I Mona Sarfaty, MD MPH, EPA Hearing, 07/31/14 Respected EPA panelists and fellow citizens. My name is Mona Sarfaty. I am a physician trained in family medicine and public health; Ihave taught students in medicine and public health for over 35 years. I amhere today to speak infavor ofEPA cleanpower proposal and regulation ofnew power plants. Forthe last 10 years, Ihave been an Associate Professorin the Department ofFamily and Community Medicine at Thomas JeffersonUniversity in Philadelphia. During this time, I have beenactively involved in effortsto improve the quality of health care as part ofthe Pennsylvania Chronic Care Initiative and a follow-on national initiative funded by the Center for Medicare and Medicaid. Primary care practices from across the state have worked togetherto improve outcomes from chronic medical conditions by strengthening their team structures, approaches, and use ofevidencebased care. Medical care institutions are under increasing pressure to show improved quality outcomes by reducing emergency room use, hospitalizations, and otheroutcomes in partbecause ofthe significant percentage ofthe national budgetthat we spend onchronic diseases--especially heartdisease, lung disease, and diabetes. Butbetter outcomes not only require improved healthcare systems; they require cleanairin a healthful environment. The greenhouse gasesthat are coming from power plants are accumulating in our atmosphere and contributing significantlyto the problem. Warmerweather causedby this accumulation is increasing ground level ozone formation while simultaneously lengtheningthe pollen season by 10 to 24 days depending on latitude. This ozone forms when heat and light act

onvolatile organic compoundsthatcome from powerplants as well as from vehicles and other minor sources. (Activities like mowing the lawn with a gasoline powered mower orthe dry cleaning process can add a little.) Once formed, the ozone spreads easily and is an irritant to the lungs. The irritated lungs become far more vulnerable to otherfactors. Pollen is also a lung stressor and causes allergic reactions in many people. Small particles in the air which also come from powerplants, orthe smoke from vehicle exhaust and forest fires, or the ambient dust and drought are also having an adverse effect on the lungs. The combination ofozone, pollen, and small particles is a triple threatto the large and growing number ofpeople who have asthma, chronic lung disease, or heart disease. Children and older persons are also especially vulnerable. Two cases ofteenagers with asthmaillustrate this triple threat.

• Case I comes from a pediatrician onthe West Coast in the East Bay near San Francisco who has observedan unusually large numberofnew allergy patients this year. In May/June 2014, during hot and very dry weather against

a backgroundofdusty drought, ateenage patientdeveloped uncontrolled asthma for the first time. This 17 year old girl hadplayed soccer all her life despite well controlled intermittent asthma. Earlier allergy testing for this young lady had indicatedpollen allergy. At the time ofthe attack she received prolongedtreatment. She had to stop playing soccer and was sent for specialty care whichrecommended a new continuoustreatmentregimenwith multiple medications. Happily, withthe newregimen, she was able to return to playing soccer.

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• Case 2 comes from a pediatrician in Atlanta, Georgia on the East Coast. She introducedme to an 18 year old African Americanpatient ofhers who told her
own story. At age 15, she moved from TerraHaute, Indianato Atlanta, Georgiato live with her Aunt after her motherpassed away. In Terra Haute, she was a high school athlete, playing 5 sports (soccer, basketball, dancing, cheerleading, andtrack). Butthe air quality inAtlanta was poorin comparison to Terra Haute and she developed asthma. The pollen season around Atlanta caused yellow pollen dust to blanket the ground, and get into her hair and onto her clothing. She had to stop outdoor activity, take multiple medications, and was able to play only I sport (indoor volleyball). Asthma attacks were more problematic during pollen season and when ozone levels
were high. The American Lung Association State ofthe Air Report Card shows elevated particle and ozone levels for the Atlanta area. Both ofthese cases illustratethe triple threat ofozone, pollen and particulatesthat originate with the rising temperatures causedby carbon pollution and the ongoing output of ozone and particle pollutants from power plants. At Jefferson's family medicine practice in Philadelphia, the common wisdom was that all the patients who movedto Philadelphia eventually developed asthma, a cough, or allergies. This observation could be made about many areas ofthe country and is supported by real trends in the development ofdisease. Between 1980 and 1995, the U.S. asthma rate doubled from 3% to 6%. By 2009, it had risen to 8% overall, and 9.5% for children. In many inner City school systems, 20% ofthe school children have asthma. This is a startling development and global warming causedby carbon pollution and conditions that result from warming and from pollution emitting power plants play a major causative role. Butthe problems do not begin and end with asthma. There is significant evidence that worsening ofheart disease and chronic lung disease is caused by this same set of factors and leads to medical visits including ER visits and hospitalizations and even mortality. An MIT study report that appearedrecently in thejournal Atmospheric Environment put specific numbers to the toll in mortality. Based on state and local monitoring ofair quality, there were 200,000 deaths that occurred in the U.S. in the course of2005 because ofpolluted air. 1 Ofthese, 52,000 were attributed to the poor air created by power plants emissions. They estimated 573 deaths inPhiladelphiadue to electric powergeneration, and nearly 3864 in the state. With better regulated cleanerand more efficient power generation leading to cleanerairthese lives might be saved. Missed days from school or work, emergency room visits, and hospitalizations could be fewer. The perils ofinaction are very real as are the benefits oftaking action. The human misery that is caused by these conditions and the societal costthat accrues are real. The effortof all medical institutions is undermined when air quality report card show poor grades. Acolleague ofmine participated in an asthma project in Philadelphia called Allies Against Asthma. Theprojectwas a collaboration involving Jefferson's physicians, various local hospitals, and elementary schools. Several othercities were conducting similar activities. The project arrangedto have school nurses coordinate with hospital emergency rooms to identifY and

Mona Sarfaty, Page 2 of33 Mona Sarfaty, MD MPH, EPA Hearing, 07/31114 work with families ofasthmatic childrento help them use every technique available to protect the children from asthma. But, the reality is that the quality ofthe air in many counties in our state does not meet the safer standards ofthe EPA and contributes disproportionately to poor health outcomes. We must address carbon and otherpollution and protect the health ofthe people who live in Pennsylvania and the rest ofthe country. While there is a tremendous amount that modern medicine can offer, the improvement that comes from health care will not compensate for poor air quality. Poor air quality must be addressed at its source. Pennsylvania has some ofthe most seriously polluting coal fire powerplants in the nation. The particulate matter, ozone, and other air pollutants that are generated by these plants belch into the air and threaten the lung function ofpeople who are exposedto them. The medical literature is full of publications from this country and from foreign countries demonstrating that cleanerair leads to improvement in health status for people with lung conditions and chronic diseases. We must take this opportunity to make progress because we still have a long road to travel. Ifenergy efficiency andpublichealth guide our decisions, we will be on sounder footing
as we go forward. Knowledge and the technology have advanced to the point where significant improvements are possible. The time to make these advances is right now. Thank You. I appreciate your attention to this presentation and your work on this vital public health issue.

1Caiazzo, eta!. Atmospheric Environment ; 79 (2013): 179-208

Mona Sarfaty, MD MPH Director, Program on Climate and Health Center for Climate Change Communication George MasonUniversity (703) 993-2086 240-338-7255 (cell)**n1sarJat}'r{~Qmu.ed**u

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