Agency for Toxic Substances and Disease Registry
Board of Scientific Counselors
MINUTES (April 1997)
TABLE OF CONTENTS
- Opening Remarks
- ATSDR Update
- ATSDR Child Health Initiative
- ATSDR's Response to Work Group Recommendations
- Brownfields Initiative
- Community/Tribal Forum Recommendations
- ATSDR Response to Five Issues
- Proposal for Community/Tribal Task Force
- Reaction from Board of Scientific Counselors
- Comments from the Public
- Chattanooga Creek Experience
- Environmental Medicine and Health Promotion
- Medical Monitoring Criteria - Hanford Nuclear Reservation
- Placing a Site on Inactive Status -Draft Criteria
- General Comments from the Public
- Closing Remarks
Opening Remarks
Dr. Karl Longley, member of the ATSDR Board of Scientific Counselors (BSC), opened the 19th meeting of
the Board on Monday morning, April 28, 1997, in Chattanooga, TN. ( Later in the morning, when a quorum of
the BSC was present, Dr. Eula Bingham, Chair of the BSC, asked for a motion to approve the minutes of the
previous meeting. The minutes of the previous meeting were approved without change.)
Dr. Longley mentioned that several guests representing the city of Chattanooga were in the audience. Dr.
Longley asked if they had any opening comments.
Mr. Moses Freeman
On behalf of the Mayor, Mr. Moses Freeman, Administrator, Department of Equal Opportunity & Fair Housing,
welcomed the BSC to Chattanooga and thanked them for meeting in the city and lending their resources and
expertise to his community. Mr. Freeman said the Mayor intends to do whatever he can to facilitate the clean
up of Chattanooga Creek. The city wants to continue working with Mr. Milton Jackson, Community Consultant
to the BSC.
Mr. William Cotton
Mr. William Cotton, Hamilton County Commissioner, District 4, also welcomed the BSC to Chattanooga.
Commissioner Cotton's District 4 has also inherited some of the Chattanooga Creek problem. He thanked Mr.
Milton Jackson, Community Consultant to the BSC, for his efforts.
Mr. John Taylor
Mr. John Taylor, City Councilman, District 7, welcomed the BSC to Chattanooga and hoped their presence
would be very beneficial to the city and the community impacted by the Chattanooga Creek. He said the
community will be working hard to pull together a steering and advisory committee. He asked whether someone
from the BSC or ATSDR staff could be available to work with them.
Dr. Longley thanked the guests for their opening remarks. He said Mr. Milton Jackson has advised the Board
of Scientific Counselors (BSC) primarily on the Chattanooga Creek issue, but has told the BSC about many
other happenings in Chattanooga to improve the environment.
ATSDR Update
Dr. Barry Johnson, Assistant Administrator, ATSDR, said agency staff members were pleased to be in
Chattanooga. This is the first time this group of scientists and experts has met outside Atlanta, Georgia. Dr.
Johnson thanked city representatives for their hospitality.
Superfund Reauthorization
Dr. Johnson said the press reports a great interest in having a Superfund reauthorization bill that could achieve
bipartisan support. A series of dialogues with key congressional staff, both House and Senate, has
commenced. Through EPA's leadership, in particular, meetings are occurring with members of Congress and
key stakeholders, including private industry, environmental groups, and community-based organizations.
Organizational Changes
Dr. Johnson said ATSDR's Deputy Assistant Administrator, Mr. William Adams, retired after 32 years of public
service, 22 years with the Centers for Disease Control and Prevention and the last 10 years with ATSDR. Mr.
Adams will be sorely missed. He was ATSDR's day-to-day anchor on matters of budget and personnel and a
principal resource in working out occasional points of difference with U.S. EPA.
Since the BSC last met, an Office of Urban Affairs was created and staffed. ATSDR was extremely fortunate
to lure Dr. Rueben Warren away from the Centers for Disease Control and Prevention. For several years, Dr.
Warren directed the CDC Program of Minority Health and is one of the nation's leaders in minority health issues.
Dr. Warren's office has three main responsibilities: environmental justice, minority health, and brownfields. Any
one would be a considerable challenge, and three represent a major challenge for Dr. Warren and his staff.
In response to the Community Tribal Forum Meeting in Houston, ATSDR has moved ahead and identified
resources to constitute a Community Involvement Branch within the Division of Health Assessment and
Consultation. They will be the primary community and tribal advocacy group within ATSDR.
ATSDR also has established a position for an ombudsperson as recommended by participants in the Houston
meeting. That position will soon be advertised and filled.
Chemical Contamination
ATSDR has been involved in a major chemical contamination. This is the illegal use of methyl parathion by
uncertified pesticide applicators. This pesticide is registered only for use on cotton and some outdoor crops.
Dr. Johnson said methyl parathion was being used indoors in an almost undiluted form. It is highly effective
against roaches and other insects found indoors. Several thousand homes in Mississippi, Louisiana, southern
Alabama, part of Tennessee (Memphis), and--as of last week--Illinois (Chicago) have been contaminated by
methyl parathion.
Working with EPA, Dr. Maureen Lichtveld has been ATSDR's lead with state health departments to determine
which homes and daycare centers should be evacuated. EPA has responded with an extremely timely and
impressive effort to decontaminate homes and temporarily relocate persons when necessary.
Medical Monitoring
After two years of evaluation, ATSDR has determined that medical monitoring and health surveillance are
required for persons living downwind of the Hanford Department of Energy facility. Some 14,000 persons will
be included in a medical monitoring program specifically for thyroid cancer and other diseases of the thyroid
gland. ATSDR is working with the Department of Energy to mobilize funds, and plans to undertake this program
early in fiscal year 1998. Part of the Hanford study includes an exposure subregistry for 131Iodine and that is the
focus of the medical monitoring program, where exposures to 131Iodine took place some 50 years ago.
Meetings
Dr. Johnson said every two years ATSDR meets with its partners: EPA, state health departments, tribal nations,
and increasingly local health departments. In March (1997), more than 200 persons met in Atlanta to share
findings, adjust programs, change procedures, and look for ways to make the health portion of Superfund and
other programs more effective.
Last week, the first symposium sponsored by the Association of Minority Health Professions Schools was held
in New Orleans. On several occasions, the BSC has heard about this program, which focuses on filling key data
gaps for priority hazardous substances through the work of faculty and students at several key historically black
colleges and universities. It was an excellent meeting. Results of ongoing research were presented.
Two weeks ago ATSDR co-sponsored a meeting on issues and applications in toxicology and risk- assessment
at the Wright-Patterson Air Force Base, Dayton, Ohio. ATSDR updated the ongoing effort in toxicological
profiles and increased emphasis on children's health being given in the profiles and elsewhere.
Dr. Johnson mentioned two future meetings. With Health Canada, the U.S. EPA, and others, ATSDR is co-sponsoring a major meeting in Montreal in May to bring together persons participating in research who are
looking at the human health impact of contaminants and fish consumed from the five Great Lakes. ATSDR is
also co-sponsoring a workshop on animals as sentinels of human health to be held this fall.
BSC Recommendations and ATSDR Action
At the November BSC meeting in Atlanta, the Board made five requests to ATSDR: a visit to a hazardous waste
site, a discussion on brownfields, a discussion on environmental medicine and health promotion, a review of
how ATSDR places a site on an inactive list, and an ATSDR response to community/tribal forum
recommendations presented at the November meeting. Dr. Johnson said the meeting agenda addressed all
five requests.
Dr. Longley asked how reauthorization affects ATSDR funding. Dr. Johnson said the reauthorization language
in both the Senate and the House bills from the last Congress would basically not change much regarding
ATSDR authorities. This will probably be the case whatever comes out of this Congress. The House's bill last
year was more generous for budget authorization than the Senate's was. The public health provisions have
not been contentious to any great degree in the debate on Superfund reauthorization.
Dr. Longley asked whether timing for reauthorization is a major concern, especially if legislation gets bogged
down. Dr. Johnson said that in 1994 Congress let the taxing authority lapse that places money into the public
trust fund the public calls Superfund. Since 1994, EPA, ATSDR, NIEHS and others, who derive all or part of
their budgets from Superfund, have operated on previously collected taxes that were placed in a trust fund.
Monies still available in that tax fund will take ATSDR through the end of 1998. Congress must act either by
renewing the taxing authority or by reauthorizing Superfund with the tax authority.
Dr. Stark was curious about the methyl parathion episode and asked how it happened. Dr. Johnson said it
began about a year and a half ago in central Ohio. An unlicensed applicator purchased a large amount of the
pesticide. He began using it in low income households that had pest infestation. At times
the material was diluted only one part with water.
EPA Region V decontaminated several hundred homes in central Ohio at a cost of approximately
$20M. Every single case of childhood intoxication was missed as a diagnosis by the health care
community in that part of Ohio. That was the first episode.
Some 6-8 months ago, the episode repeated itself in southern Mississippi, (Pascagoula), only on a
much larger scale. When EPA began examining the records, they found a different group of
applicators. Day care centers, private homes, one restaurant, and some offices were found to be
contaminated with methyl parathion. EPA has brought criminal charges against the applicators.
Dr. Johnson said EPA has done a really magnificent job of responding to the issue of contamination.
They have decontaminated a significant number of homes.
ATSDR Child Health Initiative
Dr. Robert Amler, Chief Medical Officer, ATSDR, reviewed the rationale for the Child Health Initiative.
Dr. Amler said ATSDR completed its inventory of child health projects the agency is undertaking. A
copy of the inventory was available for the Board's review. A second major accomplishment was the
creation of a Child Health Web site, a series of Web pages linked to the ATSDR Home Page.
ATSDR also formed partnerships with about two dozen nongovernment organizations, including child
health professionals like the American Academy of Pediatrics and the National Association of
Children's Hospitals. ATSDR has also formed partnerships with many environmental associations,
such as the Sierra Club, and with many child advocacy groups, such as the Girl Scouts and the March
of Dimes, Learning Disabilities Association, and others.
Dr. Amler said the BSC appointed a Child Health Work Group a year ago to follow the charge from the
BSC Chair, Dr. Eula Bingham, to develop a report on Healthy Children, Toxic Environments, with a
specific focus on the unique vulnerability of children who live near hazardous waste sites. This report
was completed, and Dr. Amler said it would be presented to the BSC by the Child Health Work Group
Chairman, Dr. Lorne Garrettson, a Professor of Pediatrics at Emory University School of Medicine and
Medical Director of the Georgia Poison Center.
Child Health Initiative/Work Group's Recommendations
Dr. Garrettson said the work group had to first define child or children. They included infants, children
and adolescents, and, when appropriate, the entire gestational period. When making
recommendations, they looked at the entirety of growth and development. Recommendations and
comments were directed to four areas: agency vision, program, collaboration, and education. The
agency should include children in all their activities as part of their mission statement. It was also clear
that ATSDR has a significant role in education and in stimulating growth within the scientific community.
ATSDR should help build expertise within the nation's biomedical community to address children's
responses to environmental toxicants.
The work group recommended that ATSDR review all its program activities to ensure the consideration
of child health issues and the ethical ramifications for children. ATSDR should also develop
collaboration on children and environmental health at the highest levels of government. Further,
ATSDR should help build expertise in children's environmental health issues through educating
biomedical scientists, physicians and other health practitioners, the public, teachers, and children. The
work group recognized that ATSDR is not only doing these things, but has the opportunity to expand
in this area to a very important and effective degree.
Dr. Garrettson gave the Board a list of questions to be asked in addressing issues on child health, a
kind of check list to help ATSDR evaluate programs and activities.
1. Are children exposed to potentially harmful substances?
2. Are any exposure pathways unique to children?
3. Do children differ from adults in their weight-adjusted intake of toxicants?
4. Do the pharmacokinetic or pharmacodynamic parameters of adults and children differ?
5. What are the effects of multiple and cumulative exposures?
6. Are latent or delayed effects of early exposure possible?
7. At what stage of development is the child exposed?
8. Could any developmental process be altered by the toxicant?
9. Are there adequate animal models for childhood exposure after birth?
10. What do these models indicate about adverse effects on exposed children?
11. Are any effects seen in more than one generation of a family?
12. Are the ethical and cultural consequences unique to children?
13. If children are not included in an agency activity, why are they excluded?
The work group suggested it might be helpful, as noted in the report, to use the list as a sign-off on
agency activities, as is done for minority or women's health issues.
ATSDR's Response to Work Group Recommendations
Dr. Amler said that ATSDR staff thought the review and evaluation process was very sound and
valuable to ATSDR. It will help the staff think through various projects and select practical ideas for not
only the current fiscal year, but for proposals ATSDR is developing for fiscal years 1998 and 1999.
Early on, ATSDR recognized considerable staff interest throughout the agency in children's health and
formed an agency Roundtable on Health that meets regularly but infrequently. With the completed
report and this Board's concurrence, ATSDR is ready to have this group work more actively in
transforming the approach ATSDR takes to child health.
The Division of Toxicology (DT) is creating a special section in its toxicological profiles to deal with child
health and reproductive toxicology. They are also putting more child health information into the public
health statements and the tox fact sheets. Priority data needs will also be addressed increasingly with
a view toward children's vulnerabilities. Medical management guidelines also will be revised to include
experts and specific childhood information in pediatric toxicology and pediatric emergency tox
management. The Division of Toxicology also plans to enhance the reporting and publication of results
from the Great Lakes Program relevant to child health.
The Division of Health Assessment and Consultation (DHAC) is working on a child-based paradigm.
They have made internal changes in the developing of public health systems and consultations that
will increasingly emphasize child health. The work group recognized that considerable attention was
already devoted to the children in a population, and that many times the public health assessment was
being developed around children as potentially the most vulnerable part of that population.
DHAC is also interested in enhancing knowledge of the demographics around hazardous waste sites,
particularly getting better age breakdowns of the children, using GIS technology.
The Division of Health Studies (DHS) is evaluating childhood asthma, birth defects, and immune
disorders in children near hazardous waste sites. The National Exposure Registry has scheduled
specialized hearing and speech evaluations of children exposed to drinking water contaminated with
TCE.
DHS developed a pediatric test battery that has been evaluated in actual field trials. Although not yet
used in health studies, it will be shortly. Each child tested takes an hour or less per examiner and
captures much information that is sensitive in detecting early signs of neurobehavioral disfunction. The
battery tests not only motor development, but also intellectual function, memory, and special sensory
functions such as vision and contrast sensitivity. ATSDR provides a complete manual on performing
and interpreting the tests and is standardizing immune, kidney, and pulmonary function tests for
children of different ages.
The Division of Health Education and Promotion (DHEP) is emphasizing child health in its partnerships
with states and tribes. In addition, DHEP is funding two pediatric specialty referral units in cooperation
with existing AOEC clinics. These will link environmental specialists with pediatric specialists.
DHEP has commissioned a case study on child health specifically and, if funding is in place, will begin
a series of case studies to deal with specific child health issues. These are part of the cooperative
agreement ATSDR has with the American College of Occupational and Environmental Medicine.
DHS and DHEP will jointly sponsor a national workshop on pediatric environmental assessment. This
will develop a template for medically evaluating children of all ages who are exposed to hazardous
substances in the environment.
All this will form a closer partnership between child health specialties and environmental professions
so they can learn from each other. Repeatedly, around the country, when children do have overt
disease, including hospitalization for environmentally associated problems, the diagnoses are not being
made correctly, and often are being missed entirely.
Dr. Amler asked the Board to consider two questions. (1) Does the Board recommend approval of the
report and recommendations of the Child Health Work Group? Has the Board identified any additional
issues or recommendations that should be considered? Reordered? (2) Does the Board recommend
a periodic evaluation and update of ATSDR-directed activities in the area of child health? What should
the future role of the Board and the Child Health Work Group be in this regard?
BSC Discussion and Recommendations
Dr. Eula Bingham, Chair of the BSC, opened the child health initiative report for discussion and
comment.
Ms. Cellarius asked whether any consideration was given to retroactive activity, revisiting health
assessments from the viewpoint of impact on children. Dr. Amler said the principal thrust will be on
future health assessments and consultations. However, in going through demographics and looking
specifically at age groups, we may find better ways to code or file information we already have from
completed health assessments.
Dr. Allan Susten, ATSDR, agreed with Dr. Amler's comments and said health assessments always
look at the most likely exposed population. Many dealt with children because of their pattern of activities
and sensitivity to various toxicants. It is proposed to have parts of the public health assessment explicitly
state that we have either looked at child health concerns or that children have not been identified as
a population that would be exposed at a site.
Dr. Longley said the new paradigm is that children are not small adults. He asked whether there would
be a reevaluation with that in mind or whether different dynamics are involved. Dr. Susten said as
research begins to look more at the pharmacokinetics, pharmacodynamics, and toxicology, and our
understanding of substances and their effects in children improves, this information will be incorporated
in health assessments.
Dr. Stark said the child health report is a very nice piece of work, thorough and thoughtful, and
approaches children's health in ways not looked at before. She was concerned about the line between
children being aware of the environment as a potential hazard and their being afraid to do anything or
misinterpreting what they hear because their judgment is not mature.
Dr. Amler agreed there is a very important fine line between informing, alarming, and frightening. The
younger the individuals and the less their maturity in cognitive function, the less they are able to
separate and divide out different ideas and concepts.
Dr. Roberts agreed and said it is very important to involve children in environmental education. We've
seen very positive results of their involvement in recycling and smoking. Is the Merit Badge restricted
to the mining industry or is it possible to consider it also for the inner city and older homes? Dr. Roberts
asked that the work group consider evaluating the effectiveness of using children as educators. It may
sound good, but is it effective?
Dr. Morandi questioned proposals for extramural research that include children. In her experience,
including subjects below 8-10 years of age, exponentially increases the level of complexity in dealing
with ethical questions and the institutional review board. She asked whether agencies thought of giving
guidelines to institutions that solicit proposals for such research
Dr. Andrews said whenever studies are funded by the Department of Health and Human Services, a
discussion must be conducted on whether institutional review is needed. Some standard guidelines are
available in newsletters and on a Web page. This information is widely disseminated for institutions that
have multiple project assurance. Dr. Andrews will provide the BSC with anything ATSDR has, and he
assured Dr. Morandi that there was information for children specifically.
Dr. Bingham asked whether the health assessment would differ with the use of the list of 13 questions
and if ATSDR had done a pilot test. She would like some examples or a pilot test on how it would work.
ATSDR could pick a completed investigation and redo it to see whether it was any different. If the
health evaluation is not different when you ask these questions, why is that? Is it because you did such
a good job before and really paid attention, or is it because you don't have answers to the questions.
Perhaps we don't have scientific information to answer the questions.
Dr. Amler said any difference after these 13 questions are incorporated in pilot studies will depend on
which ATSDR program or activity they're being applied to. For example, he could envision a very
obvious change in some publications: Tox Profiles, Medical Management Guidelines, and Case Studies
in Environmental Medicine. These will look different because they will have different types of
information. There may be less difference in public health assessments because traditionally much
of that has already been incorporated. It may not be quite as dramatic or visible in writing.
If it would be helpful, Dr. Amler said ATSDR could present a pilot from each area at the next
meeting and briefly run through the questions for a specific activity or program. Dr. Bingham
said it would help her, but other members may not be interested. She asked whether ATSDR
could have a session on what other agencies are doing in health care or prevention for children.
Dr. Stark said it would be wise to identify gaps in knowledge and areas that should be focused
on. Until those gaps are filled, this pilot testing will not be possible. This would help identify
areas where more work is needed. Dr. Longley suggested a listing at a future meeting of what
ATSDR considers the most significant data or information gaps that must be filled before the
outlined program can be reasonably applied.
Dr. Garrettson said the work group would be highlighting those data gaps in reviewing ATSDR
programs and activities. Certainly Dr. DeRosa's group is in a catbird seat to help highlight gaps. The
work group was impressed by what they have done and the potential for what they could do further.
Highlighting the current data gaps is certainly a possibility for the future.
Following Dr. Bingham's questions on change, Dr. Garrettson asked where we would expect to see
the biggest impact or change. One change would be a whole paradigm shift, if DHAC can do that. The
other in the Division of Health Education and Promotion concerns the whole issue of ethical
consequences of what we do. Dr. Morandi said not only children's work as educators, but all activities
with them can bring up enormous ethical questions. Many of those are not well thought through by our
medical community. ATSDR may find itself tapping into the fairly substantial pediatric ethical
community for further expertise because of questions raised as we look critically at what we do.
Dr. Bergeisen said EPA is currently categorizing all its child health initiatives, after the President's
Executive Order. EPA risk assessors traditionally consider children as a "sensitive" subpopulation
whenever they do risk assessments. In most risk assessments, that is described under the risk
characterization.
Dr. Bergeisen believes the idea of presenting child health information developed by other
agencies is excellent. He was prepared to present this information at the next Board meeting.
He suggested that the American Industrial Health Council, which also has a child health
initiative, be invited. They could describe to the Board what goes on in industry to protect
children's health.
Dr. Johnson said that working with the Board of Scientific Counselors and the Child Health Work
Group, ATSDR has tried to produce something it can act on now. A year ago, ATSDR chose to focus
on things it could and should be doing now.
A mechanism is already in place to coordinate children's health programs. The Environmental Health
Policy Committee is the senior environmental policy committee within the Department of Health and
Human Services. It has representation from EPA, the Department of Defense, and a host of other
federal organizations. A committee specific to children's health is co-chaired by Dick Jackson, NCEH,
and Ken Olden, NIEHS..
Dr. Johnson said ATSDR does not foresee a major agency effort in children's research. A focused
program on research will likely be at NIEHS and EPA and perhaps CDC. ATSDR's role will be some
limited research but more importantly to convey to other organizations where key data gaps are and
to highlight some practical things we know should be factored into the research that is conducted.
Dr. Johnson said the children's health report shows things ATSDR can and should be doing in
education and changing how we practice health assessments. The work group, in Dr. Johnson's view,
has done an excellent job of showing ATSDR what it can do now with existing resources.
Dr. Longley made a motion and Dr. Roberts seconded the motion that the BSC approve the
report and recommendations of the Child Health Work Group. The motion was approved
unanimously.
Dr. Bingham also noted that the second item on the Child Health Initiative, that there be a
periodic evaluation of the Child Health activities, will be discussed at the next meeting of the
BSC.
Brownfields Initiative
Dr. Rueben Warren, Associate Administrator for Urban Affairs, ATSDR, gave the Board an overview
of the Brownfields Initiative. He said this is a Brownfields Economic Redevelopment Initiative in which
"EPA is promoting redevelopment across the country of abandoned and contaminated properties that were once used for industrial and commercial purposes." Although brownfields targets job
opportunities and commercial development, EPA said in congressional testimony that brownfields
redevelopment must include public health concerns. Specifically, EPA mentioned ATSDR and county
health officials and reiterated the importance of public health.
EPA National Brownfields Initiative
Mr. James Maas, Environmental Protection Agency, thanked the Board for its interest in the
Brownfields Initiative, gave a brief overview of its origin, and mentioned the creation of a new
Brownfields National Partnership Action Agenda.
Mr. Maas discussed what is happening with public health agencies. EPA has a commitment from
ATSDR and NACCHO to provide information to local health agencies and pilot communities on
brownfields. EPA also has a commitment from ATSDR and NACCHO to convene a series of public
dialogues with local health officials to educate and discuss brownfields issues. EPA formed the
National Environmental Justice Advisory Council (NEJAC) to advise EPA on environmental issues, but
specifically on brownfields. There are six subcommittees, one of which is the Facility and Waste Siting
Subcommittee, chaired by Mr. Charles Lee, to look at the brownfields issue and make sure EPA keeps
public health and communities in the forefront. One top finding that EPA kept hearing in meetings
across the country was that public health and environmental protection are matters of primary concern
to communities.
ATSDR Involvement
Dr. Rueben Warren said the Brownfields Initiative focuses primarily on job opportunity, educational
development, and commercial development. It is not focused specifically on health, but he said it
provides an impressive opportunity to integrate health into an initiative targeted at improving the quality
of life in communities.
Dr. Warren said his visits to brownfields sites the last two weeks had really affirmed his belief in what
he hoped will be the agency's direction to assure and improve health in accord with the Brownfields
Initiative. He could assure us of a couple things. One is that state and local health departments, which
are responsible for the health of people in their local jurisdictions, will be major players in brownfields
activities. Also, communities at greatest risk that have the most to lose, also have the most to gain.
They, too, will be major players. Other federal partners, the Centers for Disease Control and
Prevention, Health Resources and Services Administration, NIH, and--a new partner--the Office of
Minority Health in the Office of the Secretary will be evolving federal partners.
The academic community is increasingly involved with brownfields. Howard University Urban Affairs
Institute, and Florida A&M University's Institute on Public Health are beginning to talk about what they
can do in the Brownfields Initiative.
ATSDR has been working with the Congress of the National Black Churches, which represents 65,000
black churches with 19 million members. At their last board meeting, they had brownfields on the
agenda and discussed how they can partner with ATSDR to assure that brownfields considerations are
part of what they do.
ATSDR talked with the Coalition of Hispanic Health and Human Service Organizations, CHHHSO, the
largest Hispanic organization of its kind in the country. They are interested in partnering with us on
brownfields. Major Asian American and Pacific Islander organizations are also interested in working
with us on brownfields. And as you know, we continue to include Native American tribes in our activities.
Although health is not strictly a goal for brownfields, if communities can embrace public health as a
part of their agenda for achieving quality of life and economic and job opportunities in their
communities, Dr. Warren believes we will have succeeded in the public health arena. Right now being
part of the brownfields process is a desire. It can become a need, and our response over the coming
years can translate that need into a demand.
Developing Public Health Leadership at the Local Level
Dr. Chris Roshein, Division of Health Education and Promotion, provided some perspectives that the
National Association of County and City Health Officials (NACCHO) has on local health department
leadership in brownfields and economic development issues. NACCHO represents all local health
departments in the nation, about 3,000 groups. She presented information developed by Heidi Klein,
NACCHO, through a phone survey of about a dozen local health officials who have experience in
brownfields.
Comparing NACCHO's Superfund activities with proposed activities for brownfields, Dr. Rosheim noted
the similarities. In both cases, local health departments do not have clear-cut roles or responsibilities.
They lack statutory authority in Superfund and certainly in brownfields, but they do have responsibility
in both cases to protect residents and address community health concerns.
Some differences perceived by local health departments are that local politics may be even more
complicated in brownfields issues because economics, redevelopment, insurance, and banking factors
are all involved, rather than just the environmental and health agencies with which they have been working. The second problem is that health issues are really peripheral to these people and are perceived as
slowing down the process.
Key issues of brownfields that concern local health departments are land use and clean-up decisions,
environmental justice and the protection of all populations in the community, and effective interaction
with developers and realtors. Local health departments do not have experience working with the
groups involved in brownfields.
Perceived leadership roles for local health departments include interpreting results of environmental
impact assessments, communicating health impacts and risks of redevelopment, linking with existing
organizations to ensure that the process is community driven. A leadership role means making sure
that community health concerns are brought into the forefront of the process. Another leadership role
is to serve as a conduit of information between federal agencies and the community.
Dr. Rosheim listed some needs that local health departments identified to help them take a leadership
role. One is technical assistance, such as risk communication courses. In the past, NACCHO and
ATSDR, through cooperative agreements, have done such courses related to environmental
contamination at Superfund sites. Another means is conferences to discuss strategies and success
stories. This could be done collaboratively by EPA, NACCHO, and ATSDR at a session of the
NACCHO annual meeting in July in Houston. A brownfields session there will involve several partners
and Mr. Charles Lee.
A second need is identifying the importance of local health department participation in brownfields
efforts. A third area is financial support for local health departments. It is not yet a funded mandate for
them to be involved, and they will need support to give courses, send out materials, and hold meetings
in the community.
Dr. Rosheim highlighted some recommendations that local officials made to NACCHO. They want
NACCHO to present a unified platform at the national level of the role and importance of public health
in local redevelopment. They want to use NACCHO's communication networks to educate local health
departments about brownfields. Nationally, NACCHO has a monthly newsletter and various computer
linkages for reaching out to local health departments. Local health departments also think risk
communication materials should be supplied.
Local health departments think NACCHO should conduct sessions at conferences to facilitate
dialogue, co-sponsor or host a series of community dialogues to discuss the local health department
role, and create and disseminate case studies where local health departments have successfully
advocated for community concerns.
They would also like NACCHO to draft a paper on the leadership role for local health departments,
modify the community environmental health education and needs-assessment tool (which was
provided to the Board) to include brownfields issues, and establish long-term collaboration with the
United Church of Christ Commission for Racial Justice. Ms. Heidi Klein had also asked local health
departments for recommendations for federal agencies. One is to develop clear messages regarding
brownfields public health participation. Others are to emphasize the importance of local health
department participation to EPA grantees, facilitate local health department collaboration with state
environmental protection offices, and involve local health departments from the beginning when land-use decisions are made.
Dr. Roshein said ATSDR has a plan under way to work with NACCHO on brownfields and is currently
reviewing a NACCHO proposal in this area. In the coming year, ATSDR anticipates conducting in-depth
interviews with three local health departments about their brownfields experiences to help define a
leadership role for local health departments. When ATSDR has an idea of what the leadership roles
could be, it will ask local health departments nationally, based on their current roles, what kinds of
training they might need, if they're interested in playing public health leadership roles, and how to foster
interest where we find it. In this way, a valuable public health role can be created for them in the
brownfields process.
Community Perspectives
Mr. Milton Jackson said they selected the old glass factory site that the Board saw during the morning
visit and planned to negotiate with companies to move into those plants because the buildings are
structurally sound from the outside. They didn't know about the inside condition of the buildings. They
planned to discuss the use of these buildings with various automobile industries. Mr. Jackson said there
was now a new local administration and he hoped the community could work together to move things
along. He was very optimistic.
ATSDR Issues and Concerns
Dr. Warren asked about any specific concerns with the overview presented on the Brownfields Initiative.
Dr. Stark raised two questions. In the EPA presentation, 3,000 pilot sites were mentioned. Dr. Stark
asked whether these were really pilots, and if so, how they would be evaluated? Mr. Maas said the
3,000 did not refer to EPA pilots but to an estimate of brownfields properties that might exist. The actual
number of pilots was very limited. Dr. Stark asked how EPA plans to evaluate the pilots. Mr. Maas said
EPA is trying now to gather the pilots' successes and stories of lessons learned. They are developing
a database so that if a brownfields property becomes a pilot, the community has a database to consult
when approaching public participation, public health, and child development.
Dr. Bingham asked whether EPA had a list of brownfield properties it could share with the
Board. Mr. Maas did not have a list of the 78 current pilots but offered to get the information,
which is also available at an Internet Web site.
Dr. Stark asked Dr. Warren whether ATSDR was working only with minority communities at brownfields
properties. She also asked whether brownfields properties are in non-minority communities and
whether ATSDR plans to work with them as well. Dr. Warren said the Brownfields Initiative is based
on the geographic location of the properties, whatever community surrounds them.
Ms. Connie Tucker, Southern Organizing Committee, raised several questions about community
involvement and what EPA is doing to ensure community participation. Mr. Mass said that EPA
requires information in the applications on what process the community went through to secure
community input. On the Superfund side, EPA issued policy guidance to give some definition of what
it considers good community involvement.
Dr. Henry Cole asked whether there was a model of stakeholder participation or community
involvement that is broadly representative and raises many of the questions Ms. Tucker raised earlier.
For example, is the clean-up adequate, how will the land be used in the future, will there really be local
jobs, and is the development commensurate with local values and local needs? Could a model of that
kind of process be advertised and held up, or is the development so situation driven that each case is
totally different and you can't get stakeholders bringing their particular needs to the table?
Dr. Johnson added one last perspective to the brownfields discussion. A year ago, ATSDR began an
effort to promote the presence of local health departments in the brownfields program. ATSDR is
strongly supportive of the goals and purposes of the brownfields effort. However, in some cases,
commercial properties were changed through brownfields-like efforts into different kinds of commercial
properties and shortly thereafter community health problems arose. Local health departments,
commanding the trust that most of them do, should be at the table making the decisions that are
currently being made by developers, insurance folks, lenders, and the like.
Community/Tribal Forum Recommendations
Dr. Bingham mentioned unfinished business from the previous BSC meeting and invited Dr. Johnson
to respond to the five issues approved by the Board at the last meeting.
ATSDR Response to Five Issues
Concerning Community/Tribal Forum recommendations, Dr. Johnson said the three consultants to the
Board of Scientific Counselors, Ms. Cellarius, Mr. Jackson, and Mr. Pardilla, had proposed to the BSC
that a Community/Tribal Forum be convened. The Board accepted that proposal, and such a Forum
was held in Houston, Texas.
At the November (1996) board meeting, Dr. Roberts and Dr. Morandi, both of whom attended the
Houston meeting, as well as the three community consultants, presented a series of recommendations
to the Board for consideration. On behalf of the planning committee and other aspects of the
Community/Tribal Forum, Dr. Roberts presented five specific proposals. The Board adopted those five
proposals and in November asked ATSDR to respond to them.
The first proposal was to recognize the key role of the Community/Tribal Forum in providing
community level information to the Board of Scientific Counselors through the community consultants.
As noted in the January 15th letter to Dr. Eula Bingham, Chair of the BSC, ATSDR's response was
agreement with this recommendation and the plan for some kind of annual meeting with the
Community/Tribal Forum, tempered by the ability to fund such a forum.
The second recommendation was to "recognize the role of the Community/Tribal Forum Planning Committee as an advisory group to the community consultants, who will coordinate planning of future meetings for the Forum." ATSDR concurred with the recommendation. Subsequent discussion with
ATSDR's Office of General Counsel indicated that a "Community/Tribal Task Force" would be
preferred language to a planning committee or a steering group. The task force would be established
as a full and standing subcommittee under this Board.
The third recommendation was to approve an additional planning committee member to represent
communities affected by a federal facility. ATSDR agreed with that and said any kind of
Community/Tribal Task Force, or similar standing subcommittee to this Board, should include
adequate representation of persons who are impacted by federal facilities.
The fourth recommendation was to acknowledge the Keystone Center Group for their highly effective
planning and facilitating of the Houston meeting. Future meetings would be much more effective if
outside facilitators chosen by the committee are used and such assistance will be used for future
meetings.
ATSDR agreed with the importance of facilitation for meetings of the Forum and Task Force. However,
facilitators will need to be selected in compliance with federal procurement regulations.
The fifth request was that two Board of Scientific Counselor's members be included on the Planning
Committee. Dr. Roberts has functioned in this capacity and agreed to continue. A second BSC
member would be needed because of the volume of planning activities. ATSDR said this was a matter
for the Board to decide because the agency should not have a role in who the Board appoints to
various task forces or subcommittees.
Proposal for Community/Tribal Taskforce
Ms. Cellarius mentioned that an effort was made by mail to gather ideas from all persons who attended
the forum in Houston. In the responses, the idea of a task force was suggested as an enlargement of
the planning committee. This task force would convene another forum and also work with ATSDR on
community-input issues when communities want something to come before the Board and when
ATSDR wants input from communities.
Ms. Cellarius said that she, Milton Jackson, and Jerry Pardilla, had developed recommendations for
persons to serve on the Community/Tribal Task Force. A notice of the creation of this task force was
written with the aid of lawyers and it was her understanding that it was to be published by ATSDR in
the Federal Register.
Letters with applications were sent to all persons who attended the Houston Forum and others who
might be interested in serving on the Community/Tribal Task Force, which was broadened from six to
nine members. They wanted to create this task force as soon as possible so that work could proceed.
At the end of the first year, they propose to rotate off at least three members and have new members
elected so the task force will always be renewed with new members.
The Board had asked for recommendations from the consultants based on the group that applied. The
criteria were set out in the proposed Federal Register letter so that people would know what the Task
Force was to do. The criteria included cultural diversity because of the wide variety of communities
affected by toxic wastes. In addition, people should represent a site where ATSDR is active so that they
had been involved in working with ATSDR. The consultants want to help ATSDR better understand and
meet community needs and thus avoid community disappointment. Communities need to find out why
some of them receive more satisfaction from government responses than others do. The consultants
hope the task force will be a problem-solving group, as well as a sounding board. They also sought
gender diversity and diversity of federal sites and industrial toxic waste sites in an attempt to truly
represent the whole United States.
Although they had hoped to receive more applications, they received 14 from which they selected nine,
most of whom they knew, had met, and believed would meet those criteria. They submitted the names
to the Board as recommendations for membership in the first year of the task force. In subsequent
years, they plan to add additional members.
They want to start work right away and will have a meeting soon if resources are available. They will
discuss the entire charge to this group, will plan another Community/Tribal Forum, and will respond
to other questions the BSC gives them. For example, at the last Board meeting, the BSC requested
a list of community experiences showing the types of health interventions most often desired when a
community has problems. This hasn't been done yet but is on the agenda.
The task force would also like two Board members assigned to help them. Dr. Bingham agreed.
In response to the comment by Ms. Cellarius on the Federal Register Notice, Dr. Johnson said no
Federal Register notice was posted. When the community consultants brought this proposal to
ATSDR, the agency decided to withhold a Federal Register notice until the Board had approved
creation of a Community/Tribal Task Force. The idea was not to advertise or request nominations for
a Board subcommittee that was not yet formed. The Board should first decide whether it wishes to
create such a standing subcommittee. Dr. Johnson saw two possibilities. One was to proceed with what
the consultants proposed; the other was to withhold approval and do a broader kind of announcement.
Ms. Cellarius asked whether the Federal Notice she saw was only a draft. Dr. Johnson said it was, and
he decided to withhold it because it implied the establishment of a standing subcommittee that was not
yet approved. He noted that some misunderstanding existed between his staff and the three community
consultants.
Reaction from Board of Scientific Counselors
Dr. Bingham asked the Board for reaction to the plan. Dr. Osorio said all--or almost all--recommendations were from people at the Houston meeting. She thought an active outreach was
needed because some persons who might be interested might not be in that loop. The parameters
were good, but she wanted a little broader effort at outreach.
Ms. Cellarius agreed but thought a broader outreach had already occurred. Ms. Shira Flax, ATSDR,
said they asked for broader outreach by circulating a letter from the three community consultants to
the field staff and to other community representatives throughout the nation who were unable to attend
the Houston meeting.
Dr. Stark asked whether the three ex-officio members would be part of the Task Force and what the
term will be for each member. Ms. Cellarius said the consultants would serve in an ex-officio capacity
and the term for other members would be 3 years. Three members would rotate off each year.
Dr. Roberts asked how the 14 applicants found out about the Task Force, and Ms. Cellarius said it was
through a letter sent to all Houston participants.
Comments from the Public
Ms. Tucker said some people did not respond because it wasn't clear what the responsibilities were.
She thought it's a good move for the BSC to have a group advising them made up of people who
actually live in communities where ATSDR is active.
Ms. Tucker said there is--at least in spirit--strong support for ATSDR involving communities in this
process. They applauded the concept. She asked about the cultural diversity on the list, and Ms.
Cellarius identified the proposed members. Ms. Tucker said a look at demographics around waste sites
reveals disproportionately communities of color, but the task force shows a disproportionate
representation of whites, so there's something wrong already.
Ms. Lucinda Hodges gave the Board a brief overview of problems in Alberton about a year ago
following a derailment and the release of chemicals. During this year, people in her community have
suffered terrible health effects, joint pain, memory loss, skin rashes, migraines, and visual impairment
so severe that some people will be blind. They expected ATSDR to help, to fully comply, and work with
their community group in good faith.
Ms. Barbara Miller, Kellogg, Idaho, provided some articles on community exposure to lead. Since
1992, the community has asked ATSDR as well as the different health and welfare and their own local
public and private health departments to help establish a lead health program for their community
needs. The entire county, approximately 15,000 men, women and children, is presently being exposed
to lead and other heavy metal contamination and is suffering the health effects.
Ms. Miller also asked what happened to the recommendations made at the Tribal/Community Forum
last September. She wanted to know what plan was set up to begin to work with invited community
representatives to get the help they need. Is it uniform and comprehensive, and does it involve the
number one priority addressed at the forum, which is community involvement? How will it directly help
affected individuals of these communities?
Ms. Miller said that since education and outreach about lead have been endorsed as priorities of their
lead health project, the community would like to know how DHEP, as explained by Dr. Lichtveld, differs
from the educational program within the medical assistance plan presented by Dr. Pam Tucker. Which
has more benefit for the people of Kellogg?
Ms. Sandra Reid, Oak Ridge, Tennessee, said she was asked by the Coalition for Healthy Environment
to come and speak. She said we need some real-time analysis that will include not just effects of
single-substance pollutants, but multiple effects that impact persons living within these communities.
Ms. Reid said someone doing dose reconstruction in their community showed that atmospheric
releases from mercury were miscalculated by 40% and the most directly affected area was a school
in a predominantly African American community called Scarborough that was never part of the
process. Ms. Reid never saw anyone from Scarborough participate in the meetings, nor did she see
any meeting held in the Scarborough community. The only study ever done was a pilot program by
CDC back in the early 1980s on 179 persons, looking only at acute exposure with a very, very
superficial analysis.
Regarding the Community/Tribal Forum, Ms. Reid believes it has floundered. She was one of the
participants on that project. There should be effective representation from a specific type of community
where they are dealing with the health effects so that they can represent the issues of that community.
Federal facilities cannot represent the issue of an inner city community because we are not facing that
kind of problem, we cannot speak to it. Specific representatives are needed to advise the Board who
can articulate concerns and identify what will happen within that community.
Dr. Bingham said the several issues in front of the BSC included the Task Force and other issues
brought by groups from Montana, Bunker Hill, and the Oak Ridge nuclear site. Also, there was the
issue of what happened with the ATSDR review and the comparison with evaluations the state of
Tennessee has funded.
Dr. Bingham suggested that the issues, which are all important, be kept separated. On the Task
Force issue, she suggested that Dr. Roberts and the community consultants devise a plan for
further outreach and write up what these individuals would be expected to do, how much time
it should take, and whether people could make themselves available. Dr. Bingham was looking
for more effective outreach.
Dr. Bingham asked that a list of sites where ATSDR is currently active be made available so one
can write to whomever would be considered a community representative. If more than one
community group exists, write to all. That's one way to outreach directly. ATSDR is active in a lot of
places, but certainly not in thousands, so such a list is a criterion for selection. She suggested that be
done. The Board could look at it tomorrow and either approve it or make suggestions. If they approve
it, by the next board meeting, we could have a list to act on that people feel better about. She will even
seek some advice on whether we could do some kind of a mail ballot for the Board.
The other issues certainly need to be responded to in some way. She asked Dr. Johnson whether he
or someone at ATSDR could respond to some of them. That may not be possible overnight, but it is
important to look hard at what the agency has done. It can never do enough, but maybe something
more can be done to make these issues less painful.
Certainly, Bunker Hill is a painful story in our environmental history in this country. It was one of the first
things she learned about when she entered this field. There are no easy answers, but she thinks the
Board needs to discuss what has or has not gone on and come to some resolution. In a very
straightforward way, the agency needs to state what it's doing.
Dr. Bingham asked Dr. Roberts to present the proposal on the Task Force that he and the community
consultants developed during the break.
Dr. Roberts said an outside facilitator is needed to help develop and implement the process for
creating the Task Force. Also an ATSDR representative is needed at a higher level to facilitate this
effort across division lines through the agency.
Dr. Roberts proposed that before the next meeting a facilitator be obtained and a ballot prepared with
the names of individuals who represent a broad area of the communities. Dr. Roberts said Dr. John
Andrews' name came up as the possible ATSDR contact.
Dr. Johnson asked about a time frame for this and whether it could take another six months to resolve
the issues. Dr. Roberts suggested using the planning committee, getting support staff and an outside
facilitator, identifying as many communities as possible, and setting up the criteria they need to meet.
One Board member recommended having some sort of qualifications and letters of reference. After
this, a ballot can be produced and mailed out to BSC members before their next meeting. Dr. Roberts
mentioned the need to publish a notice in the Federal Register.
Dr. Bingham said this information should be sent to as many communities as possible, but if
the community has to be actively involved with ATSDR, that's where representatives would be
picked. Dr. Roberts agreed and said at the next meeting he would like to have an official list by
communities like Ms. Doris Cellarius submitted.
Dr. Stark suggested a paragraph be attached to the name of each individual to include the name of
their site and what their involvement with the site had been, similar to the way we vote for officers and
committee members for many organizations.
Dr. Osorio said that following appropriate outreach and talking with people, as a minimum, what is
needed is (a) the criteria used and all persons who met that criteria, (b) a paragraph about what makes
them good representatives (who they are, what population they represent, and what organizations they
belong to). If two letters of recommendation are required, they should be put in a bundle. Thus,
everybody to be voted on has the same opportunity to shine and be considered. Dr. Longley suggested
that a document describing what's expected of the individuals and the kinds of functions they would be
performing be part of the same packet.
Dr. Bingham asked for a show of hands of those in general agreement with Dr. Roberts'
proposal. Dr. Roberts said this is a lot of work for an individual, and Dr. Johnson and the group
should decide whether to go with an outside, relatively unbiased facilitator to do it. Dr. Johnson
committed to that and said ATSDR will do it within its procurement mechanisms. Dr. Roberts
agreed to help, saying it must be done legally.
Dr. Johnson said Dr. John Andrews would be the lead, senior ATSDR person, and Dr. Roberts
said Dr. Andrews would work with him.
Dr. Bingham said there is diversity in the planning committee described in the document from last
November. It may not be perfect, but we recognize that frequently it's people of color who are around
these sites.
The Board agreed unanimously by a show of hands to form the Community/Tribal Task Force
as a Subcommittee of the Board.
Chattanooga Creek Experience
Members of the BSC and other guests toured the Chattanooga Creek site early Monday morning
before the regular BSC meeting, with ATSDR and EPA staff as guides for the site visit. On Monday
afternoon, Mr. Robert Williams, Director, Division of Health Assessment and Consultation, served as
panel moderator and said the panel theme would be local, state, and federal activities, related to
Chattanooga Creek.
Agency/Partners/Community Perspectives
Mr. John Steward, ATSDR Public Health Assessment Coordinator, gave an overview of the site. The
Chattanooga Creek site has been extremely challenging for ATSDR. Contamination of the creek
began approximately 100 years ago. Investigators have identified 42 potential sources of environmental
contamination. The creek begins in the state of Georgia and runs northward about eight miles from the
Georgia state line to south Chattanooga and into the Tennessee River.
ATSDR's activities began in 1992 when the agency was petitioned to investigate community health
concerns associated with Chattanooga Creek and with ambient air among residents of the Alton Park
and Piney Woods neighborhoods. This community comprises approximately 6,700 persons in south
Chattanooga.
After visiting the community in March 1992 to determine residents' concerns, ATSDR decided to
conduct a total health assessment of the Chattanooga Creek site and the ambient air concerns. The
plan included addressing community health concerns and identifying public health needs and the
needs of stakeholders.
Public health assessment findings released in 1993 noted that persons were exposed to various
chemicals from the creek, including solvents, PAHs, and PCBs. Bacteria present in the water was also
identified as a hazard. People could be exposed from contact with sediment, from surface water, and
from consuming fish. ATSDR also identified physical hazards along the creek and stated that breathing
the air had been a public health hazard.
These findings led ATSDR to conclude that Chattanooga Creek was a public health hazard. The many
health complaints of persons in the community included asthma, lung cancer, breathing problems and
coughing, headaches, eye irritation, skin irritation, all of which were possible outcomes of exposures
to creek contaminants. More information would be needed, however, to attribute these exposures only
to environmental contamination of the creek.
ATSDR identified a public health action plan, the components of which included health education to
help residents better understand what they were exposed to and how to avoid such exposures, a health
study to determine specific health outcomes that were concerns of the residents (particularly the
cancer and respiratory questions), a better characterization of creek contamination, a demographic
evaluation of the community, and a follow up on ongoing recommendations ATSDR made.
While ATSDR was conducting the public health assessment, they became aware of some very serious
concerns about tar deposits along the creek bed. This led to identifying the tar deposits along
Chattanooga Creek as an urgent public health hazard in 1993. ATSDR issued a separate health
advisory recommending that people be separated from the waste and that EPA place the site on its
National Priorities List for characterization and clean-up, and supporting existing state advisories
regarding contact with surface water and fish.
Another parallel activity was health education. ATSDR did a needs assessment of the community to
determine what should be communicated and the most effective way to identify target groups, including
school children, teachers and parents, homeless persons, community residents, and government
agencies. ATSDR began providing health professionals' education through the local medical center.
This increased the awareness of health care professionals and gave them risk communication training.
ATSDR conducted a school-based education program about the hazards and raised awareness that
Chattanooga Creek could affect health. In the elementary schools, a contest was held to draw pictures,
and this has become quite famous as the "Creek Geek".
ATSDR also conducted community health education through fact sheets, site visits, and meetings with
residents and began planning an occupational nursing education effort.
Mr. Carl Blair, ATSDR regional representative, Region IV, gave an overview of recent activities at
Chattanooga Creek. He said there is now concern about residential soil sampling and the air pollution
problem remains. The state permits many sites to operate along the creek, and they discharge
contaminants into the air.
ATSDR wants to continue updating physicians in area medical centers about contaminants in the creek
and also help them identify citizens who may be exposed to creek contaminants, whether by air or past
exposures.
Early in the process, ATSDR conducted many activities at the creek to address community health
concerns. Much concern still remains about past exposures. ATSDR will continue working with the
community, with health education a critical need. Dr. Marilyn Edmondson, with the American
Association of Occupational Health Nurses, will discuss her plans to address citizens' health concerns,
with the goal to educate them and leave a mechanism to educate future generations of both children
and adults in the Chattanooga Creek area.
Mr. Williams said one of ATSDR's continuing initiatives in the area is education. Dr. Edmondson is the
Environmental Health Education Project Coordinator. She is trying to create a sustainable
program/service with faculty and practicing nurses to provide a continuing health education program
here.
Nursing Initiative
Dr. Marilyn Edmondson thanked the planning committee members: Dr. Ryan, Ms. Deborah Matthews,
Mr. Milton Jackson, and Ms. Brenda Millsap. She gave an overview of the project and how they are
trying to address some problems that were mentioned earlier.
Two categories of nurses are targeted. One category is faculty members at schools of nursing who can
develop strategies for integrating this content into nursing education programs. This will provide
continuing turnover of the information as graduate nurses begin practicing in this community. The
second category is nurses already practicing (e.g., community health nurses, public health nurses, and
school nurses) who have access to the community and are currently doing continuing education in
other topics.
Dr. Edmondson said they are educating front line workers who will have access to the community.
Overall, she said, nurses, like physicians, have very limited knowledge of environmental health and,
consequently, don't consider it in their assessment of children from these areas. She wants to sensitize
the nurses to environmental health issues.
Ms. Bonnie Bashor -
Director of Environmental Health Studies and Services
Tennessee Department of Health
Ms. Bashor gave an overview of the state health department perspective regarding Chattanooga
Creek. In 1983, the health department began working with a multidisciplinary task force composed of
state, local, and federal agencies responsible for environmental cleanup and health. For several years
the task force recognized that the creek was very contaminated and tried to devise a plan to attack it
and get it cleaned up. The consensus was to begin first with area industries and the municipal sewer
system to stop illegal discharges, then to clean up dumps and hazardous waste sites in the flood plain,
and finally to clean up the creek. Ms. Bashor said progress has been steady through the years, a little
slow, but steady.
In 1984, the Piney Woods community asked the health department to do a health study. Community
concerns were rashes and respiratory symptoms, especially in children. A door-to-door survey with a
questionnaire from the American Thoracic Society looked at self-reported symptoms and diseases and
found an increased prevalence of self-reported respiratory diseases and respiratory symptoms. The
results were reported to the community at two meetings.
In 1993, ATSDR announced that money was available for health studies. At that time, the Chattanooga
health assessment was being completed with a recommendation for health studies. Ms. Bashor asked
Carol Brody, Administrator for the Chattanooga County Health Department, and Mr. Milton Jackson
if they supported a study. They applied and were awarded money in mid 1994 for a year of protocol
development and a year of study. Before writing the protocol, they met with Mr. Jackson and
representatives from the health department to discuss study content and set up. EPA held a
community meeting to explain the protocol. Mr. Jackson set up a community meeting with various
groups for Ms. Bashor to present the protocol.
The last laboratory results were received the end of March 1996. By April 10th, all participants were
sent letters with their individual results and a recommendation to show these results to their own
doctors. Cindy Preech, nurse coordinator for the study, phoned everyone who had abnormal results.
Persons not contacted were sent certified letters, explaining the abnormal results and stating that this
one-time test was part of a study and not for diagnosis. Participants should consult their own doctors
for interpretation. Preliminary statistical analysis and initial draft of the study were completed by
December 1996. They are now working cooperatively with ATSDR to refine the statistical analysis and
discussion.
Mr. Howard Roddy -
Administrator of the Chattanooga Hamilton County Health Department
Mr. Roddy gave a perspective of the local health department, which has the longest involvement with
the Alton Park, Piney Woods community. He said his health department's involvement dates back to
April 1977, before EPA released results of the Chattanooga Creek study.
Environmentalists from Chattanooga Hamilton Health Department posted signs advising residents not
to swim or fish in the creek or have any contact with the very hazardous water and contaminants in the
creek. Very early they sent environmentalists and health educators into local schools within the
Chattanooga area to educate kids about risks of exposure to the creek, warn parents about the
hazards of creek exposure, and provide alerts. Several alerts, particularly in the summer, advised kids
against swimming there, because many kids still swam and fished in the creek.
The health department operates a homeless health care clinic for primary medical care. Often
homeless patients had skin conditions and other problems attributed to creek exposure. Homeless
persons would sometimes bathe and fish in the creek, and this resulted in medical problems,
particularly skin irritations.
The health department collaborated actively with local, state, and federal agencies, including ATSDR,
about January of 1992, when it received a petition from Alton Park and Piney Woods residents and
the Tennessee Department of Environment and Conservation, both the central and regional field
offices. Mr. Everett has worked very closely with the Environmental Epidemiology Department, and they
have been involved in several health studies. The Piney Woods health study, which surveyed residents
in the Piney Woods area and also the group in Edmonton dates back to 1986. Results showed that
residents did have increased exposure resulting in increased respiratory conditions from living in the
area of exposure.
The Chattanooga Hamilton County Air Pollution Control Board has also been very actively involved in
monitoring for toxic air pollutants in the Piney Woods area. The Tennessee Valley Authority helped with
a survey on toxic pollutants in 1980. Community health centers not only helped with the survey but,
when residents living in the area showed increased respiratory problems and other medical problems,
they were referred to the Alton Park and Dodson Avenue Community Health Centers for treatment.
The health department provided both ATSDR and the state health department input about the design
of various health studies. They have attended community meetings to remain updated on the status
of the cleanup and to educate residents in the community about the creek. Mr. Roddy said one role
of their local health department has been to inform and address concerns of local elected officials,
keeping them posted about the schedule for cleanup and community education.
Mr. Wayne Everett -
Environmental Field Office Manager
Mr. Williams introduced Mr. Wayne Everett, Environmental Field Office Manager, Division of the
Superfund, Tennessee Department of Environmental Conservation, who briefly discussed several
areas the BSC saw during the morning site visit and some clean-up activities that occurred.
Mr. Everett noted that Tennessee developed their Superfund law in 1983. In 1994/95, they began
reviewing the Chattanooga Creek flood plain and looking at studies previously done by the Water
Control Division. They considered the sites from the point of view of water pollution, surface water,
groundwater, and human contact. Mr. Everett identified several sites where they provided direct
remediation. These included the following sites: Hanover Road site, Stewart site, North Flow site,
Morningside Chemical Company, Southern Piedmont, Morgan Street Dump, Tar and Chemical
Company, and the Tennessee Product site.
Mr. Milton Jackson -
BSC Community Consultant
Mr. Milton Jackson said the community must work together to further complete any remediation efforts.
He looks forward to working with all concerned groups.
BSC Discussion and Recommendations
Dr. Morandi asked whether some preliminary analysis of the completed health evaluation study of the
creek could be shared. Ms. Bashor said this would be premature.
Dr. Shoemaker said waste is being left at several places where it originated, and some sort of cap was
added to keep the water out. She thought the waste would still move because all the water is moving
toward the creek. Mr. Everett agreed but said an extremely tight clay cap prevents the downward
movement of water. Dr. Shoemaker said sideways movement was still possible.
Dr. Bingham asked whether any more wells could be contaminated. Mr. Everett said each time they
evaluate one of these sites, they search all the wells that were installed, with the help of the Tennessee
Department of Environment and Conservation, and register all wells that are primarily for drinking
water. He said some wells were installed primarily for Superfund monitoring. There are also some
deep industrial wells used for industrial processes. He did not know of any drinking water wells within
a 3-4 mile radius of the site.
Dr. Longley followed Dr. Shoemaker's question and asked about soil characteristics at the sites where
caps were placed. Was it sandy, silty, or clay? Mr. Everett said it was mostly clay. That is why a lot of
sediment has coalesced with the clay and clay materials at the Chattanooga Creek site over 75 years.
Open Comment Period
Dr. Bingham asked for any comments from the public on this issue.
Ms. Deborah Matthews, a resident of the Piney Woods community, expressed two concerns. One was
the health assessment done by the state and Vanderbilt University in 1995. In the latter part of 1994,
they identified residents who were willing to go to the health center for some studies. She was deeply
concerned because her neighbors have not received the results. She said it is a crime that they have
not received them because their lives have temporarily been put on hold. She also said the study was
flawed because not enough persons from Alton Park participated, and, therefore, most persons came
from Avondale. She asked when the study would be released.
Ms. Bashor said the study will be released just as quickly as they can finish the statistical analysis and
have outside peer review. Ms. Matthews said her neighbors should not have to wait for peer review, but
should have some type of information immediately. She said from 1995 to 1997 was too long for study
participants to wait. Ms. Bashor said letters were sent with individual results. Ms. Matthews said that is
all they did, and the letters did not have any explanation. Some persons took them to their doctors, but
some of them didn't understand. Ms. Bashor said a nurse coordinator talked with almost 200 persons
individually and went over the results with them. Ms. Bashor was sitting next to the nurse and heard the
discussion. Ms. Matthews said she knew at least five in her neighborhood who didn't receive letters and
would be happy to give Ms. Bashor the names. Ms. Bashor agreed to send another copy of the results.
Another concern of Ms. Matthews was that the health assessments do not include children. The
children are suffering from learning disabilities, attention deficit, and excessive daytime sleeping. She
wished more assessments involved children. Ms. Bashor said the study design allowed for children
down to the age of 10 to be tested. They did not include smaller children because they wanted a good
sample for the lung function test. Experts on those tests said children under 10 could not do the test
reliably, so they had a cutoff for anyone under 10.
Ms. Bashor mentioned that the nurse coordinator publicized this study on television and radio and with
flyers in the schools. She spoke about it at churches, boys and girls clubs, day care centers, and
several other areas in Alton Park Piney Woods and in Avondale. Ms. Matthews asked how many were
involved from the Alton Park, Piney Woods community. Ms. Bashor said 214 persons in Alton Park
Piney Woods and 114 in Avondale, the comparison area, were all tested.
Regarding the initiative with the American Association of Occupational Nurses, Ms. Matthews was
concerned about the way they involved communities. Her community received no information. They
need more community involvement, more foresight than hindsight. She asked for a survey of the Alton
Park community to have the homes and soil tested.
Environmental Medicine and Health Promotion
ATSDR Perspective
Dr. Maureen Lichtveld, Director, Division of Health Education and Prevention, gave an overview of
ATSDR's new environmental health promotion framework. She described the roles of ATSDR and its
partners, especially the affected community, in achieving goals of prevention, intervention, and capacity
building through health education, risk communication, medical intervention, and health promotion.
Dr. Lichtveld highlighted four strategies in medical intervention to meet the environmental medicine
needs of communities: (1) facilitate access to environmental medicine services, (2) strengthen
expertise in environmental medicine, (3) increase access to ATSDR's toxicologic and human health
databases, and (4) provide some services directly.
Dr. Lichtveld asked the Board to address three questions: (1) Capacity building. ATSDR would like to
dialogue with the Board and Dr. Lichtveld asked, What expertise, competencies, and other capacities
are needed to make the framework work?; (2) Populations. What is the role of environmental medicine
in addressing differences in rural and urban settings when we look at disease prevention and health
promotion? (3) Response. Under what condition is a health study or a more sustainable type of
intervention indicated in the funding to communities? This is an important issue because often when
ATSDR does one or the other, communities may perceive that as the wrong response.
Dr. Stark said New York State is trying to move to the same sort of model as ATSDR, that is as much
as possible to localities and decentralizing services. They face the same kinds of issues ATSDR faces.
She asked what ATSDR meant by "full partnership", how the community and professionals should
perceive that. Dr. Lichtveld noted that they probably would not always be able to achieve that. To date,
ATSDR has worked to create a partnership between communities and the local health department with
them doing their own community needs assessment. That is a start, with the community finding out its
own needs and concerns and then ATSDR providing technical backing and backing to the local health
department to define and design an intervention based on those needs. Dr. Lichtveld said community
members will echo that full partnerships means a lot more to them, but full partnership is not going to
be achievable in all circumstances.
Dr. Stark said although the role of ATSDR and, in fact, of most state health departments is not to do
assessments of individual's health or to provide individual clinical services, yet that is frequently what
the community wants and what they are going to get. Community members want us to send them to
the doctor to tell them what is wrong. She also said, wherever you go, ATSDR will eventually have to
leave the site. This is not acceptable to some communities, and so how you deal with this and what you
leave behind will increasingly be an issue.
Another issue is professional education. In New York, trying to do global education of physicians and
nurses generally is not very fruitful. Most professionals are not interested. However, focusing on
physicians and nurses who are in communities or dealing with people who have these issues can be
fruitful. With scarce resources, the focused approach will probably work better, at least for the near
term.
Dr. Lichtveld said ATSDR's approach is a focused evaluation of a targeted population that has been
exposed, where the agency can measure something, can prevent an illness, and has an opportunity
to build local capacity that will then continue to address the concerns. Environmental medicine services
may be a little confusing, but Dr. Lichtveld indicated that this is not health care. ATSDR provides the
assessment and the specialty referral. When hypertension and diabetes are found, it is unethical for
a physician to make those diagnoses and not have an opportunity to follow up.
Dr. Bingham said the issue Dr. Stark raised is one reason ATSDR gets hit on so frequently. The
perception is that ATSDR is a public health agency, that they do certain things, that individuals will be
examined and told what their problems are, and that individual health care will follow. That is a very
serious perception problem for ATSDR. It must be explained in much simpler language than ATSDR
has done thus far. The issue is what the agency does and what communities think the agency should
do. Dr. Bingham said if communities think ATSDR should be doing specific things, they will have to talk
with their congressional representatives. Dr. Lichtveld said ATSDR cannot provide health care.
Dr. Osorio said some states have managed care contracts to provide indigent care in communities.
One strategy is to go to some managed care organizations and talk about protocols on the kind of
information that is collected. This is a point of control that the state can have working with ATSDR and
local governments. We could help tweak the system in a more public health orientation. Dr. Lichtveld
said that is an example of facilitating the access. If we could get every family medicine physician to at
least think about environmental exposures when taking a history, we have made great progress.
Dr. Bergeisen agreed with Dr. Osorio's comments and reinforced reaching out to managed care
organizations, HMOs, and the like. Although it is important to educate family physicians, it is even more
important to educate organizations that control family physicians, such as managed care organizations.
We know very little about managed care, how that system works, and how to gain access to the
system. It would behoove ATSDR to learn more about those systems.
When EPA talks about partnerships, communities usually want to have veto power over decisions that
are made on sites. If we select a remedy and provide for community input, the community really wants
to say "no," you will not do that or "yes," you will do that. At times that is very difficult for EPA to
relinquish. A partnership in which a community gets veto power and EPA doesn't, sets up a difficult
situation for both EPA and ATSDR at a Superfund site.
Dr. Bergeisen said one complaint EPA often hears from communities is that after ATSDR does a
health assessment and health education for the community and physicians, it pulls out. EPA, however,
stays on with its remedy. Then, when questions arise about the remedy, ATSDR is somewhere else.
Dr. Bergeisen asked how ATSDR plans to deal with these issues given the limited financial and human
resources. Sustainability for ATSDR at a site is not keeping agency staff there but following up with
ATSDR's partners. Both ATSDR and EPA will be out eventually, but the local health department will
be in the community forever.
Dr. Johnson said ATSDR has really struggled with how to define things and probably needs to return
to basics in terms of vocabulary and expression. For individual medical issues, ATSDR is authorized
by law to refer individuals into clinical settings for diagnosis. After diagnosis, all ATSDR can do is refer
and then try to help people get into a health care system. ATSDR does not have authorization under
Superfund to go further, to provide medical care or treatment.
Dr. Johnson agreed with the comment on managed care. As he said earlier, ATSDR plans to monitor
for thyroid cancer and other thyroid diseases for a very large Washington State population that was
potentially affected by Iodine 131 released from the Hanford facility approximately 50 years ago. This
is leading ATSDR to look into HMOs and other effective mechanisms for persons to be screened for
thyroid cancer. Dr. Johnson thought that by the November meeting, ATSDR should have some
experience to discuss if the Board wants that on the agenda.
Finally, Dr. Johnson said ATSDR is very anxious to somehow get community health centers, which are
existing structures financed by another part of the U.S. Public Health Service, involved in the
environmental health and medicine arena. It may only be as Dr. Osorio described, having those
physicians and health care providers know whom to turn to or call on in their community practice. .
Dr. Roberts said that in dealing with HMOs two points come to mind. The catchword now is
"guidelines," and if you couch your remarks in terms of guidelines, you will get their attention. Second
is cost shifting between providers. We must be aware that shifting to the local health department is not
always best. In fact, he sees tough times ahead for local health departments, being pulled in different
directions while, at the same time, their support is crumbling. Dr. Roberts agreed that working with
national organizations will greatly facilitate the local departments regaining a more effective position
in public health.
Dr. Roberts was concerned about laboratory support. Although screening is important, if the individuals
who are screened positive have nowhere to go, then we have done them a disservice.
Finally, Dr. Roberts said several different groups have latched onto the term "environmental medicine"
but are defining it quite differently from how ATSDR is defining it.
Partners in Health Promotion - AOEC
Dr. Sandra Mohr, president-elect of the Association of Occupational and Environmental Clinics
(AOEC) and an assistant professor of occupational health in the Environmental and Occupational
Health Sciences Institute, gave an overview of what AOEC is and how it works with ATSDR. AOEC is
a network of 55 clinics spread across 27 states, Washington, D.C., and two Canadian provinces.
Today, North America--tomorrow, the world.
Most AOEC clinics have an academic or education focus. Becoming an AOEC clinic is not easy. First
it must have a trained occupational and environmental physician, and then it must demonstrate (be
staffed) some occupational health nursing, industrial hygiene, health and safety officers, or social
workers. AOEC focuses primarily on the clinics, that is, the diagnosis and treatment of occupational
and environmental illnesses, and on health promotion, disease prevention, and health education.
In its partnership with ATSDR, AOEC has developed expertise in education and training about
hazardous substances in the environment and also environmental education, risk communication, and
some site specific problems and issues. AOEC operates as a clinical referral resource for health care
providers, disseminating educational materials.
Dr. Mohr then focused on several special projects AOEC has done recently and on some new
initiatives.
Hoboken, New Jersey.
In Hoboken, a cooperative group of artists, 37 persons, bought an old building to create home sound
studios. It had been a factory using mercury in production around the turn of the century, later was
another kind of factory, and finally was a warehouse. They found the building contaminated by mercury
and contacted the New Jersey Department of Health. Dr. Mohr's clinic was contacted and did a site
visit on Christmas Eve last year. They found mercury, and the building was condemned. No network
of clinics other than the AOEC would give that kind of a quick response.
Michigan Department of Health
In Michigan, a family found their ground water contaminated with arsenic, apparently naturally-occurring. Because of groundwater flow patterns, a band of communities was affected. Many persons
had GI and neurologic complaints. The Michigan Department of Health, ATSDR, and AOEC obtained
rapid response from the AOEC clinic at Wayne State University. Residents were fully evaluated, using
standardized diagnostic protocol.
Boise, Idaho
Dr. Anthony Suruda, Rocky Mountain Center for Occupational and Environmental Health, assembled
a curriculum for rural health practitioners about multiple hazard waste sites in the area. This integrated
program with Boise State University was done in cooperation with ATSDR, the Boise Environmental
Health Services, an integrated family practice residency, and AOEC.
Pediatric Environmental Health
AOEC is also embarking on a new focus in pediatric environmental health. In partnership with ATSDR,
they have developed environmental medicine materials, health education activities, risk
communication, clinical diagnosis, and consultation, with a focus on adults. When asked how many
textbooks in internal medicine or family medicine talk about these same issues in children, Dr. Mohr
said very few.
AOEC also wants to put on national workshops on pediatric environmental exposures and development
of diagnostic and treatment protocols, perhaps for use with family physicians in the managed care
setting. Right now they are looking for two AOEC clinics to be designated for special emphasis in
pediatric environmental health problems. These will be the focus of their network for child and health
care providers with expertise and training in pediatric environmental health and can provide guidelines
for all child health providers.
The lead work is a model. Most pediatricians now know to check children for lead, but they have never
heard of many other things and in some communities they really do need a focus. This would provide
pediatric focus for environmental specialists. Children have unique opportunities for exposure that
adults don't, different exposure mechanisms, they breathe faster, their physiology is different, they are
out of doors more, and playing in the dirt more. Therefore, they are particularly susceptible to
environmental exposures.
Dr. Bingham suggested that because of clinic locations, pediatricians could very rapidly be brought
into the network loop. Pediatricians could train environmental clinic people, who in turn would influence
pediatricians as they work in the community or academic settings.
Dr. Mohr thought that was an excellent idea.
Dr. Roberts asked who paid for the Christmas Eve visit to the site. Dr. Mohr said the New Jersey
Department of Health and AOEC asked them to evaluate the building and the residents on behalf of
ATSDR. The money came through AOEC, which received it from ATSDR.
Dr. Bingham said the partnership with ATSDR is important. She believes AOEC clinics will shrink in the
next few years, because it is so difficult now in medical practice. Pressures are on universities. People
are selling hospitals or giving them away. It is a different ball game. These clinics need some kind of
help, perhaps from ATSDR, but ATSDR should have a partnership with the clinics. Managed care
organizations and HMOs will be more and more prominent and must be dealt with.
Dr. Bergeisen asked what ATSDR is doing in capacity building to create AOEC clinics in areas of the
country where none exist. Dr. Mohr said efforts are under way to recruit clinics in the Midwest.
Oklahoma has a very active AOEC clinic. Kansas has none, but the University of Kansas just recruited
its first occupational health physician, Dr. Lynn Frazier, and hopes to establish a clinic there. Last year,
AOEC held its regional meeting in the Midwest to drum up interest in South Dakota, North Dakota,
Montana, and Idaho, and get as many individual members as they could. They hope individual
members can take the concept back and say they want their clinic to be an AOEC clinic.
Dr. Morandi said their clinic has very tight connections with NIOSH centers. They have access to
industrial hygienists, and the occupational people practice in the clinic, but that is only for a team at
most. No other clinics have those kinds of resources, even in an academic setting. They need a means
of doing what Dr. Roberts suggested, money to support these activities and obtain the expertise needed
to investigate buildings, such as the one in Hoboken.
Dr. Stark said New York has a unique arrangement in that the state partially funds the clinics. New York
has more than any other state, and they are jointly funded through state funds and worker's
compensation money. This might be considered as a model in other states to support these clinics.
The unions also support them so they do not depend strictly on fee-for-service or on the good graces
of universities.
Dr. Mohr agreed all clinics would like to operate under the New York-type model. She belongs to a
NIOSH ERC Center and is very privileged to have that. Those funds may also dwindle or dry up, and
they worry about that. The model of worker compensation premiums contributing a few cents on the
dollar to a pool to train health and safety officers, support young people seeking master's degrees in
industrial hygiene, or train occupational environmental physicians is a wonderful idea, and they are
lucky to have made it work.
Dr. Johnson said ATSDR is extremely pleased with the development of the Association of Occupational
and Environmental Clinics. As long as 10 years ago, he and then NIOSH Deputy Director, Dr. Ed
Baker, took the idea to then president of AOEC, Dr. Laura Welch. Through vision and energy, she
made a lot of what the Board heard start and come together. ATSDR has continued to provide seed
money for AOEC's structure and for specific AOEC projects.
Dr. Bingham asked for further comments on questions presented to the Board. Regarding the
competencies and other capacities needed to support ATSDR's environmental medicine framework,
Dr. Bingham mentioned working with AOEC and pediatricians. Dr. Stark mentioned the need to
develop capacity within local county and city health agencies. Because they typically do not have the
expertise or knowledge to deal with any of these issues, this is one area where ATSDR can do a lot.
Dr. Bingham said states do not provide primary care, but many cities and counties are big providers
of primary care. The focus should be on environmental issues for local and county health departments
that are actually primary care providers.
Dr. Johnson said the Health Services and Resources Administration (HRSA) might support ATSDR
to pull together a model project, but it would focus on finding out what works in the context of multiple
players, communications issues, and issues of community empowerment. ATSDR has taken the
proposal forward for others to consider.
Dr. Roberts said that discussions of capacity building tend to focus on the clinical. He cautioned that
capacity building, especially in occupational environmental medicine, means building a group of
people. Occupational medicine physicians deal with a team of industrial hygienists, safety people, and
others.
Dr. Bingham thought it would take a two-day symposium to properly address the role of environmental
medicine in addressing differences in disease prevention and health promotion for rural and urban
populations.
Ms. Cellarius suggested that fund raising as conducted for charitable causes could be a vehicle to
support clinics. Dr. Osorio said other kinds of networks exist for rural areas. She has worked with some
and has given many clinical seminars to the western stream of clinicians who provide services in rural
areas, most of whom are farm workers. Dr. Lichtveld said ATSDR works with nurses in addition to
physicians, for example at Chattanooga Creek. This is important in rural areas where physicians may
come once a week, but nurses are there everyday.
Dr. Bingham asked for clarification on the third question about conditions under which a health study
or sustainable intervention strategy was indicated in responding to community concerns. Dr. Johnson
asked why ATSDR's health studies criteria wouldn't apply in making this decision. The BSC has
approved and ATSDR adopted and accepted criteria on when to conduct a health study.
Dr. Lichtveld said they do apply. Dr. Lybarger said ATSDR has developed formal criteria in the
guidance document for health studies. Many issues related to health promotion activities versus a
health study come down to community perceptions and desires to have more service-oriented activities
instead of addressing a formal hypothesis in a health study.
Dr. Lybarger said ATSDR would like some discussion from the Board on how those decision-making
issues come to bear. For methyl parathion, for example, there certainly seem to be very good criteria
for addressing information gaps through health study activities. This will be done with a follow-up cohort
surveillance activity instead of addressing immediate health intervention questions. Sometimes,
however, a community wishes a study of an issue that can't necessarily be answered with our criteria,
but sort of straddles the fence. It's a matter of perceptions versus objective decisions about what can
and cannot be addressed by a study. That is where ATSDR needs some guidance from the Board.
Dr. Bingham said some of the questions that were raised didn't directly relate to the
presentation. She suggested ATSDR set the framework, give some examples, and make it an
agenda item for a subsequent BSC meeting. Then, the Board can discuss it.
Medical Monitoring Criteria - Hanford Nuclear Reservation
Dr. Jeffrey Lybarger, Director, Division of Health Studies, gave a brief overview of the ATSDR medical
monitoring criteria, which it has published in the Federal Register and is now using at one site. He
asked whether the Board was willing to endorse use of the criteria for continued application in
communities near hazard waste sites.
Dr. Lybarger said several issues would be presented to the Board. One relates to the idea of significant
risk. This term was used in the law and brings in a very subjective sense of how we evaluate significant
risk. Another issue involves the determination of appropriate medical tests and how we decide to do
those. Substantial community involvement is needed in making these decisions. The level of ATSDR's
effort in the Hanford study was considerable. Dr. Lybarger asked whether ATSDR can sustain that
effort level at future sites. He discussed ATSDR's legislative responsibilities, specific criteria, and the
Hanford study example of using those criteria. He said seven criteria were published in the Federal
Register.
Ms. Paula Kocher, Office of General Counsel, said, from the legislative history, Congress clearly did
not want and did not authorize ATSDR to provide medical care. They went as far as a referral
mechanism but weren't clear on what they meant by mechanism. The Agency believes it has
appropriately interpreted this to mean several different methods for referral, as opposed to providing
any medical care directly.
Regarding the criteria, Dr. Lybarger described two as exposure criteria. There should be evidence of
exposure to hazardous substance in the environment that may have subsequent adverse health
outcomes, and there should be a well defined, identifiable target population of concern. Dr. Lybarger
said we need to know who were exposed and that they were exposed.
Other criteria relate to outcome. A body of knowledge is needed to make a reasonable association
between exposure to hazardous substances and specific adverse health effects. ATSDR has not said
this criterion means we must demonstrate an excess of illness in a very specific population. Indeed,
if we catch this early enough, that may not be evident because of certain illness latencies. We must
make sure that a body of reasonable knowledge at least shows in the given population that this is truly
a dose-response relationship.
Monitoring should detect adverse health effects consistent with the existing body of knowledge and
affected by prevention and intervention measures. This goes back to the history of screening as a
public health tool, direct screening toward a specific outcome of concern. It is not a general, total-body
evaluation of any possible health effect a person may have.
The last three criteria, which ATSDR calls system criteria, relate to interaction with the community and
establishing a logistics system that works for them. General requirements for a medical screening
program should be satisfied, and these, as spelled out further in the Federal Register notice, include
sensitivity and specificity of the test and whether the test is acceptable to the community. Historically
this has dealt with several issues related to cost, although in the Hanford situation that was not a major
factor. How invasive the test is to the persons involved is another factor in those general criteria.
An acceptable treatment or intervention for the condition and a referral system should be in place
before intervention of a medical monitoring program. If the original four criteria are met, it is a
reasonable basis for setting up a major interaction system with the community and the medical care
system in that locality. The logistics of the system and whether the proper people are on staff need to
be resolved.
Dr. Lybarger gave then an overview of the Hanford Monitoring Study, focusing on the specific criteria
addressed for this effort. The stringency or liberalness of these criteria had been widely discussed, and
ATSDR also had a public comment period. Dr. Mark Roberts served on the medical review panel that
reviewed the Hanford protocol.
BSC Discussion and Recommendations
Dr. Johnson said the criteria for medical monitoring that Dr. Lybarger discussed are extremely
important for ATSDR. At the November 1994 BSC meeting, ATSDR brought to the Board seven
proposed criteria for dialogue. Dr. Johnson had asked that the Board take no action, either approving
or disapproving, because ATSDR was in litigation. The agency had been sued by a coalition in the
Washington State area, and the Board's involvement in any kind of decision action might affect that
litigation, for or against.
Since 1994, ATSDR has independently peer-reviewed the seven criteria and has now applied them
to the Hanford, DOE site. It took ATSDR two years to work through the Hanford process. Dr. Mark
Roberts was a very valuable technical advisor and can add his perspective.
The Agency is now prepared to apply these medical monitoring criteria to other sites. This is serious
business because it raises expectations in communities for some kind of health care response and
because of the long-term costs. ATSDR would like the Board's informed opinion on the adequacy of
the seven criteria, keeping in mind ATSDR's experience with them at Hanford. ATSDR would like the
Board's endorsement, if the Board is willing to provide that, so that ATSDR can use these criteria at
other sites. If ATSDR finds they are not efficacious at other sites, the agency will bring that back to the
Board at a later meeting.
Dr. Bingham asked for comments on the criteria.
Dr. Stark said there is no criterion for stopping this process. That is, once a medical monitoring
procedure is set up, where does it stop? Dr. Lybarger said the only experience ATSDR has is similar
to its registry program. Although no specific criterion addresses it (stopping), the question has been
raised and is affected by the observed efficacy of the program over a period of time related to the
natural history of the disease. Any specific criteria for stopping will depend on what we are screening
for and must be decided on a disease-by-disease basis.
Dr. Stark suggested a statement be added to the system criteria for a formal way of assessing whether
continuation is necessary (e.g. the natural history of the disease or a periodic examination). If, after 10
years, no excess is seen, it could be stopped. She believes it should be formally stated so it won't go
on until every last person in that cohort dies. Dr. Johnson said ATSDR has agreed with the Department
of Energy to conduct a review of the medical monitoring at five-year intervals. A sub-registry aspect of
this is being handled independently of medical monitoring in that ATSDR agreed with DOE that it will
step back on five-year cycles and evaluate the effectiveness and efficaciousness of the program. .
Dr. Roberts said the issue of when to stop medical monitoring should be addressed, but he was not
sure changing criteria in the middle of the stream would be appropriate. If change means revisiting and
reconvening some work groups, it will not help the process. It would be better to ask how it worked
from the agency's standpoint. Are there changes that need to be considered?
Dr. Osorio said if ATSDR had gone through a long, involved process with representative constituency
groups voicing their opinion in a give-and-take, changing it might not be appropriate. She said nothing
is etched in stone, but a very thorough evaluation with specialists in cost benefit is warranted. She
asked how information will be provided to the Hanford participants.
Dr. Lybarger said part of the contractual agreement with persons who do the actual testing will be an
environmental community interaction mechanism. This will allow for cooperative work with available
community groups. A state notification system is in place, and people will be notified through different
mechanisms about the availability of the testing program. Protocols, guidance, and answers to many
frequently asked questions need to be developed. It will be worked out once the contractor is on board
and the systems are in place.
Dr. Shoemaker asked how ATSDR will fund the Hanford study. Dr. Johnson said the funding issue is
complex. Monies will not come from ATSDR's base budget. The potentially responsible party for
Hanford is the Department of Energy, so monies come from their budget. Monies come from the
Hanford facility budget, supplemented by monies from DOE headquarters budget.
Monies for medical monitoring of non-federal facilities must come from the CERCLA budget as
appropriated by Congress through EPA. As we understand it, those monies are cost recoverable. So,
much like the cost of cleaning up a site, the cost of medical monitoring would be included in what the
government attempts to cost recover.
Dr. Bergeisen said traditionally in occupational medicine medical surveillance is done not necessarily
for conditions for which you know cause and effect. Monitoring a worker population may include a look
at liver function tests. Is that something envisioned as part of this medical monitoring program or must
it be a specific clinical outcome?
Dr. Lybarger said the history of medical screening or monitoring can be taken two ways. The first is
looking at a surrogate of some kind of environmental condition, and that is also commonly used in the
workplace. This is not the intent here. Second, in most screening programs outcomes are selected
because they are associated with the chemicals workers may be exposed to, usually as a supplement
to some administrative or barrier system used to protect those workers.
ATSDR would like the outcomes to be specific to the exposure we are concerned about. It must be
clear, ATSDR will not come in and do a complete physical examination. In a long-term commitment
system, such as ATSDR proposes with medical monitoring, the agency must be as specific to the
condition as possible.
Dr. Bergeisen suggested changing the specific adverse health effect to a specific clinical outcome
because abnormal liver function tests show an adverse health effect, even though there is no clinical
outcome.
Dr. Bingham was concerned with the criteria language, specifically the reference to an accepted
treatment. She asked how the agency plans to treat somebody exposed to mercury. Under the criteria,
they wouldn't qualify for monitoring. And how are you going to intervene if somebody has been exposed
to mercury? Dr. Lybarger said medical monitoring is not the only service the agency can provide.
Dr. Bingham was a little nervous if the criteria were developed specifically for the Hanford site because
what works well for 131Iodine and thyroid cancer might shut off other possible monitoring and prevent
ATSDR from using medical monitoring for anything else.
Dr. Stark said having very tight criteria is essential in ATSDR's situation because once it becomes
known that ATSDR may do medical monitoring in a variety of situations there will be many requests
for it. This is what most communities want but cannot be done, except in very highly specified situations.
Dr. Morandi said regarding the reasonableness between exposure and outcome, some situations will
generate strong disagreement, even among the scientific community. Peer review comments also
reflect differing interpretations of what "reasonable" means.
Dr. Lichtveld said monitoring for effects of mercury is ongoing for six of the 37 children as they grow
and develop. Is that medical monitoring? Not under these criteria. But these children are being
monitored. Another very timely example deals with methyl parathion. EPA cannot continue to relocate
the nearly 7,500 individuals involved. If, indeed, there are exposures of initial concern, you cannot get
to a point where you relocate as the only means of intervention. In those cases, we are doing periodic
testing of urinary levels of para-nitrophenol.
Dr. Bingham said if there are different kinds of medical monitoring, ATSDR should provide a
definition for the different types.
Dr. Bergeisen wondered whether this could be called environmental medical surveillance and
everything else called medical monitoring. For medical surveillance, you would have strict criteria, but
for other situations, like mercury, kids, or the methyl parathion, you would call it medical monitoring.
Dr. Stark preferred to use the expression "specific disease" because a disease gets treated. The
situation here is actually measures of exposure, looking for metabolic measures of exposure, not for
disease outcomes. That is the essential difference between the two programs. Dr. Morandi said this
would be a contradiction of one of the criteria. Dr. Stark said a change would be necessary.
Dr. Shoemaker said the real difference between the Hanford site and other cases is that somebody
else is paying the bill. It must be clear that under circumstances with external funding available, ATSDR
will undertake certain kinds of activity. Otherwise you open yourself up to Dr. Stark's point that
everybody wants this, and you don't have the resources to do that.
In response to Dr. Morandi's question, Dr. Johnson said ATSDR has done a brief analysis, and, if the
seven criteria are applied, ATSDR estimates that 2-4% of the 1200 Superfund sites would qualify. He
also said money is not unimportant, but if we are spending billions and billions of dollars to clean up
sites, he would hope we would not pinch pennies. If people are at elevated risk for hypertension with
lead, for thyroid cancer with radioactive substances, or for leukemia where volatile organic substances
have been documented in water supplies, funding decisions should not be predicated on how many
pennies it is going to cost in relation to the dollars being spent on clean up.
Dr. Morandi cautioned that ATSDR can get such a huge demand from everybody who has concerns
that the agency cannot be effective even in serious cases.
Dr. Johnson agreed and said this is why the agency needs criteria and has brought the seven criteria
to the Board. Dr. Stark said the need is for criteria that are really exposure and disease specific.
Dr. Johnson asked for a statement of the law related to this issue.
Dr. Osorio questioned the use of "reasonable association" because even among scientists, let alone
community groups, there is no agreement. She said you need clearly stated goals and some kind of
evaluation phase, maybe after two years, to reassess what is going on. She also said ATSDR needs
a scientific and community advisory group to help with ongoing medical and feasibility evaluation for
both starting and ending a program. She asked how participants in the Hanford study would be
identified.
Dr. Lybarger said there will be a mechanism to reconstruct and identify the original population and a
voucher system for use at a local health care provider on tests to be conducted wherever they live. This
is needed because a fairly sizeable proportion of these people will have moved in the past 40-50 years.
Dr. Johnson said participants would be drawn largely from the ongoing thyroid disease study, which
has already established those kinds of linkages and follow-ups. In some ways ATSDR is piggybacking
on something that already exists and works.
On the issue of law, Dr. Bergeisen quoted CERCLA that "Where the administrator of ATSDR has
determined that there is a significant increased risk of adverse health effects in humans from exposure,
et cetera." Then further down it says, "This program shall include but not limited to..." So, that gives a
way out, some leeway. "...periodic medical testing where appropriate of population subgroups..." --
which fits -- "...to screen for diseases." This is where diseases come in for criteria No. 3. "...for which
the population, a subgroup, is at significant increased risk." Just using the language of CERCLA,
specific adverse effects can be replaced with the word "disease."
Dr. Stark said she would remove the word "reasonable," and CERCLA's language "There is a body
of knowledge that has established an association between an exposure to a hazardous substance and
a specific disease," would tighten the wording. Dr. Bingham questioned who established the
association. Dr. Stark's recommendation was to define this as specifically and narrowly as possible
under the law.
Dr. Johnson said using "diseases" in ways consistent with the statutory language would be acceptable.
ATSDR would be uncomfortable going too far afield on Item C of the criteria, making it too prescriptive
and too narrow. The agency needs some opportunity to exercise its professional judgment in concert
with outside experts, as it did in Hanford and as it is likely to do in Bunker Hill. Dr. Johnson asked the
Board not to tie the ATSDR's hands too tightly, but to let it exercise professional judgment with the
infusion of expert opinion from outside the agency. Dr. Bergeisen asked whether ATSDR preferred to
keep the language as is, and Dr. Johnson said, yes.
Ms. Cellarius said a community group that lives atop the agriculture state landfill in New Orleans asked
her to come to the meeting and talk about their desire for medical monitoring. It is a good example of
the interest out there and their lack of definition of services. They feel certain EPA will leave them living
there, and they want ATSDR to assure that medical monitoring of the population will be required at a
clinic in the community. They are sure people are sick and getting sicker, and they want medical
monitoring so that if they continue to get sicker, they will get proper care.
Dr. Morandi asked whether ATSDR is opening itself up to litigation by not complying with the letter of
the law as it is written.
Dr. Bingham mentioned that the different levels of intervention or medical monitoring must be
defined. She believes there is confusion for the Board and for the communities.
Dr. Roberts said he saw the drafts and redrafts, and it seemed to take a life of its own. He urged the
agency to do everything it can to streamline the process and take advantage of the experience gained.
He also cited a need for criteria in terms of objective measures. This was important for any judicial
review of the work ATSDR is doing.
Dr. Tucker mentioned that there is a need to define these as public health action follow-ups and in
terms of different things that can be operative. The reason there is not clarity is they are still in
development and there is a need, obviously, to work with communities to develop them.
Dr. Tucker noted the importance of examining whether we will do more harm than good if we put
medical monitoring in place, in terms of how many lives are we saving, how many people would be
seen by a doctor, misdiagnosed and suffer harm. First, you must weigh the human benefits versus the
potential human harm.
This is what Dr. Tucker thought is meant by prevention effectiveness rather than a cost/benefit analysis.
You have to look at resource issues, but there are also ethical issues.
Dr. Bingham agreed and said if that is one of the criteria on which decisions are made, it should be put
in the criteria.
Dr. Bingham closed the discussion and said they could continue with specific issues at the
next meeting. She asked Dr. Johnson to comment on the agency's reaction to the discussion
and to the Board's specific requests.
Dr. Johnson said, on the basis of the discussion, ATSDR needs to respond to the Board in three areas.
The first area was the need for a "glossary" covering the terms used, such as "monitoring,"
"surveillance," "intervention," etc. Dr. Johnson thought the discussion had been very illuminating in the
sense that ATSDR doesn't have precision yet in their expressions. Something is needed that will
clearly delineate for communities and others what medical monitoring means, what it doesn't mean,
and what other kinds of interventions, such as surveillance, registry, et cetera are available. Dr.
Johnson noted that something that improves how ATSDR expresses the various public health
responses is clearly needed.
A second area is related to the need to change in the medical monitoring criteria "adverse health
effects", to "disease." This would need to be consistent with language in CERCLA.
The third area dealt with including an additional criterion to bring forward the importance of doing
periodic evaluation(s), having objective measures of effectiveness and perhaps efficaciousness of the
medical monitoring program. This should be explicitly stated as an additional criterion.
On the question of approval by the Board, Dr. Johnson mentioned that the Agency had gone through
the requisite announcement of the medical monitoring criteria. They've had an outside peer review.
They've had an expert review and he saw the Agency being in a stage of refinement of something that
they had already gone forth with publicly.
Dr. Bergeisen asked if lack of Board approval would hamper any ATSDR effort.
Dr. Johnson mentioned that ATSDR needs to proceed with the Bunker Hill activity. That is the next site
that ATSDR has targeted to bring forward and run past the medical monitoring criteria. The criteria that
ATSDR will use will be those that have been announced and published. ATSDR will certainly be
mindful of the discussion that the Board had. He expected that, if Bunker Hill qualifies, there would be
some statement of periodic evaluation, and objective measures.
Several BSC members proposed different approaches for showing the Board's position on the ATSDR
criteria for medical monitoring. Dr. Bingham asked Dr. Roberts for any closing comments and if he had
a motion on the issue of medical monitoring criteria.
Given the experience in the application of the final criteria that were listed in the Federal
Register, Dr. Roberts moved that, at the next site where ATSDR was involved, ATSDR should
use the final ATSDR criteria for medical monitoring and consider also the suggestions and
concerns that were mentioned in the Board's discussion.
ATSDR should then come back at the next meeting and give the BSC an update. If the Board
then wanted to recommend change(s) in the criteria for medical monitoring, specific
recommendations could be made at that time.
Dr. Roberts noted further that this approach did not tie the hands of ATSDR.
Dr. Morandi seconded the motion.
Dr. Bingham asked for a vote and the "ayes" were unanimous. The motion was passed.
Placing a Site on Inactive Status --
Draft Criteria for Site Inactivation
Mr. Robert Williams, Director, Division of Health Assessment and Consultation (DHAC), noted that at
the last meeting of the BSC, ATSDR was asked to bring forward criteria for inactivating a site. In
response to this request, ATSDR convened an internal work group to develop a site inactivation
framework.
Mr. Williams noted that the inactivation framework was marked "Draft" and at this point represented
only ATSDR's opinion. It hasn't had stakeholder input and it hasn't had community input. This is one
of the issues ATSDR would like to work on with the Community/Tribal Task Force.
Mr. Williams discussed several issues on why ATSDR needs a position on site inactivation. One issue
was resources. Another issue was consistency throughout ATSDR and throughout the cooperative
agreement partnerships. Also, at the same time, ATSDR needs to assure that it has addressed the
needs and concerns of the community and that their mandated and authorized activities have been at
least considered and at most completed prior to inactivation. Mr. Williams also discussed
communication. ATSDR needs to be able not to just announce activities but to communicate with the
stakeholders when the Agency gets to a point of inactivation so that the community can have a part in
that decision making.
Mr. Williams mentioned that ATSDR is not the only agency that has a procedure for inactivation. EPA
has a list of sites known as CERCLIS, Comprehensive Environmental Response Compensation
Liability and Information System. It is a list of sites at which EPA is considering whether or not there are
hazardous substances and for possible inclusion of the site on the NPL, National Priorities List.
Through a process called archiving, EPA is looking at those sites to see if they should be referred to
states for action or do they need a federal presence.
Mr. Williams noted that ATSDR is looking for some way to ensure that its resources are being applied
in the most efficacious manner. ATSDR does this up front by setting public health priorities. At what
sites is there ongoing exposure? At what sites are there public health concerns or ATSDR has found
a public health hazard?
Site inactivation means that ATSDR will suspend its public health activities within a community or with
a tribe and suspend work on a particular site. At the same time, ATSDR doesn't see site inactivation
as being a permanent action. This isn't site closure. This is site inactivation. As new information and
data become available, ATSDR will consider that information and respond appropriately.
Mr. Williams discussed how ATSDR believes site inactivation would work. He was struck by a number
of comments from the community that focused on setting expectations up front, getting people to
communicate at the very beginning. In order for site inactivation to work, ATSDR must start at the
beginning by identifying stakeholders' concerns and needs when the Agency first enters a community,
when ATSDR first begins work with a tribe, when ATSDR is first active at the site.
Mr. Williams noted further that ATSDR needs to clarify what its role is, its responsibilities, what it can
do, what it cannot do, and clarify the expectations that others have of ATSDR. Once ATSDR has done
this, it can sit down and with the stakeholders develop and implement a site specific public health
action plan. This public health action plan can cover health assessments, health education, health
investigations, any of the number of activities that ATSDR may conduct at a site. Additional activities
can be added to the plan as work on the site progresses.
Mr. Williams mentioned that there will be some instances where even though the Agency has done
everything to the best of its ability and in its opinion has addressed all the concerns, the community may
not agree. These are cases where ATSDR would refer to the ombudsperson for dispute resolution.
Only after all the actions Mr. Williams highlighted were addressed would ATSDR consider site
inactivation. ATSDR would use a decision tree (included in the BSC briefing) and a checklist (under
development) to go through and make sure that ATSDR has addressed each of the considerations that
were agreed to with ATSDR. What were the needs and concerns?. Has ATSDR addressed those? Has
ATSDR carried out its mandated and authorized activities before the decision for inactivation is made?
Then at that time, ATSDR would notify the stakeholders of its intent to inactivate so that they can be
involved and informed in the decision. Again, Mr. Williams noted, this is site inactivation. It is not site
closure. New information will become available at times that will change ATSDR's conclusions and
recommendations. When that happens, ATSDR will consider that information and respond
appropriately.
Mr. Williams then described the decision flow diagram. All of the decisions would be reached with
community involvement and participation, with stakeholder involvement and participation. Decisions
will not be reached in a vacuum.
BSC Discussion and Recommendations
Dr. Bergeisen asked what the role was for EPA in terms of ATSDR's decision to inactivate a site?
Mr. Williams noted that ATSDR considers EPA one of the stakeholders. "Stakeholders" was not
defined in the handout and that was intentional because there are many different ways stakeholders
can be involved. EPA and other environmental agencies will be involved throughout this process.
Dr. Stark thought the process is really a very good one and a necessary one. She thought the proposal
to use the community/ tribal task force will probably be very fruitful.
Dr. Bingham asked about the criteria for the various decisions?
Mr. Williams mentioned it depends what you mean by criteria because there are a number that are
obviously involved such as criteria to do the health assessment, and criteria to use medical monitoring.
There are many different criteria that would be involved as we go through the decision-making process.
ATSDR was trying to lay out something generic and a framework so that when ATSDR meets with the
community/ tribal task force and others to develop this further there aren't any preconceived notions
of what ATSDR means. They are not trying to telegraph anything. ATSDR really wants to have input
from others in the design.
Ms. Cellarius discussed the draft document with some of the communities in her state. One of their
major concerns was the infrastructure that is left in place. How will the Agency be able to evaluate the
adequacy of the infrastructure and will there be any funding. They said their health departments don't
want to be left responsible for any extra work. She had mentioned this to the Board before.
Ms. Cellarius mentioned they were impressed that ATSDR had such a thoughtful process.
Dr. Roberts mentioned that it is very helpful to have a set of criteria to go by to deal with the community
but also to address and respond to the political pressure that comes about on why ATSDR is
inactivating a site.
Dr. Bingham mentioned that while ATSDR was waiting on the community/tribal forum group to actually
get in place, ATSDR could send the draft to community groups, with a request for input.
Dr. Bergeisen mentioned that ATSDR might ask Mr. Charles Lee, Director of Research, Commission
for Racial Justice, United Church of Christ, to do the distribution for ATSDR through the National
Environmental Justice Advisory Council (NEJAC) mechanism.
Dr. Shoemaker mentioned that there may be a problem with one of the loops in the flow
diagram. She would be happy to discuss this with the program staff. Mr. Williams said he would
look into it and make any necessary changes to the flow diagram.
Dr. Bingham thanked Mr. Williams for a good presentation.
General Comments from the Public
Mr. Terry Clark - Tifton, Georgia
Mr. Terry Clark thanked ATSDR for all that they have been doing at Tifton. He noted though that
much more is needed.
Basically, he was asking that the government do what it says it is going to do. Mr. Clark found that in
South Tifton, the people responsible for contaminating their community are the people that they are
hearing in the public meetings all the time. They are not hearing from the government. Basically, they
are hearing from the polluters. They are having the polluters tell them they are going to look back and
take more tests to see if the soil is contaminated. Mr. Clark didn't think that contaminants left, just
because they dug them up. He asked, "What is the purpose of this second set of tests?"
He also asked, "Who are they working for?" It is definitely not the people of South Tifton. Meetings that
are held in the community are supposed to have community input as well as input from the polluters.
The reason why Mr. Clark says it is not the people of South Tifton is because " they are having
meetings forced down their throats and when they ask for an extension, it is ignored."
There is a lot of confusion in the Tifton community that is brought in by the Federal Government. If you
can't form a partnership with the people that are mostly impacted, sitting around the table is useless.
It seemed far fetched to Mr. Clark that a committee can sit around the table and tell him about what
is going on in his neighborhood, when they haven't been there.
Mr. Clark noted further that in his community and most of the people of color communities around the
United States, in order for the government, the Federal Government, for which they pay their tax dollars
to protect their health, the whole community must be "crippled and dead" before they warrant a further
investigation.
Mr. Clark mentioned that the local newspaper is telling the people that it is costing Chevron $10,000
a day for equipment to be standing still. But, there is not one sentiment in the paper about the health
of the people in South Tifton. In the local newspaper it seems that the grass root organizations are cut
out by "editing" in order to fit the purpose of Chevron.
Mr. Clark mentioned that there is no concern when it comes to people of color. He commented that
as he looked around the table he only saw one African American sitting on the Board. It seemed easy
to raise question around the Board, but if these questions and action are not implemented in the people
of color community, then it is useless. It is easy to sit and spend tax dollars.
Another thing that troubled Mr. Clark was every time they come to one of these meetings, they are at
a disadvantage simply because the highest, the most expensive places in the cities and towns that they
visit, is where they have to pay money that they really can't afford. He could take that money to his
community and combat against some of the health issues that he believes exist in his community. And
more than that, he could feed a whole lot of hungry, poor people in his community with the price the
government is spending on these expensive meetings.
Mr. Clark noted further that he would like for the EPA to answer just a few questions. How much sense
does it make to take toxic waste from one community and place it in another one? You have already
taken the tests in South Tifton and it has shown that the soil is contaminated. Why is a second set of
tests necessary for the toxic waste at Tifton, Georgia? Also, Mr. Clark would like the EPA to explain to
him why the polluters are being allowed to dictate to them the method of clean up.
Further, Mr. Clark wanted to know why is it possible that the polluters are informed and meetings are
held around their agendas but the technical advisor representing the community under the Federal
Government program is always left out because he has a meeting date that they can't accommodate.
The community technical advisor should be at these meetings to be able to explain to the community
what is going on.
Mr. Clark mentioned that ATSDR or the Environmental Protection Agency may not want to admit it, but
ever since they started digging that chemical up at the Chevron site, the illness in Tifton County has
escalated. There is no justice when you sit around the table and talk about it, but don't implement any
action in the people of color, poor white neighborhood.
Mr. Clark heard the Board say something about children's interest. He asked how they were going to
do so much for children when the health of the people that work for those children's health is not being
addressed. He thought that these are some issues that need to have some attention given to them
simply because they are taxpayers, too, in South Tifton. He was sick and tired of being "bamboozled."
Mr. Clark felt that their health concerns are not adequately being addressed. He mentioned that
ATSDR has done a lot and they are appreciative of that, but they need to do more.
Dr. Eula Bingham, Chair of the BSC, thanked Mr. Clark for his comments. She mentioned that
when the transcript is ready, she would like to have his comments typed and sent to the EPA
Region IV and to the administrator of EPA.
She remarked that ATSDR also heard Mr. Clark's comments.
Ms. Mary Washington - People Working for People (PWP)
Ms. Mary Washington is acting president of People Working for People, Incorporated, Tifton, Georgia.
She represents a community of people of color and a membership approximately 2,000 plus. PWP and
the South Tifton community wish that the BSC would address the issues that concern the grass root
organizations, their apprehensions, their lack of trust and most of all, the significance of this board and
also Region IV, EPA, in Atlanta, in establishing functional, productive and acceptable relationship with
impacted African-American communities and other communities of color.
Today it is essential that recommendations by the grass root organizations, impacted communities,
economically and socially deprived or disadvantaged communities are recognized. It is also extremely
important that they become active participants in the processes and practices of this board and other
governmental agencies. As participants, they would not feel as though they are guinea pigs, mere
statistics or social security numbers that you can study and later be disposed of or erased.
Ms. Washington mentioned that the South Tifton community had several recommendations.
First, it urges reasonable and honest dialogue from federal and state agencies with quality time for
relationship that is acceptable to all parties. Second, provide appropriate testing with methodology and
with results that are identified with integrity and honesty. Third, guarantee qualitative and quantitative
testing performance with real, actual detection limits. Fourth, guarantee that methodologies and
reference data and test samples are not injected with biased rhetoric and tainted with injustice and
racism. Fifth, convince them that the quality of life in their community is the same quality of life that
they will find in the Board's neck of the woods. Let's envision that ATSDR told you that you had a high
level of DDE in your body, but they also failed to tell you that the test results showed exposure to
dieldrin, hexachlorobenzene, DDT, transnonachlor and various dioxins and furans.
Ms. Washington asked, "How would this scenario end?" Ms. Washington then asked the BSC to write
its own.
Ms. Washington mentioned that they strongly protest the type and quality of information, the
dissemination of this information and the methodology of communicating to individuals, test subjects
as they did in South Tifton. Also, the South Tifton community asked that the ATSDR do a thorough
examination and scrutinize the levels of contaminants that are found in test subjects and that they feel
that any level of contaminants indicates that people have been exposed.
Ms. Washington mentioned that it is the agencies that must dispel the myth that government is
untrusting, unreliable and unfair. But to foster and establish a functional relationship, ATSDR must
ensure integrity in its investigations, exemplify reverence in its relationships with communities and
executive trustworthiness in collaborations with impacted communities, who seek justice from injustice.
Dr. Bingham noted that Mr. Clark and Ms. Washington have echoed in different language some of the
same problems or issues that they see in their community.
Dr. Grace Hewell - Community Health Specialist
Dr. Grace Hewell is a graduate of Columbia University School of Public Health. She is a community
health specialist.
She thanked the BSC for coming to Chattanooga and mentioned the benefits from the early efforts of
ATSDR personnel, who made it possible for the waste site to be on the National Priorities List.
Dr. Hewell mentioned that when she called the White House and asked for help because they really
didn't have the resources, they sent a woman from EPA Region IV, who came and worked with the
people. There wasn't any intimidation and confrontation because she was sensitive to people of color.
She was sensitive to the concerns of the people in their community.
Dr. Hewell gave the BSC a certificate for the work of ATSDR and EPA in Chattanooga. Dr. Bingham
accepted the certificate on behalf of Dr. Johnson.
Dr. Hewell noted that the city council and the county board of commissioners had just passed
unanimously a resolution to bring the National Environmental Justice Advisory Council into
Chattanooga. She was pleased to present a certificate to Mrs. Deborah Matthews, a grass roots
resident, and a member of Alton Park Piney Woods Neighborhood Improvement Cooperation.
Ms. Connie Tucker
Southeast Organization for Social and Economic Justice
Ms. Connie Tucker supported Dr. Hewell in the certificate for ATSDR because it is true that had it not
been for ATSDR's assistance in Chattanooga, it would have taken a lot longer to get on the NPL.
Ms. Tucker did not hear an assessment of health effects associated with all of the chemicals that are
present on site. She did not hear an assessment of the impact of those chemicals present in the
community. She didn't think that was done and that is just an example of where ATSDR needs to go.
In addition, not only are there chemicals in that community as a result of the Superfund site, but there
is also ongoing pollution in that community, toxic pollution that we all know about. It seemed to Ms.
Tucker that if a community is contaminated, so contaminated it belongs on the Superfund list and there
is ongoing pollution where the community is being exposed to the most toxic pollutants in the world,
that ought to be a consideration and a health assessment. The reason they keep raising these
concerns is because Chattanooga, as well as Tifton and many of the other communities that are in
their network are laboratories of what chemicals do to people. And at the very least, ATSDR should
be providing that kind of -- making that kind of contribution to the body of science.
Ms. Tucker appreciated ATSDR's commitment to begin to incorporate community input in the
development of the task force but diversity should be based on who is impacted. That includes all the
people of color groups, as well as low income and the percentage of representation ought to reflect
their impact. But more than that, we also ought to be looking at rural and urban situations. There are
a variety of situations that we ought to make sure they are at the table in a task force so that a board
of scientific counselors will get a holistic input from the varied situations that are out there being
affected by a chemical exposure.
She challenged the Board not to go and get people who are going to soft pedal, who are going to try
to praise ATSDR when the praise may be premature. That is not how progress occurs.
Rev. John G. Terrell -
Concerned Citizens League of America
Rev. John Terrell asked what true diversity looked like. It would take in gender, race, cultures,
occupation, socioeconomic conditions of the people in the various communities. When we begin to use
diversity correctly, our decision-making becomes a little bit easier because everybody has become
involved and everybody is represented as much as they should be. That is what true diversity looks like.
Mr. Terrell mentioned that he looked at the Board and saw only one black person. He had hoped to
see American Indian, Asian or whatever. He thought the Board would get more accomplished if there
was diversity around the table and in the task force that the Board talked about.
Mr. Terrell mentioned that the community must be involved. They understand about the resources.
When everybody understands what is on the table and they are involved in the ultimate answer that
comes out of the ultimate conclusion that is drawn, then you are going to see some results and you
are going to see thing move much faster.
Dr. Bingham thanked Mr. Terrell and mentioned that the BSC took to heart the comments about the
diversity around the table. She was sorry that several Board members couldn't attend the Chattanooga
meeting including Mr. Jerry Pardilla, who is a Native American, and Dr. Linda Murray, who is a very
well-respected and famous African-American physician. Unfortunately, Dr. Murray was involved with
the worker's Memorial Day celebrations that were taking place around the country. Also, Dr. Ing Kang
Ho, who is Asian American, serves as a member of the BSC. He was out of the country.
Mr. Earnest Marshall
Tri-Community Collaborative, Inc.
Mr. Earnest Marshall thanked the BSC for the chance to speak. He thanked ATSDR for support in
addressing some local concerns. Mr. Marshall mentioned that they are making sure that what is
happening in their neighborhood is taken care of properly. As far as what happened in Tifton, Georgia,
he didn't know why they chose his neighborhood to dump the dioxin in. Their neighborhood had a
meeting the other night and decided that they didn't want dioxin dumped into the tri-community.
Letter to BSC Chair from Dr. Joel Hirschhorn - Hirschhorn Associates
Dr. Bingham noted that there was an item that the BSC didn't discuss. She mentioned that she
received a letter in the mail from Hirschhorn Associates. Apparently, Dr. Joel Hirschhorn is a consultant
and has critiqued a letter or a report that ATSDR sent out.
Ms. Cellarius mentioned that Dr. Hirschhorn's letter was with reference to some contamination that was
reported for the community in South Tifton and there were a lot of people from South Tifton at the
meeting. She asked if something could be done to assure people that ATSDR will pay attention to this
issue. Dr. Hirschorn had an interpretation that the levels of contamination need to be addressed for
the current hazard that dioxin presents.
Dr. Johnson noted that ATSDR would be pleased to respond to Dr. Hirschhorn. ATSDR has had
telephone conversations with him. He was asked to state his concerns. ATSDR has yet to receive a
statement of his concerns.
Dr. Johnson mentioned that the results of the blood samples that were taken were provided back to
the participants in the Tifton community. If Dr. Hirschhorn has additional insight that should be factored
in to further dialogue with this community, ATSDR would welcome his insight.
Closing Remarks
Dr. Johnson thanked Dr. Charlie Xintaras, Ms. Diane Allgood, and Dr. John Andrews for the staff
preparations. He had a special thanks to those Board members who had great difficulty in getting to
Chattanooga because of the severe weather. He appreciated the extra effort that was made to get to
the meeting.
Dr. Johnson acknowledged the service of Lofton Carr and Nestor Young, two Region IV EPA
employees, for providing the BSC with a tour of the Chattanooga Superfund sites and for giving the
Board's members an important perspective on the remediation activities in the area. He also thanked
Robert Safay and Carl Blair, ATSDR regional representatives, for help in planning the tour.
Dr. Johnson gave special thanks to Mr. Milton Jackson for hosting the Board's meeting in Chattanooga
and to the colleagues in Chattanooga, who provided further expressions of hospitality.
Dr. Johnson mentioned that a number of the issues the BSC heard are as important to ATSDR as they
are to the communities who express them. He has designated a person who will be the ATSDR lead
on environmental justice issues. Also, ATSDR is recruiting for the position of ombudsperson to assist
in dispute resolution.
Dr. Johnson remarked that he hoped that the organizations who come and express their views will
have similar vigor in seeking out ATSDR's views as well as other views. ATSDR finds it remarkable at
times that characterizations are made of the Agency without any contact with the Agency prior to such
characterizations. He urged that ATSDR continue what has been started in terms of substantive
communication with communities, with tribes, and with the BSC.
NIOSH Collaboration
Dr. Morandi mentioned that the BSC was supposed to prepare a statement in support of ATSDR
collaboration with NIOSH to encourage environmental medicine initiative partnerships.
Dr. Bingham suggested the BSC address that at the next meeting. She thought ATSDR had the
sense of their earlier discussion on this issue. Dr. Barry Johnson agreed.
Chattanooga Council Meeting Invitation
In closing remarks, Dr. Hewell extended an invitation to the BSC and the ATSDR staff to participate
at a council meeting scheduled for 6:00 p.m at the Chattanooga city hall. Dr. Barry Johnson and Dr.
Charlie Xintaras were escorted by Dr. Hewell to the Chattanooga city hall where they were formally
introduced to the Mayor.
Next Meeting of the Board of Scientific Counselors
Dr. Charlie Xintaras, Executive Secretary of the BSC, will canvass members and announce a
schedule for the next two meetings.
There being no further business to conduct, Dr. Eula Bingham, Chair of the BSC, adjourned the
meeting at 3:05 p.m.
NOTE: After the meeting was adjourned, Dr. Eula Bingham and Dr. Barry Johnson suggested the
following agenda items be considered for the November meeting of the BSC.
1. Models to use in determining contaminant levels in water distribution systems.
2. ATSDR's interim policy on dioxins in soil.
3. Review and critique of ATSDR's methyl parathion experience--emphasis on use of biological data
and environmental data to support relocation decisions.
4. Report from Community/Tribal Task Force
5. NIEHS worker safety and training program
I hereby certify that, to the best of my knowledge,
the foregoing summary of the minutes is accurate and complete.
6/27/97
Date:
________/s/________
Eula Bingham, PhD
Chair
Coded by Charles Xintaras
This page last updated on July 1, 2001
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