fallon ranges.
F. Chaff
(1) Radio Frequency (RF) chaff is a glass fiber substrate with a
thin coating of aluminum. Typical chaff rounds contain 200,000 fibers
(.001 inches in diameter) and weigh five ounces. Chaff is expended on
our ranges east of Fallon to train aircrew on vital defensive
countermeasures when encountering enemy surface-to-air missiles. As a
chaff bundle is deployed from an aircraft, it ``blossoms'' to attract
or decoy the enemy radar. The fibers will disperse with the prevailing
wind.
(2) Historical concerns about chaff have revolved around its
potential harm to the environment. In March 2000, an independent study
on the environmental effects of RF chaff by a team of research
scientists from various universities concluded that existing chaff
systems are environmentally benign and not a health hazard. The
chemical composition is very similar to that of desert dust. A copy of
this report is available from the NSAWC Range Department, LCDR Lynn
Tawney at (775) 426-2108.
(3) The total amount of chaff expended on the Fallon ranges amounts
to \1/4\ ounce per acre per year. This amount is several orders of
magnitude less than EPA standards for dust, vehicle exhaust, power
generation and industry.
2. INSTALLATION RESTORATION (IR) PROGRAM
A site investigation to determine the nature and extent of possible
contamination at NAS Fallon was begun in 1988. Past practices had
resulted in contamination by fuels such as gasoline, diesel and jet
fuel; solvents containing PCE and TCE; and landfills containing
garbage, trash, and demolished building materials including asbestos.
Fuels and solvents have contaminated the shallow groundwater (between
4' to 10' below ground surface) beneath portions of the base. Over 100
wells are systematically sampled to monitor these contaminants and
ensure that the contaminants are controlled before they could effect
human health or the environment. The program is designed to prevent
contaminated groundwater from leaving the base boundary and to date
none has.
The city of Fallon and the Paiute-Shoshone Tribe pump drinking
water from the deep basalt aquifer near Rattlesnake Hill, over 7 miles
northwest of the base. Due to the nature of the groundwater system in
the Carson desert and the location of NAS Fallon there is no
possibility for the contamination beneath NAS Fallon to reach the
drinking water supply used by the City, Navy and the tribe. The closest
drinking water wells to the main base boundary belong to the Navy and
they are located over 3 miles to the northwest of the base, which, is
the southernmost point of the basalt aquifer. The water in the shallow
aquifer (ground surface to 50 feet) underlying the base flows to the
south away from drinking water supplies. The nearest settlement is 32
miles away.
For questions call John Dirickson at (775) 426-3184.
3. WATER INFORMATION UPDATE
The current EPA arsenic standard is 50 parts per billion (ppb). A
new EPA arsenic standard was finalized at 10 ppb in January 2001. The
EPA Administrator has announced her intention to review the technical
basis for the rule and to extend the effective date for it. NAS Fallon
and the city share the same basalt aquifer water source with resultant
naturally occurring arsenic levels of 90-110 ppb. An EPA Notice of
Violation was issued to NAS Fallon in January 2000 to reduce the amount
of arsenic in the base's drinking water system. In September 2000 the
EPA issued an administrative order requiring NAS Fallon to meet at
least the current 50 ppb maximum contaminant level for arsenic in
drinking water by late 2004. NAS Fallon has three wells that are each
approximately 500 feet deep. The water chemistry for the NAS Fallon
wells and the city of Fallon wells is essentially the same.
Arsenic treatment is required for the city of Fallon in 2003 and
NAS Fallon in 2004. NAS Fallon is conducting pilot studies to select
the best treatment technology. A joint NAS/City effort to construct a
water treatment facility is under consideration. Interim measures at
NAS Fallon consist of:
(1) Free Reverse Osmosis (R.O.) filtered water available at 37
locations on base. All units are tested twice annually to ensure we
meet drinking water standards for arsenic (the R.O. units routinely
test to less than 1 ppb for arsenic).
(2) Commercial bottled water is available in work spaces and at the
Child Development Center.
(3) A free bottled water machine is available 24-hours a day in the
Sierra House of the BOQ.
(4) Free water testing can be obtained by military members not
living in base housing or on the city water system.
(5) R. O. filtered water systems will be installed in base housing
commencing approximately May 1, 2001.
The point of contact for water issues is Mr. Mark Jones (775) 426-
2785.
__________
Statement of Ken Tedford, Jr., Mayor, Fallon, NV
Recognizing that my time is brief, let me begin by saying that the
city of Fallon sincerely appreciates the efforts of the Senators,
Congressman and your staffs--just as we appreciate the work being done
by the Governor's Office and the State Health Division. These are
trying times for our community and, while we have pulled together in
the only way we know how, it is comforting to know that others want to
help.
I'm not going to spend any time discussing the cluster's cause, or
possible links between the children. I believe the State Health
Division and others will cover that. The city has cooperated in every
way we know, first as the steward of the municipal water system and
later as we have begun to assess other city-owned facilities. Thus far,
nothing has been found. We recognize that the Health Division's expert
panel believes that an environmental link may not be found, due in part
to the fact that the ALL found in this cluster is not typically caused
by environmental triggers. Nonetheless, we will continue to cooperate
in that search.
Our efforts have been focused on the children, the affected
families, and public education. The City Council and I have formed a
group called ``Fallon Families First'', comprised of local community
leaders and social service providers, to coordinate these efforts. I
asked my wife Jennifer to chair the committee, and they are doing a
yeoman's work. Please realize that our city does not have a social
service infrastructure. We are too small. So we have had to reach out
to groups like the FRIENDS Family Resource Center, the local hospital,
mental health professionals, the clergy, the school district, the
County and others.
Today there is a single source of assistance for the families, the
Family Resource Center. Patient services are coordinated by the Nevada
Health Advocates in Carson City, and hopefully soon with the National
Leukemia and Lymphoma Society Chapter in Sacramento. Fundraising is
handled through the Mayor's Youth Fund. You can see the white ribbons
worn by guests here today, a suggestion by a mom of one of the
patients. It's the latest step in our effort, and we plan to continue
raising funds as long there are needs.
Fallon Families First recently held its first public meeting, a
panel discussion focused on the disease itself. Local physicians, a
mother of a stricken child, and a mental health professional, who
people know and trust, helped answer the questions weighing on the
minds of those attending. Efforts like this will continue as they are
needed. A series of informational mailings is also being coordinated
with the County and the local telephone company. This week the city
launched its first Web site. Part of this effort has been driven by the
need to communicate about the leukemia cluster, and part by our desire
to be generally more accessible.
So what remains to be done?
I can tell you without hesitation that the most frustrating part of
this process has been the lack of information. People want answers, and
I don't have them. The investigation is ongoing, but it's bound to take
a long time. Where do people go for answers? I believe, in cluster
situations like this, a clear sense of communication needs to be
established early in the process. Perhaps if the State Health Officer
declares a cluster to be in existence, that could trigger a Federal/
State/local partnership. The mayor's office seems to be the place
people automatically go, but in small towns like ours we don't always
have the information. I have assembled my own team of local citizens
and other experts who can help the city. But in other towns, the mayor
might not be so fortunate. I think a standard support team or ombudsman
should be made available to towns like ours.
Finally, I would be remiss if I didn't speak briefly about the
arsenic in our water. I KNOW the Senators are aware of this situation,
just as I know the experts will testify that the arsenic is probably
not linked to the leukemia cluster. But the two things have become
linked in the media and in earlier meetings, so I feel we owe you at
least an update.
Fallon's municipal water supply contains arsenic at levels of 100
parts per billion. The U.S.E.P.A. has ordered us to remove the arsenic,
which is naturally occurring here. As you are well aware, the EPA
standard has long been under review. It was 50 parts per billion. It
was temporarily lowered to 10. Now it is back at 50. We have no idea
where it will finally be set. For the city of Fallon it doesn't matter
any more.
The city of Fallon, through its environmental engineering firm
Shepherd-Miller, has begun pilot testing the technology we will use to
remove the arsenic. It appears that a process called '`enhanced
coagulation'' is working best. We will finish the pilot testing by the
end of May. Then we will design and site a treatment facility. Our goal
is to have construction finished in time to comply with the EPA order,
which gives Fallon until September 2003. This date is significantly
earlier than any other public water system, and it's still not clear
how much arsenic we will have to remove. Nonetheless, we are
proceeding. And we are doing so without regard to costs, or where the
money will come from. We have also been in consultation with U.S. Navy
officials about a joint plant.
My suggestion to this body today is that you make Fallon a test
case. The issue of the EPA standards revolves around ``best available
science'' and the fact that there is no ``off the shelf '' technology
to remove arsenic on a municipal scale. Things like household reverse
osmosis systems won't work on the scale we're talking about here. We
believe that since Fallon is required to remove its arsenic more
quickly than other municipalities, there may be benefits to those who
follow from learning from what we do. Perhaps the Federal Government
could pay for the cost of Fallon's treatment facility, in exchange for
the availability of the science and treatment methods resulting here
that can be utilized by all those who follow.
We're dedicated to treating city water. Others will have to address
the many private county wells that have high arsenic levels. And all of
us will have to respond to public education issues and outside media
attention that now surround the arsenic. But with your help, we can put
this chapter in our history behind us and focus all our energies on the
leukemia cluster, the children and their families.
We must maintain our focus on these families. As I said earlier,
this is a lonely time for our town. Many people want to speculate, many
others are well intentioned in their scrutiny. Others are just curious.
But when the camera lights are off and the media attention fades, our
town will be left to care for our children and assess the long-term
impacts of this unusual cluster. Your presence here today is a chance
to change that. I hope you will be able to stick with us, and I thank
you for taking the time to come here today.
__________
Statement of Gwen Washburn, Chairman, Churchill County Commission
Good morning, Honorable Senators. First, as Chairman of the County
Commission, I want to tell you that the County Administration is first
and foremost concerned about the health and well being of the people. I
am happy to have the opportunity this morning to address the issue of
the leukemia cluster identified in this community, and to discuss ways
to investigate and mitigate the problem. I will give you a little
information about Churchill County and what the County Commission is
doing at this time.
Churchill County has sustained a steady growth of about 3 percent
over the years and now is home to about 26,000 people. The population
is expected to double in the next 15 years. We are a progressive small
community, boasting modern schools, a community college, an arts center
and the most modern hospital in western Nevada. We have a mix of long
time agricultural-oriented families, military personnel, young working
families and retired people. Many people are born and grow old here
with nothing more than average health problems, so the community is
alarmed and feels helpless in the face of a childhood leukemia
epidemic.
The community has reacted to this crisis in a quick and calm
manner, working cooperatively together with all agencies in an attempt
to find any answer or common link between the cases. The County
Commission is very concerned about the health and welfare of not only
our 26,000 residents, but also those that visit us each year as
military personnel or tourists. Certainly, none of us are experts in
the health field, nor are we research scientists. We have no choice but
to leave the investigations to the experts. What we can do, have done,
and will continue to do is support all scientific and responsible
efforts to find an answer.
We have actively participated in Governor Guinn's investigation and
in Assemblywoman de Braga's investigation. We joined forces with the
city of Fallon and Churchill Community Hospital in development and
distribution of a fact sheet (Attachment #1) that attempts to answer
the most commonly asked questions about leukemia and what the community
is doing about it. We also support Mayor Tedford and the Community
Hospital in their individual efforts to assist the families of the
victims with the Fallon Families First organization, and the health
information center.
I, personally, have spent many hours in consultation with personnel
of the University of Nevada, Reno, Extension Service to update and
reactivate a drinking water safety program known as Nevada GOLD (Guard
Our Local Drinking water). The University responded favorably and
quickly by hiring a research specialist to locate and correlate all
existing water studies in an attempt to find any possible cause of
cancers in our local (outside the city of Fallon) shallow wells.
Studies have shown that water from the shallow aquifer is variable and
may contain Magnesium, Sulfates, Chloride, Nitrates, Fluoride, Arsenic,
Iron, Manganese and other minerals above levels recommended by EPA.
(Attachment #2) Nevada GOLD is also teamed with the local hospital to
provide water sample bottles, instructions and transportation of water
samples to the State Health Laboratory giving all well owners the
opportunity to have their water tested for bacteria and heavy metals.
(Attachments #3-7). They also are, rightfully, taking the lead in
educating the public about drinking water safety.
Our local water quality, whether the causative agent or not, was
immediately pointed to as the cause of leukemia by the general
population, encouraged and perpetuated by the media. The matter has not
remained local. We see copies of news articles from across the Nation
with headlines proclaiming Fallon and Churchill County to be an
unhealthy place to live. This press coverage has resulted in damage to
our community. People are turning down jobs, houses go unsold, business
has declined, our sales tax revenues are down and we were recently
listed as a depressed area by EDA, (Economic Development
Administration). (Attachment #8-11).
One of the first questions raised by the general public concerned
the use of chemicals and chemical processes in the county, and what
regulations were in effect to assure public safety. Churchill County
relies on the Nevada Department of Environmental Protection to issue
any emissions and/or discharge permits relative to any business or
industry that locates in our county. The only county requirement other
than proper zoning, until recently, was a business license. Out of
concern for the health and well being of our citizens we now require a
Special Use Permit. This helps county officials and haz-mat experts
know what chemicals are being used in the community. The information
required for a Special Use Permit is also intended to assist emergency
responders, if the need should arise.
We asked ourselves, what has changed in the community since the
early 1990's? Several things emerged. We have no way of knowing which,
if any, of them singly or in combination are to blame until more
research is done. Less irrigation water in the valley to recharge our
shallow aquifers: Are toxins building up in the shallow aquifer? More
people on one-acre lots: Are deep soil disturbances related to
building, more fertilizers and pesticides used for landscaping and
lawns, or nitrates from septic leach lines to blame? The 1997 flood:
Was more Mercury or some other toxin that had previously been
undisturbed released into the Carson River to end up in Lahontan
Valley? The Gulf War: Was some toxic or carcinogenic substance
introduced to the community when personnel and/or equipment returning
from the war came to NAS Fallon? Transportation of hazardous material:
How much hazardous material is being transported through the city of
Fallon in trucks traveling the Highway 95 North/South route, and is it
properly contained? Petroleum based products: Were there changes made
to the chemical formulations of fuels, paints, tars, asphalt,
fertilizers, lubricants, etc?
We are anxious to locate and take reasonable corrective action for
any environmental cause that may be found to contribute to the
incidence of leukemia or like diseases in our community. A thorough and
accurate scientific study of all possibilities will take many years and
millions of dollars. The medical experts have already expended many
resources examining the patients and their families. The community, and
individuals have lent their support. The State of Nevada is considering
committing money. Now I will ask you to do the same.
First and foremost is the proper health care for victims
of leukemia and related illnesses. Provide special assistance funds to
be administered through Social Service programs or special insurance
underwriting.
We need to have thorough scientific research underwritten
by Federal Grants. The studies should seek out information on leukemia
trends before the cluster appeared for the sake of comparison. There is
no doubt that information gathered and analyzed in this area will
provide benefit for other areas also.
Grants to the University of Nevada and Churchill Community
Hospital that will enable them to continue public education programs in
drinking water safety and nutrition and disease prevention is
essential.
Provide low interest, long-term loans to small business
affected by loss of sales through the leukemia scare.
If water is identified as the cause of ANY health risk to our
citizens we need Federal help to build a system to bring safe water to
those who live outside the city limits of Fallon. County Commissioners
have been considering this for a long time and have developed a plan
for the system including a source of supply. (A Draft Copy of the plan
was delivered to Senator Reid in the fall of 2000). The estimated total
cost is in the $200,000,000-$250,000,000 range, obviously far beyond
the means of a small community, even if our population doubles as
predicted. We know the government is developing a plan to assist small
community water systems for towns under 10,000 population. Our
population outside the city of Fallon is about 16,000, too large to
qualify for that assistance, leaving the people who reside in rural
Churchill County in a ``no win'' situation at this time. As a side
note, for many years qualified Veterans have not been able to exercise
their right to guaranteed home loans in this area because of the water
quality. We urge the Federal Government to look at ways to assist areas
such as ours to develop safe water supplies.
In the short term, Federal assistance to help residents
with the cost of testing all existing domestic wells and installing
treatment systems if the water test results deem a system necessary,
would be a blessing to this community. It is estimated that there are
about 4500 domestic wells in use at this time, and complete water
analysis costs about $120 or more per sample. Cost of various in-home
treatment systems range from several hundred to several thousand
dollars, amounts beyond the means of many homeowners.
Churchill County Commissioners have approved a proposed hazardous
materials by-pass route for this community, with the idea of beginning
to acquire rights-of-way for future construction. (Attachment #12) At
this time all trucks that travel north/south on US 95 must travel about
a mile through the city, turn 90 degrees, travel three blocks and turn
90 degrees again on the three busiest streets in town. There are no
truck stops on this stretch of highway for several hundred miles, so
hungry, tired truckers must stop beside the street in town where
thousands of people pass by. This route is very near four schools. The
east/west route is US 50, straight through the heart of town, and
passes near two schools and the hospital. If hazardous waste
transportation should prove to cause ANY health hazard to our community
the Federal Government would be obligated to provide assistance to
build a route that keeps the threat of exposure to a minimum.
On behalf of the Churchill County Commissioners, I thank you for
taking time to listen to our concerns and ideas. We sincerely hope that
you will be able to assist our community in some way to ease the
suffering of the leukemia victims and their families and to help us
find the ways and means to lessen or better yet, prevent more
occurrences of this and other cancers.
______
Responses by Ken Tedford, Jr., Mayor, Fallon, NV to Frequently Asked
Questions about Churchill County Leukemia Cases
Question 1. The city of Fallon prepared this document as a public
service. The City is not considered an expert on the subject of
leukemia. Sources of information include the State Health Division,
National Cancer Institute, Leukemia & Lymphoma Society and American
Cancel Society. In addition, information was taken from newspaper
articles, Web sites and reports prepared by the City's own
environmental consultants. This information is not provided as medical
advice or as an official report of scientific research, but as public
information.
What are the current findings about the leukemia cases in Churchill
County?
Response. A preliminary investigation was conducted by the Nevada
State Health Division to ensure that public health officials were aware
of all cases of childhood leukemia in the area and to identify any
common characteristics among the case families. Case families were
asked about their residential history, sources of water for drinking
and cooking, medical history, family history, and potential sources of
chemical and radiation exposure.
Eight of the eleven cases have been diagnosed in the last 10
months. Patients' ages at time of diagnosis range from 0 to 19 years
old. The cases are scattered throughout Churchill County. All the
patients have acute lymphocytic leukemia (ALL). Nationally, 2,000 new
cases of ALL are diagnosed each year. None of the children from
Churchill County has died from the disease.
State Health officials have completed interviews with 10 case
families and data has been examined for eight of the families. Based on
an initial analysis, there does not appear to be a common
characteristic among the case families. All of them lived in Fallon for
varying lengths of time between 1996 and 1999. The families had various
sources of drinking water (some drank tap water from the municipal
system, some drank tap water from domestic wells, and some drank
bottled water) and reported no consistent exposures to any particular
environmental hazard. It is however, important to note that people may
not always be aware of their exposure to an environmental hazard.
Question 2. What is leukemia?
Response. Leukemia is a form of cancer. Childhood acute lymphocytic
leukemia (ALL) is a disease in which too many underdeveloped infection-
fighting white blood cells, called lymphocytes, are found in a child's
blood and bone marrow. ALL is the most common form of leukemia in
children, and the most common kind of childhood cancer. It is also
referred to as acute lymphobastic leukemia.
Question 3. What is a cancer cluster?
Response. A disease cluster of any kind is the occurrence of a
greater than expected number of cases of a particular disease within a
group of people, geographic area, or a period of time. Cancer clusters
may be suspected when people report that several family members,
friends, neighbors or coworkers have been diagnosed with cancer.
Various statistical methods are used to determine whether the
reported number of cancer cases is really a larger number than would
normally be expected to occur. True clusters are difficult to define
and, if they turn out to be real, the causes are often obscure. Most
non-occupational cancer clusters turn out to be the result of the
random nature of the disease.
Clusters have been identified throughout the world but only one
case can positively be linked with a contaminant. Some high-profile
cancer/leukemia cluster cases include: Tom's River, NJ; Hinkley, CA;
Woburn, MA; La Hague, France; and Seascale, Britain.
Question 4. How are cancer clusters investigated?
Response. Epidemiologists, scientists who study the frequency and
distribution of diseases in populations, may investigate reported
disease clusters, including suspected cancer clusters. Investigations
of suspected cancer clusters can be limited by the current status of
scientific knowledge and tools related to genetics; effects of
environmental factors on humans; the availability of statistics on
cancer and other diseases by local area; and resources.
Question 5. What causes leukemia?
Response. The cause is unknown.
Question 6. What are the risk factors for childhood leukemia?
Response. For the most part, lifestyle risk factors such as diet
and exercise, while important in adult cancers, are not linked to
childhood cancers.
Question 7. What are the symptoms of leukemia?
Response. Early signs of ALL may be similar to those of the flu or
other common diseases. General symptoms can include feeling tired or
weak all the time, weight loss, fever and loss of appetite. Most
symptoms of acute leukemia are caused by a shortage of normal blood
cells. Anemia is a result of a shortage of red blood cells. Anemia
causes shortness of breath, fatigue and a pale skin color. Not having
enough white blood cells can increase the risk of infection. Not having
enough platelets can lead to bruising, bleeding, frequent or severe
nosebleeds and bleeding from the gums.
Question 8. What should I do if I think my child may have leukemia?
Response. Immediately consult your physician or healthcare provider
for assistance, evaluation, and early intervention. Your physician will
complete tests he or she determines to be needed to make an accurate
diagnosis and begin treatment, if necessary. A blood test is required
to diagnose leukemia.
Question 9. How is leukemia treated?
Response. Treatment decisions for each child are based on a number
of individual factors. It is generally treated with chemotherapy.
Chemotherapy refers to the use of anticancer drugs that enter the
bloodstream and spread throughout the body to kill cancer cells.
More than 95 percent of children with ALL enter remission after 1
month of treatment. Remission means that about 99 percent of the cancer
cells have been killed; but there are still some leukemia cells in the
body. That's why further phases of treatment are needed.
Bone marrow transplants are also used in the early stages of some
types of leukemia.
Question 10. Can children who have leukemia be cured?
Response. The overall 5-year survival rate for children with ALL is
80 percent. The aim of treatment is to bring about a complete
remission. Complete remission means that there is no evidence of the
disease and the patient returns to good health with normal blood and
marrow cells. Relapse indicates a return of the cancer cells and return
of other signs and symptoms of the disease. For leukemia, a complete
remission that lasts 5 years after treatment often indicates cure.
Treatment centers are reporting increasing numbers of patients with
leukemia in complete remission at least 5 years after diagnosis of
their disease.
Question 11. Where can I get more information about leukemia?
Response. State Health Division officials have set up a Community
hotline, open weekdays between 8am and 6pm for inquiries: 1-888-608-
4623.
State Health Division Web site, Health2k.state.nv.us
Leukemia and Lymphoma Society of America, www.leukemia.org
or 1-800-955-4572
Childhood Leukemia Center, ww.patientcenters.com
National Cancer Institute, www.nci.nih.gov or 1-800-4-
CANCER
American Cancer Society, www.cancer.org or 1-800-ACS-2345
Department of Health and Human Services, www.os.dhhs.gov/
Centers for Disease Control, www.atsdr.cdc.gov/
Question 12. What caused these cases of leukemia in the Fallon
area?
Response. The Fallon leukemia cases are the State Health Division's
top priority and investigators are looking into many theories for the
unexpected concentration of cases. During a public meeting on February
5, officials from the Health Division stated that they are not ruling
out the possibility of a cause, but acknowledged that this occurrence
could be happenstance, a statistical anomaly.
Question 13. Is there an elevated rate of other types of cancer in
Fallon?
Response. The State's Cancer Registry has been analyzed and
Churchill County does not have an increased rate of any other types of
cancer.
Question 14. What is being done to investigate these cases?
Response. The State Health Division is conducting an extensive
epidemiological investigation. The investigation, which began 6 months
ago, centers on collecting and analyzing data. Much of the data
consists of statewide statistics and information from the 11 children
and teens with leukemia as well as their families. The Health Division
is including experts from the Centers for Disease Control and
Prevention (CDC) and other States to assist with this investigation.
Environmental sampling and other testing may follow.
The city of Fallon has retained a nationally recognized
environmental and engineering consulting firm, Shepherd Miller, to
conduct chemistry testing of the city's water.
Question 15. Are other government officials getting involved?
Response. The Nevada Legislature is holding hearings in Carson
City. The goal of these hearings will be to unite data, resources and
information in an effort to share information and address concerns.
Participating in the effort is the city of Fallon, the Environmental
Protection Agency (EPA), Nevada State Health Division, Nevada Division
of Environmental Protection and the Nevada Department of Agriculture.
Also testifying will be experts on arsenic, leukemia, drinking water
and pesticides.
U.S. Senator Harry Reid has said that Federal officials, including
representatives of the Centers for Disease Control in Atlanta and a
congressional health committee are expected to get involved in the
investigation. Reid said he would send environment committee staff
members and an eco-toxicologist to Fallon to conduct preliminary
interviews and gather information. An initial investigation is
scheduled for mid-February with a field hearing to be held in the
spring.
Question 16. How long will it take to determine the cause?
Response. Hundreds of cancer clusters have been investigated, some
for many years, and only one clearly identified a cause. Although this
is discouraging, the Health Division believes it is important to
properly investigate these cases.
Question 17. Could Navy jet fuel be the cause?
Response. According to the commander of the Fallon Naval Air
Station jet fuel spills and fuel dumping by planes are so rare and well
documented that the fuel cannot be a contribution factor in the
childhood leukemia cases. The base has 100 monitoring wells and no fuel
contamination has been recorded off Navy property.
No jet fuel has contaminated the municipal water supply.
Question 18. Is there a link between atomic tests and leukemia?
Response. Department of Energy officials say that radiation from
the test has not migrated from the site to Fallon. The test wells have
been monitored since 1963 and the EPA checks the wells annually.
Scientists from the energy department, EPA and Desert Research
Institute use eight onsite wells and a dozen offsite wells to search
for radioneuclides like tritium. The ground water below the test site
does not connect with the basalt aquifer, Fallon's source of drinking
water. Fallon is 28 miles from the site of a 1963 nuclear bomb test.
Question 19. Where does the City of Fallon's water come from and
why is arsenic in the water?
Response. The city's water source has been an underground basalt
aquifer for the past 58 years. Water is withdrawn from the aquifer
through four deep wells. Arsenic is a naturally occurring mineral. The
amount of arsenic in Fallon's drinking water is 100 parts per billion.
The city of Fallon Municipal Water System routinely monitors for
constituents according to Federal and State laws. The City monitored
for 49 synthetic organic compounds and 56 volatile organic compounds
and there were no detected quantities of any of these contaminants.
Question 20. Is there a link between the arsenic and leukemia?
Response. There is currently no evidence that arsenic causes
childhood leukemia. Dr. Randall Todd, the State epidemiologist, says
it's unlikely the longstanding occurrence of arsenic caused a sudden
spike in the area's leukemia rate. The water has been tapped from the
same source for 58 years with no reported clusters of any type in the
past.
Question 21. What is the City doing to take the arsenic out of the
water?
Response. In 1990, The city of Fallon entered into a Compliance
Schedule Agreement to remove arsenic from its public water supply once
a standard was set. The City has been waiting for a permanent Federal
standard on acceptable levels; that standard appears to have been set
by the outgoing Clinton administration.
The City has been distributing quarterly notices to customers that
advise using alternative sources for drinking water, including bottled
water, filtered water available for purchase at grocery stores or water
filtered at home through a reverse osmosis system.
In April 2000, the City retained a nationally recognized
environmental and engineering consulting firm, Shepherd Miller, to
conduct chemistry testing of the city's water. These tests are ongoing
in order to rule out suspected leukemia causing agents. The next phase
includes testing for three other substances in order to exhaust all
possibilities.
The City has exceeded required testing requirements, in both the
frequency of testing and the types of contaminants. Additional tests
have been completed on contaminants, that are linked, or suspected to
be linked, to leukemia. Water tests show no contamination from fuel,
radiation, pesticides, or herbicides.
The City is working with Shepherd Miller to determine which arsenic
treatment technologies are best suited to Fallon's water chemistry and
will be installing a treatment system to meet all Federal requirements.
The design of a treatment facility is scheduled for completion by
June 30, 2002 and startup testing will begin June 15, 2003. Initial
compliance for arsenic removal should commence September 15, 2003. The
City is on target to make these EPA deadlines.
Question 22. Should I have my private well for drinking water
tested?
Response. If you don't know what's in your well, you should have it
tested. You should know the arsenic levels, bacteria levels, and other
contaminants present. You should contact the Health Division hotline at
1-888-608-4623 or Bureau of Health Protection Services in the Nevada
State Health Division, 775-687-4750 extension 237.
Question 23. What can I do to help the families?
Response. West End Elementary School is participating in the
Pennies for Patients campaign to raise funds for the Leukemia and
Lymphoma Society. Additional information on fundraisers and community
support activities will be provided as it becomes available.
Table 5.2.--Historical Lahontan Valley Underground Water Quality & MCL Exceedence\1\
----------------------------------------------------------------------------------------------------------------
No. of Records Percent of
Constituent MCL (ppm) Which Exceed Records Which
MCL's\2\ Exceed MCL's
----------------------------------------------------------------------------------------------------------------
TDS.................................................... 500 1103 40
Magnesium.............................................. 150 30 1
Sulfate................................................ 250 368 13
Chloride............................................... 400 117 4
Nitrate................................................ 10 590 21
Flouride............................................... 2 203 7
Arsenic:
Current Standard..................................... 0.05 955 34
Anticipated EPA Standard............................. 0.01 1898 68
Detection Level...................................... 0.002 2656 95
Iron................................................... 0.6 188 7
Manganese.............................................. 0.1 810 29
Copper................................................. 1 2 0
Zinc................................................... 5 1 0
Barium................................................. 2 0 0
Color.................................................. 15 342 12
pH..................................................... 6.5-8.5 506 18
----------------------------------------------------------------------------------------------------------------
\1\ See Appendix 5.2 which is a tabulation of the water quality records sorted by Township, Range & Section
\2\ There are a total of 2,792 records in the data base, however some of them are duplicate wells sampled at
different dates.
Dixie Valley Ground Water.--Based upon current MCLs, the water
quality of the ground water in the Settlement area within Dixie Valley
is good. Based upon 13 well analyses, the average TDS is 264 ppm and
individual wells vary from 152 ppm to 355 ppm. Higher TDS (in the order
of 800 ppm to 1000 ppm) is reported in 2 wells located 17 to 20 miles
north of the settlement area. (These areas to the north near the playa
are not included in the proposed well field for the Dixie Valley Ground
Water Development Project.).
______
HOW TO TEST YOUR DRINKING WATER
The Nevada State Health Division recommends that individuals with
private wells do a bacterial analysis every 6 months and a chemical
analysis once a year. When testing for personal reasons, a chemical
test costs $100 and a bacterial test costs $12.
To Prepare Water for Bacterial Testing: 423-2281.--You can get
sterile bottles from the Churchill Community Hospital (Business Office)
located at 801 E. Williams in Fallon or the Nevada State Health
Laboratory (address on attached forms). Carefully follow the directions
on the form for taking samples. These can be mailed in a mailer
provided with the bottle.
To Prepare Water for Chemical Test.--Use a clean 1-gallon plastic
container. You can purchase a bottle of distilled water in your grocery
store, empty it and refill with your water as outlined in the attached
directions.
Where to take Samples: (775) 688-1335.--Take your sample to the
State Lab on the University of Nevada, Reno, campus. The lab is located
just west of the Medical school and north of Lawlor Events Center. The
address is 1660 N. Virginia. Take Virginia Street north to Seventeenth
Street, turn right, go 0.1 mile to the second stop sign, turn left, and
the lab is immediately on the left after the left turn.
Reading Your Test.--Enclosed are samples of the report sheets that
will have the results from your test. If you need help understanding
the results or have questions, contact the local health department
(423-2281) or your County Extension Office (423-5121).
When you receive test results compare them with the Federal
drinking water standards found below.
Federal Drinking Water Standards
[Primary and Secondary Contaminate Levels]
------------------------------------------------------------------------
Contaminant Max Level
------------------------------------------------------------------------
Primary Regulations:
Inorganic Chemicals
Arsenic................................. 0.05 mg/L
Barium.................................. 1 mg/L
Cadmium................................. 0.010 mg/L
Chromium................................ 0.05 mg/L
Lead.................................... 0.05 mg/L
Mercury................................. 0.002 mg/L
Nitrate (as N).......................... 10 mg/L
Selenium................................ 0.01 mg/L
Silver.................................. 0.05 mg/L
Flouride (depending on temperature)..... 1.4-2.4 mg/L
Organic Chemicals:
Endrin.................................. 0.0002 mg/L
Lindane................................. 0.004 mg/L
Methoxychlor............................ 0.1 mg/L
Toxaphene............................... 0.005 mg/L
2,4-D................................... 0.1 mg/L
2,4,5-TP Silvex......................... 0.001 mg/L
TTHM.................................... 0.10 mg/L
Turbidity................................. 1 TU-5 TU
Coliform Bacteria......................... 1/100 ml (mean)
Radiological:
Radium 226 and 228...................... 5 pCi/L
Gross Beta.............................. 4 mrem/year
(50 p Ci/L)
Gross Alpha............................. 15 pCi/L
Sodium & Corrosivity...................... Monitoring only
Secondary Regulations:
Chloride................................ 250 mg/L
Color................................... 15 color units
Copper.................................. 1 mg/L
Foaming Agents.......................... 0.5 mg/L
Iron.................................... 0.3 mg/L
Manganese............................... 0.05 mg/L
Odor.................................... 3 threshold odor number
PH...................................... 6.5-8.5
Sulfate................................. 250 mg/L
TDS..................................... 500 mg/L
Zinc.................................... 5 mg/L
------------------------------------------------------------------------
__________
Bacteriological Test, Nevada State Health Laboratory, Reno, NV
DIRECTIONS FOR TAKING WATER SAMPLES
Caution.--Bottle is sterile and contains a bit of necessary powder.
Do not open bottle until Step 5 below and Do not wash out bottle.
Procedure
1. Select sampling outlet closest to the water source (pipe,
kitchen faucet, etc.)
2. Remove aerators, hoses, sprinklers, etc., from the fixture.
3. Turn on valve and let water run for 2 to 3 minutes.
4. While water is still running, unscrew the bottle cap carefully.
Do not touch mouth of bottle.
5. Do not rinse bottle, but fill to the shoulders; replace the cap
and tighten firmly. 100 mls of water are required for testing.
6. For samples from an open reservoir, make a quick pass with mouth
of bottle forward at a depth of one foot. Tighten cap firmly.
7. Complete information slip with your name, location, county,
date, time of sampling, and return mailing address.
8. Submit sample(s) to laboratory within 30 hours of collection and
maintain temperature below 20+ C (68+ F) during
shipment or sample is unsatisfactory. (Do not allow to freeze.
9. Do not mail sample(s) on Friday, because our laboratory is
closed on the weekend. Samples mailed on Friday and received on Monday
cannot be tested because the 30-hour time limit will be exceeded.
10. Please do not bring Fecal Streptococci water samples on Friday.
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Statement of Mary E. Reid, Area Specialist, Water Resources, University
of Nevada, Cooperative Extension
INTRODUCTION
Common Problems with presence of arsenic in drinking water
See Health effects below.
Drinking Water Standards: Federal Standard for Maximum
Contaminant Level (MCL)
0.05 milligrams per liter (mg/l)
0.05 parts per million (ppm)
Special characteristics (odors, colors, etc.)
None
To identify. Actions to take if thought to be present.
No simple home test available. If thought to be present, bottled
water is an option.
To ascertain presence and levels in water. Sampling procedure.
If known to occur in the general geographical area, an inorganic
chemistry test for presence and level of arsenic present must be done
in a laboratory. In Nevada, a standard inorganic water analysis done by
the Nevada State Laboratory includes testing for arsenic.
Areas in Nevada where arsenic is found in drinking water
Carson Valley, Cold Springs, Eagle Valley, eastern sides of the
Truckee Meadows, Fallon, Fernley, Hazen, Hidden Valley, Topaz, Verdi,
and Virginia Foothills.
SOURCES
Arsenic occurs naturally in rocks, soils and sediments. High levels
may occur in some coals. High levels of arsenic have been found in
water from areas with geothermal activity. Marine algae and seaweed
usually contain considerable amounts of arsenic.
Arsenic is used in the manufacture of pesticides and is also used
in making glass and glassware. Other industrial uses for arsenic
include copper and lead alloys and pharmaceuticals. Trace amounts of
arsenic may be found in some fertilizers.
The burning of coal and smelting of metals are major sources of
arsenic in air. Industrial waste from electroplating can be a source of
arsenic in water. Water used for geothermal energy production may
contain high levels of arsenic.
HEALTH EFFECTS
Arsenic is a poison in humans at 100 milligrams or more and has
proved lethal at 130 milligrams. Health effects of long term exposure
to elevated arsenic are vague and not clearly defined. Acute and
chronic toxic effects may include chronic gastro-intestinal upset and
diarrhea, liver damage, nervous system changes, blood imbalance, and
skin changes. Exposure to inorganic arsenic can cause skin cancer,
mainly tumors of low malignancy.
Arsenic has been associated with pulmonary cancer in the
manufacture and use of arsenic-containing pesticides and in the
smelting of copper.
removal form drinking water
Distillation and reverse osmosis are two practical methods of home
treatment for drinking water that contains arsenic.
------------------------------------------------------------------------
Treatment type Average Purchase Cost
------------------------------------------------------------------------
Distillation................................... $100-$800
Reverse Osmosis................................ $90-$800
------------------------------------------------------------------------
SUMMARY
Arsenic has been shown to affect health and is an undesirable
constituent in drinking water. If drinking water exceeds the Federal
standard for arsenic, there are methods for treating the drinking water
that will reduce the arsenic level. No home treatment method should be
considered without having a laboratory test of the water first.
As with any home treatment method for water, it is not possible to
install a reverse osmosis or a distillation unit and forget it. Both
require ongoing monitoring and maintenance. The only way to tell that a
unit is functioning properly is to do regular water tests.
REFERENCE
De Zuane, John. 1990. Handbook of Drinking Water Quality. Van
Nostrand Reinhold, New York.
McGowan, Wes. 1987. Water Processing for Home, Farm and Business.
Water Quality Association, Lisle, Illinois.
Shelton, Theodore B. 1991. Interpreting Drinking Water Quality
Analysis; What Do the Numbers Mean? Rutgers Cooperative Extension, New
Brunswick, New Jersey.
U.S. Environmental Protection Agency, Office of Drinking Water.
1982. Manual of Individual Water Supply Systems.
World Health Organization. 1981. Environmental Health Criteria 18:
ARSENIC. World Health Organization, Geneva, Switzerland.
______
Churchill Economic Development Authority and Small Business
Development Center,
Fallon, NV, April 6, 2001.
Hon. Gwen Washburn, Chairman,
Churchill County Commissioner,
Fallon, NV.
Ref: Childhood Leukemia Business Impact
Dear Chairman Washburn: In reply to your questions in regards to
impacts to the Fallon, Churchill County business community.
Our office has received calls from several businessman stating that
they see a decline in their business, due to the adverse publicity that
has proliferated as a result of the leukemia cluster in Fallon,
Churchill County. they have concerns for the viability of their
business if the publicity is sustained over a long period.
It goes without saying that the most important concern of Churchill
Economic Development Authority is the welfare of the leukemia victims,
however we also have concerns for our local business community as well.
Should the adverse publicity in regard to our arsenic problems, coupled
with the acute lymphocytic leukemia cluster continue, there is no doubt
that some local business will suffer.
In checking with banks, rental estate and title companies there
definitely is a slow down in the sale of homes, and many of the Navy
personnel wives do not want to move to Fallon.
I hope this answers your question. If our office can be of further
assistance, please feel free to contact us at your convenience.
Sincerely,
Shirley G. Walker,
Executive Director.
______
Fallon Auto Mall,
Fallon, NV, February 8, 2001.
Mayor Ken Tedford,
City Hall,
Fallon, NV.
Dear Ken: I am writing you today purely on an informational basis
only.
In regards to the recent publicity Fallon has been receiving over
it's water quality, (arsenic content), child leukemia cases, and now
our most dangerous Hwy. 50, I feel it is important to rely the impact
these pubic images are playing on our local economy.
In our dealership, which commonly does 50 to 60 percent of our
business to folks outside our county, we have found this business to be
off as much as 40 percent.
In comments we receive regularly we believe much of this loss is
directly due to the new image of Fallon by outsiders.
Now, I am sure you are treating these issues with the highest
priority possible, but I felt that you should know directly the
economic impact this publicity is having on local business.
I trust you will do everything possible in your power to address
these issues and promote Fallon as a great place to lie and do
business.
Sincerely,
Kurt Henning,
President.
______
[Name deleted]
Attorney & Counselor at Law,
January 21, 2001.
Arthur Mallory,
Thom Stockard,
365 S. Maine Street,
Fallon, NV.
Re: Current Status
Dear Mr. Mallory and Mr. Stockard: I wanted to write this letter so
that I could inform you of my decision as soon as possible. I will be
working all day Monday and will not have the chance to speak with you.
I am concerned about the water in Fallon. We addressed it briefly when
I was out there but since then I have read a few other reports, lastly
one in our paper here saying that two more cases of childhood illness
could be linked to Fallon.
I am concerned because of the possibilities. My wife and I have two
kids, she is pregnant with a third and we anticipate having at least
one more. I do not know that the water is a problem, but I could not
live with myself if we moved there knowing that there was a possibility
for problems and then something were to happen.
The problem is I was looking forward to receiving an offer and
working out in Fallon. I wanted to let you know that if something could
be worked out I would still like to work there, I know that you are
looking for someone who will live in Fallon. I understand the reasons
and if I was in your position I would want the same thing. If you
cannot find someone that you like, I would propose something else. I
could live in Sparks and commute. I could commit to be there for the
months that I am on call by either renting a place or making other
arrangements. I could also commit to stay for at least 5 years. That
would let the water situation sort itself out, and as an incentive it
would also be the time period for any retirement to vest.
I know that your first option is someone to live out there, however
if you cannot work that out please consider this proposal. I will not
be coming out on Thursday, as we have decided that we cannot live in
Fallon until we know more about the water situation and that will
probably take some time to sort out. If something cannot be worked out
it was a pleasure to have met you both and I appreciate your
hospitality. If there are any questions please do not hesitate to call
or write. I hope to hear from you.
Sincerely,
[Name deleted]
__________
Statement of Henry Falk, M.D., Assistant Administrator, Agency for
Toxic Substances and Disease Registry, Public Health Service, U.S.
Department of Health and Human Services
Good afternoon Mr. Chairman and members of the committee. My name
is Dr. Henry Falk, Assistant Administrator of the Agency for Toxic
Substances and Disease Registry (ATSDR).
Thank you for inviting ATSDR to speak with you today. We share your
concerns about the health and well being of children and families in
Fallon and across the country. We also share your desire to adequately
address the concerns expressed about illness and disease that might be
associated with the environment. In fact, addressing these types of
concerns is at the root of ATSDR's creation.
ATSDR is a Federal agency created by Congress in 1980 by the
Comprehensive Environmental Response, Compensation, and Liability Act
(CERCLA), or what is more commonly known as Superfund legislation. As
such, ATSDR is the public health agency charged with determining the
nature and extent of health problems at Superfund sites including
Federal Superfund sites, and advising the U.S. Environmental Protection
Agency (EPA) and State health and environmental agencies on needed
clean-up and other actions to protect the public's health.
ATSDR works in close collaboration with the EPA, other Federal,
State, local, and tribal governments, health care providers and
affected communities. As an agency of the U.S. Department of Health and
Human Services (DHHS), ATSDR has made a difference to all of these
partners by providing new information to assist in remedial
decisionmaking and evaluation. Our work includes answering the health
questions of impacted community members, recommending preventive
measures to protect public health, and providing diagnosis and
treatment information to local health care providers. ATSDR administers
public health activities through: partnerships; public health
assessment and consultation activities; exposure investigations; health
studies and registry activities; development of toxicological profiles
and attendant research; emergency response; health education and health
promotion; and community involvement.
ATSDR works in particularly close coordination with our DHHS sister
agency, the Centers for Disease Control and Prevention. Jointly we have
worked with the Nevada Health Division to investigate the cancer
cluster in Fallon. For our part, ATSDR will assist in the investigation
by reviewing all relevant environmental data for toxic substances and
assessing whether people have been exposed to any of these contaminants
at levels of concern.
Unfortunately, the cancer cluster in Fallon is not a unique
situation. Increasingly, ATSDR is being asked by State and local health
departments to help respond to compelling community concerns about
apparent outbreaks of serious, noninfectious disease with unknown
cause. As a small agency, responding to these requests would be
impossible for ATSDR alone. To supplement our own staff, ATSDR works in
close collaboration with State health departments, and has been funding
environmental public health activities in States since 1987. ATSDR
currently funds public health activities in 28 States through separate
cooperative agreements that provide assistance to conduct public health
assessments, health education activities, and epidemiologic studies.
Because of our Superfund mandates, most of our cancer cluster
investigations and assistance are related to concerns about Superfund
sites, hazardous waste, and exposure to toxic substances.
The site work we do directly or through our State partners has
changed over time. Our original mandate under Superfund called for
public health assessments at all National Priorities List (NPL) sites
and these originally constituted the great majority of our workload.
While we still actively work at NPL sites, it now constitutes a smaller
proportion of our site activities. Increasingly, our site work now is
at immediate removal sites, active waste sites, occasionally
Brownfields sites, and, like Fallon, sites where communities, States or
congressional officials have petitioned ATSDR to investigate or assist
in evaluating their health concerns related to toxic substances.
Activities related to the vermiculite mine in Libby, Montana,
provide a very good example of a current site where ATSDR's work has
made a difference, which also began with a reported cluster of disease.
The situation in Libby offers a dramatic example of past exposure
resulting in serious disease. In 1999, reports from Libby documented
cases of non-occupational asbestos-related pulmonary impairment among
family members of former mine employees as well as others in the
community with no connection to the mining operations. They were
suffering (or dying) from asbestosis, mesothelioma, and lung cancers
related to their asbestos exposure. Finding non-occupational asbestos-
related pulmonary disease is extremely unusual and suggests that
dangerous levels of asbestos exposure have occurred within the Libby
community. The latency period for mesothelioma, for example, is 40
years. This means that the health care community could be seeing the
effects of exposure to asbestos-contaminated vermiculite from Libby for
an entire generation.
In 2000, ATSDR conducted a medical testing program to assess the
public health implications of past human exposure to tremolite asbestos
in Libby. More than 6,100 Libby-area residents and former mine workers
were screened. This number included 70 from Elko, Nevada, who met the
screening criteria for Libby. They all answered an extensive
questionnaire about their possible exposures and received both chest x-
rays and pulmonary function tests.
ATSDR recently reported a preliminary analysis of the medical
testing results from the first 1,078 participants, or 18 percent of the
total number of participants in the medical testing program. These
results showed a very high percentage of individuals reporting contact
with the vermiculite, and evidence of health impacts, particularly in
the form of thickening and scarring of the outer pleural lining of the
lung.
ATSDR will soon complete the evaluation of the Libby medical
screening program and is working with local, State, and Federal health
care providers to address health issues that are identified.
Specifically, to help local residents obtain medical care, ATSDR has
worked closely with the DHHS Regional Health Administrator and other
DHHS agencies, such as the Health Resources and Services Administration
(HRSA), and the State of Montana to ensure appropriate treatment is
available.
Such partnerships are critical to providing needed health services
at Libby, Elko, and now Fallon. Such partnerships are also critical to
fully assessing the true existence and potential cause of disease
clusters. As a part of the latter, ATSDR and CDC are reviewing and
responding to the Pew Environmental Health Commission Report. The
report recommends strengthening Federal, State and local public health
capacity to tackle environmental health problems and establish a
nationwide Health Tracking Network on chronic diseases and related
environmental hazards. ATSDR has made significant progress in
developing registries of individuals exposed to specific substances and
tracking them over time to assess health status and provide updated
information over time to exposed individuals. At the request of Sen.
Baucus (D-MT) and others, we plan to establish a registry of
vermiculite exposed individuals from the Libby area. The agency also
has considerable experience working with State health departments and
communities to conduct epidemiologic investigations of specific health
outcomes in communities near environmental sources of hazardous
substances.
In keeping with the Superfund mandate to ``. . . establish and
maintain a national registry of serious diseases and illnesses . . .'',
we at ATSDR see ourselves as having a direct responsibility under
CERCLA to participate with CDC and others in developing disease
surveillance or tracking systems, particularly for diseases with known
or potential relationships to hazardous waste and toxic substances. In
addition, because of our close working relationship with EPA, we are
interested in how to link environmental data bases with developing
health tracking data. Although we are very far from a comprehensive
system at this point, ATSDR does have some ongoing, albeit limited,
efforts underway as part of our Superfund work. These include an
epidemiologic study investigating the cause of childhood cancers in
conjunction with Superfund sites in four States, and a pilot program to
develop health tracking of multiple sclerosis in a number of
circumstances where concern about the frequent occurrence of this
disease arose in relation to adjacent hazardous waste sites.
But we recognize that more can be done. Mr. Chairman, the public
naturally becomes concerned when they see situations such as half of a
class of third graders needing to bring asthma inhalers to school, or
when persons compare notes about their first diagnosis of multiple
sclerosis at a 20-year high school reunion, or when multiple parents
within the same neighborhood watch their children suffer from brain
tumors and other severe illnesses, or when women who do not smoke and
who did everything right during their pregnancy give birth to small or
sick babies. Sadly, in a country as large as ours, these unusual
occurrences are not so unusual at all. All over the country, citizens
turn to their local, State and Federal health authorities and ask what
could be causing these and other types of clusters of health problems.
In communities near obvious sources of environmental contamination,
people understandably worry that somehow environmental pollution might
be playing a role.
At ATSDR we are committed to doing what we can to address these
very real concerns.
As I've stated earlier, we are working every day at sites
around this Nation to address the health concerns of communities
affected by toxic exposures.
We are working with our colleagues at CDC to address the
issue of health and disease tracking.
And, we continue to strengthen our ongoing partnerships
with Federal, State and local agencies, which is integral to answering
these questions.
Mr. Chairman, on a personal note, I started my professional career
as a pediatrician at the Centers for Disease Control in 1972, and my
first investigation was of a leukemia cluster in Elmwood, Wisconsin. I
did several more such investigations over the next 18 months, none of
which revealed an obvious cause for the clusters. However, my fourth or
fifth such investigation was of 4 cases of liver cancer in a factory
which turned out to be the first reported cases of vinyl chloride
induced liver angiosarcoma in polyvinyl chloride polymerization
workers. This subsequently led to much improved and safer working
conditions for the entire industry worldwide. I have seen how
agonizingly frustrating this work can be; but I also feel that if we
are in the mode of carefully scrutinizing health data, then we will be
positioned correctly to detect new problems when they arise.
Mr. Chairman this concludes my testimony. I will be happy to answer
any questions that you or members of your committee might have.
__________
Statement of Thomas Sinks, Ph.D., Associate Director for Science,
National Center for Environmental Health, Centers for Disease Control
and Prevention, Department of Health and Human Services
Good morning, Mr. Chairman and members of the committee. I am Dr.
Thomas Sinks of the Centers for Disease Control and Prevention (CDC)
where I am the Associate Director for Science within the National
Center for Environmental Health. I am pleased to review CDC's
assistance to the Nevada State Health Division's investigation of acute
lymphoblastic leukemia (ALL) in Fallon, Nevada. I will discuss how CDC
provides the technical assistance and infrastructure in responding to
disease investigations, and briefly characterize cancer clusters, the
roles of State and Federal agencies in investigating them, and
coordination between agencies.
I want to begin by assuring the parents of Fallon, and all parents
whose children are diagnosed with cancer, that we at CDC are deeply
concerned about the health and well being of children. We are
encouraged by the wonderful improvements in the clinical treatment of
ALL--today 80 percent of children with ALL will have healthy and
productive lives. However, we need to identify the causes of ALL to
prevent it and decrease the number of children who suffer from it.
State health departments are on the front line in responding to
cancer clusters and other disease clusters, and the CDC plays an
important role in providing infrastructure and technical assistance.
CDC has a close relationship with our sister agency ATSDR (the Agency
for Toxic Substances and Disease Registry) and we coordinate our
response to cancer and disease cluster inquiries. Cancer and disease
cluster activities at CDC have included field investigations, convening
a national conference on the clustering of health events, publishing
recommendations for the epidemiologic investigation of disease
clusters, and providing technical assistance to health departments
involved in specific cluster investigations.
Last month CDC released the first National Report on Human Exposure
to Environmental Chemicals, an important new research tool that will
provide better information on levels of exposure to environmental
chemicals, and over time what these levels mean for public health.
Using a technology known as biomonitoring, CDC's environmental health
laboratory measures chemicals directly in blood and urine samples
rather than estimating population exposure using measurements from air,
water or soil samples. By showing what the U.S. population is exposed
to under ``normal conditions,'' the report can become a vital tool for
epidemiologists to compare blood and urine levels of chemicals in
suspected disease cluster areas to the baseline exposure data for the
general population. We will be using this same type of biomonitoring
technology to assist the Nevada State Health Department in
investigating these cases of ALL. We are working to be able to transfer
this technology to State public health laboratories so that they can do
their own biomonitoring of chemical exposures.
TECHNICAL ASSISTANCE TO NEVADA
CDC has worked with the Nevada Health Division since July 2000,
providing technical assistance in each phase of the investigation. CDC
helped plan, and participated on, the expert panel review last February
15th. The panel commended the Nevada Health Division's work and
recommended six followup steps; four of which involve active assistance
from CDC and ATSDR. I recently met with CDC and ATSDR staff to
coordinate our agencies' assistance to the State. CDC and ATSDR will
help the State complete: (1) a cross-sectional exposure assessment of
environmental contaminants in drinking water, house dust, and the blood
and urine of county residents, (2) an assessment of environmental
contaminants and possible pathways leading to human exposure, (3) the
establishment of a tissue bank for future research into the causes of
ALL, and (4) the continuation of the expert panel to provide
independent review of the investigation.
CANCER CLUSTERS
Cancer clusters provide opportunities as well as challenges for
public health agencies. The phrase ``cancer cluster'' implies that more
cancer cases or cancer deaths have occurred in a specific geographic
region than expected. A cancer excess may, or may not, be the result of
an exposure to a unique carcinogen.
Public health agencies are challenged by cancer clusters because of
the number of public inquiries--probably thousands of perceived cancer
clusters have been reported. For example, more than 2000 published
newspaper articles from January 1990 to January 2000 contained the
words ``cancer cluster.'' A survey of 41 State health departments found
they registered about 1900 cancer inquiries in 1996 alone. An
additional challenge is the unrealistic expectation placed upon public
health officials to identify and remove the cause of each cancer
cluster. In reality, 85 to 90 percent of evaluated cancer cluster
inquiries do not find an excess number of cancer cases. Although 10 to
15 percent of cancer clusters have involved an excess in cancer cases,
only a handful led to important discoveries of preventable causes of
cancer.
Cancer clusters can provide an opportunity for cancer prevention
and control. Cancer education and screening programs are important
tools in the fight to prevent and control cancer and can be used
effectively in some cancer cluster circumstances. Scientific
investigations of cancer clusters and local environmental concerns,
however, may take years to complete and the findings are often
inconclusive. If a cancer cluster and hazardous levels of an
environmental contaminant coexist, removal of the health hazard seems
prudent, regardless of its role in causing cancer.
CDC AND STATE ROLES IN RESPONDING TO CANCER CLUSTERS
At CDC, three centers are involved in responding to cancer
clusters. Our National Center for Chronic Disease Prevention and Health
Promotion supports statewide, population-based cancer registries
through the National Program of Cancer Registries (NPCR.) Cancer
registries and their use to identify and monitor cancer trends are an
essential tool for evaluating cluster inquiries. The Nevada Cancer
Registry (NCR) received more than $1,480,000 from CDC's NPCR from 1994
through 2000 to track cancers including ALL. CDC's National Center for
Environmental Health conducts exposure assessments and epidemiologic
studies that evaluate how people are exposed to environmental hazards
and identify preventable environmental causes of cancer. The CDC's
environmental health laboratory measures known and suspected cancer
causing agents in human blood and urine. CDC's National Institute for
Occupational Safety and Health (NIOSH) addresses exposures to cancer
causing agents in the workplace by conducting laboratory science and
epidemiological investigations in fields like toxicology and
immunology. NIOSH also responds to requests from employers, employees,
and other government agencies for investigations involving possible
work-related cancer. Finally, CDC's sister agency ATSDR plays a
critical role in responding to clusters as you will hear from ATSDR
Assistant Administrator, Dr. Henry Falk.
ENHANCING CANCER CLUSTER EVALUATIONS
Three key ingredients needed for an adequate response to public
concerns about cancer clusters are sufficient infrastructure, assurance
of scientific credibility, and coordination between agencies. State
infrastructure requirements include cancer registration and tracking,
cancer prevention and control, and a mechanism for rapidly identifying
hazardous levels of environmental contaminants; recommendations
supported by The Pew Environmental Health Commission. A significant
advance in children's cancer surveillance is taking place with the
consolidation of pediatric cancer specialists within the Children's
Oncology Group with funding from the National Cancer Institute.
Scientific credibility requires that experts from many fields work
together. Independent review by expert panels also ensures the
credibility of State investigations. Scientific credibility could be
further enhanced by developing investigative priorities from hypotheses
for why certain cancers might cluster. A work group to establish such
investigative priorities is needed.
Coordination between agencies is essential. The successful
collaboration in Fallon, Nevada involves multiple departments within
the State, the Federal Government, and academic institutions. Agencies
involved from the Department of Health and Human Services include not
only CDC, but also ATSDR and the National Cancer Institute.
Representatives of the Fallon Naval Air Station have also volunteered
their complete cooperation in the investigation.
CDC is currently in the process of assessing the nation's public
health infrastructure and its needs. CDC has convened an agency-wide
workgroup, along with ATSDR, to review and respond to the Pew
Environmental Health Commission Report. This report recommends the
strengthening of Federal, State and local public health capacity to
tackle environmental health problems and establish a Nationwide Health
Tracking Network to identify and track chronic disease and potential
environmental factors. CDC is working to establish a nationwide
laboratory network to assist communities in evaluating toxic
emergencies and human chemical exposure. This will help communities
monitor disease trends and evaluate whether these are linked to
exposures in the environment. In addition, CDC has recently released a
report focusing on a broader perspective of the current status of
public health infrastructure. The report is entitled Public Health's
Infrastructure: Every health department fully prepared; every community
better protected, and is available on CDC's website. Assessment of the
nation's public health infrastructure will help us to determine how to
best target resources to build capacity at the State and local level,
and will enhance our ability to interact with communities to address
their local public health needs.
I applaud the people of Fallon for their positive response during
this stressful time. Strong communities are strengthened by people
drawing together to help one another through difficulty. I assure you
that the CDC will continue to collaborate with our Federal partners and
assist the State of Nevada. Thank you, Mr. Chairman and members of the
committee, for the opportunity to testify before you today. I would be
happy to answer any questions you might have.
__________
Statement of Ramona Trovato, Director, Office of Children's Health
Protection, Environmental Protection Agency
Good Morning. My name is Ramona Trovato and I am the Director of
the Office of Children's Health Protection at the U.S. Environmental
Protection Agency. Thank you for inviting me here today to discuss our
response to environmentally-related health problems. It is deeply
distressing to know that a number of children in this community have
developed leukemia. Even one child with leukemia is one too many.
The Environmental Protection Agency's mission is to protect human
health and safeguard the environment. We protect human health by
limiting peoples' exposure to contaminants in the air we breathe, the
water we drink, and the food we eat. The Environmental Protection
Agency works through the States to protect public health. About half of
the Environmental Protection Agency's budget is sent directly to the
States for their use in environmental and public health protection. In
fiscal year 2001, the Environmental Protection Agency is providing $3.5
billion to the States for all environment programs. This same year,
Nevada received more than $6 million in clean water State revolving
funds and $7.8 million for drinking water State revolving funds.
The protection of human health requires a partnership at the local,
State and Federal level. I would like to begin by addressing the
government's response to environmentally-related health problems
through some past examples, and then talk about how we can address some
of the issues facing your community. Given the unique roles of each of
the different agencies, it is essential for environmental officials at
all levels of government to work with their public health counterparts
to address the environmental health needs of our citizens.
how does the environmental protection agency respond to cancer clusters
We currently address potential cancer clusters through an informal
agreement among government agencies. Through this partnership, each
agency brings their particular expertise to the investigation as
needed. The current process is as follows: State public health
departments perform the initial phases of cancer cluster investigations
according to defined protocols. If further investigation is warranted,
the Centers for Disease Control and Prevention may be asked to provide
technical assistance to States on a case-by-case basis. Additional
assistance may be provided by the Agency for Toxic Substances and
Disease Registry and the National Cancer Institute.
If findings indicate a suspected environmental linkage,
the National Institute of Environmental Health Sciences, and/or the
Environmental Protection Agency may be consulted.
Through its participation in this partnership of Federal, State,
and local agencies, the Environmental Protection Agency has a long
history of dealing with environmentally-related health problems in
communities. I'd like to give you a specific example of how the
Environmental Protection Agency has partnered with other agencies to
address a real problem.
Case Study: Community Confronts Childhood Cancer
In 1996, due to public concerns about high rates of certain types
of cancer among children in the Dover Township/Toms River area of New
Jersey, a study was conducted by the Agency for Toxic Substances and
Disease Registry and the New Jersey Department of Health and Senior
Services. They found a previously unidentified contaminant in two
drinking water wells. These agencies then asked for the Environmental
Protection Agency to identify the contaminant. Through a cooperative
effort led by the Environmental Protection Agency's Las Vegas
laboratory, the contaminant mixture, called SAN trimer, was identified.
This contaminant was found in low part-per-billion levels in the two
wells already known to have been impacted by a local Superfund site.
The existing treatment system at these wells was not effective at
removing the contaminant. Because this area is part of a Superfund
site, the Environmental Protection Agency directed Union Carbide, the
site's potentially responsible party, to install a carbon treatment
system on the two contaminated wells to supplement the existing
treatment. The new carbon treatment system removes the contaminant to
non-detectable levels. The Environmental Protection Agency, with the
National Institute of Environmental Health Sciences, is overseeing
long-term chronic studies to determine if this contaminant causes
cancer.
HOW DOES THE ENVIRONMENTAL PROTECTION AGENCY RESPOND TO SUPERFUND SITES
Working under the mandate of the Superfund legislation, the
Environmental Protection Agency works closely with the Agency for Toxic
Substances and Disease Registry to perform the necessary activities to
respond to environmental hazards and associated health threats in
communities. The Agency for Toxic Substances and Disease Registry
performs health assessments around Superfund sites, as well as in
communities upon request. The Agency for Toxic Substances and Disease
Registry's public health assessment process determines those
potentially exposed and makes recommendations to reduce exposure and
mitigate potential health outcomes. The Environmental Protection Agency
responds to these recommendations and intervenes where possible to stop
exposures. Communities can petition the Agency for Toxic Substances and
Disease Registry for a community health assessment and can petition the
Environmental Protection Agency to request a preliminary assessment. If
the preliminary assessment indicates a problem, then the Environmental
Protection Agency can take immediate action and begin the process of
cleanup.
Case Study: Citizen Complained of Strange Odor--Methyl Parathion
(Pesticide)
In 1994, a resident of Lorain County, Ohio, was worried about a
strange odor in his home. He called the local State agriculture
department to find out what it was and what to do about it. The citizen
had recently had his home sprayed to eliminate cockroaches and other
pests. State sampling revealed the presence of methyl parathion in his
home. Methyl parathion is a highly potent pesticide used on cotton and
food crops. It was registered only for outdoor use, not for indoor use.
The State agricultural representative turned to the Environmental
Protection Agency, who investigated the illegal indoor application of
methyl parathion and found an unlicensed applicator had been spraying
inside homes and distributing bottles of this pesticide to homeowners.
With help from the media and churches, citizens were alerted and people
who had their homes treated were asked to come forward and have their
homes tested for methyl parathion. The Environmental Protection
Agency's Superfund program, with the Agency for Toxic Substances and
Disease Registry, provided $21 million and expertise to decontaminate
and restore 233 homes in Lorain County. Similar incidents turned up in
Michigan, Mississippi, Louisiana, Tennessee, Illinois, Arkansas, and
Alabama. After contaminating hundreds of homes in six States, the
individuals responsible for the problem were identified, prosecuted and
convicted.
In these cases, the Environmental Protection Agency and the Agency
for Toxic Substances and Disease Registry issued a joint public health
advisory about the problem, produced public outreach and educational
material, and coordinated a Federal response. The two agencies also
worked together on procedures for testing the presence of methyl
parathion residues in homes and in the urine of residents, developed
criteria for relocation of residents and procedures for cleanup of
contaminated homes. The Agency for Toxic Substances and Disease
Registry is still following the exposed children to determine residual
health problems.
On a final note, the Environmental Protection Agency canceled the
use of methyl parathion on many food crops because it was found to
present acute dietary risks, especially in children.
HOW DOES THE ENVIRONMENTAL PROTECTION AGENCY RESPOND TO
WATERBORNE ILLNESS?
The Environmental Protection Agency also responds to cases of
illness that are believed to be associated with contaminated drinking
water. The Environmental Protection Agency works through a formal
agreement with other agencies to resolve the problem that caused the
illness. The State health department responds first and if they need
assistance, they call on the Centers for Disease Control and
Prevention. The Centers for Disease Control and Prevention may then
request consultation or participation by the Environmental Protection
Agency in detecting, monitoring, sample testing, and providing
engineering assistance for water supply pathways or water treatment
plants.
Drinking Water Infrastructure: Meeting the needs of small communities
The Environmental Protection Agency also helps communities address
public health threats through the Drinking Water State Revolving Loan
Fund, established to provide States with a continuing source of
financing for drinking water infrastructure projects. Last year, the
Environmental Protection Agency provided more than $880 million to
States to finance the costs of infrastructure improvements. The program
places a particular emphasis on the needs of small systems that serve
10,000 or fewer residents. Congress required that at least 15 percent
of the funds be provided to small systems.
Case Study: Cryptosporidium A waterborne intestinal parasite
In 1993, hospitals and schools in Milwaukee, Wisconsin began
reporting widespread absenteeism among employees and students due to
gastrointestinal illness. The medical community and local health
departments, together with the Centers for Disease Control and
Prevention recognized that this outbreak was too widespread for a food-
borne illness. The Milwaukee public water system was contacted and high
levels of turbidity were identified in the drinking water. These high
levels were estimated to have lasted for 16 days before the problem was
identified and corrected. It was later estimated that during the
outbreak, Cryptosporidium levels in treated water may have exceeded 100
oocytes per 100 liters. During that time, an estimated 400,000
individuals in Milwaukee became ill from Cryptosporidium and at least
50 cryptosporidiosis-associated deaths were reported.
Scientists and water treatment engineers from the Environmental
Protection Agency and the Wisconsin Department of Natural Resources
provided assistance by evaluating and correcting problems with the
treatment plant. Together the team identified that the problem arose
from a change in treatment practices, lack of familiarity with these
new practices, unusually high levels of Cryptosporidium in the source
water, and delays in correcting the problem when it first occurred.
Together with local, State and Federal Government agencies, experts
restored the quality of the drinking water and introduced additional
safeguards to help ensure the future safety of drinking water for
Milwaukee residents. What else are Federal agencies doing to address
environmental health concerns?
Since 1997, the Environmental Protection Agency, the Department of
Health and Human Services, the Department of Housing and Urban
Development, and many other Federal agencies have joined together to
focus on environmental health threats to children. The interagency
group first identified those diseases and disorders that affect
children's health and may be associated with an environmental
contaminant. The diseases and disorders selected were: asthma;
developmental disorders, including lead poisoning; and childhood
cancer. Asthma affects about five million children and is the leading
cause of hospitalization in children. Developmental disorders are the
leading cause of lifelong disability. Childhood cancer is the leading
cause of disease-related mortality in children ages 1 to 14. Each year,
more than 8,000 cases of childhood cancer are diagnosed.
The specific causes and confluence of factors that contribute to
asthma, developmental disorders, and childhood cancer are generally
unknown. Therefore, the decision was made to focus on research to help
us better understand the influences, mechanisms and interactions of
environmental factors that contribute to childhood disease. Where we
have sufficient knowledge to act, we have developed strategies to
address environmental health concerns. The national asthma strategy was
launched in January 1999; the national lead strategy was released in
2000; and the Environmental Protection Agency and the Department of
Health and Human Services have jointly funded research centers to
investigate children's environmental health concerns. (An additional
center is funded by the Environmental Protection Agency). Five of the
nine centers conduct research related to asthma; the remaining four
conduct research on development disorders. Also, the National Cancer
Institute is conducting research into childhood cancer and developing a
national registry of all children with cancer.
Asthma Strategy
There is an epidemic of asthma in the United States. Nearly 1 in 13
school-aged children has asthma. Asthma is one of the leading causes of
school absenteeism, accounting for more than 10 million missed school
days each year. Asthma is the leading cause of hospitalization for
children. Asthma symptoms that are not severe enough to require a visit
to the emergency room can still prevent a child from living a fully
active life.
The Environmental Protection Agency and the Department of Health
and Human Services developed a strategy that focuses on research and
public health preventive programs. Twenty-four million dollars was
provided in fiscal year 2000 to expand the Environmental Protection
Agency's research and public information programs to address indoor and
outdoor asthma triggers. This effort is closely coordinated with the
Department of Health and Human Services program which has committed
$128 million to address asthma. We've just begun to work with State
environmental and health departments to address this epidemic.
LEAD STRATEGY
Another collaborative effort on behalf of the Federal Government is
the Federal strategy to eliminate lead paint hazards in homes where
children under age six live. Childhood lead poisoning is entirely
preventable, yet today it remains a serious environmental health risk
facing children. Lead is highly toxic to young children and can cause
reduced intelligence, impaired hearing, and behavioral difficulties,
and at higher levels can harm a child's internal organs. In the United
States, almost one million children under the age of six have toxic
levels of lead in their bodies. The strategy attempts to decrease this
number to virtually zero in 10 years. It coordinates measures in many
Federal departments and agencies aimed at preventing lead poisoning by:
Acting before children are poisoned by eliminating and
preventing residential lead paint hazards;
Identifying and caring for children already poisoned;
Conducting research to drive down remediation costs; and
Continuing surveillance and monitoring programs.
The Department of Housing and Urban Development provides grants to
cities and States to address lead paint hazards in low-income housing.
LONGITUDINAL COHORT STUDY
Last year, Congress enacted the Child Health Act of 2000 that
authorizes the National Institute for Child Health and Human
Development to conduct a longitudinal cohort study to examine the
impact of environmental pollutants on children. This long term study
will evaluate the link between environmental factors and developmental
disorders, from conception through early adulthood. It will help the
Federal Government understand how the environment, family, and society
interact with the genetic makeup of the developing fetus and child. The
goal is to identify specific areas where prevention, intervention, and
treatment will make a difference for America's children. As the
Framingham study provided us much of what we know about heart disease,
this study could be the watershed in children's environmental health
protection. It will require the dedicated and determined effort of all
our partners in the environmental and health communities to complete
this effort.
HOW CAN EPA HELP
EPA has scientific and technical experts throughout the country
experienced in environmental monitoring, sampling, laboratory analyses,
modeling, remediation and emergency response. We can work closely with
the citizens of Fallon, the Agency for Toxic Substances and Disease
Registry, the Centers for Disease Control and Prevention, and the State
of Nevada to conduct environmental assessments. Our assessment
activities could include environmental testing, surveying industrial,
mining, and waste disposal activities in and around Fallon, searching
records to understand historical uses of the area and inspecting
potential release sites.
Moreover, EPA has more than 40 hot lines and websites, that provide
assistance on a variety of topics, from acid rain to safe drinking
water. In addition, the EPA has a number of websites that provide
information for professionals and families regarding a wide variety of
environmental topics including pesticides and children's environmental
health.
In addition, the Agency for Toxic Substances and Disease Registry
and the Environmental Protection Agency jointly fund the Pediatric
Environmental Health Specialty Units in each of the 10 regions. The
pediatric units provide a clinical referral resource for health care
providers and parents. Health care professionals diagnose and evaluate
health threats associated with exposure to hazardous substances. In
addition, children can be seen at these units by health care
professionals. These units serve an important role in the health care
community due to their expertise in recognizing environmental health
problems and treating children with these problems. The closest site to
Fallon, NV is located in San Francisco at the University of California.
This pediatric unit can be reached at (415) 206-4320.
CONCLUSIONS
Thank you for allowing me to address the committee and the
community of Fallon. I am so sorry that your children are suffering. I
hope that together we can make a difference. I have a few suggestions:
Replicate the waterborne disease response model, which I
mentioned earlier, to address other environmental health problems.
Bolster the State and local public health infrastructures
to monitor and respond to environmental health threats and put in place
preventive health programs that alert us to problem areas that are
likely to occur and to take the appropriate actions before communities
suffer.
Strengthen the partnerships among environment and health
agencies at Federal, State, and local levels.
Establish a national health tracking system for chronic
diseases such as asthma, birth defects, cancer and developmental
disorders, to ensure a rapid response to emerging environmental related
health concerns.
Conduct the national longitudinal cohort study on
environmental factors affecting child health.
Children are our future and we should do everything in our power to
protect them.
__________
Statement of Dr. Shelley Hearne, Executive Director, Trust for
America's Health
Mr. Chairman, Senator Reid, and members of the committee, thank you
for the opportunity to come to Nevada to provide real perspective to
our nation's ability to respond to health crises like the pediatric
leukemia cluster you are facing here in Fallon.
My name is Dr. Shelley Hearne and I serve as the executive director
of the Trust for America's Health--a new nonprofit health advocacy
organization committed to preventing disease and protecting the health
and safety of our communities. I am very proud to have former Governor
Lowell Weicker, Representative Louis Stokes, and Chairman John Porter,
along with many other national leaders in public health serve on our
Advisory Council.
By way of background, I am an environmental health scientist--
serving for almost 20 years in government, non-profits and as a faculty
of the Johns Hopkins School of Public Health. Most recently, I was the
executive director of the Pew Environmental Health Commission--a blue
ribbon independent panel charged with developing recommendations to
improve the nation's health defenses against environmental threats.
Let me start by being candid. Our public health service is falling
short in its duty to watch over the safety and health of the Americans,
particularly when it comes to chronic diseases that may be associated
with environmental factors.
Chronic diseases are responsible for 7 out of 10 deaths in this
country. More than a third of our population, over 100 million men,
women and children suffer from chronic diseases. These diseases cost
our citizens and government, $325 billion a year. By 2020 chronic
diseases are estimated to afflict 134 million Americans and cost $1
trillion a year. And the CDC estimates that 70 percent are preventable.
But our Federal Government is not actively pursuing how to prevent
this epidemic of chronic diseases.
As a Nation, we have been increasing our research into how to treat
disease. As a result, we have some good news here. More children with
leukemia survive today than ever before. But there is bad news. The
rates of childhood leukemia have been steadily rising for the past two
decades. As a Nation, we have not invested in preventing chronic
diseases.
This health crisis in Fallon is a tragedy. My heart goes out to
these families, this community. But as a health scientist, I grow more
angry as I watch this story increasingly repeated in communities all
across the country. In 1997, there were almost 1,100 requests by the
public to investigate suspected cancer clusters. Many of these are
preventable diseases, preventable tragedies and our public health
resources are insufficient to effectively respond to these challenges.
Let me give you an example from my home State of New Jersey.
Parents in Brick Township complained to politicians and health
officials for years about a feared autism cluster in their community.
But health agencies could not even confirm the cluster for years
because they lacked the most basic investigative tools. New York has a
similar story. In Elmira, New York, the State health officials have
been investigating an unusually high incidence of cancer among children
who attended the Southside High School. Fifty-three (53) cases of
cancer have been reported from the 7,500 current and former students
who attended the high school since it opened in 1979. Thirteen of the
cases were reported in the past 3 years. The high school was built on
land that has served as an industrial site since the Civil War. No one
knows why this is happening.
Even though we know about the increasing numbers of chronic disease
clusters and the staggering human and financial toll they have on our
country, we have no systems in place to detect chronic disease clusters
nor do we have the capability to respond to these health crises. Our
Federal, State, and local agencies only coordinate tracking and
responding to infectious diseases such as polio, yellow fever and
typhoid. Diseases that a national tracking and response system helped
to eradicate back in the late 1800's.
Over a century later, we never modernized our public health system
to respond to today's health threats. As a result, we are hamstringing
our health specialists from finding solutions and effectively taking
action--regardless if it's childhood leukemia in Fallon or a nationwide
asthma epidemic.
Let me give you some examples of our scattered State health
tracking systems from the State of Nevada.
Even though birth defects are the No. 1 cause of infant
mortality, Nevada does not track birth defects. The Pew Commission gave
Nevada and 16 other States an F in its report, ``Healthy from the
Start'' which was released in late 1999.
Nevada does not track developmental diseases such as
cerebral palsy, autism and mental retardation even though the National
Academy of Science estimates that 25 percent of these diseases in
children are caused by environmental factors.
Even though studies have shown autoimmune diseases like
Lupus to be increasing, Nevada does not have a system to track these
diseases.
Nevada's cancer registry has been severely neglected for
years. It is the only State that charges hospitals to report cancer
cases--a perfect formula to ensure poor participation.
Unfortunately Nevada is not unusual, it is the norm. This is
because our Federal Government has failed to establish a comprehensive
national approach to tracking and responding to chronic disease.
The Pew Environmental Health Commission based out of the Johns
Hopkins School of Public Health studied our nation's capacity to
identify and respond to chronic disease clusters for 2 years and
proposed creating a nationwide Health Tracking Network to solve this
problem.
The Nationwide Health Tracking Network is based on four principles:
(1) building a coordinated system of tracking chronic diseases and
associated environmental factors; (2) providing the resources and
training to local health departments to analyze the data; (3)
immediately responding to health problems identified through the
system; and (4) providing the national leadership to coordinate health
and environmental activities throughout the Federal Government so that
these programs do not operate in isolation of one another.
The Nationwide Health Tracking Network consists of five components:
1. Establishing essential data collection systems.--The first
component builds on existing health and environmental data collection
systems and establishes data collection systems where they do not
exist. The Network will coordinate with the local, State and Federal
health agencies to collect this critical data.
In all 50 States, the Network would track:
Asthma and other respiratory diseases;
Developmental diseases such as autism, cerebral palsy, and
mental retardation;
Neurological diseases such as Alzheimer's, multiple
sclerosis, and Parkinson's;
Birth defects; and
Cancers, especially in children.
The Network also would track exposures to:
Heavy metals such as mercury and lead;
Pesticides such as organophosphates and carbamates;
Air contaminants such as toluene and carbamates;
Organic compounds such as PCB's and dioxins; and
Drinking water contaminants, including pathogens.
Building upon the existing systems for infectious diseases, the
Federal Government will establish the standards for the health and
exposure data collection necessary to create uniformity throughout the
system. With Federal resources such as funding, training and lab
access, State and local public health agencies will collect, report and
analyze the data.
2. Creating an Early Warning System.--The second component is an
Early Warning System that would immediately alert communities of health
crisis such as lead, pesticide and mercury poisonings. The existing
system of local health officials, hospitals and poison centers that
alert our communities to outbreaks like food illness and the West Nile
virus would also alert our communities to these health crises.
3. Improving response to chronic disease emergencies.--The third
component consists of improving our response to identified disease
clusters and other health crises. The Network would coordinate Federal,
State and local health officials into rapid response teams to quickly
investigate these health problems, providing the teams with trained
personnel and the necessary equipment.
4. Addressing unique local health problems.--The fourth component
is a pilot program consisting of 20 regional and State programs that
would investigate local health crisis and clusters that are currently
not part of the Nationwide Health Tracking Network. These programs
would alert the public and health officials to new developing disease
clusters outside of the Nationwide Health Tracking Network. These
pilots programs also would serve as models for tracking systems for
inclusion in the Network.
5. Creating community and academic partnerships.--The fifth
component establishes relationships with five Academic centers and with
our communities. Our community relationships would ensure that the
tracking data is accessible and useful on a local level, and our
research relationships would train the work force, analyze data, and
develop links between the tracking results and preventive measures.
[The background and basis for this Network and other Commission
findings and recommendations are attached as part of the written
testimony. These are also available on the website at http://
pewenvirohealth.jhsph.edu or http://health-track.org]
This Network would provide our communities, scientists, doctors,
hospitals and public health officials with missing data on where
chronic diseases are clustering and associated environmental factors
that would enable us to develop prevention strategies. Over 30 key
health organizations have endorsed this recommendation, ranging from
Aetna US Health Care to the American Cancer Society to the American
Academy of Pediatrics to the Association of State and Territorial
Health Officers (ASTHO).
The American Chemistry Council supports the concept, noting that
``. . . data generated by a national tracking program can shift the
focus from debate and speculation about disease trends to intervention
and prevention based on scientific evidence.''
Developing prevention strategies are critical to reducing the $325
billion a year Americans spend on chronic diseases. In less than 15
years, the estimated cost of chronic disease is predicted to rise to $1
trillion. The estimated cost of the Network is about $275 million or
less than 1 dollar per every man, woman and child.
These data will allow us to spend our limited treatment and
research dollars more effectively by identifying which chronic diseases
are increasing. We have doubled our research dollars in the National
Institutes of Health, yet these scientists do not have even the most
basic information about why these diseases occur, where they strike,
whom they choose as their victims, and how to take action to prevent
future clusters.
Without a Network, we will remain in the dark; still unable to
answer these questions.
The most cost effective use of tax dollars today would be to invest
in preventing the leading killers in this country. And the American
public agrees. The American public is so concerned about this issue
that 63 percent feel that public health spending is more important than
cutting taxes. Seven out of ten registered voters (73 percent) feel
that public health spending is more important than spending on a
national missile defense system.
A recent public opinion poll by Princeton Survey Research
Associates revealed that nine out of ten (89 percent) registered voters
support the creation of a national system.
Most local health departments face declining funding, inadequate
training for staff, limited or no laboratory access, and outdated
information systems. CDC and ATSDR have not been able to adequately
help. For instance, there is no Federal funding for an environmental
health specialist or even chronic disease investigator in Nevada. This
is true for almost all States. Nor could CDC or the Agency for Toxic
Substances and Disease Registries (ATSDR) give Nevada written guidance,
standards or protocols on how to investigate this childhood cluster.
The health agencies have never developed a concrete response program to
these growing cluster demands.
Due to concerns of Bioterrorism, the CDC is taking many steps
toward developing a public health infrastructure including upgrading
computer and communications systems for collecting and sharing
infectious disease data among local public health departments. We could
simultaneously build on these initiatives and enhance these efforts to
ensure a nationwide strategy for chronic disease prevention. These are
the diseases that Americans are dying from today, not tomorrow's
theoretical threats.
On a Federal level, there are a few programs that relate to chronic
diseases, but do not track and respond to the chronic disease clusters.
The irony is the Administration's proposed budget recommends severe
cuts for the nation's chronic disease prevention programs. We need to
be going in the exact opposite direction. Health defense should be the
country's No. 1 commitment.
Who is guarding our health? The answer is that the public health
service has fallen short of its duty--lacking the tracking, troops and
leadership. This is exactly where our Federal Government is needed--to
develop the tracking and monitoring systems, supply the troops and
offer the leadership to prevent chronic disease.
To modernize our public health resources so that we can identify
clusters before they grow, we must take rapid action to control their
spread and find solutions to prevent diseases. CDC must be given the
direct mandate to aggressively respond to communities' concerns like
those in Fallon, with modern tools and health-tracking systems. And
Congress must prioritize $275 million per year, less than a dollar per
person to make this happen. It is just a tenth of 1 percent of the
overall spending of health care dollars in this country.
Without this type of investment, we will only watch asthma, certain
cancers and other chronic disease rates continue to rise. There will be
many more Fallons. And that will be the greatest tragedy of all.
__________
Shundahai Network,
Pahrump NV, April 19, 2001.
Committee on Environment and Public Works,
U.S. Senate,
Washington, DC.
Subject: Fallon Leukemia Cluster
Dear Committee Members: I am writing in response to a request for
public testimony concerning factors to consider connection with the
Fallon Leukemia cluster. I would like to see this committee carefully
consider the role of fire in the disbursal of hazardous materials
through the environment, including fire's role in remobilized
radioactive isotopes and other contaminates deposited in Nevada as a
result of weapons testing. I would request the committee to consider
the dangers associated with fire as a remobilizing agent of
radionuclides from the Nevada Test Site and other testing ranges in the
State.
During the period of above ground testing from 1951 to 1963,
radioactive releases from the Nevada Test Site emitted over 12 billion
curies of radioactive material into the atmosphere, 148 times as much
as the nuclear disaster at Chernobyl. Other pre-1971 nuclear tests
released 25,300,000 curies, and from 1971-1988, 54,000 curies were
released, including the 36,000 curies from the Mighty Oak accident,
which was itself 2000 times greater than the release at Three Mile
Island. Over half of all underground tests have leaked radiation into
the atmosphere (DOE Report on Radioactive Effluents, 1988). DOE has
been out of compliance with Federal and State permit requirements in
the areas of air emissions, water releases, and solid waste disposal
(DOE Nevada Operations Office Five Year Plan, 1989).
There is contamination in soil, air, ground and surface water.
Strong winds, common to this area of Nevada, can carry plutonium-
contaminated dust across a large area. Fallout from above ground
nuclear tests in the United States and other countries has
radioactively contaminated the atmosphere around the Earth. Project
Faultless in Hot Creek Valley was found to have caused radioactive
contamination in groundwater. According to EPA Publication 520/4-77-
016, cumulative deposits of plutonium (Pu-239 and Pu-240) have been
found in soil over 100 miles north of the NTS at levels of 790 mg per
acre. Plutonium has a half-life of 26,000 years, and plutonium
contaminants ingested in microscopic amounts are capable of causing
cancer for 200,000 years. There is no cost-effective technology for
decontaminating such sites. No surveys have been conducted to determine
health effects on Native American or other residents from Nevada Test
Site (NTS) releases. Currently the Nuclear Risk Management for Native
Communities project is working to answer some of these questions.
It is known that plutonium translocates to specific radiosensitive
organs, especially reproductive organs.
During the years of 1999 and 2000, almost 3,000,000 acres of Public
Lands in the State of Nevada were subjected to fires, both wild fire
and prescribed burns. Fire remobilizes contaminants. Particles are
lifted from the ground into the air, then mobilized through environment
on wind currents. The particles are resuspended for an indefinite time
period, finally redeposit onto the earth. This process creates fallout.
As a result of this process, fire can carry containments across the
globe.
We understand that the Nevada BLM oversees management of 1,722,330
acres of public lands considered contaminated with UXO, (unexploded
military ordinances). BLM lands border NTS (Nevada Test Site), Nellis
Bombing and Gunnery Range, Tonopha Air Force Base, together with the
Fallon Range. No one knows the amount or extent of nuclear
contamination in the area surrounding the NTS and Nellis Air Force Base
which tests depleted uranium (DU) bombs. In 1997 it was estimated that
30 tons of DU had already been deposited in the target area (Draft
Environmental Assessment Resumption of Use of Depleted Uranium Rounds
at Nellis Air Force Range Target 63-10), a total of 9,500 combat mix
rounds (7,900 DU rounds) being expended annually, there.
Depleted uranium or U-238 has an atomic mass of 238. Its half-life
is 4.468 billion years (Rokke, 2001). It's natural occurrence is 2.1
parts per million. Uranium is silver white, lustrous, malleable,
ductile, and pyrophoric. This makes DU an ideal metal for use as
kinetic energy penetrators, counterweights, and shielding or armor.
High density and pyrophoric (catches fire) nature are the two most
significant physical properties that guided its selection for use as a
kinetic energy penetrator.
A study performed at Yucca Proving Grounds found DU residues in all
components of the environment, that environmental concentrations varied
widely, that corroded DU residues are soluble and mobile in water, that
wind dispersal during testing is the prevalent means of dispersal of DU
particles, and that an unknown degree of risk was posed to human health
by DU in the environment. Moreover, there appears to be no insight into
the issue of long-term (100 to 1,000 years and longer). DU forms of
both soluble and insoluble oxides. The inhalation of the insoluble
oxides presents an internal hazard from radiation if retained in the
lungs.
The long-term effects of internalized depleted uranium are not
fully known, but the Army has admitted that ``if DU enters the body, it
has the potential to generate significant medical consequences.''
Inhaled DU particles or respirable size may become permanently trapped
in the lungs. Inhaled DU particles larger than respirable size may be
expelled from the lungs and ingested. DU may also be ingested via hand-
to-mouth transfer or contamination of water or food supplies. DU, which
is ingested, or enters the body through wind contamination, will enter
the bloodstream and migrate throughout the body, with most of it
eventually concentrating in the kidney, bone, or liver. The kidney is
the organ most sensitive to DU toxicity.
More testing of soil and plants needs to be done to determine what
radionuclides might be released into the air in a fire, since a fire
and its relationship to the resuspension of contaminants has not been
the subject of study. Plutonium and radionuclides concentrate in dust,
thus higher concentrations are found in the dust sampling than in
regular soil sampling. The standard air monitors and surface water
samplers usually used are not sufficient to measure submicroscopic
particles of plutonium. Further, plutonium contamination is not
homogeneous, so simplistic sampling methods are inadequate (John Till,
President, Risk Assessment Corp; 2000). Wind-blown particulates must be
considered. Debris and gas will go somewhere, but where? Into the water
or the soil?
Radiation detection devices that detect and measure alpha
particles, beta particles, x-rays, and gamma rays emissions at
appropriate levels from 20 dpm up to 100,000 dpm and from .1 mrem/hour
to 75 mrem/hour must be acquired to sess the distribution of particles.
Standard rad-meters or Geiger counters do not measure these levels.
In order to assess the health risks and damage due to exposure to
tritium (radioactive hydrogen), three blood tests must be done. White
blood cells must be tested for the presence of micronuclei, indicating
the loss of DNA repair processes and leading to increased cancer risk.
Red blood cells must be examined for genetic modification of surface
glycophorin-A molecules, also indicating DNA damage. A study of
Japanese nuclear bombing victims 40 years from the time of the blasts
showed DNA codes were still unrepaired. In addition, chromosome
painting allows chromosomes to be stained for identification of
structural and sequential or numerical abnormalities linked to
radiation and chemical exposure, cancer, and inherited diseases.
In addition to the redistribution of containments, we need to
consider the effects of fire upon other substances. For example, we
must consider chemical reactions which may take place when multiple
herbicides are burned together. For instance, one chemical being most
often utilized on public lands is Tordon. But Tordon is also called
Grazon, and the active ingredient is picloram, better known as Agent
White, similar to Agent Orange, and one of several defoliants used in
Vietnam. In fact, Agent White (picloram) appeared in 5 of the 15
defoliants used there. Agent White is currently being sprayed by the
U.S. on the coca fields in Columbia as part of the drug war. In 1998,
Dow Chemical, manufacturer of Agent White (picloram) tried to halt its
use, warning that it does not bind well with soil, easily washes into
the groundwater and could cause irreparable damage to the Amazon
Rainforest. Yet, U.S.G.S. Pesticide 1992 Annual Use Map showed
estimated annual agricultural use of Agent White to be less than 0.370
pounds per square mile per year. The map shows the entire State of
Nevada has been exposed. This is a lot, and has probably increased
since that time. If it's dangerous to the water and forest areas of
Colombia, it is dangerous here in the U.S. The use of Tordon is banned
in some countries.
Also commonly used are 2, 4-D which forms poisonous gas in fire. It
is on the Hazardous Substance List because it is regulated by OSHA. The
chemical is a mutagen (changes the genetic structure), a teratogen
causing birth defects, and a carcinogen particularly related to breast
cancer. Short term effects of its use include the death of animals,
birds, fish, and plants within 2-4 days after exposure. About 91.7
percent of 2, 4-D will eventually end up in water. In 1990, the Clean
Air Act announced 2, 4-D as a hazardous air pollutant. Run off vapors
can kill non-target plants. Agent Orange was a mix of 2, 4-D and 2, 4,
5-T. Another name for 2, 4, 5-T is Weedar. And both of these chemicals
appear on the recommended list of chemicals used on public lands.
Garlon is also known as triclopyr (both names appear separately on
the recommended treatment list as if they are different herbicides).
Triclopyr's chemical structure is very similar to 2, 4, 5-T. The MSDS
sheet includes the following data: Nitrogen oxides, hydrogen chloride,
and phosgene may result under fire conditions and NIOSH/MSHA requires
approved SCBA and full protective equipment for firefighters. Garlon-
treated wood that is burned during forest fires, or in wood stoves at
home produces a dioxin, one of the most damaging compounds to living
organisms. Garlon is an endocrine disrupter.
It mimics a plant hormone, acting systematically to kill the plant
or tree. The hormone that Garlon mimics is perceived by the human body
to be estrogen. In women, this may result in breast cancer,
miscarriages, infertility, birth defects, and possibly ovarian cancer.
In men, it can cause prostate or testicular cancer and reduction of
sperm count. It also may aggravate liver and kidney disease. We do not
know what the effects of burning multiple pesticides and the full
extent of the risk to public health from such events.
I suggest that a more appropriate methodology for determining
causation of the Fallon leukemia clusters would use a multidimensional
model for analysis. In other words, rather considering singular
etiologies, as suggested by Prescott from CDC at the hearings, a more
complex multi-factor dynamic process may be in operation. We might
hypothesize very generally that exposure to radionuclides such as
tritium, plutonium, or DU, might cause mitochondrial damage to cells.
In addition to other functions, mitochondria contribute to a sort of
``programmed cell-suicide''. For example, in certain stages of fetal
development, humans have webbed fingers. The mitochondria detect this,
and at the appropriate time, seek to destroy the web cells, leaving
humans with fully formed fingers. This cell-suicide is necessary.
However, when exposed to an error or to toxins or radionuclides,
the mitochondria engage in a process of ``unprogrammed cell suicide.''
Thus, healthy cells are destroyed. Such suicides may lead to
destruction of critical elements of immune system function, resulting
in cancers, leukemia, and the inability to fight the effects of various
viruses and bacteria. The cells may be more vulnerable to effects of
exposure to chemicals or pesticides. In addition, adequate production
of certain neurotransmitters and hormones might be disrupted leading to
diabetes or neurological damage. These medical conditions have been
reported as increasing in the general population, and though differing
in appearance, may be reflecting a basic underlying cellular assault
caused by radiation exposure. I refer you to the work of Guy Brown.
Thank you for your thoughtful consideration.
Sincerely,
Dr. Bonnie Eberhardt Bobb.
______
[Pew Environmental Health Commission Report, September 2000]
Companion Report on America's Environmental Health Gap: Why the Country
Needs a Nationwide Health Tracking Network
FOREWORD BY COMMISSION CHAIRMAN LOWELL WEICKER, JR.
With the mapping of the human genome, we are on the verge of a new
wave of advances in health. With this remarkable achievement,
researchers will be able to shed new light on the links between genetic
predisposition and such factors as behavior and exposures to pollutants
in the environment in order to prevent many of the chronic diseases
that today cause so much suffering.
But there is a catch. We must have the basic information about the
health of Americans and our environment before we can make the fullest
use of this exciting genetic knowledge. The way to get this basic data
is to track it--systematically, comprehensively, on a coordinated basis
at all levels from the local community to the Nation as a whole. We
have to track what and where the hazards are in the environment,
whether people are at risk from exposures to these hazards, and the
health of our communities. Our information about environmental factors
must run as deep and comprehensive as our knowledge of the genome.
This report examines our current public health response
capabilities to environmental threats, and recommends the establishment
of a Nationwide Health Tracking Network. The Pew Environmental Health
Commission is charged with developing a blueprint to rebuild the
Nation's public health defenses against environmental threats. We know
there are pollutants entering our air and water each year with
suspected or known adverse effects on the health of our communities.
What we are limited in knowing if there is a link between that
pollution and the increases we are seeing in chronic diseases because
we aren't tracking environmental health factors.
We need to gather the facts now. Americans have a right, and the
need, to know.
EXECUTIVE SUMMARY
At the dawn of the 21st century, America is facing an environmental
health gap. This is a gap in critical knowledge that hinders our
national efforts to reduce or eliminate diseases that might be
prevented by better managing environmental factors. This is especially
true for chronic diseases and conditions, such as birth defects, asthma
and childhood cancer, which strike hundreds of thousands of American
families each and every year.
What is the environmental health gap? It is the lack of basic
information that could document possible links between environmental
hazards and chronic disease. It is the lack of critical information
that our communities and public health professionals need to reduce and
prevent these health problems. While overt poisoning from environmental
toxins has long been recognized, the environmental links to a broad
array of chronic diseases of uncertain cause is unknown.
The national cost of chronic disease is staggering: 4 of every 5
deaths annually, 100 million people suffering each year and $325
billion in annual healthcare and lost productivity. While our
healthcare system is one of the best in the world in treating disease,
the environmental health gap is crippling our ability to reduce and
prevent chronic disease and help Americans live longer, healthier
lives.
The Pew Environmental Health Commission proposes a Nationwide
Health Tracking Network to close this critical gap. With a
comprehensive tracking network, we can advance our ability to:
Identify populations at risk and respond to outbreaks,
clusters and emerging threats;
Establish the relationship between environmental hazards
and disease;
Guide intervention and prevention strategies, including
lifestyle improvements;
Identify, reduce and prevent harmful environmental risks;
Improve the public health basis for policymaking;
Enable the public's right to know about health and the
environment; and
Track progress toward achieving a healthier Nation and
environment.
The proposed Network would be comprised of five key components:
(1) national baseline tracking network for diseases and exposures;
(2) nationwide early warning system for critical environmental
health threats;
(3) State pilot tracking programs to test diseases, exposures and
approaches for national tracking;
(4) Federal investigative response capability; and
(5) tracking links to communities and research.
Investing in prevention through these five components is estimated
to cost the Federal Government $275 million annually--less than 0.1
percent of the current annual economic cost of treating and living with
chronic disease--a very modest investment in a healthier America.
the grim picture--an environmental health and prevention gap
Americans today are sophisticated about their health. More of us
are asking if there is something in the air, water or diet that could
be making us sick. Is it our behavior--or something in our genes?
Unfortunately, we are left with too many unanswered questions.
Recently, a major research study found that most types of cancer
are not inherited genetic defects, but are explained mainly by
environmental factors. Environmental factors include environmental
tobacco smoke, toxic chemicals, dietary habits and viral infections.\1\
Despite many years of effort, scientists still are searching for
answers about the relationship among the factors in our behavior, genes
and the environment that cause disease and disability.
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\1\ Published in the July 13, 2000, edition of the New England
Journal of Medicine, the study examined the medical histories of 44,788
pairs of twins listed in the Swedish, Danish and Finnish twin
registries in order to assess risks of cancer at 28 anatomical sites
for the twins of persons with cancer. It concluded that genetic factors
make a minor contribution to susceptibility to most types of neoplasms,
and the environment has the principal role in causing sporadic cancer.
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Earlier this year, it was announced that researchers have mapped
the human genome, a breakthrough that is expected to open new doors to
understanding chronic disease. Scientists will use this emerging
genetic knowledge to fight disease. But if we are going to prevent
disease, researchers also need more complete information about
environmental factors, their effect on people, and the resulting health
outcomes. In this way, scientists will have the capability to link
genetic and environmental information and could begin to answer our
questions about the complex causes and prevention of chronic disease.
Few would dispute that we should keep track of the hazards of
pollutants in the environment, human exposures, and the resulting
health outcomes--and that this information should be easily accessible
to public health professionals, policymakers and the public. Yet even
today we remain surprisingly in the dark about our Nation's
environmental health.
We have as a Nation invested heavily in identifying and tracking
pollutants in the environment, particularly for regulatory and
ecological purposes, but only minimally in tracking exposures and the
distribution of disease and its relationship to the environment. As a
result of decades of neglect, we have a public health system that is
working without even the most basic information about chronic disease
and potential environmental factors. The Commission found that
information on trends in health conditions potentially related to the
environment is largely unavailable. Here are a few illustrations of
what this environmental health gap means:
Only four States report tracking autoimmune diseases,
such as Lupus, even though there is increasing evidence to believe
rates of these diseases are rising and the environmental links remain
unknown.
Despite evidence that learning disabilities have risen 50
percent in the past 10 years, only six States track these disorders and
we have no answers about causes or possible prevention strategies. Most
States do not track severe developmental disabilities like autism,
cerebral palsy and mental retardation. A recent report of the National
Academy of Sciences estimates that 25 percent of developmental
disorders in children are caused by environmental factors.
Endocrine and metabolic disorders such as diabetes, and
neurological conditions such as migraines and multiple sclerosis, have
increased approximately 20 percent between 1986 and 1995, based on
surveys by the Centers for Disease Control and Prevention (CDC). Most
States do not systematically track these diseases and conditions.
For most of the United States, there is no systematic
tracking of asthma despite the disease having reached epidemic
proportions and being the No. 1 cause of school absenteeism. Between
1980 and 1994, the number of people with asthma in the United States
jumped by 75 percent. Without prevention efforts that include a strong
tracking component, the Commission has estimated that the number of
asthma cases will double by 2020.
Birth defects are the leading cause of infant mortality
in the United States, with about 6,500 deaths annually. Since the mid-
1980's, rates of low birth weight and pre-term births have been rising
steadily despite increased prevention efforts. The causes of 80 percent
of all birth defects and related conditions remain elusive even as
evidence mounts that environmental factors play an important role. The
Commission found that less than half the Nation's population is covered
by State birth defect registries, which inhibits our ability to find
solutions.
The tracking programs that do exist at the State and local levels
are a patchwork because there are no agreed-upon minimum standards or
requirements for environmental health tracking. The Commission found
different standards, created to meet different objectives or regulatory
requirements, and little synchronization in the collection, analysis
and dissemination of information. In addition, much of the data that is
collected is never analyzed or interpreted in a way that could identify
targets for further action. Most of this data is never released to the
public.
There is limited ability to take action at the State level without
additional resources and leadership from the Federal Government. For
decades, State and local health agencies have faced declining
resources, with the result that many now face the 21st century with
outdated information systems, limited laboratory access, inadequate
staff training and an inability to develop viable tracking programs.
The Commission's survey of State and local agencies found a critical
lack of funding for these activities despite unprecedented public
demands.
Environmental tracking for pollutants is crucial, because often the
hazards can be removed or abated before they cause harm. But such
monitoring is not sufficient by itself. Tracking actual human exposures
to hazards in the environment is frequently the missing link between
public health efforts to evaluate a risk nationally and the ability to
respond to a health threat in a specific community. This should include
improving national efforts to track population exposures to
contaminants and providing the investigative tools for local health
officials.
Finally, there is a national leadership void, resulting in little
or no coordination of environmental health activities. As a result,
public health prevention efforts are fragmented and too often
ineffective at reducing chronic and disabling diseases and conditions.
The CDC and EPA have some basic building blocks of a tracking
network in place, but much more needs to be done. Currently 50
infectious diseases are tracked on a national basis. We need a
comparable modern network to track chronic diseases and discover the
environmental contributions to them.
THE PUBLIC'S EXPECTATIONS
The public understands that we are not doing enough to protect our
communities. A recent national survey of registered voters found that
the majority are concerned about risks to their health from pollutants
in the environment, and believe that government is tracking these
hazards and possible links to chronic health problems.\2\ When they
learn that in reality there is no disease tracking, they are
concerned--seriously concerned. Most Americans surveyed say that taking
a national approach to tracking environmental health should be a
priority of government at all levels.
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\2\ Health-Track is a project supported by The Pew Charitable
Trusts through a grant to Georgetown University. The survey, by
Princeton Survey Research Associates, was conducted in April 2000 of
1,565 registered U.S. voters and has a margin of error of 3
percent for results based on a full sample.
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Without comprehensive environmental health tracking, policymakers
and public health practitioners lack information that is critical to
establishing sound environmental health priorities. In addition, the
public is denied the right to know about environmental hazards,
exposure levels and health outcomes in their communities--information
they want and have every reason to expect.
At the same time Americans demand a right to know about these
hazards, they also expect government to gather health information in a
way that protects citizens' privacy. Americans understand the
importance of population-based health tracking as well as the need to
keep individual health records private. Fortunately, public health
agencies have an outstanding track record for zealously guarding the
public's confidentiality and privacy. To ensure this continued balance,
the Pew Commission established a set of principles for Protecting
Privacy and Confidentiality and Our Environmental Health Right-to-Know
(listed in the back of this report). The Commission believes that
adherence to these principles will enable public health agencies to
continue their traditional commitment to the confidentiality of
individually identifiable health records without significantly
hampering their obligations to the public health.
The Federal Government tracks many things all the time. It knows
how many women dye their hair every year (three out of five), but has
only rough estimates of how many people have Parkinson's disease,
asthma, or most other chronic diseases that cause four of every five
deaths in the U.S. each year. We have the right to know more.
THE PEW ENVIRONMENTAL HEALTH COMMISSION'S RECOMMENDATION--A RIGHT TO
KNOW OUR ENVIRONMENTAL HEALTH
To fill the Environmental Health Gap, the first step is to
establish a tracking capacity for chronic diseases and environmental
exposures that also link to hazard data. To this end, the Commission
offers the following comprehensive recommendation:
Create a federally supported Nationwide Health Tracking Network
with the appropriate privacy protections that informs consumers,
communities, public health practitioners, researchers, and policymakers
on chronic diseases and related environmental hazards and population
exposures. This will provide the capacity to better understand, respond
and prevent chronic disease in this country.
This tracking network would be a tiered approach, with a national
baseline of high-priority disease outcomes and exposures that allows
flexibility at the State and local level for specific concerns. At a
minimum, all information would include race, ethnicity, gender, age and
occupation. The blueprint for the Nationwide Health Tracking Network
involves five components of information and action:
Tier 1: National Baseline Tracking of Diseases and Exposures
This will be a nationwide network of local, State and Federal
public health agencies that tracks the trends of priority chronic
diseases and relevant environmental factors in all 50 States, including
Washington, DC, Puerto Rico and U.S. territories. The information will
allow us to identify populations at high risk, to examine health
concerns at the State level, to recognize related environmental
factors, and to begin to establish prevention strategies.
The Federal Government will have the responsibility to establish
minimum national standards for health and exposure data collection. The
State and local public health agencies, with Federal support and
guidance, would be responsible for the collection, reporting, analysis
and response.
As a starting point, the Commission identified certain diseases and
exposures that should be collected by all 50 States, based on review of
the scientific literature, environmental data, reported health trends
and targets identified by public health agencies. These are:
Diseases and Conditions: Birth defects; Developmental disabilities
such as cerebral palsy, autism and mental retardation; Asthma and
chronic respiratory diseases such as chronic bronchitis and emphysema;
Cancer, including childhood cancers; and Neurological Diseases,
including Parkinson's, Multiple Sclerosis and Alzheimer's.
Exposures: Persistent organic pollutants such as PCBs and dioxin;
Heavy metals such as mercury and lead; Pesticides such as
organophosphates and carbamates; Air contaminants such as toluene and
fine particles; and Drinking water contaminants, including pathogens.
To translate this information into action will require a
revitalization of the public health infrastructure by providing
adequately trained health professionals to collect and interpret the
data at the local, State and national levels; to respond to concerns
and to ensure a healthy environment. The information produced by the
network will be widely disseminated and easily accessible--
simultaneously protecting both the public's right to know and
individuals' privacy.
Finally, all of these efforts will be coordinated and made
available to our communities and public health researchers. To ensure
the information is accessible and useful in evaluating the progress of
disease prevention efforts, a National Environmental Report Card should
be jointly developed by CDC and EPA by 2003. It would provide an annual
overview of key environmental factors and health outcomes, allowing all
interested parties to track progress and shape national goals. It
should be adaptable so that State and local agencies can build on this
for their own Environmental Health Report Cards.
Tier 2: National Early Warning System
This early warning system would act as a sentinel to allow rapid
identification of immediate health problems, including chemical
catastrophes. This would build on the existing infectious disease
monitoring network around the country by including environmental
sentinel exposures and health outcomes. The existing partnership of
hospitals, poison centers and public health agencies that make up the
tracking network for outbreaks like food and waterborne illnesses and
bioterrorism attacks also should identify and track early warning signs
of outbreaks of health effects that may result from environmental
factors. This would be the first stage in an environmental outbreak
response capability. At minimum, the Commission recommends that this
should include: Acute sensory irritation such as eye and respiratory
problems, Heavy metal poisoning, and Pesticide poisoning.
For example, if a terrorist or accidental event occurred involving
misuse or release of toxic chemicals, an early warning system with
environmental capacity could quickly recognize the episode, identify
the chemical exposure and more rapidly initiate effective treatment and
response.
Tier 3: State Pilot Tracking Programs
The Network also would support a coordinated series of 20 State
pilot programs in order to respond to regional concerns and test for
exposures and disease outcomes that could be tracked on a national
level. These pilots would be ``bellwethers'' for better understanding
potential health and environmental problems.
Selecting appropriate health and environmental indicators is
essential to the success of a national network. This requires
systematic development of tracking methods that are flexible, practical
and adaptable to the unique public health needs of States.
States may be interested in developing pilot tracking capacity for
certain disorders, diseases and exposures in order to strengthen the
response to local health concerns. For example, there have been
increasing concerns about environmental links to attention deficit
disorder, lupus and endocrine disorders, such as diabetes.
Pilot programs covering specific health problems also would provide
the Network with a broad reach for rapidly addressing many different
health concerns, while at the same time testing methods and evaluating
the need for broader tracking of certain health problems.
Tier 4: Public Health Investigative Response
Trained public health officials at the Federal, State and local
level need to be able to respond to health concerns that are identified
through this network. The Federal Government must provide States and
localities with the support and capacity to assure a coordinated
response to investigate threats linked to the environment.
By developing the capacity to track trends at the national level
and conduct investigative surveys anywhere in the nation, the Network
would be prepared to respond to outbreaks, clusters and emerging
threats. While this is a routine response for infectious outbreaks, we
presently lack a similar ability to respond to chronic disease
investigations.
There are many needs for a response capacity. For example, the
recent National Academy of Sciences study on mercury and its
neurodevelopmental effects on children exposed in utero underscored the
need to study exposures and health outcomes of pregnant women across
America. This capability also would permit quick response at the local
level to citizens' concerns about potential problems, such as
spontaneous abortions among women who live near hazardous waste sites.
Tier 5: Tracking Links to Communities and Research
The Network would depend on a strong community and scientific
foundation to ensure its relevance, effectiveness and vitality.
The public has a right to know the status of our environmental
health at the national, State and local level. It is paramount that the
Network be grounded in community groups so that local concerns are
adequately addressed in the design of the system, that tracking data is
readily accessible and that this information is useful for local level
activities. To insure this interaction, the Network should support
community-based organizations to routinely evaluate the tracking
systems with regard to individual and local needs and to ensure
dissemination and interpretation of the Network data.
ACTION STEPS NEEDED TO DEVELOP THE NETWORK
To establish this Nationwide Health Tracking Network, the
Commission calls on the Administration, Congress, the Secretary of
Health and Human Services, and the Administrator of the Environmental
Protection Agency to support and implement the following action plan:
The Administration and Congress should provide funding
support within 1 year to develop and establish the Nationwide Health
Tracking Network. This should include support and incentives for State
and local agencies, healthcare providers, community-based agencies and
insurers to become active partners in tracking population health and
identifying, treating, and preventing health problems related to the
environment. The Commission estimates that the annual cost for a
Nationwide Health Tracking Network is $275 million.
The Administration and Congress should guarantee public
access to the Nationwide Health Tracking Network to better understand
community environmental exposure and health outcome information. As
part of this right-to-know requirement, the EPA, CDC and the Surgeon
General should jointly develop a National Environmental Health Report
Card by 2003, which will give all Americans an annual overview of key
hazards, exposures, and health outcomes in order to gauge progress and
shape national goals. The approach should be adaptable to the needs of
State and local agencies to facilitate similar report cards at the
State and local levels.
The Secretary of Health and Human Services, in
collaboration with the EPA Administrator, should by 2001:
LDesignate a national lead authority for environmental
health tracking to oversee development of a nationwide network
and coordinate all related health and exposure monitoring
activities, including those of EPA, CDC and the Agency for
Toxic Substances and Disease Registry (ATSDR); and
LEstablish a Council on Environmental Health Tracking
to work with the HHS, EPA and State tracking leadership to set
up science-based criteria, minimum State standards and privacy
and confidentiality guidelines for a tiered approach that
supports both national priorities and State flexibility.
Every Governor should appoint an environmental health lead
in the State health department.
CDC/ATSDR should help build State capacity to launch the
Network, monitor the data, and respond to potential health concerns by:
LPlacing an Environmental Health Investigator in every
State;
LExpanding the CDC Epidemic Intelligence Service and
Public Health Prevention Service to recruit and train public
health officers in environmental epidemiology and tracking;
LWorking with the National Association of County and
City Health Officials to develop similar leadership capacity at
the local level with support and guidance from HHS; and
LProviding technical resources to local and State
public health agencies, including improvement of regional,
State and local laboratory capacity to evaluate community
exposures and complement State investigative abilities.
______
The Case of Libby, Montana
Last November, Federal agencies began investigating what is
believed to be the single most significant source of asbestos exposure
in the United States. Residents of the small town of Libby, Montana,
have watched for decades as neighbors, friends, and loved ones fell ill
with respiratory problems. Many died. Townspeople thought it might have
something to do with the vermiculite mine that was the town's largest
employer from its opening in the 1920's until it was shut down in 1990.
But until the Federal health investigation this year, no one knew for
certain. As far back as the mid-1950's, State health officials had
reported on the toxic asbestos dust in the mine, but no one followed up
on possible exposures or health impacts to the town's 2,700 residents.
It turned out that along with vermiculite, the mine also was
releasing tons of tremolite, a natural but rare and highly toxic form
of asbestos, into the region's environment. It takes 10 to 40 years for
asbestos exposure to manifest in chronic, and often fatal, respiratory
diseases, including asbestosis, rare cancers and emphysema. Therefore,
early intervention as soon as potential or actual exposures were
detected could have prevented these long-term harms.
So far, nearly 200 people reportedly have died from diseases
connected to the
asbestos-tainted vermiculite. Newspapers account that another 400 have
been diagnosed with asbestos-related disease, including mesothelioma, a
rare and fatal cancer of the lung lining associated with asbestos
exposure. Every month, more Libby area residents are diagnosed with
asbestos-related diseases. As many as 5,000 people are expected to
undergo medical testing for asbestos-related diseases by Fall 2000.
``Active [tracking] of asbestos-related disease might have picked
this up much sooner, and started preventive activities 10-20 years
ago,'' said Dr. Henry Falk, administrator of the Agency for Toxic
Substances and Disease Registry. In that case, more lives would have
been saved and the severity and possible spread of the outbreak
reduced.
Now, public health officials have to cope not only with ensuring
that Libby residents are protected from this environmental hazard, but
also investigating other sites and possible worker exposures around the
country where this asbestos-laden vermiculite was shipped, processed
and used in large quantities.
Clearly, this case illustrates the tragedy of not tracking the
environmental health of our communities. Every year there are towns and
cities across the United States where residents are asking themselves,
their health officials and elected leaders, why they or their children
are getting sick. Until we establish a national tracking network
capable of bringing together in a coordinated fashion the information
about environmental hazards in the community, the exposures of people,
and data on health problems, we will risk having more cases like Libby,
Montana.
______
The Case of Pesticides in Mississippi
In November 1996, one of the nation's worst and most costly public
health disasters involving pesticide misuse was discovered in rural
Jackson County, Mississippi. The event in Jackson came on the heels of
similar events in Ohio and Michigan.
Initially, health officials became aware of a possible problem when
church members reported a noxious odor and yellowed walls in their
church after fumigation. Before long, numerous residents began
complaining of various symptoms, mainly resembling influenza. Suddenly,
officials were facing a possible pesticide threat potentially larger
than any in Mississippi's history.
The initial investigation revealed that illegal pest control
spraying in homes and businesses had taken place, potentially exposing
thousands of residents in the area to methyl parathion (MP), an
organophosphate insecticide intended for outdoor use that attacks the
central nervous system, causing nausea, dizziness, headaches, vomiting
and in severe cases, death. EPA officials began considering relocation
of residents and decontamination of homes at what would be a staggering
cost.
Fortunately, public health officials had a health-tracking tool
that was able to pinpoint who was at immediate risk and allowed for a
more targeted, rapid response. Using biomonitoring--the direct
measurement of human exposure to a contaminant by measuring biological
samples, such as hair, blood or urine--health officials could determine
individuals' exposure levels to MP. In this case, biomonitoring allowed
scientists to identify the residents who were most at risk and
prioritize evacuation and cleanup in the most dangerous situations, not
just every house suspected.
Armed with this information, EPA, ATSDR and State health officials
were able to implement an effective health defense plan. In Mississippi
and Alabama, over 1,700 residents had to be temporarily relocated and
nearly 500 homes and businesses had to be decontaminated at a cost of
almost $41 million. While no one died or was seriously injured in the
short term, many of the early victims were misdiagnosed with the
influenza virus--a fact that only underscores the need for a nationwide
health tracking network to monitor environmental threats.
A national early warning system for pesticide poisoning might have
detected this problem sooner and led to a quicker halt of the illegal
pesticide applications in other States. In turn, this would have
prevented widespread exposures, and in some cases, evacuations, and
higher human and financial costs. This case also points to the
importance of another feature of a network--the laboratory resources
and other infrastructure to conduct rapid and effective biomonitoring
to protect the health of our communities.
THE COMMISSION'S HEALTH TRACKING ANALYSIS
In the 1970's and 1980's, the nation's environmental regulatory
infrastructure was built, fueled by the passage of Federal laws aimed
at cleaning up the environment. Unfortunately, these same laws failed
to support core public health functions of environmental health. More
than a decade ago, the Institute of Medicine report, The Future of
Public Health sounded a warning, saying the Nation had ``lost sight of
its public health goals'' and allowed the public health system to
``fall into disarray.'' With diminishing authority and resources,
public health agencies at all levels of government grew detached from
environmental decisionmaking, and the infrastructure failed to keep
pace with growing concerns about health and environment.
The Commission's study of health tracking found that today, there
still is no cohesive national strategy to identify environmental
hazards, measure population exposures, and track health conditions that
may be related to the environment. Just as important, there is a
national leadership void, resulting in little or no coordination of
environmental health tracking activities.
The few existing environmental health tracking efforts are a widely
varied mix of programs across multiple Federal, State and local
agencies. These programs have evolved, often in isolation from each
other, to respond to disparate regulatory mandates or program needs.
Unfortunately, there are no identifiable linkages between hazard,
exposure and outcome tracking, and there is limited coordination in the
collection, analysis, or dissemination of information. The combination
of lack of leadership, planning, coordination and resources have left
important questions about the relationship between health and the
environment unanswered. For example:
Are environmental exposures related to clusters of
childhood cancer and autism?
What are the impacts of pesticide exposure on children's
health?
What proportion of birth defects is related to
environmental factors?
Are changes in the environment related to the dramatic
increase in asthma?
Are adult-onset diseases like Parkinson's and Alzheimer's
related to cumulative environmental exposures?
Are there increases in Systemic Lupus Erythmetosis (SLE)
and multiple sclerosis (MS) in communities with hazardous waste sites?
Are learning disabilities related to environmental
factors?
Is attention deficit disorder (ADD) related to exposures
that occur in a child in the womb?
Are endocrine disrupting pollutants in the environment
related to the increasing incidence of breast and prostate cancers?
How does particulate air pollution increase the risk of
death in the elderly?
What is the relation of diet and lifestyle to chronic
disease?
With the exception of childhood blood lead screening, there have
been few systematic efforts to track individual levels of exposure to
any hazardous substance. CDC and EPA have developed the methodologies
for biological and environmental monitoring of a wide range of
substances. However, inadequate support and inconsistent funding have
restricted their application and availability. These findings were
underscored in a recent report of the U.S. General Accounting Office
that calls for a long-term coordinated strategy to measure health
exposures to pollutants. With the goal of improving the public health
response to environmental threats, the Pew Environmental Health
Commission conducted an examination of the national capacity for
tracking environmental hazards, exposures and health outcomes. The
study had the following objectives:
To examine the existing public health capacity for
environmental health tracking;
To identify the environmental health priorities of the
nation's public health agencies;
To examine the coordination among agencies, healthcare
providers and researchers on environmental health tracking efforts; and
To develop recommendations for implementing an effective
national strategy for environmental health tracking.
The complete study is available at the Commission's website: http:/
/pewenvirohealthJhsph.edu.
A LOOK AT NATIONAL CAPACITY FOR TRACKING
``Tracking'' is synonymous with the CDC's concept of public health
surveillance, which is defined as ``the ongoing, systematic collection,
analysis and interpretation of health data essential to the planning,
implementation, and evaluation of public health practice, closely
integrated with the timely dissemination of these data to those who
need to know (Thacker et al., 1988).'' Effective environmental health
tracking requires a coordinated approach that identifies hazards,
evaluates exposures, and tracks the health of the population.
Figure 1 provides a schematic representation of the steps in
environmental health tracking.
[GRAPHIC] [TIFF OMITTED] T8069.028
Hazard Tracking
What are the hazards to health in our environment? Environmental
hazard tracking identifies potential hazards and examines their
distribution and trends in the environment. It is an essential
component in prevention strategies, particularly in the absence of
definitive knowledge about the health impacts of environmental
exposures. EPA and the State environmental agencies have primary
responsibility for hazard tracking, which includes networks for data
collection on water and air quality, environmental emissions, hazardous
and radioactive waste generation, storage, and disposal, and the use of
toxic substances and pesticides. These efforts are the foundation of
our national environmental protection efforts.
The EPA Toxics Release Inventory (TRI) is an example of an
effective and publicly accessible hazard tracking program. The TRI
contains data on annual estimated releases of over 644 toxic chemicals
to the air and water by major industries. Data are reported as annual
total releases by chemical. TRI is an innovative way to provide
communities with information about the nature and magnitude of
pollution in their neighborhoods. While there are many pollution
sources not covered and a 2-year time lag in making the data public,
TRI provides the best snapshot of local and national environmental
releases of key toxins by major industries.
The Commission analyzed the 1997 TRI data to determine the ranking
of 11 categories of associated possible toxicological effects (Table
1)\3\. Substances with potential respiratory effects were released in
the largest amount in 1997. Neurotoxicants and skin toxicants were next
highest in total pounds released. Actual population exposures to these
toxicants are not currently tracked and their relationship to disease
is unclear. This approach to hazard tracking provided the Commission
with an important starting point for identifying needs for tracking
exposure and health outcomes.
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\3\ This analysis includes both suspected and recognized toxicants.
An agent is listed as a recognized toxicant if it has been studied by
national or international authoritative and scientific regulatory
agency hazard identification efforts. Suspected agents are included if
they are shown to have target organ toxicity in either humans or two
mammalian species by a relevant route of exposure.
Table 1.--Ranking of Toxicants based on 1997 Toxics Release Inventory (TRI)3
----------------------------------------------------------------------------------------------------------------
Ranking based on 1997 Total Air & Water
Types of health effects TRI release Releases (pounds)
----------------------------------------------------------------------------------------------------------------
Respiratory.................................................. 1 1,248,977,984
Neurologic................................................... 2 1,211,458,945
Skin or sense organ.......................................... 3 1,109,718,312
Gastrointestinal or liver.................................... 4 1,086,264,404
Cardiovascular or blood...................................... 5 823,375,664
Developmental................................................ 6 811,686,192
Reproductive................................................. 7 498,142,705
Kidney....................................................... 8 488,554,582
Immunological................................................ 9 234,713,891
Carcinogenesis............................................... 10 209,271,142
Endocrine.................................................... 11 173,331,065
----------------------------------------------------------------------------------------------------------------
Reference: Environmental Defense Scorecard (www.scorecard.org)
While the Nation has developed a hazard tracking network, little
has been done to link these findings to efforts to track actual
population exposure levels or track the health of communities where
these releases occur.
EXPOSURE TRACKING
Are communities being exposed to harmful levels of pollutants?
Understanding exposure levels is essential in understanding and
preventing environmentally-related disease. Ideally, exposure tracking
includes the systematic measurement of harmful environmental agents to
which individuals are exposed. Exposure tracking also helps evaluate
the effectiveness of public health policies. It should be closely
coordinated with ongoing hazard tracking.
The National Health and Nutrition Examination Survey (NHANES)
illustrates a national approach to exposures. The survey examines a
nationally representative sample of about 5,000 Americans each year.
Environmental exposure measurements are only one part of NHANES, a
broad-based national survey of nutrition and health.
One of its strengths is that it allows policymakers to evaluate
public health intervention policies. For example, NHANES data showed a
drop in average blood lead levels between 1976 and 1980, a period that
corresponded with the removal of lead from gasoline. These data enabled
policymakers and regulators to determine that the ban on leaded
gasoline was effective. NHANES has also provided a national profile of
exposure to environmental tobacco smoke, thus supporting initiatives to
reduce exposures.
Unfortunately, NHANES is not designed to track exposures at the
State and local level, and so does little to help public health
professionals in responding to a community's local concerns about a
possible cluster of health problems related to the environment.
There is potential for progress, however, given advances in
sampling and detection for a broad array of human monitoring
techniques. But the failure to develop and support a national capacity
for exposure tracking and coordinate with ongoing environmental hazard
tracking has left a large gap in our approach to environmental
protection. The GAO underscored the need to close this gap in a report
that called for a national approach to measuring Americans' exposures
to pollutants in order to strengthen prevention efforts.
HEALTH OUTCOME TRACKING
Are environmental exposures and population exposures related to
increased disease? Understanding trends in the incidence of diseases
that may be related to environmental exposures is fundamental to
protecting public health. The Commission reviewed a number of national
health outcome data bases to examine the availability of information on
diseases that may be linked to the environment. Three are particularly
worth noting:
The National Hospital Discharge Survey (NHDS) conducted
since 1965 is a continuous survey based on a sampling of patient
medical records discharged from hospitals. The survey collects
demographic information, admission and discharge dates, diagnoses and
procedures performed.
The National Ambulatory Medical Care Survey (NAMCS) and
the National Hospital Ambulatory Medical Care Survey (NHAMCS) are
national surveys designed to provide information on the types and uses
of outpatient health care services for office-based physicians,
emergency rooms and hospital outpatient centers, respectively. This
allows us to measure the number of doctor visits pertaining to specific
health concerns that may be environmentally-related, such as asthma.
The National Health Interview Survey (NHIS) is a
multistage sample designed to represent the civilian, non-
institutionalized population in the United States. The survey is
conducted by the CDC's National Center for Health Statistics (NCHS). It
has been conducted continuously since 1957. Due to budget reductions,
the survey was redesigned in 1997 to track a much more limited set of
health problems.
These data bases are not designed to describe either State and
local communities or environmentally-related health outcomes, but they
provide warning signals or ``big picture'' level information on the
prevalence and trends of health outcomes in need of closer study. For
instance, the NHIS data show the 10-year national trend in rising rates
of asthma and clearly established it as an epidemic chronic disease.
From 1986-1995, the surveys of about 5,000 people annually found that
endocrine and metabolic disorders increased by 22 percent, while
neurological and respiratory disease increased by 20 percent.
However, the role of the environment in these health outcomes
remains unknown. Without an adequate tracking process, such links are
difficult to clarify. This type of snapshot data does not provide the
full panoramic view needed by health professionals to identify
clusters, uncover risks or guide the prevention programs that make
people healthier.
a look at state and local capacity for tracking
The Commission interviewed environmental health leaders from public
health agencies in the 50 States and a sample of local health
departments as part of its examination of State and local public health
capacity for environmental health tracking. While some States and
localities have well-developed programs, others have virtually no
capacity for environmental health tracking. Overall, the survey found
that the State and local infrastructure for environmental health
tracking has been neglected; with the result that today many have
outmoded equipment and information systems, and lack technical and
laboratory support. As a result, fundamental information about
community health status and environmental exposures is not available.
In a Commission survey of State health officials, it was found that
while over three quarters of State health departments track blood lead
levels, biomonitoring for other substances, including hazardous
pesticides, is very limited. Only about 25 percent said their
departments can measure human exposure to environmental contaminants by
monitoring the air in a person's breathing zone, an important
investigative capability in responding to a health threat. Most of the
chronic diseases and health problems that the Commission identified as
priorities are not being tracked.
Even for health problems that most States do track--cancer,
infectious disease and birth defects--tracking efforts have significant
problems. For instance, an earlier Pew Commission report found that
while 33 States have birth defect registries, the majority was
inadequate in terms of generally recognized standards for an effective
tracking program. Another Commission study found similar gaps in State
efforts.
Finally, information that is tracked according to current standards
is often not usable for intervention, policy, and scientific purposes.
First, State data sets commonly lack enough samples from more refined
geographic areas to make it possible to characterize health hazards,
exposures and outcomes at the local level. In addition, the
Commission's survey found that many departments lack the staffing,
expertise, or technology to analyze and in some cases even to access
existing data sets relevant to local environmental health. Rather,
local health practitioners find themselves focusing on enforcement and
reacting to complaints. Another concern is the absence of national
standards to ensure consistent data collection.
State and local public health agencies are the foundation of the
nation's health tracking capacity. The first requirement for an
effective, integrated network is strong State and territorial public
health organizations with linkages to strong local health agencies, as
well as Federal agencies, healthcare providers, State environmental
agencies and communities. While the States and localities may have the
will, this vision of a Nationwide Health Tracking Network will only
come together with the support, guidance and leadership of the Federal
Government.
THE TIME IS RIGHT
Advances in hazard identification, exposure assessment health
outcome data collection and information technology provide
unprecedented opportunities for advancing tracking and improving our
understanding of the environment and health.
Despite the challenges, there are unprecedented opportunities to
strengthen the national infrastructure for environmental health
information, expand public access to this important information and
protect the privacy of individuals. New technologies in biomonitoring
have the potential to transform the nation's capacity to track
exposures to pollutants and understand their impacts on health.
Advances in communication and information technology have expanded
opportunities for public access and given us new tools to analyze, map
and disseminate health data. New technology also can improve safeguards
to protect the confidentiality of identifiable personal health
information. We have better tools than ever before to meet the public
health missions of protecting Americans' health and privacy.
New initiatives at CDC and EPA have the potential to address
tracking needs, including information technology development and State
and local capacity-building, along with exposure measurement,
interagency coordination and public access to health information.
Opportunities exist, but we need to do more to advance the science and
support for inclusion of environmental health components.
The integration of public health information and tracking systems
is listed as a top priority of the CDC. Spurred by concerns about
bioterrorism, a Health Alert Network is being developed to improve
tracking and information sharing on key infectious diseases and
priority chemical and poison agents that may be used in terrorist
attacks. In addition, there are several other data systems being
developed by CDC and EPA that could be building blocks in a national
tracking network. However, national vision and leadership to bring this
all together on behalf of environmental health issues will be required
if any of these current initiatives are to become building blocks for a
national environmental health tracking network.
Environmental health tracking will give us an unprecedented
opportunity to ensure our environmental policies are successfully
reducing exposures in our communities and safeguarding public health.
Reduction of risks from hazards in the environment and people's
exposures and the improvement of public health are fundamental goals of
environmental regulations. At present, tracking activities are focused
primarily on hazard identification for regulatory permitting and
enforcement. Improved capacity to measure peoples' exposures to hazards
and track health outcomes will strengthen the scientific basis for
these important policy decisions. In addition, environmental health
tracking will give practitioners and policymakers better indicators of
progress, and assure that benefits of healthier communities continue
well into the future.
The public increasingly wants and demands more credible
environmental health information so that they can make independent and
fully informed decisions. The Internet explosion has further fueled
this desire.
Recent public opinion research confirms that Americans want to have
access to national, State and community level health data. In fact,
they are incredulous when informed that health tracking information is
not readily available. The Internet now allows the public quick and
highly accessible information on most facets of their lives. There is a
widespread belief that health tracking information should be and needs
to be available to the public. With growing concerns about environment
and health, this public demand should help support the Network.
Recently, a group of environmental health leaders held a summit co-
sponsored by the Pew Environmental Health Commission, the Association
of State and Territorial Health Officials, the National Association of
County and City Health Officials, and the Public Health Foundation at
which they strongly endorsed the Commission's efforts to strengthen
environmental health tracking.
Summit participants endorsed a tiered approach to national
environmental health tracking that is consistent with the Commission's
five-tier recommendation. It includes: national tracking for high-
priority outcomes and exposures; a sentinel network to identify acute
and emerging hazards; a coordinated network of pilot regional, State
and local tracking programs; and aggressive research efforts to guide
and evaluate tracking.
WHY WE NEED A HEALTH TRACKING NETWORK NOW
Earlier this year, a scientific breakthrough was announced that has
incredible potential to help us understand the links between people,
their environment and behaviors, genetic inheritance and health.
As researchers begin to apply this new genetic knowledge to the
study of disease, we will have more information than ever before to use
in revealing the connections between environmental exposures, people's
behaviors and genetic predisposition to health problems. But only if we
have the basic information about what is going on in our communities--
the hazards, the exposures and health problems that Americans are
experiencing.
The ``building blocks'' of knowledge provided by the Nationwide
Health Tracking Network will enable scientists to answer many of the
troubling questions we are asking today about what is making us sick.
The Network will provide the basis for communities, health officials,
businesses and policymakers to take action for making this Nation
healthier. The result will be new prevention strategies aimed at
reducing and preventing many of the chronic diseases and disabling
conditions that afflict millions of Americans.
The Commission is calling upon our national leaders to take the
steps outlined in this report, and with a minimal investment,
revitalize our nation's public health defenses to meet the challenges
of this new century. It is time to close America's environmental health
gap.
______
THE PEW COMMISSION PRINCIPLES FOR PROTECTING PRIVACY AND
CONFIDENTIALITY AND OUR ENVIRONMENTAL HEALTH RIGHT-TO-KNOW
Without a dynamic information collection and analysis network,
public health agencies would be ineffective in protecting health. The
Commission recognizes the substantial benefits that accrue from
personally identifiable health information and provides these
principles to assist agencies in addressing privacy and confidentiality
concerns associated with collection and use of this information in
environmental health investigations.
The Commission is aware of the sensitivity of individually
identifiable health information and is committed to protecting the
privacy of such information and to preventing genetic and other
sensitive health information from being used to discriminate against
individuals. The Commission believes that the values of public health
activities and privacy must be reasonably balanced.
The Commission also is aware of the need to increase public
confidence in our nation's public health system by making
nonidentifiable health information and trends widely available and
providing access to the analyses of collected data. This also will
serve to better inform communities about the value of public health
data.
The Commission believes that adherence to the following principles
will enable public health agencies to honor their traditional
commitment to the confidentiality of individually identifiable health
records without significantly hampering execution of their obligations
to the public health:
Recognize that it is largely possible to balance the
protection of individually identifiable health information and the
acquisition, storage and use of that information for environmental
health purposes;
Protect individuals' privacy by ensuring the
confidentiality of identifiable health information;
Disclose only as much information as is necessary for the
purpose in cases where the public health requires disclosure of
identifiable information;
Require that entities to which identifiable information
has been disclosed take the same measures to ensure confidentiality
that are taken by the disclosing agency;
Utilize the best available organizational and
technological means to preserve confidentiality of information
(includes such measures as limiting access, staff training, agreements
and penalties as well as updating of security measures);
Provide individuals the opportunity to review, copy and
request correction of identifiable health information.
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