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Given the apparently widespread indoor use of methyl parathion and the limited understanding of associated public health implications, is the current strategy of health professional education, community health education, and the national health alert the most appropriate and effective methodology?
See Public Health Practice Workgroup report following this section.
Field Survey of MP Environmental Degradation Products
The EPA should design and implement an environmental sampling study to determine the environmental degradation products of MP in indoor settings, especially PNP. The study should include a sufficient sample of representative homes (by region, time of application, type of application, etc.) to allow inference to other homes in the region.
7-day Study with Daily A.M. and P.M. Urinary PNP
The agencies should conduct a minimum 7-day pilot study of minimum daily a.m. and p.m. urinary PNPs in households currently undergoing environmental sampling. Individual environmental exposure questionnaires such be administered before each sample collection. In addition to urinary PNP, urinary creatinine should be measured on all samples to allow for creatinine adjustment. The study should be performed in a sufficient number of residences to make these observations under varying exposure conditions. The results of this study will help to determine the variability of spot urine samples, the usefulness of individual exposure questionnaire data in selecting optimal sampling times, and the value of adjustment for urinary creatinine. NB: The public health protection of households participating in this more intensive monitoring overrides research issues: if on-site inspections demonstrate an imminent hazard situation or if urinary PNP results indicate overexposure in the course of data collection, the usual relocation interventions must be put into effect, regardless of the impact on the study.
Dermal Absorption Studies
Humans: The work group feels that it is critical to conduct a dermal absorption mass balance study correlating MP dermal dose with urine PNP excretion pattern in human volunteers. Such a study should be contracted to recognized experts in human dermal exposure studies and must be approved by the institution's Institutional Review Board.
Animals: The effects of combined dermal exposures to MP and PNP, as well as combined exposure to MP and other pesticides identified in the field, should be investigated in a relevant animal model (pig, monkey, hairless guinea pig).
Subchronic Toxicity Study in Animals To Determine Dermal RfD
A subchronic toxicity study in rats to determine a dermal RfD for MP would be very useful for risk assessment in this situation. EPA and ATSDR should review available databases to determine if such data are currently available. If not, agencies should consider initiating such a study.
Pilot Study of Urinary PNP and RBC Cholinesterase
Data from occupationally exposed agricultural workers indicates that depression of RBC cholinesterase is unlikely at urinary PNP levels less than 1,000 g/L. The assumption that chronic low-level MP exposure will not depress RBC cholinesterase levels should be confirmed. A representative sample of people should be offered both urinary PNP and blood RBC cholinesterase monitoring. These may be individuals who are referred or self-referred to AOEC clinics for evaluation. If the sample is not random, sample should be compared with the target population in terms of levels of environmental exposure, urinary PNP, demographics, etc., to assess the possibility of selection bias. The RBC cholinesterase assays should ideally be performed by a single reference laboratory with demonstrated quality assurance for this assay. Before a single laboratory is identified, however, the issue of sample preservation needs to be addressed to determine if shipping samples to a central location is technically and logistically feasible.
Cohort Study of Neurobehavioral Effects in Children Exposed to MP in Utero and Postnatally
The panel recognizes the need for and importance of a cohort study to assess the relationship between in utero and postnatal exposure to MP and neurobehavioral effects in these populations. This epidemiologic study should be designed to address key risk management questions: What is the dose-response relationship between indoor exposure to MP and neurobehavioral effects in the highest risk groups? The study should be able to determine the exposure levels that produce no observable adverse effects on central nervous system function in these populations and would be very useful in setting future relocation criteria. This study is likely to be complex and expensive; nevertheless, it is a reasonable expenditure given the huge amount of resources devoted to current interventions. ATSDR should enlist the assistance of an expert peer review committee to assist in reviewing and providing guidance in the design of this study. There is a small window of opportunity to implement this study, especially if reversible effects are considered an important outcome.
PUBLIC HEALTH PRACTICE WORKGROUP
CHARGE TO THE WORKGROUP
Good communication is as important as good science for protecting public health. ATSDR and EPA should be commended for including an emphasis on communication in this expert panel workshop. The federal, state, and local agencies, despite tremendous time and resource constraints, have also stressed communicating with affected populations.
Clearly, there is a commitment to public health education and a recognition that communication is essential to coping with the methyl parathion situation. A suggestion or recommendation in this document does not imply that agencies have failed to take such action. In fact, given agency expertise and commitment, we would be surprised if many of our suggestions have not been acted upon in some way. Finally, our mission is not to critique current agency programs, nor do we have the information to do so. Thus, any examples of communication problems, unless otherwise stated, are derived from research or experience with issues other than MP.
Although agencies need guidance on step-by-step processes, this document does not attempt to serve as a manual. We cannot emphasize strongly enough that we see the following guidance as a beginning of agency consideration of communication issues, not a communication plan.
The efforts of the public health practice work group would not have been possible without the input of affected people from three states, and the personnel from ATSDR, EPA, and state agencies who provided information, reality checks, and invaluable ideas.
Finally, in this section of the expert panel report we have not examined the larger policy decisions about the most appropriate public interventions. We have not looked at whether agencies should be conducting mitigation or pursuing other strategies, nor have we examined where responsibility should lie. We assume such strategies have already been examined not only from technical perspectives but also from social ones.
Why is communication important?
Communication should be oriented toward helping affected people make decisions and empowering them to implement those decisions. Affected participants, agencies at all levels of government, and local organizations should be involved in communication planning.
Coherent communication planning is needed for short-term, mid-term, and long-term communication.
Agencies are devoting considerable effort to ensure that good science underpins their intervention strategy on methyl parathion (MP). Agencies avoid sampling or monitoring without at least a short-term plan. To do otherwise would lead to poor risk management. Similarly, communication without a plan is equally unwise. It can lead to confusion that is hard to overcome, as agencies have often discovered after faulty news reports on any number of environmental issues. Distrust, once created, is very difficult to dispel (Slovic, 1993).
Communication without planning can also be a great drain on agency energy and resources. For example, brochures made public before considering the content and method of distribution may languish unused; coordination failures may lead to inundations of phone calls for which staff are unprepared; misinformation of the community can be more difficult to remedy than lack of information.
Getting over the "there's not enough time" syndrome
Insufficient time is the most common reason for skipping planning. One result is that agencies spend much time fighting communication fires rather than planning for them or avoiding them. In fact, ad hoc communication efforts often take far more time than carefully planned ones. Just as a poor sampling plan can slow down assessment because of the need to rethink and resample, it is ultimately more time-consuming to develop a brochure or fact sheet without thinking through how it will further your communication goals.
If the "there's not enough time" syndrome is affecting efforts to communicate about methyl parathion, consider the following potential options:
Too often agencies do not have well-thought out protocols for communication emergencies that can be general but flexible to the situation. Because, unfortunately, MP situations are now being found in other areas, federal agencies should have generic standard operating procedures (with sufficient flexibility to modify for local conditions) about how to handle newly found outbreaks.
Standard Operating Procedures should include
Integrated scientific, management, and communication planning
Effective communication cannot be added after scientific and technical decision making are completed. Such an approach ensures that there will never be enough time for communication planning. In addition, given that "people problems" can be the stumbling block of risk management strategies, social science and communication input are needed to develop effective risk management strategies. To maximize resources, risk management and communication strategies must be complementary.
Planning requires thinking through the appropriateness of risk management strategies, given the social dynamics that may be quite different from remediations at Superfund sites. Similarly, communication strategies should be developed mindful of considerations such as field constraints and the state of the science. Optimally, planning of technical and communication efforts will be collaborative, particularly in MP intervention, where individual behavior is integral to risk reduction. To conserve resources, it will be useful consider of how to complement communication and risk management strategies at each phase of helping a family through the MP process.
Limitations of Information Dissemination Strategies
Communication can take many forms. Agencies are familiar with traditional information dissemination conducted by public information or press offices. This type of information dissemination tends to be one-way (National Research Council, 1989, 1996). Information release has other limitations:
Therefore, communication strategies should promote effective problem solving, which requires
We strongly suggest the development of local advisory committees that include not only local civic leaders but also affected individuals who have the energy and commitment to serve as leaders on this issue.
Steps for Communication Planning
Materials development should not occur without knowing the concerns and needs of the people to whom they are directed.
Development of materials is too often the first step in agency communication, although to be effective it needs to be part of a larger communication strategy that takes into account, at minimum, audience concerns and questions, as well as communication strategies. Without appreciating the information that affected individuals want, communications planners are unlikely to develop materials that will respond to their concerns, leaving readers frustrated, potentially reducing agency credibility, and ultimately draining agency resources through calls from confused community residents.
There are many guides for communication planning. Here are some basic questions that should be addressed (adapted from Chess and Hance, 1994):
1. What are your communication goals?
Goals will differ at various times and places. Some basic goals are
2. Who are your audiences?
When asked whom to reach, agency personnel are often tempted to say "everyone," particularly because many individuals have the potential to use illegal applicators. However, even Pepsi Cola, with far more resources that agencies will ever have to devote to MP communication, segments its audiences to target its messages to particular markets. In essence, agencies are now involved in a form of social marketing, purveying information and advice rather than commercial products (Rice).
We see three key audiences for agencies to consider, each of which have specific subaudiences:
Those who have been identified as exposed.
Those who are exposed but do not yet know it.
Those who should be alerted about the risk of illegal applicators.
The following discussion focuses largely on the audience of immediate concern for agencies, according to agency representatives involved in the expert panel: those who have been identified as exposed. A later section outlines strategies for communication with those who are exposed but do not yet know it. Agencies should outline communication plans for each of these broad audiences, before implementation, the plans should be integrated in such a way that they build on each other and maximize resources. For example, although different audiences may need different information, ideally some materials can be developed that serve all three.
3. What do audiences want to know?
At first contact, people want to hear answers to their questions, not just what agencies think is important. Social and cultural backgrounds may influence what people see as important. To find out what people want to know and how they might be involved, a variety of approaches can be used. One involves maximizing the time agency personnel spend with individuals by ensuring that personnel keep track of questions asked. The key questions can be incorporated into routine agency communication.
For example, a standard intake questionnaire might ask individuals what questions they have regarding MP. Those questions can be not only be answered, but quickly compiled to serve as the basis for the development of materials. Other potential approaches to finding out audience concerns quickly and efficiently are consulting local community leaders, reviewing news clippings, and receiving routine input from a local advisory committee. However, these approaches are short cuts that should be complemented with formal research (see later section).
Three affected residents (all with Level 1 homes) who were available to the expert panel for consultation indicated they would like more clarity on health information, including both short-term and long-term potential implications. Equally important was information on the process that the agency would be using to deal with their families and homes. They each wanted an outline, with a timeline, of basic steps in the process (e.g., testing, conveying of results, relocation and remediation). They also wanted detailed information about each step. Some of the affected individuals had questions that were specific to their situation but also were likely to have broader interest. The questions concerned the impact of exposure on children; referrals to doctors with specialized expertise (this was particularly important to one family where children were raised from birth in a contaminated environment and had severe respiratory problems that continued after removal from their home); and appreciation of the appraisal process.
The individuals we spoke with felt they did not have adequate access to information on these issues and others. They also did not have an open means of communication with the agencies and were typically referred from place to place when calling for information. Thus, even if agencies are devoting considerable resources to communication, there may be significant communication gaps that need to be identified and addressed.
People may also want more information than agencies think it is wise for them to know at initial stages. That is, some people, even before they know the level of contamination of their home, may want fairly detailed information on the potential health effects of MP, even though the information may not ultimately be relevant to them (e.g., they have a level 4 home). However, a rule of thumb is that agencies should provide people with as much information as they ask for, while providing appropriate caveats (e.g., symptoms are unlikely to occur in people who live in level 4 homes).
4. How will you communicate with audiences?
Identify local capacity and leaders.
There are established methods for identifying local capacity and conducting local needs assessments (including Superfund guidance that will have some applicability although the time frames, dispersed geographical distribution of affected homes, etc. undoubtedly will require some different protocols). We recommend that a flexible protocol be developed to help agencies quickly assess the social infrastructure and identify the most useful organizations with which to collaborate. The collaborations can vary in duration, scope, and extensiveness. Collaborations can involve one-time activities or ongoing relationships that maximize existing channels of communication.
It is beyond the scope of our work to specify all potential channels of information. However, we strongly recommend that a list of potential organizations that might be useful should be developed and that agencies use different forms of partnerships in dealing with them. For example:
5. What message do you want to get across?
Messages should be created based on answers to the following questions:
What do people want to know?
What do agencies think people should know?
What are people likely to misunderstand if not explained?
A short-term strategy (within a week) for specific message and materials development might include the following steps:
Using an iterative approach
Such materials should be used for a limited time while health educators/community relations staff implement a more methodologically stringent approach to materials development. Because of the need to revise materials for a variety of reasons, including the development of new information, agency materials should not be elaborately formatted or printed. In this way, materials can be adapted easily.
Materials might be developed on the national level in collaboration with local agencies and representatives of affected people. Development of specific national materials should be delegated to state and local agencies. Materials for national use should leave space for local contact information. Local or regional agencies can also adapt the materials to suit their particular needs or develop different information. However, decentralized adaptation should be far more resource- effective than development of similar materials by many agencies.
Select key audiences to be told of changes in agency protocol
The three affected people who came to the expert workshop had little or no understanding of agency timelines, processes, or decision-making criteria. It should not be assumed that transmitting changes in the protocol is a major issue for all affected people. Agencies need to know who has said what to whom--what promises have already been made? What do people understand those promises to be? It may be wise for agency staff to conduct one-on-one sessions with those who might be affected by changes in protocol. The agency might consider, for credibility purposes, maintaining promises to those to whom clear promises have already been made. Agencies might also conduct follow-up confirmatory biomonitoring to ensure that affected residents are truly not eligible under the new protocol. Although needs assessments should be conducted at local levels to determine awareness of past protocols and number of people affected by changes, etc., we are concerned that major announcements of changes in protocol may cause greater confusion than they resolve.
Regardless of approach, agencies should be careful to avoid the perception that information is being withheld. Local announcements of changes in protocol might be placed in the context of agencies' continuing efforts to improve scientific understanding of MP and the most effective ways to reduce contamination. A strategy will need to be developed for local levels that ensures that no parties are blindsided and that, if at all possible, affected residents hear of changes firsthand, rather than from media sources.
6. What milestones need to be planned for?
Some of the milestones, as we understand them, are the following:
a. Initial point of contact
Affected parties are likely to want not only to report information but to receive it.
Even callers who do not know the extent of their exposures may want information about health concerns: What are potential health effects? Short-term/long-term adverse health impacts? What is the process they should expect to be involved in and timeline for it? When is testing appropriate? What does testing include? What are stages after that?
b. Home and urine testing
Giving homeowners materials with instructions for conducting their own testing; can be followed by confirmatory testing for those levels that seem potentially problematic. (This model was used with some success in the New Jersey Radon program.)
c. Communication of test results
d. Follow-up steps:
For each step in the timeline, information needs and strategies need to be considered, which is beyond the scope of this report. One possible approach is discussed below:
Potential case management approach
For working with families who have been found to be exposed to high levels of MP (either through environmental assessment or biomonitoring), it is not sufficient for the agencies to recommend relocation without keeping families informed of agency progress. One way agencies may be able to better work with the relocated families is to use a team approach to case management that is increasingly used by social service agencies. This approach increases accountability and responsiveness to the information needs of the affected community residents. This is necessary to reduce the likelihood that affected residents will be referred from office to office when they call to obtain information of the status of their cases.
We recommend consideration of piloting a program in which team of agency officials is assigned to manage and keep track of a specific number of families to whom relocation has been recommended. Each member of the team would be responsible for a specific number of cases, each of whom can call this team member for information on the status of their case and next steps. The team members will have a clear idea of the protocol to be followed, which would be standard for all affected community residents once guidelines are in place. Residents who choose relocation need to have someone specific to call in the agencies for information regarding their progression through the protocol, from test results, relocation, medical monitoring, and remediation.
Responsible individuals in the agencies may also consider training key community residents who have gone through the process to be able to take some of the workload of the agency team members. Community residents who have been particularly active and have a strong relationship with the agency representatives may become invaluable extensions of agency officials. They may be trained to distribute information to the community regarding the procedures that affected residents can expect to go through when their homes have been identified as potentially contaminated.
7. How can the media be used effectively?
This could be the topic of a separate report. Given limited time to consider this issue, we focused on innovative approaches that agencies might use to incorporate local resources. For example, although good news is often not as salient a news peg as bad news, agencies can focus on the development of feature and human interest stories that promote how families have coped successfully with the process of dealing with MP contamination. Call-in talk shows often reach large audiences and, rather than using agency personnel, talk shows might involve affected individuals who can provide constructive firsthand experiences as well as technical experts. Some of the most effective media outreach might include that of affected residents and community leaders who can send letters to the editor (for years one of the most-read sections in newspapers).
8. How can constructive participation be encouraged?
We cannot emphasize strongly enough that local level solutions will need involvement of affected individuals and local leaders in many phases. We reiterate here some of the approaches we have mentioned:
9. How can feedback be gathered for program improvement?
The MP program will be evolving overtime. The key to program improvement is soliciting feedback from participants including affected individuals, agency staff, and local partners. Because staff are already overburdened, we suggest the following:
Identifying Exposed Populations
Similar questions to the nine posed above should shape the strategy for identifying exposed populations.
The agency representatives who provided information to this panel have expressed a concern that the cases identified are merely the "tip of the iceberg." This possibility should not deter the agencies involved from continuing or expanding efforts to identify other populations that have been exposed. We believe that before these identification efforts, agencies need to devise a standard protocol to deal with newly exposed individuals and new areas of contamination. This protocol should then be communicated effectively to the newly identified populations so that follow-up expectations from the community can be met.
Impact of media campaigns: It is not known whether the media campaign used thus far has reached the populations at risk or what message they have received and understood. Therefore, there is a need to assess what the people who have been reached from the campaign already implemented have understood from the information, what they expect will be done in their cases, and what other general expectations they have regarding the agency's responsibilities. To address these questions within the exposed population that have already been identified, it is recommended that the agencies take an individualized approach to case management. (See section on communicating with exposed populations.)
Impact on rural populations: There is a concern that rural populations are not being reached by the bulletins being issued for the identification of possibly exposed individuals. There is a need to assess whether the populations at risk are being reached effectively. This can be done by direct sampling (such as telephone interviews) of the target populations to assess awareness of the campaign.
Preventing New Exposures
Development of strategies for this population should also be based on the nine questions above.
We recommend piloting potential prevention strategies at the local level that can be implemented as models for action at the national level. These approaches are based on models that have worked with other health risks, and these models may be available for modification and application to the current situation on MP. (For example, research on community-based approaches to reducing lead contamination may be of use.) Because we realized that the agencies will be planning major strategies, and we did not have time to develop a step-by-step planning outline, we focused on innovative approaches that might be overlooked.
It may be possible for the manufacturer to backtrack from distribution lists to target individuals such as farmers. This approach does not necessarily represent an immense additional burden for the agencies involved. On the contrary, we believe that this may help curtail the spread of the problem in a cost-effective manner by targeting information to those who may be distributing the pesticide illegally to consumers. It is also possible to utilize existing channels of contact to farmers that already exist through the Department of Agriculture. Other agencies might issue a short, half-page brochure that includes information about the availability of new and safer batches of MP (with the stenching additive) that they must use as soon as possible. The pamphlet would also include information on the outbreak and effects of indoor use and the consequences of not following these recommendations, such as prosecution. This approach to the sources of MP can be complemented with the amnesty and recall strategies.
Potential incentives to encourage the recall may be the understanding that people who do not come forward during the allotted time of the amnesty WILL be prosecuted. This can be conveyed by using the examples of people who have already been prosecuted, jailed, and fined. The recall could also serve to reduce the risk of illegal dumping of the MP materials. Although the agency contacts we spoke with implied that such an amnesty program is impossible, gun recall efforts and tax amnesties should be explored as potential options.
Although "quick and dirty" assessments of the sort encouraged in this report are essential to expedite immediate communication, efforts of this magnitude require research, just as scientific research is needed to develop effective risk management strategies. We suggest convening a small team of researchers, agency representatives, and others to consider a meaningful, manageable research agenda. (The risk communication research agenda proposed in 1995 as a result of a national symposium could serve as a generic guide to consideration of priority needs.) We strongly recommend that social science research include input from practitioners and affected people in the initial conceptualization of research so that it ultimately is as on target as possible. The following questions describe some research that may be useful, but is not meant as inclusive:
The above topics are merely some initial thoughts. We strongly recommend that agencies fund meaningful research that will provide useful insights, using researchers with extensive background in the issues.
In less than 2 days, it is impossible for us to consider many other aspects of communication regarding MP exposure. However, we hope the above provides further fodder for agency thinking and action. The following are our key recommendations:
Table of Contents
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