S. HRG. 107–318

CHILDHOOD LEUKEMIA CLUSTERS

IN FALLON, NV

FIELD HEARING

BEFORE THE

COMMITTEE ON

ENVIRONMENT AND PUBLIC WORKS

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

FIRST SESSION

ON

RESPONSES BY THE FEDERAL GOVERNMENT TO ‘‘DISEASE CLUSTERS’’

RESULTING FROM POSSIBLE ENVIRONMENTAL HAZARDS

APRIL 12, 2001—FALLON, NV

Printed for the use of the Committee on Environment and Public Works

(

CHILDHOOD LEUKEMIA CLUSTERS IN FALLON, NV

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78–069 PDF 2002

S. HRG. 107–318

CHILDHOOD LEUKEMIA CLUSTERS

IN FALLON, NV

FIELD HEARING

BEFORE THE

COMMITTEE ON

ENVIRONMENT AND PUBLIC WORKS

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

FIRST SESSION

ON

RESPONSES BY THE FEDERAL GOVERNMENT TO ‘‘DISEASE CLUSTERS’’

RESULTING FROM POSSIBLE ENVIRONMENTAL HAZARDS

APRIL 12, 2001—FALLON, NV

Printed for the use of the Committee on Environment and Public Works

(

COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS

ONE HUNDRED SEVENTH CONGRESS

FIRST SESSION

BOB SMITH, New Hampshire, Chairman

HARRY REID, Nevada, Ranking Democratic Member

JOHN W. WARNER, Virginia

JAMES M. INHOFE, Oklahoma

CHRISTOPHER S. BOND, Missouri

GEORGE V. VOINOVICH, Ohio

MICHAEL D. CRAPO, Idaho

LINCOLN CHAFEE, Rhode Island

ROBERT F. BENNETT, Utah

BEN NIGHTHORSE CAMPBELL, Colorado

MAX BAUCUS, Montana

BOB GRAHAM, Florida

JOSEPH I. LIEBERMAN, Connecticut

BARBARA BOXER, California

RON WYDEN, Oregon

THOMAS R. CARPER, Delaware

HILLARY RODHAM CLINTON, New York

JON S. CORZINE, New Jersey

DAVE CONOVER, Republican Staff Director

ERIC WASHBURN, Democratic Staff Director

(II)

(iii)

CONTENTS

Page

APRIL 12, 2001—FALLON, NV

OPENING STATEMENTS

Clinton, Hon. Hillary Rodham, U.S. Senator from the State of New York ........ 8

Ensign, Hon. John, U.S. Senator from the State of Nevada ................................ 4

Gibbons, Hon. Jim, U.S. Representative from the State of Nevada .................... 5

Reid, Hon. Harry, U.S. Senator from the State of Nevada .................................. 1

WITNESSES

Beardsley, Tammy, Fallon, NV .............................................................................. 12

de Braga, Marcia, Assemblywoman ....................................................................... 9

Prepared statement .......................................................................................... 66

Falk, Henry, assistant administrator, Agency for Toxic Substance and Disease

Registry, Atlanta, GA .......................................................................................... 47

Prepared statement .......................................................................................... 143

Gross, Brenda, Fallon, NV ...................................................................................... 11

Guinan, Mary, MD., Ph.D., Nevada State Health Officer .................................... 27

Prepared statement .......................................................................................... 160

Guinn, Hon. Kenny, Governor, State of Nevada ................................................... 5

Hearne, Shelley, executive director, Trust for American’s Health ...................... 53

Prepared statement .......................................................................................... 202

McGinness, Hon. Mike, State Senator, Nevada .................................................... 7

Naughton, R.J., Rear Admiral, Fallon Naval Air Station, Fallon, NV; accompanied by Captain D.A. ‘‘Roy’’ Rogers, Commander .......................................... 30

Prepared statement .......................................................................................... 167

Prescott, Stephen, MD., Huntsman Cancer Institute, University of Utah ......... 14

Prepared statement .......................................................................................... 151

Sinks, Thomas, associate director for Science, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA .... 49

Prepared statement .......................................................................................... 196

Tedford, Hon. Ken, Mayor, Fallon, NV .................................................................. 32

Prepared statement .......................................................................................... 171

Responses to frequently asked questions about Churchill County Leukemia Cases ................................................................................................... 174

Todd, Randall, State Epidemiologist, Nevada State Health Division ................. 25

Prepared statement .......................................................................................... 166

Trovato, E. Ramona, director, Office of Children’s Health Protection, Environmental Protection Agency, Washington, DC ...................................................... 51

Prepared statement .......................................................................................... 198

Washburn, Gwen, commissioner, Churchill County, NV ..................................... 34

Prepared statement .......................................................................................... 172

ADDITIONAL MATERIAL

Letters:

Bobb, Bonnie Eberhardt ................................................................................... 102

Churchill Economic Development Authority .................................................. 191

Fallon Auto Mall ............................................................................................... 191

Shepherd Miller, Inc ......................................................................................... 222

Shundahai Network ......................................................................................... 205

Recommendations, Water Sampling Practices, Nevada State Health

Lab ..................................................................................................................... 179–189

Page

iv

Reports:

Bench Scale Test Results for Arsenic in Fallon, NV, Shepherd Miller,

Inc .................................................................................................................. 278

General Accounting Office, Health, Education, and Human Services Division, Washington, DC................................................................................ 105–150

Groundwater Sampling and Analysis of Fallon, NV, and Naval Air Station, Shepherd Miller, Inc......................................................................... 321–594

Leukemia Hearings, Fallon, NV, February 12–14, 2001 ............................. 67–102

Pew Environmental Health Commission ........................................................ 207

Treatment Technologies for Arsenic in Fallon, NV ....................................... 233

Statements:

Reid, Mary E., area specialist, Water Resources, University of Nevada,

Cooperative Extension .................................................................................. 190

Savitz, David A., Environmental Exposures and Childhood Cancer ............ 152

Study, Household Solvent Exposures and Childhood Acute Lymphoblastic

Leukemia........................................................................................................... 154–160

(1)

CHILDHOOD LEUKEMIA CLUSTERS IN

FALLON, NV

THURSDAY, APRIL 12, 2001

U.S. SENATE,

COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS,

Fallon, NV.

The committee met, pursuant to notice, at 9:00 a.m., at the

Fallon Convention Center, 100 Campus Way, Fallon, NV, Hon.

Harry Reid (acting chairman of the committee) presiding.

Present: Senators Reid, Ensign, and Clinton.

Also present: Representative Gibbons.

OPENING STATEMENT OF HON. HARRY REID, U.S. SENATOR

FROM THE STATE OF NEVADA

Senator REID. The United States Committee on Environment and

Public Works is called to order.

First of all, I’d like to welcome everyone here. This is what we

call a field hearing. I’m particularly thankful for the support that

we’ve gotten from the community in Fallon. It’s been a lot of work

to put this together and the hosts have worked very hard to provide this facility for us and to work with the staffs of the various

Members of Congress who are concerned about what’s taking place

in Fallon. This has been a community effort, as I mentioned. All

local officials have been cooperative, and especially the parents of

the children who are sick.

I’m fortunate today to have with me my two colleagues from Nevada, Senator Ensign and Representative Gibbons. Senator Clinton

will be here shortly. Her plane is about to land. When she arrives,

I’ll say a couple things about her. I want everyone to know, by virtue of my being the Ranking Member of this committee and also

under the auspices of Chairman Bob Smith of New Hampshire, I

have extended an invitation to Senator Ensign and Representative

Gibbons to act as de facto members of this committee today. I’m

also pleased, of course, to have with us the Governor of the State

of Nevada, Kenny Guinn, Assemblywoman de Braga, and Senator

McGinness, who have expressed to me their deep concern about the

incidence of leukemia in Fallon. I want to extend a special welcome

to our witnesses, some of whom have traveled great distances to be

with us here today. We’re extremely fortunate to have national experts on a range of issues important to the community, including

children’s health, childhood leukemia, cancer clusters, and environmentally-related health problems, as well as State, local, and U.S.

Navy officials, with a wealth of expertise and a demonstrated comVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 H:\DOCS\78069 SENENV1 PsN: SENENV1
2

mitment to addressing the difficult circumstances surrounding the

citizens of Fallon.

The second goal of this hearing is to examine the Federal Government’s approach to identifying and responding to so-called disease clusters, including health problems that may be linked to environmental conditions. There’s a widespread concern among the

citizens of this country about our being exposed in our day-to-day

lives and about what we’re exposed to and what effect exposures

may have on our health and especially the health of our children.

While a number of Federal agencies are doing an excellent job of

supporting State and local officials in addressing community health

concerns, the support system often seems uncoordinated, ad hoc,

too little, and many times too late. So I believe the time has come

for the Federal Government to craft a coordinated approach for responding to the needs of communities for support and guidance in

identifying and addressing disease clusters and outbreaks.

Now, here’s how we’re going to proceed today. After the opening

statements of my colleagues, we’re going to have three panels of

witnesses. The witnesses on the first panel will make remarks of

up to 5 minutes, then we’ll have questions of the panel members

from the Members of Congress, and then we’ll proceed to the second and third panels the same way. Preceding these panels, we’re

going to hear from the Governor of the State of Nevada, Kenny

Guinn. After the third panel has finished with questions, there will

have been circulated in the audience little cards, and any questions

that people have to ask Representative Gibbons, Senator Clinton,

Senator Ensign, or myself, we will be happy to answer those, time

permitting. Those questions that are in writing that have your address on them, if we don’t have the opportunity to respond today,

we will respond to those in writing. The cards are in the lobby, and

we’ll make sure that they’re circulated also, for those of you who

missed them when you came in.

We must complete this hearing by one o’clock today. There’s another event scheduled to take place in this room this afternoon.

Mayor Tedford has worked minor miracles to provide us the space,

and I have assured him, my staff has assured him, that we’ll wrap

this up in time for him to set up for the next event. If anyone

wants to submit written testimony, please do so. The hearing

record will remain open for 1 week. Testimony provided by April

19 will be included in the record.

I think also one of the important things that I want to talk about

is—and we make mistakes here. My staff gave me my pages in reverse order. So I’m now on page 3—I’m on page 2, I’m supposed

to be on page 3, but it’s a minor problem. We’re going to look at

a very complex problem, as I’ve indicated. I have 5 children and

soon will have 11 grandchildren, and I can think of nothing more

heart-breaking than a childhood suffering from a serious health

condition and nothing more frustrating than not knowing the cause

of that condition. So, today, we’re going to examine all of this, and

we’ve got people who will help provide some answers. We’re facing

a very complex problem, people should understand, and I’m not

going to pretend that there’s going to be easy answers to the questions, but this committee is committed to give the full weight of the

Federal Government toward answering the many questions that

3

have been posed. In this room today we have a unique opportunity

to share in the experience of working on the goals of Fallon and

nationally. One of these goals is to find ways in which the Federal

Government can help join Federal, State, and local, and even private sources, to support ongoing investigations in the high incidence of childhood leukemia in this community and address any

other environmentally-related concerns. I want to applaud the

State of Nevada, Governor Guinn, for the work that has been done

at this point. I think that other States could take a lesson from the

work that has been done here, and from those of us who work in

Washington, we’ve watched and certainly applaud your efforts.

We’re going to now hear from Senator Ensign, Representative

Gibbons, and then Senator Clinton will probably be here by then.

[The prepared statement of Senator Reid follows:]

STATEMENT OF HON. HARRY REID, U.S. SENATOR FROM THE STATE OF NEVADA

I’d like to welcome everyone to this field hearing of the U.S. Senate Environment

and Public Works Committee.

I’d particularly like to thank the Fallon community for the hard work and support

that has gone into hosting this event. And, I’d like to recognize in advance the family and community members, and local officials, for participating in the hearing: as

the people closest to the issues to be addressed, your testimony is vital.

I’m fortunate to be joined by one of my newest colleagues on the committee, Senator Hillary Rodham Clinton. In addition to her longstanding commitment to children’s health and to a clean environment, Senator Clinton is facing some of the

same challenges facing us here, in connection with a cancer cluster in a community

in her State of New York.

I have also by virtue of my being the ranking member of this committee, and

under the auspices of Chairman Bob Smith of New Hampshire, invited my colleague

John Ensign and Congressman Jim Gibbons to act as de facto committee members.

I’m also pleased to be joined by Governor Guinn, Assemblywoman de Braga, and

Senator McGinness, who I know share my deep concern about the high incidence

of childhood leukemia in Fallon.

And, I want to extend a special welcome to our witnesses, some of whom have

traveled great distances to be here. We are extremely fortunate to have national experts on a range of issues important to the community—including children’s health,

childhood leukemia, cancer clusters, and environment-related health problems—as well as State, local and United States Navy officials with a wealth of expertise and

demonstrated commitment to addressing the difficult circumstances facing the citizens of Fallon and the surrounding area.

Today we will examine what I consider to be one of the most pressing issues facing this community and our Nation: how we can support and enhance the response

to environment-related health threats, and health outbreaks such as the high incidence of childhood leukemia here in the Fallon area. Quality investigations into the

factors that contribute to these health problems will enable us to better protect public health through preventative measures, and through more effective response

when disease clusters and outbreaks do occur.

As the father of five children, and grandfather of soon to be eleven, I can think

of nothing more heartbreaking than a child suffering with a serious health condition, and nothing more frustrating than not knowing the cause. Yes, we are facing

a highly complex situation, and I’m not going to pretend that I think there are easy

answers. But, this committee commits to give the full weight of the Federal Government toward answering the many questions herein posed.

Here in this room today we have a unique opportunity for sharing experience and

expertise toward our common goals, in Fallon and nationally.

One of those goals is to identify ways in which the Federal Government can help

to join Federal, State and local resources to support ongoing investigations into the

high incidence of childhood leukemia in this community and address any other environment-related health concerns. I applaud the State of Nevada for its tireless work

on this issue.

A second goal of this hearing is to examine the Federal Government’s approach

to identifying and responding to so-called disease ‘‘clusters’’—including health problems that may be linked to environmental conditions. There is widespread concern

among the citizens of this country about what we are exposed to in our day to day

4

lives, and what effect exposures may have on our health and the health of our children. While a number of Federal agencies are doing an excellent job supporting

State and local officials in addressing community health concerns, the support system often seems uncoordinated, ad hoc, and too little too late.

The time has come for the Federal Government to craft a coordinated approach

for responding to the needs of communities for support and guidance in identifying

and addressing disease clusters and outbreaks.

Here’s how we’ll proceed. After brief opening statements by my colleagues, we

have three panels of witnesses. Witnesses on the first panel will make remarks of

up to 5 minutes each. Then we’ll ask some questions of the panel. The same for the

second and third panels.

After the third panel has finished with questions, and if time allows, we will provide answers to questions raised by people attending this hearing. You may submit

written questions by filling out one of the cards located on the table in the lobby— these cards also will be distributed by staff. If we do not have time to get to all

of the questions, we will send a written response if you include your address on the

card.

We will need to complete the hearing by 1 p.m., as another event is scheduled

to take place in the room this afternoon. I recognize that Mayor Tedford has worked

minor miracles to provide us this space, and I have assured him we’ll be sure to

wrap up in time for the room to be set up for the next event.

If anyone wants to submit written testimony, I encourage them to do so. The

hearing record will be open for 1 week—testimony provided by April 19 will be included in the record. With that, I welcome my colleagues.

Senator REID. Senator Ensign?

OPENING STATEMENT OF HON. JOHN ENSIGN, U.S. SENATOR

FROM THE STATE OF NEVADA

Senator ENSIGN. Thank you, Mr. Chairman. I want to personally

thank you for not only convening this hearing, but also for inviting

Representative Gibbons and myself to appear at the hearing and

to participate. This is an incredibly emotional issue. I think all of

our prayers and sympathies go out to the families. I myself have

three children. Two of our children have had fairly serious medical

problems—and the nights that you spend in a hospital with your

children are very painful, probably more painful for parents sometimes than they are for the children. So I think all of our sympathies and prayers go out to the families.

It’s because of those emotions that we’re here to recognize work

that is being done by everybody concerned. It’s important because

we need to, find causes for these clusters. Most of the time we

aren’t able to find the causes, but that should not stop us from pursuing them. What if this happens to be the cluster that gives us

the breakthrough to stop, clusters in the future. That’s why maybe

some good can come out of this tragedy that has befallen this community. This situation illustrates the importance of everyone working together—the Federal Government, the State government, the

local government, private entities, and the military—putting their

best effort forward to be able to try to come up with a cause so that

we don’t have these types of things happening in the future. We

all know that prevention is the best type of medicine, and if we can

discover a cause, perhaps we eventually can come up with prevention measures in the future.

So I want to, once again, thank the chairman. Senator Reid and

I have been working together since I took office in the Senate. I

just was informed today that I’ve been a Senator now for 100 days

as of today, along with my colleague, Senator Clinton. As all of you

know, Senator Reid and I had kind of a rough and tumble election

2 years ago. However, this is the type of positive relationship that

5

the people of Nevada can look forward to, with the two of us working together, with the rest of the congressional delegation, other

Senators and our Governor and members of the State senate and

assembly, working together to try to find solutions for Nevada

problems. As you’ll hear later from Senator Clinton, this is not just

a Nevada problem. This is a national problem, and even a worldwide problem.

So thank you, Senator Reid, for allowing me to be here.

STATEMENT OF HON. JIM GIBBONS, U.S. REPRESENTATIVE

FROM THE STATE OF NEVADA

Mr. GIBBONS. I want to associate myself with the remarks of

Senator Reid and Senator Ensign with regard to the importance of

this issue, the sympathies that we have and share with families

who are afflicted by this disease. All of us sitting here today have

children, all of us know and understand the importance of their

lives and their future and the effect that something like this could

have, not only on them, but on their community as well. The purpose, I believe, of this hearing today is for us to gain the information, for us to gain the knowledge, if it is possible, to help both the

families, the children, and this community survive and overcome

this terrible incidence of leukemia.

There is so much to be learned, there’s so much that we don’t

know. It is very difficult, in my mind, to find the answer or to point

a finger at this point in time as to the culprit of this disease. So

we are here today—and certainly it can be shown, by the number

of people in this room and their acute interest in this subject, the

high profile that this issue has. Hopefully, as Senator Ensign has

said, what we will receive is information that will help us overcome

this issue, and will help not only the families and the children afflicted, but also the community, so that this community can move

on and remain one of the great Nevada communities that has already been and will be in the future.

So thank you, Senator Reid, once again for having me here

today. It’s indeed my pleasure to sit on a dais with such distinguished members of the U.S. Senate.

Senator REID. I’ve just been advised that Senator Clinton’s airplane has landed. We’ll reserve her statement until she arrives.

Governor Guinn.

STATEMENT OF HON. KENNY GUINN, GOVERNOR, STATE

OF NEVADA

Governor GUINN. Thank you very much, Chairman Reid, Senator

Ensign and Congressman Gibbons. It’s a pleasure to have you here

and soon, hopefully to arrive, Senator Clinton.

We here in Nevada have been working with this problem over

the past year or so now, and we want to certainly thank all of you

for having the interest to come here to hear the expert testimony

that you will receive from Dr. Guinan and our staff. They have

worked very hard. They have been focused on the issues at hand

in terms of leukemia and cancer, the problem that we have here

with the ALL in this community. It is certainly a serious concern

for all the parents and the children who are involved, but it’s also

a serious concern for those who live in Fallon and for those of us

6

who live in the State of Nevada. So it’s greatly appreciated, the fact

that you would take the time out of your busy schedule to come

here to hear this testimony that you will hear today.

Dr. Guinan and her staff have worked diligently and they have

been very closely coordinated with the CDC, which has given us

great guidance and help, and also the expert review committee that

is set up. So, today, as you see the process that they travel through

and the great detail that they have been working on, I think you

will be impressed. By the same token, this is not just a Fallon issue

or a Nevada issue, I truly believe that cancer clusters have been

established throughout this country over the years. Some have

been unknown for the last 20-plus years. It is time for those of you

who have the wherewithal and the ability to coordinate this on a

national level to do so, and I truly appreciate—and hopefully that

will be your guidance as you come out of this program here today,

after hearing the testimony.

Certainly, it is the unknown that causes the frustration. When

there is an issue like this—and we know about cancer, but if you

do not know the agent that is creating the cancer cluster, then it

becomes an area that is of fear and not understanding that unknown. So, today, when you hear these issues, if there’s anything

you can do to help us to promote it more on a coordinated basis,

which I’m sure you will do, and take it throughout this great land

of ours in America, then we will all be better for having this hearing here today.

I will leave the rest of the information that you’ll get from the

State of Nevada, certainly from these experts, who have worked

day and night. Over five full-time staff people have been allocated

to this, but the real support that we’ve received so far is from the

staff of the CDC and also from these expert oversight members,

who come from some of the very best cancer research areas of the

universities. So hopefully today you will hear a great deal of detail

on what the study has been doing, and if there’s anything you can

do to help us after that, I’m sure the citizens of Fallon in this great

State of ours will most appreciate it.

Senator REID. Governor Guinn, we appreciate your being here

today. You and I spoke before the hearing started, and we understand you have a legislative session that’s in full blow at this time

and you’ve got to get back and protect the interests of the State,

and we want you to do so. We appreciate your taking time out for

this. There’s no busier time than when the legislature’s in session.

So you’re excused, and we appreciate your being here.

Governor GUINN. Thank you very much. We will cooperate and

provide you with all the data and do everything we can to help you

formulate your plan and your ideas for all Americans. Thank you

very much.

Senator REID. We would now like to hear from Mike McGinness,

who is the Senator who represents this area. Senator McGinness,

we also appreciate your being here, with the legislature being in

session. We would ask you to address the committee now and tell

us what you feel is appropriate.

7

STATEMENT OF HON. MIKE MCGINNESS, STATE SENATOR,

NEVADA

Senator MCGINNESS. Senator Reid, thank you very much. I appreciate the opportunity to be here. Senator Ensign, Congressman

Gibbons. As you mentioned, Senator Reid, I too will be heading

back to Carson City. The judiciary committee has a large work session today. Congressman Gibbons and I were freshmen in the judiciary committee in the assembly in 1989. We do have some deadlines, but I appreciate the opportunity to be here today.

For the record, I’m Nevada State Senator Mike McGinness, representing the central Nevada Senatorial district. I appreciate the

opportunity to provide testimony. Fallon, NV, is my birthplace. In

fact, about a hundred yards down the road here, there was a clinic

where I was born. I’m here because of the concern for the children

and these families that are facing such trials. Again, I wish to

thank the committee for making these children such a priority.

Your attention to their illness can only contribute to the awareness

and assist in the current investigation. I would like to thank Governor Guinn. When he convened all the parties earlier this year,

there was a genuine spirit of cooperation to work toward seeking

information and peace of mind for the children and their families,

and I encourage a continued collaboration in the investigation.

I have great confidence in the leadership of this community.

There’s a rich history of strong progressive leaders, individuals that

have acted responsibly since the discovery of this cluster. Many of

us have difficulty dealing with the negative publicity, since the

very reputation of this community has been questioned. The community has responded to the needs of the families at every available opportunity, and I know they’ll continue to do so. We want the

community, the State, and the Nation to know that Fallon, NV,

will find the cause and cure for this malady today, if possible.

Particularly pleasing is news that the Centers for Disease Control will move the investigation to a new level. The CDC will be

in Fallon on Tuesday to begin phase two of the investigation. As

Federal officials, anything you can do to expedite their investigation will be appreciated. The community can take comfort in the

fact that government at all levels is acting responsibly. I would

hope that the committee finds that credit is due to the city of

Fallon, Churchill County, the State of Nevada, the U.S. Navy, and

the Federal agencies for their response. Anything that can be done

will be done.

In closing, let me thank you again for coming to Fallon and making the care and comfort of these children and their families a priority, and I appreciate the opportunity.

Senator REID. Senator, good luck on the remaining 60 days or so.

Senator Clinton, you came at a very appropriate time. We’ve just

completed hearing from Governor Guinn and the State Senator

who represents this area, Senator McGinness. We indicated that

your plane was a little bit late. Let me say to everyone here assembled, as Senator Ensign indicated, Senator Clinton—this is her

hundredth day of being in the U.S. Senate, and this is the first

time that she has traveled outside the State of New York to do

business. We all have been involved in things in Washington. I personally am very glad that she’s on our committee, the Environment

8

and Public Works Committee. As you’ve seen reported in the press

in recent days, she has done a tremendous job on this committee

and in the Senate, and we’re fortunate that she’s here in Fallon

with us today.

Senator Clinton, would you give us an opening statement?

OPENING STATEMENT OF HON. HILLARY RODHAM CLINTON,

U.S. SENATOR FROM THE STATE OF NEW YORK

Senator CLINTON. Thank you, and I’m delighted to be here. I

apologize for being a little bit late. It took longer than I thought,

but I got to see some beautiful country as I flew over. I’m very

pleased to have this opportunity to join the Congressman and my

colleagues, Senator Ensign and Senator Reid, for this important

hearing. I know that we wish we weren’t here in a way. We wish

we were here for some other reason. I’d love to come back to Fallon

and get to know more about what goes on in this community and

have a chance to learn more about what our naval base does or

what the agricultural interests are, but we’re here because we have

a very sensitive and difficult issue to address, and it’s one that I

care deeply about.

As Senator Reid might have said, we have cancer clusters

throughout our country. We certainly have them in New York, and

I think even some of the witnesses we’re going to hear from today

will speak of some of those. There’s a high school in a place called

Elmira, NY. For reasons we haven’t yet been able to determine,

there are a number of cancers in our children who attended that

school, and, suprisingly, there’s no way yet that we can understand

the reasons for it. We know it’s built on an old industrial site. We

know that’s a community that has had a lot of heavy industry,

going back to the Civil War. So we’re looking for answers. We have

breast cancer clusters throughout New York. Some of the highest

rates of breast cancer can be found anywhere in our country. This

is not something that is confined to Nevada or New York, it’s something that we face around America, and I think that the Congressman and the Senators and I are here today to hear from you and

to hear from experts who have been looking into the issues surrounding the leukemia here in Fallon with the hope that we will

be able to put together some information and recommendations

that could possibly lead to answers.

I want to thank my friend, Senator Reid, for holding this hearing. It’s such a pleasure working with him, serving with him. I’m

delighted that it’s also the hundredth day for Senator Ensign,

whom I’ve had the pleasure of getting to know over the last

months. I’ve known Senator Reid for a number of years, and I see

Mrs. Reid here, and there aren’t two people who are more dedicated and devoted to the people of Nevada than they are, and the

service that he’s given over the years really stands alone and what

he does every day to make the Senate run, which is no easy task,

I have learned, is remarkable in and of itself. So I want to thank

him, not only for his leadership, but for his friendship as well.

We’re going to work in a bipartisan way to deal with the environmental challenges that face us, the health care challenges that we

confront. I’m looking forward to hearing from the witnesses, because they’re really the reason for this hearing, and then taking

9

what we learn and going back to Washington and, again, working

in a bipartisan manner, working with members of the House as

well as the Senate to try to find some answers, and I appreciate

all of you giving me the honor of being able to attend today.

Thank you very much.

Senator REID. The first panel that we’re going to hear from today

consists of Assemblyperson Marcia de Braga, who has devoted

weeks and weeks of her life to the problem that faces her district,

her assembly district; Ms. Brenda Gross, a mother of a child with

leukemia from Fallon, NV; and Tammy Beardsley, a mother of another child with leukemia in Fallon, NV. On this same panel, if you

would step forward, please, we’re going to hear from Dr. Stephen

Prescott. Dr. Prescott is from the Huntsman Cancer Institute at

the University of Utah, in Salt Lake City. Dr. Prescott is one of the

leading experts in the world on cancer generally, and we’re very

fortunate that he’s traveled to Fallon from Salt Lake to share his

expertise with us.

I would remind the witnesses that we all have a lot to say, we

have a number of questions that—we’ve reviewed what you’re

going to talk about and the questions we want to ask. So if you

would do your best to stay within the 5-minute guideline, it would

be appreciated. You’ll see these little lights up here. Green means

you’re in good shape, yellow means you have a minute to go, and

red means you’re out of time. So do the best you can. We’re not

going to call for the sergeant-in-arms to throw you out if you go a

little bit over, but we do have to meet the responsibilities that we

have with the mayor in getting us out of here by 1 o’clock. We’re

going to take no breaks during the hearing. The court reporter’s

fingers are—we have a reporter that has the best fingers in northern Nevada. She said she can take testimony for 4 hours, and we’re

going to test her and see if she can.

Assemblywoman de Braga, please proceed.

STATEMENT OF MARCIA DE BRAGA, ASSEMBLYWOMAN

Ms. DE BRAGA. Thank you. It’s a great pleasure to welcome you

to Fallon, and we want to thank you for convening these hearings.

In the fall of 1999, I read with sadness a story in our local newspaper about a fund-raiser for a 5-year-old who had ALL, acute

lymphocytic leukemia, and then there were a few more cases and

more sad stories. I called the State health division and asked if

they thought that four cases of ALL in 3 months was an unusually

high number in a small community like ours. I was told it might

be just an isolated cluster, but they would look into it. In less than

a year, eight more cases were discovered. The statistical probability

of this number of cases occurring in an area with our population

is 1 in 10 quintillion. In other words, there is almost zero possibility that this cluster happened by chance.

In mid-February, the Assembly Natural Resources Committee,

which I chair, held 3 days of legislative hearings. The purpose of

the hearings was to bring together the experts, the data, the research, the knowledge, funds, and other resources in an effort to

expedite the search for an environmental cause or contributing factors. The hearings also served to attract considerable media attention and with it a great many offers and promises from individuals

10

and agencies and from local and State and national officials to

work together for a common and urgent purpose.

Others testifying will give you statistics and progress reports.

What I want to focus on is what I learned through the legislative

hearings and through listening to the people whose lives have been

affected by this tragedy. As a result of the hearings, we prepared

a list of possible causes created from our research and the testimony we received. The entire list is in your packet, along with the

names and agencies of individuals that our recommendations have

been forwarded to. It basically asks those in authority to leave absolutely no stone unturned. Our recommendations also include providing information to the public and expanding the scope of the investigations to cover a longer period of time, other disease

groupings, the analyzing of water, soil, and air, and the testing of

blood, bone, tissue, and hair of the children. I’m happy to report

that yesterday the Assembly Ways and Means Committee approved

$500,000 to be used specifically for those purposes.

In addition, the committee recommends cleaning up the things

that our community is concerned about, and doing it now and not

waiting for science to catch up or to provide positive proof. We

unanimously agree that the cancer registry and other data must be

processed in a rapid manner, so that information is current and

readily available to help the environmental officials and the general public.

This leukemia cluster may only be a part of the whole picture.

An eminent pediatric oncologist has advised us to investigate all

marrow diseases and to look for any increases in other forms of

cancer among children and adults. We know that two additional

ALL cases were diagnosed in 1992, and in 1991, a 5-year-old died

from myelodysplastic syndrome, a less common form of leukemia.

We know that earlier this year a youngster was diagnosed with

aplastic anemia, another marrow disease. We know that there may

be additional cases that are connected to Fallon but were not diagnosed here, and we know that there are clusters of other diseases

that are also suspicious.

I think it’s vitally important that everyone involved be proactive

and not rely on old data, that we look beyond the environmental

improvements that are already being done to what needs to be

done next, and that we approach our problems with the hope and

optimism that through determination and perseverance we can, if

not find a definitive answer, at least eliminate possible causes and

add to our information base.

Our legislative committee has sponsored a bill that would require

public and private entities certified to do environmental testing to

report to the Nevada State Health Division or NDEP any findings

of specific values that exceed the established maximum contaminant levels. Those findings would have to be made public if a significant health risk was posed. I think it’s imperative that we put

these protections into law and aggressively pursue our search for

causes. That includes working to eliminate known contaminants. In

so doing, obviously we improve the general health of all contributors.

Why do I feel so strongly that we have a responsibility to move

forward in every way possible? Because this is about children, chilVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00016 Fmt 6633 Sfmt 6601 H:\DOCS\78069 SENENV1 PsN: SENENV1
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dren whose lives have been turned upside down by something terrible that’s beyond their control. This is about a beautiful, smiling

little girl whose hair is gone. This is about a promising young athlete whose energy now lasts for only minutes. This is about a teenager whose HMO won’t pay for a bone marrow transplant. This is

about furthering what is known about cancer so that communities

might be spared what happened here. I applaud your efforts to create a nationwide team to deal with these situations, if and when

they arise.

Senator Clinton, I read that you said, ‘‘There is no such thing as

other people’s children.’’ You, Senator Reid, Senator Ensign and

Congressman Gibbons have clearly demonstrated that belief by

coming to Fallon to hold these hearings. We can’t thank you

enough for your concern and your willingness to help our community and communities like this everywhere.

Thank you.

Senator REID. We’re going to now hear from Brenda Gross. She

really has raised the consciousness of the entire community to this

terrible disease. She’s the mother of four children. Her testimony

was one of the highlights of Assemblywoman de Braga’s hearings.

Would you, please, proceed.

STATEMENT OF BRENDA GROSS, FALLON, NV

Ms. GROSS. Thank you and good morning.

I would like to thank you for allowing me this time to express

my thoughts and share with you some of the hardships that my son

and my family went through. I’m here today speaking to you to

stress the importance of an aggressive approach on this investigation. My son, Dustin Gross, is 5 years old. He was diagnosed April

17, 1999. He is doing very well today, and I’m very thankful for

that. We went through some very hard and trying times. As a parent, when your child is very ill like that and there is a possibility

that you could lose them, it is frustrating, because you do not have

any—you’re the parent, you’re supposed to take care of everything

and you cannot. You have to rely on the doctors for this, and thank

goodness for the doctors.

One thing that I would like to stress is that when going through

these things, your child going through many, many blood transfusions, surgeries and such things that are needed, and the chemotherapy treatments, you often wonder, as you’re watching this,

What did I do? Did I need not feed him correctly? Did I allow him

to do things incorrectly? Did I—what, as a parent, did I do wrong?

That’s why I feel so strongly that we need to find the cause, because we do not want another child to go through this. I feel very

strongly that there is a cause. I don’t know if it’s environmental,

I don’t know what the cause is, but I do feel that there is a cause

here in our community. It is not by coincidence that 12 children

have a certain type of leukemia.

I would like to give my thanks and tell my appreciation to the

State health department. They have been doing a very good job on

their research. Obviously, I wanted to be more aggressive, but I do

understand their approach. Some of my ideas are maybe perhaps

helping with the State health department, such as needed funding,

needed manpower, expert team assistance, CDC assistance, whatVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00017 Fmt 6633 Sfmt 6601 H:\DOCS\78069 SENENV1 PsN: SENENV1
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ever it takes, whatever type of testing it takes to protect our children.

A couple of my concerns—and I have mentioned this to the State

health department—that I’d like to express to you is, on some of

the testing—and I want to stress I’m not pinpointing any of this

as being the cause, but when they do the research on the base, the

naval base, and look at how they release—we’ll just say the jet

fuel, because that’s been an issue—and how this is monitored and

tested and researched, my understanding—and I may be incorrect,

but my understanding is that it is the Department of Defense and

the naval base and the Government that does this research and

tracks and monitors all of this. I would like to see an outside company come in. I’m not saying that they are doing anything incorrect, but they do this, my understanding, on a continuous basis,

these tests and checking things out. It might become habitual to

them, because it is their job, and maybe we need an outside firm

or company to come in there and look things over in a different

point of view.

Another thing is, I feel that the research with these clusters, we

should try to check the other clusters in our Nation, see if there’s

a common link there. I just think a national-type—and if we could

do a national panel or what not—I mean, I don’t know how that

works, but I think that that would definitely benefit the research.

Also, third, I do not know if our State of Nevada has a location

or a center for the doctors to send their reports to for these cancers.

Do we have one—I know that a lot of it goes to CDC, but do we

have something that is just for the State of Nevada for tracking?

Because sometimes, to my understanding, the CDC gets behind on

some of this. Do we have something here for our State to track

these clusters or cancers?

Senator REID. You’ll hear from Dr. Prescott. He has some information on that.

Ms. GROSS. Great, thank you.

I would also like to thank our community. This community has

been wonderful and overwhelming and very supportive, and I love

living here and I love Fallon. My focal point throughout this whole

testimony is to continue the aggressive research on this, not to let

up on it. Even as we continue in our lives and this—hopefully we

don’t have another childhood that gets leukemia—and it kind of

goes by the wayside, I hope we don’t let up on it. I want to stress

to push this very strong. It sounds to me these clusters have been

going on for many years, and that’s too many years.

Senator REID. It’s very difficult to have a mother of a sick child

come and testify in front of TV cameras and all the people here assembled. We’re fortunate that not only have we heard from Brenda

Gross, but we also are going to hear from Tammy Beardsley, who

did not want to be here, but she’s here.

Would you, please, proceed.

STATEMENT OF TAMMY BEARDSLEY, FALLON, NV

Ms. BEARDSLEY. Thank you, Senator Reid.

Forgive me if I’m a little nervous. I threw this together very

quickly, and I probably won’t be as well read as Brenda, but I’m

going to try and speak from my heart. I also was born and raised

13

here, and I also love this community very much and I’m here just

to help.

I’m here to represent my 5-year-old son, Zach, who was born

healthy, no list of health problems, no history of health problems

and, yet, he has cancer. If I’m a bit shaken, he just got back from

Oakland last night for some procedures and he’s recovering today.

So my husband’s not here. So my emotions are a little high. Forgive me if I whittle my words.

I’m not sure what made Zach so sick, and while I don’t think it

has anything to do with the arsenic in the water, I do think we

need to make better choices when it comes to our environment. I

drive by and I see cows, hundreds of them, in one pen, and when

they waste on each other, we give them lots of antibiotics to make

them healthy. We want them to produce fresh meat and eggs and

cheese and all the rest of it and, yet, their living conditions aren’t

healthy. I think we need to look into that. I think we need to look

into how much stuff are we gonna throw out, how much stuff are

we gonna buy, how much money do we all need, how many new

homes do we need to build? We really need to talk about this. I’m

talking from my heart now to my fellow human beings. If we don’t

stop buying more than we need, if we don’t stop eating more than

we need to eat, if we don’t stop throwing out food, if we don’t stop

wasting so much of our planet, we’re going to start seeing more and

more sick children.

I come from a very healthy family. I’m in the fitness business,

I’m in the nutrition business. My children have lived healthy lives,

and now we’re fighting cancer. I don’t know how I got in this mess,

and, of course, I want out of it, but I think we need to take a look

at the way we’re treating our home—not our home, but our planet,

because I think we’re going to create more disease and I think

we’re going to create more sick children. I think we need to take

a look at the way we treat animals, the way we treat our home,

the way we treat each other, and maybe we can stop creating sick

children.

Senator REID. Thank you very much.

We now have the opportunity to hear from Dr. Stephen Prescott,

who’s the executive director of—who is accompanied by Dr. Joseph

Simone, the senior clinical director of the Huntsman Cancer Institute in Salt Lake City, part of the University of Utah.

This cancer clinic, Dr. Prescott, I hope you’ll tell us a little bit

more about it, but we in Nevada are so fortunate through the good

offices of the University of Utah, especially the generosity of one

man, John Huntsman, who has given about a quarter of a billion

dollars of his own money to establish this institute, and the reason

it’s so important to the State of Nevada is that much of the work

that is done there takes into consideration what goes on in northern Nevada.

So, Dr. Prescott, first of all, I would like you to outline your academic background, so the people here in Nevada have some knowledge of who you are and how you came to your job, and then tell

us a little bit about the Huntsman Cancer Institute and specifically

tell us something about this disease.

14

STATEMENT OF STEPHEN PRESCOTT, M.D., HUNTSMAN

CANCER INSTITUTE, UNIVERSITY OF UTAH

Dr. PRESCOTT. I will do so, Senator Reid. Thank you for having

me here and thanks to all the members of the panel. I share Senator Clinton’s views. It’s very hard to say that I’m pleased to be

here, because it’s such a sad situation that brings us here.

Speaking of my own background, I’m an immigrant to the Great

Basin region. I’m originally from Texas. I’ve been on the University

of Utah faculty since 1982, and for the 10 years before I joined

Huntsman Cancer Institute, I was a co-director of the Eccles Institute of Human Genetics, where we focused on trying to find the genetic basis for diseases. We were one of the original centers in the

human genome project. We developed much of the technology behind it and its application to human disease. I then became the director of research at Huntsman Cancer Institute and then, about

2 years ago, the executive director.

Senator REID. You are a medical doctor?

Dr. PRESCOTT. I am. I have a medical degree from Baylor College

of Medicine, which is in Texas.

Senator Reid, this year, about 2,400 children in the United

States will be diagnosed with acute lymphoblastic leukemia, which

is what’s happened to these children here in Fallon. This is the

most common form of childhood cancer. The good news, if there is

any to be had, is that the chances for cure for these children is

really remarkably different today than it was 25 or 30 years ago.

At that time, only about 10 to 20 percent of the children survived

this disease. Today, somewhere between 75 and 80 percent will

survive. In large part, that was due to the efforts of Dr. Joe

Simone, our senior clinical director, when he directed St. Jude’s

Children’s Medical Center in Memphis, TN, where those first dramatic improvements occurred.

These improvements continue, and we believe that one day this

will be an entirely curable disorder, but despite this success, there

are many challenges ahead of us, and that first one is, quite obviously, as I’ve just said, the cure rate isn’t 100 percent, and until

it is, we must work toward that goal. The second goal is that we

have to be able to cure these children with fewer side effects. To

achieve this, we must uncover the causes of childhood leukemia,

and in this regard, we believe the future to be bright. Although we

don’t know it today, there is great cause for optimism. We just now

are beginning to understand the events that cause a single cell to

become cancerous, and these advances can be attributed to many

types of research, but particularly in the area of genetics.

I want to pause for a minute, because genetics can mean two

things. The one easily understandable is, genetic means when you

inherit a risk from your parent, and I’m not talking about that

today. What I mean, in this case, is the second type of genetics, if

you will, in which we acquire damage to our genes during our lifetime. All the rest of the genes in the body are normal, except those

that are in the cancerous cells. We now know that ALL happens

through this mechanism. The gene that regulates the growth of a

cell becomes damaged and it begins to grow abnormally, out of control. It no longer responds to signals from the body that say ‘‘stop

growing now.’’

15

But, as we’ve heard this morning, the most difficult questions

that comes up for a physician or for our government representatives to answer are when a parent asks—and this happens all the

time—‘‘Why did my child get leukemia, and was there anything I

could’ve done to prevent it?’’ It’s easiest to answer the second question, and the answer to that is, clearly, no, there was nothing you

could’ve done to prevent it. The answer to why is, unfortunately,

we don’t know yet.

When clusters, or these dramatic increases in the number of

cases in small geographical areas, occur, we always revisit this

issue of whether a cancer-causing agent from the environment or

an infection resulted in the increased number of cases. It’s unfortunate that thus far this approach has not identified any causes for

acute lymphoblastic leukemia, but we would argue it is possible

that we’re missing some subtle relationships, if an environmental

or infectious cause is present in the community but only affects a

certain fraction of the population. That is, they may have a particular genetic makeup that renders them more susceptible to this

infection or to a particular environmental agent. The studies today

have not examined that issue, because they simply didn’t have the

capacity to do so.

The recent completion of the sequencing of the human genome

and the technology that it has created has given us an unprecedented opportunity to revisit some of these questions, both about

the cause of cancer, such as ALL, and new ways of treatment and

prevention. Our specific focus at Huntsman Cancer Institute is exactly this—to understand the genetic blueprint of cancer, and one

of our approaches is to use what are called DNA chips. Investigators in our childhood cancer program, led by Dr. Bill Carroll, have

used this now to define specific pathways in different types of leukemia, but particularly in ALL. With the understanding of these

new pathways, we believe we’ll invent new ways to treat children

more effectively and with fewer side effects.

We also know that certain of these pathways are unique to

groups of patients who will respond well to current treatments and

those who will be resistant to treatments or will have relapses. We

believe it’ll be possible to use these genetic fingerprints to assign

children to the two different groups—standard therapy will work or

they need a different type of therapy. In fact, this approach will be

implemented nationwide within the next few weeks through the

Children’s Oncology Group—again, on protocols led by Dr. Bill Carroll from our organization. We believe that this someday will lead

to the ability to tailor therapy, like a custom-made suit. What will

be the best treatment, for this particular type of leukemia in this

particular patient, to optimize the chance of cure and to minimize

the number of side effects?

As I said before, we believe the same approach could be applied

to clusters of ALL or other cancers to try to understand why they

occur. For example, we would ask, Is there a specific genetic pathway, one specific pathway that’s damaged in all these children in

Fallon who have ALL? If this turns out to be the case, it would

suggest that there is a common cause in these children. It wouldn’t

tell us yet whether it’s environmental or infectious, but it would

say they all followed the same pathway to their cancer. To do this,

16

responding ad hoc now to Senator Reid’s question, one of the things

that will be essential is a mechanism to rapidly report the cases

to a centralized body and to collect samples. As you know, your expert panel recommended a scheme exactly like this, and I believe

it to be crucial that there is a prospective way in which to identify

cases, report them rapidly to a central body, and to collect samples

under a defined protocol so that we can carry out this type of testing to try to find these pathways.

So in conclusion, although these various projects to define these

genetic pathways are just underway or, in some cases, not yet implemented at all, we’ve made remarkable progress and we believe

that by combining sophisticated analysis of DNA changes in patients and in tumors—or in this case, the leukemia cells—that we

will have better diagnosis, more rational forms of therapy, and ultimately invent new forms of therapy and prevention.

Thank you.

Senator REID. Now the panel will ask questions of the witnesses,

and we’ll have 5 minutes to ask questions before we go to the next

person, and if we need more questions, we’ll do more than one

round.

Assemblywoman de Braga, I’ve heard from a number of people

here in Nevada who believe that the number of cancers and other

diseases in this area may have been elevated for years, that this

isn’t something that’s new. Do you have any thoughts in that regard?

Ms. DE BRAGA. Thank you, Senator.

I think that’s a real possibility. I spoke to that a little bit in my

testimony. I personally know of three other cases, but we also have

somewhat of a transient population. So there is a good chance that

there are cases that were diagnosed elsewhere but that have their

basis here. I heard from a lady who lives in San Diego, and I spoke

about that in my testimony as well. She’s not included in this

present cluster. However, I think we need to expand that, because

I think that there are more cases and more marrow diseases.

Senator REID. Is this San Diego woman sick?

Ms. DE BRAGA. No. She had a baby in San Diego. They moved

to the base in Fallon when the child was a month old, lived here

for over 3 years, and moved to Japan when the baby was 4. He

died when he was five. She said—and I didn’t know whether to

laugh or cry—she said, ‘‘You know, when my son died, I thought

God wanted him and that was why he died.’’ And she said, ‘‘After

reading this, the environmental possibilities, I’m not so sure.’’ And

what she wanted to tell me about was mosquito spraying when she

lived here, the fogging that was done, and she thought, after reading a lot of this, that that was a real possibility. There’s a lot of

stories out there that—— Senator REID. That’s interesting, Marcia. There was a lawyer in

Las Vegas, a young man doing very well. He spent most of his

time—I just thought of this as you mentioned this. He was a Mormon missionary in New Zealand, and he and his companion were

walking, and there was heavy spraying taking place and they were

sprayed, and his family felt that’s why he died at such an early

age. I don’t know if it has anything to do with that or not, and

maybe Dr. Prescott can tell us.

17

Also, would you give me your thoughts about—you’ve spent as

much time as anyone else on this issue, and I’d like your thoughts

as to what aspects a cluster investigation would most benefit from

the involvement of the Federal Government. Do you have any

ideas?

Ms. DE BRAGA. I’m sorry, what aspects of the——

Senator REID. What do you think the Federal Government can

do, in your layman’s opinion, to help with this investigation?

Ms. DE BRAGA. A lot, because I think there are a lot of resources

through the Federal Government that aren’t available to us in the

State of Nevada, and I think that was just demonstrated here this

morning, that there are a lot of resources. I think that when you’re

limited in the amount of data, research, and experts that you have

available to you, it narrows the scope of your investigation, and I

think that’s where the Federal Government can play a huge part.

I’m not just talking about any dollars that are available, I’m talking about the new knowledge that’s out there, that’s going to speed

this up and help us to find a cause.

Senator REID. Marcia, one of the other problems that I face, Senator Ensign and all of us up here face, is the delicate line we walk

between what Brenda Gross wants and the fear that is around in

the community generally. Does what we’re doing here have an adverse impact upon the community? As you know, Senator, the work

that you’ve done in this regard, it’s a real delicate line that we

walk. What is your comments? Has what has taken place regarding

this investigation been damaging to Fallon?

Ms. DE BRAGA. I’ve heard a lot of people say that, yes, it has,

that we don’t want this attention, that focusing on—and I think

somebody mentioned it this morning—the negative aspects hurt

real estate sales, those types of things. Of course, we don’t want

our community to have a bad image, but I don’t believe that’s—I

would rather live in a place that cared more about its children than

it does its image and that it’s being proactive, fixing the things,

whether they are the direct cause or not, so that they’re doing everything that can be done to protect children. So the economy

slumps a little. I don’t personally believe that’s the case. I think

the attention that’s focused here is absolutely phenomenal. We can

go along pretty complacent and say, ‘‘Oh, my gosh, this is sad’’, but

unless we make a real aggressive effort like is being done here, like

Brenda commented on, we don’t draw the attention and we don’t

get the forces moving to solve the problem. So I think maybe we

have to give up a little, but I’m not sure that’s true. I think this

is the kind of image we want, that this is a community that cares

more about its kids.

Senator REID. I’m confident, in the long run, that we’ll be here.

I’m going to hear now from Senator John Ensign. What those of

us in Nevada tend to forget is that this is Dr. John Ensign. Before

coming to Congress, John Ensign was a veterinarian, and as we all

know, the training of a veterinarian is very comparable to the

training for a medical doctor, and he’s been a big help in helping

me understand some of the scientific problems we face here.

Senator Ensign.

Senator ENSIGN. Thank you, Mr. Chairman.

18

First, I want to say to both of you, obviously, our sympathies go

out to you and we’ll pray for your children. As bad as what you’re

going through, at least it’s not 20 years ago. Our treatments today

are much more successful. We have people like Dr. Prescott out

there doing the research. So 20 years from now, it’ll even be better.

But, once again, it is important that we focus on the preventive aspects so children don’t end up with this and we don’t have them

go through some of the treatments. Even though we’re happy those

treatments are there, they’re still brutal for children to go through.

I want to also thank you, Assemblywoman de Braga, for the

work that you’ve done on this. You’ve been a leader on this issue.

I think your efforts should be applauded. I want to ask some questions of Dr. Prescott. One of them has been puzzling to me, because

I hear reported often, in most of the reports I hear, ‘‘lymphocytic

leukemia’’ and ‘‘acute lymphocytic’’ are mentioned yet, you mentioned ‘‘lymphoblastic.’’ All the reports I thought used the term ‘‘lymphocytic.’’ Can you address that?

Dr. PRESCOTT. They are pretty much the same thing. It’s just a

distinction based on the way that these white blood cells called

lymphocytes look, and the children, in its acute form, usually have

a less developed form of those cells. It can be either called

lymphoblastic or lymphocytic. Adults typically have a much more

mature—they may have a similar type of leukemia, but they have

more mature white blood cells.

Senator ENSIGN. Are you aware of other clusters or how many

clusters are discovered throughout the world, let’s say in the last

30 years, and how extensively they have been studied?

Dr. PRESCOTT. I think there’ll be other experts much more knowledgeable than I am about this, as that particular area—the epidemiology of clusters—is not my expertise. I can’t answer that. Very

many is the answer, but I can’t tell you precisely. I can say that,

unfortunately, as I believe you alluded to earlier, none of them

have yielded a specific cause, the investigations of it.

Senator ENSIGN. Have we ever come up with a cause for any of

the leukemias?

Dr. PRESCOTT. Yes. In some of the adult forms of myeloplastic

leukemias, there’s certainly a much stronger correlation with some

types of bone marrow toxins in those cases, but it appears to be not

the case, at least thus far, with ALL.

Senator ENSIGN. When you were talking about the genetic pathway, who would be in charge of investigating this genetic pathway,

and who would be responsible for coming up with the protocol for

making sure that this is consistent? Where can we come up with

some information?

Dr. PRESCOTT. Excellent question. At a national level, it’s being

done by the Children’s Oncology Group. This is an organization

that includes all of the major cancer centers in the United States,

and most children with cancer, including leukemia, are treated in

major centers. That’s because—although that 2,400 is a large number if it’s your child, that’s a relatively small number compared to,

say, breast cancer in the United States—the expertise to care for

those children typically resides in large urban centers, and so most

children get referred there quite promptly. I was thinking just earlier, with respect to Nevada, this creates something of a problem

19

geographically. If patients live in the northeastern part of the

State, they would come to us, without a doubt. In the western regions of the State, I suspect they’d go to Oakland or UC Davis or

maybe to Stanford. If they live in Las Vegas, they would go probably to Los Angeles.

So from the point of view of the State trying to understand the

incidence rates of a cancer like this and the approach, it would be

quite fragmented. I think there’s a risk that you could miss something, because the children are referred in different directions, and

we would argue for some rapid reporting mechanism of Nevada

residents, even if they’re getting their treatment outside of the

State.

Senator ENSIGN. Right, but the question would be, first of all, do

we have—we’re trying to find out what’s the best way for us to,

maybe, direct the Federal Government. What’s your recommendation as far as investigating these children and their genetic pathway to the potential causes?

Dr. PRESCOTT. I’d like to second the recommendation of the expert panel, and that is to establish a registry of these children and

a mechanism here, since we know there’s a cluster going on now.

I would argue that a really important component of that is rapid

acquisition of a blood sample that could be used for various studies—of course, with the consent of the families and the child, but

if they consent to that, it could be rapidly put into the system.

They exist in the Children’s Oncology Group now. So that could be

taken advantage of immediately.

Senator ENSIGN. Have those blood samples been taken from the

children? In the acute form, do these genetic pathways change? Do

we even know when they’re in the acute form of the disease, versus

farther down, maybe they’re in remission? Would we still be able

to identify their genetic pathway if they’re farther down? Do we

have these samples ahead of time, already drawn?

Dr. PRESCOTT. I can’t answer that, because I wasn’t involved in

the initial investigation, but I’m sure that Dr. Guinan or someone

can. But the answer to the second part of your question is that, in

the cases where children have already responded well to treatment,

then we would not be able to do the type of test that I just described.

Senator REID. Senator Clinton.

Senator CLINTON. Thank you, Senator Reid, and I want to thank

the panel. I particularly want to thank both Brenda and Tammy

for being here today. I know this is not an easy kind of experience

for you, and I join John in wishing your sons well and all the other

children.

I’m particularly impressed by what Assemblywoman de Braga

has done and I am grateful that she took this issue on, and the

kind of leadership that she’s shown at the local and State level to

leave no stone unturned is exactly the kind of leadership we need

across the country. You responded to Senator Reid’s question about

the kind of help that might be useful in responding to the cluster

that has been identified here. Have you given some thought and

does the assembly, with the approval of the $500,000 for investigations and bringing the cancer registry up to the current, have specific suggestions about what we at the Federal level could do to asVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00025 Fmt 6633 Sfmt 6601 H:\DOCS\78069 SENENV1 PsN: SENENV1
20

sist you in expediting what you’re attempting to bring about with

response to the cluster?

Ms. DE BRAGA. Yes. Thank you, Senator.

Again, both in terms of making available to our State or helping

our State assemble the resources that are not available—readily

available in our State, I think the Federal Government—because,

obviously, there has been a lot of research already been done. This

isn’t the first cluster. One of the things that’s unique about this

cluster is it happened in such a very short period of time. So there

may be something new to learn here, but I think it will take more

funding, because our staff is limited, and it will then take some

specific work on the part of either the present expert panel that’s

been formed or one like it, so that we can avail ourselves of the

experts that are out there and the research that’s already been

done. Senator Reid, I think, said in a news article that we don’t

want to reinvent the wheel. So if we can start at a point that is

past what’s already known and rely on—and this is going to take

a tremendous amount of help from the Federal agencies—then I

think we can speed up this process. I think that’s very important.

We don’t want what might be a readily findable cause to disappear

because too much time has gone by.

I also think that we need some means of having a central repository for information, that it can be somehow up-to-date. That’s critical, I think. I asked some health division people, if we hadn’t

brought this to their attention, how soon would they have found it

on their own through the normal channels, and they said it would

be at least 2 years. In 2 years’ time, if there’s a readily findable

cause, more children will become sick.

Senator CLINTON. I think that—and I hope that the Fallon community will see this in the years to come—because if we are able

to do what every one of the panelists recommended, then Fallon

will have made a great contribution to preventing a disease in the

future, because, clearly, we are now at a point, as I understand Dr.

Prescott’s testimony, where technologically we can really seriously

engage in the kind of discovery that was beyond our means just a

few years ago. The human genome project, the advance in information technology, the ability to correlate associations that we may

find of interest but don’t know whether they’re causal, such as pesticide spraying or arsenic in the water, all of these things, we can

now track much better than we ever could. So I think that, in a

very important way, advances in determining how to prevent cancer could really be attributed to the extraordinary response in this

community, and for that, I think the entire country and maybe

even the world eventually will be grateful to Fallon, and I hope the

people of Fallon will understand how important this is.

Senator REID. Brenda, it’s my understanding you’ve been receiving phone calls—you and other parents who have sick children

have been receiving calls from around the country from other parents who have sick children. Is that true?

Ms. GROSS. Yes, it is. I’ve gotten E-mails, phone calls, and letters

with lots of information that’s been very interesting.

Senator REID. Other parents have received the same types of

communications; is that right, Tammy?

Ms. BEARDSLEY. Yes, lots.

21

Senator REID. This is more than one or two E-mails or phone

calls; is that right?

Ms. GROSS. Yes.

Senator REID. If you added them up, the 12 families who have

sick children, it would be dozens and dozens of people who have

made contact with you?

Ms. GROSS. I’m not sure on the other families, but, myself, I have

received dozens, several dozens.

Senator REID. Tammy, you’ve also received—— Ms. BEARDSLEY. I have received dozens.

Senator REID. I think that’s important, based on what Senator

Clinton has said. I think we have to have a better method, as Dr.

Prescott indicated, of rapidly identifying these clusters, and when

we find something that appears to be a cluster, I think we have

to have some way of responding as quickly as we can, and we don’t

have that right now.

Dr. Prescott, in your experience, is it common for childhood leukemia to occur in clusters?

Dr. PRESCOTT. No, it’s not. Most of them do not occur in that

manner.

Senator REID. So this is an unusual situation, from your experience?

Dr. PRESCOTT. Absolutely.

Senator REID. You’ve indicated that in the past, when we’ve had

these clusters, that we’ve been unable to find a cause. Now, you’ve

read all the material that we’ve sent you regarding this and you

understand we have arsenic in the water and you understand,

here, we have a large agricultural community and whatever goes

with that agricultural community, and we have a very large and

important military installation here. Some people say there’s a— some studies talk about a virus that can be communicated. Do you

think that it is possible that there could be a combination of things

that I’ve outlined and other elements that are available that could

lead to environmentally causing this condition?

Dr. PRESCOTT. Yes. I think it’s less likely that it’s a combination

of things, but I want to apply an important caveat. I’d like to know

the answer to the question I posed. It may be unknowable in this

case, but I’d like to know the answer to that. Do all these children

have a common pathway to their cancer? If so, I would be virtually

certain that there’s something from the environment. Now, speaking from genetic terms—I would even include a virus in the environment or anything outside—I would surmise that it’s more likely

that it’s one thing that affected all of them than a combination of

20 percent this, 40 percent that, but I’m just speculating. I don’t

know the answer to that, but I believe that to be much more likely

or more probable. But you’re right, in these cases, we know that

many things—we know that viruses can cause cancers. We have

many examples of that. We know that some environmental toxins

can cause cancers. It’s just the specific case of ALL where we’ve

never been able to make a connection between those. Part of it

comes back to this issue that I mentioned before—and I’m reluctant to say this in front of people who recently suffer with this, but

it’s a relatively uncommon disorder. We only have 2,400. It sounds

like a huge number, but it’s a very small number compared to the

22

other types of cancers we study. So we’re often in this position of

sort of scrambling after the fact trying to go back and say, ‘‘Gee,

I wish I had a blood sample from a month ago, I wish I could test

this or test that.’’ There just aren’t big enough numbers of cases

and samples of blood or samples from the environment to make

really robust associations so that we can really get to those root

causes.

Senator REID. Dr. Prescott, having grown up in an era where—

even though I lived in a very small rural community in Nevada,

as a little boy, I was scared to death I was going to get polio. No

one knew what caused it, but we knew that the disease was devastating and children like me all over America worried about this

terrible disease. People in Fallon—even though this is certainly

nothing comparable to polio, people here worry, Is this something

I can catch, is this something that can be communicated from one

person to another? What are your thoughts in that regard for the

people of this community?

Dr. PRESCOTT. I grew up not being able to swim in the summertime as well, Senator Reid, because of the fear of polio, and I remember those days very strongly with some of my classmates who

were afflicted with it. This is obviously a crucially important question from a public policy point of view, public health point of view,

to try to reassure families where we can, and we need to do so in

an honest and legitimate way. I certainly couldn’t say to the people

here that if there were a virus that did this, that we could be absolutely confident it’s not still here somewhere. What I can say is

that that’s highly unlikely. First of all, there’s never been such a

virus described. We don’t know if that’s what the cause is or not,

and we know historically, from these many clusters that have been

described around the world, that they tend to be self-limited. So it

would be really quite unprecedented.

I know that’s an incomplete answer, but I think that one can be

relatively optimistic that it won’t continue, but we can’t—since we

don’t know the root cause, we can’t say for certain. Polio was different. Once we knew the type of virus and once a vaccine prevention was available, then we could approach that with a lot more

confidence.

Senator REID. Senator Ensign.

Marcia, I join with the rest of the Senators up here on the issue

of giving you great credit for your effort and your leadership in this

regard, as I’m sure the community does as well and the families

of those affected children. To the mothers that are sitting here,

Brenda and Tammy, your contribution to this hearing is greater

than you imagine. It’s greater than—the fact that you sat there

and told us about the trying hardship of your children. It’s greater

because we now have a greater empathy for this issue and a greater commitment to work on solving this problem. I have no questions of you. I just want to thank you for your effort, your courage

and willingness to share with us your stories on this, and you do

have our sympathies.

Dr. Prescott, I really appreciate your insight, because as you testified, it was as if a light bulb had gone on that we had for so long

been looking externally for causes.

23

Dr. PRESCOTT. Absolutely. Adult leukemias also often have these

translocations that I’ve described in my written remarks, which is

where one piece of DNA from one chromosome gets switched over

to another chromosome, and if that happens in just the right place

to where the switch was made—there’s a gene that controls the

growth of cells—now we have a bad situation, where they begin to

grow abnormally, and that absolutely happens in all types of cancer.

Representative GIBBON. Dr. Prescott, what can you tell us about

clusters of adult leukemia?

Dr. PRESCOTT. There have been clusters of adult leukemia. It’s

not necessarily the case that you would assume there should be

adults in Fallon with leukemia, because these diseases are so different. Adult types of leukemia are so different from childhood leukemia, and it would depend on what that external signal was. If

it were something from the environment or an infection, it’s perfectly plausible that it would affect only childhood leukemia or it

would lead to an increase of breast cancer. We talk about cancer

as one thing, but it’s really at least a hundred things. It’s probably

on the order of several hundred things, if we get down to the absolute root causes of it. So it’s not improbable at all that we would

see childhood leukemia without adult leukemia. Just as in this

cluster it’s only ALL and not other types of childhood leukemia.

Representative GIBBON. Although our research and science into

the trigger mechanisms lead us to look at the genetic sources that

may be found, what other considerations should be raised, at this

point? Are we focusing our effort too broadly? Should we be narrowing that effort? What is your opinion?

Dr. PRESCOTT. It’s a question I like to be asked, as the former

director of research of the Huntsman Cancer Institute. First, I’d

say that Congress has been very generous to the NIH budget, funding basic research. There’s always more that can be done, and I

think the one place that we don’t have an effective strategy in

place is to apply some of what we’ve learned from the genome

project broadly to clinical problems, I mean, really specifically. One

thing that’s often overlooked in that process is the clinical aspect

of it, finding those patients quickly and obtaining proper samples,

with appropriate informed consent and confidentiality, because we

tend to focus on the very attractive high technology, because it’s

amazing what we can do with sequencing today. That’s actually the

part now that’s simple to do, to be honest. It’s simple to sequence

the DNA.

The hard part is organizing a system so that you identify childhood leukemia cases rapidly, that you get those samples in the appropriate way, that you collect information about the treatment

they had and the outcomes they had, and you can correlate that

with the DNA sequences. That’s the way that we’re really going to

unravel the basis of many types of human disease and get into an

area that’s sometimes called individualized treatment, which is

what I was speaking about. We know that perhaps this type of leukemia might have six subsets and that one type of treatment will

be better for one subset than the other, one type of treatment will

cause more implications than the other, but if we can clearly get

down to very precise typing, we’ll do much better for the patient

24

with respect to curing the disease. This is true of all types of cancer.

It’s a long-winded answer. I apologize. To get back to you, I

would say that in a strategic sense, we don’t yet have a global approach to how to do that, and I would argue that that’s the next

great leap forward, applying those DNA studies to understand

human disease and leukemias in children.

Senator REID. Senator Clinton.

Senator CLINTON. I just wanted to add on to what the Congressman was saying, because I think what Dr. Prescott just said is so

critically important. Would it be fair to say, Dr. Prescott, that it

would not only assist us in better curing cancers by understanding

more about the individual disease, but also in preventing it. The

more information globally that we can collect and that we then use

both for cure and treatment, we also—if we have the appropriate

plan to do this—will be able to begin to, perhaps, find answers to

some of these questions that, right now, we can’t answer.

Dr. PRESCOTT. Absolutely. In the ultimate realization of this, of

applying this information about DNA sequences and our genes and

how we’re predisposed to the likelihood of disease, the distinction

between treatment and prevention goes away. If you could diagnose

early—prevention is the treatment, and it absolutely is the great

promise of this technology.

Senator CLINTON. One of the things that certainly strikes me,

just as a layperson, without any of the expertise that Dr. Prescott

obviously has, is that if we survey the way we’re living—and this

goes back to something that Tammy said, which I don’t want to

lose in the discussion. We are living very differently than our

grandparents lived. Whether we live in Nevada or Arkansas or

New York or wherever we’re living, we’re living differently, and in

the course of that different living, we’ve had so many blessings that

we’re grateful for, but I think it is appropriate for us to take stock

of what are some of the unintended consequences of the ways in

which we are living, so that we don’t overreact, but we also don’t

ignore changes that could be made that could keep us healthier

longer. This is something that may not directly fall in the realm

of science today, but without adequate research being directed toward determining—What are the environmental contaminants that

we expose ourselves and our children to on a regular basis? What

is the cumulative effect of those contaminants over time? What is

the distribution of viruses? What’s the assessment of exposure to

things that we didn’t really have in our homes or that we didn’t

understand the impact of?

I know that there are people who will say, ‘‘Well, but we’ve lived

this way for a long time and we don’t suffer any ill effects.’’ I’m

often reminded of meeting the 95-year-old smoker who says, you

know, ‘‘I’ve smoked all my life. It didn’t hurt me a bit.’’ Well, that’s

a unique case, because we know it’s hurt a lot of other people. Our

genetic makeup may have protected us over time against some of

those assaults, but the accumulation of the assaults may break

down or find that genetic pathway.

So I think that, you know, we do have to ask ourselves these

hard questions. That’s one of the reasons why environmental

health is, to me, the real frontier of where we go now in medicine,

25

because we’ve made so many advances. Now let’s take a step back

and figure out how do we prevent these things, not just enough

that we can cure with extraordinary medical research childhood

leukemias that are way beyond whatever was dreamed 25 years

ago, but how do we change some of the environmental impacts or

better understand the virus transmissions and the exposure assessments, so that we can prevent it, we can relegate it to the dustbin

of history. I think what Dr. Prescott said, I hope, will inform the

Congress. I’d like to thank this panel very much. It’s been most illuminating, and I’m sure that the information we’re going to take

back to Washington as a result of this panel, alone, will have made

our trip worthwhile. Thanks very much.

Senator REID. We’re now going to hear from Dr. Mary Guinan,

the Nevada State Health Officer. She has worked for the Centers

for Disease Control and Prevention over 20 years and now leads

our State’s response to the Fallon leukemia cluster. She has extensive expertise and her relationships within the national public

health community has given the State a unique access to assistance in conducting this cluster investigation. We’re also going to

hear from Dr. Randall Todd, Nevada State epidemiologist. Dr. Todd

is an associate of Dr. Guinan and is responsible for the technical

elements of the State’s efforts. He’s primarily responsible for developing many of the programs within the State. We’re also pleased

to have with us Rear Admiral R.J. Naughton, who’s accompanied

by Captain D.A. ‘‘Roy’’ Rogers, commander of the Fallon Naval Air

Station. We also are going to hear from the mayor of the city of

Fallon, Ken Tedford, who has worked with us so well and so hard

in arranging for this hearing, and Ms. Gwen Washburn, who’s the

commissioner with the Churchill County Commissioners.

We’re first going to hear from Dr. Guinan.

Dr. GUINAN. Senator Reid, I’m going to ask Dr. Todd to first give

us a presentation of his findings. Dr. Todd has been the lead scientist in the investigation of this cancer cluster, the first phase of

the study, and he will present those findings.

STATEMENT OF RANDALL TODD, STATE EPIDEMIOLOGIST,

NEVADA STATE HEALTH DIVISION

Dr. TODD. Thank you. Good morning, Mr. Chairman and members of the committee. For the record, my name is Dr. Randall

Todd. I am the State epidemiologist and work with the Nevada

State Health Division. I’d like to briefly describe the Health Division’s investigation into the cluster of childhood leukemia in

Churchill County and discuss the role of Nevada’s Central Cancer

Registry assisting us with that investigation.

The initial phase of our investigation consisted of confirming the

diagnosis of each reported case and conducting an interview with

each case family to identify any potentially common characteristics

or environmental exposures that might point to a preventable

cause. I should mention that we’re indebted to the Centers for Disease Control as well as the Massachusetts Department of Public

Health for their assistance in providing us with model interview instruments.

The case family interviews were conducted face to face with each

family. This involved a detailed review of the family’s residential

26

history, from the date of diagnosis back to a point in time 2 years

prior to conception of the ill child. For each residence, we inquired

as to the source of water, in-home treatment of water, and uses of

water. We also inquired about known exposures to chemicals from

agricultural or home use of herbicides and pesticides, as well as indoor uses of chemicals and solvents. For each parent, we inquired

about occupation and occupation-related exposure to chemicals,

dust, or radiation. We conducted a detailed review of the child’s

medical history and the mother’s pregnancy and breast-feeding histories. Finally, we asked case families about any hobbies, sports activities, or typical travel destinations that might have brought

them into contact with chemicals, fumes, or radiation.

From this interview process we learned that half of the case families had spent 2 years or more in the Fallon area. The others had

resided in the area for shorter periods of time. These 12 case families had resided in a total of 88 different homes over their respective time periods of interest. Of these 88 homes, 22 were located

within Churchill County, and of these 22 local residences, half were

served by public water systems, while the others obtained their

water from domestic wells.

Our initial analysis of the occupational, medical, environmental,

and other historical information provided by the case families has

not suggested any particular common denominator that would link

these cases together. We recognize, however, that some of our data

is subject to recall limitations on the part of the families. Specifically, they may not have known of an environmental exposure that

did, in fact, exist or they may have forgotten about it. For this reason, we are currently taking steps to obtain additional data

through objective environmental sampling. This constitutes a second phase of the investigation.

We’re now in the process of obtaining water samples from these

current and former case residences in Churchill County that are

served by domestic wells. These samples are being subjected to the

analyses that are routinely done for public water systems. In other

words, any test required by the safe drinking water act for public

water systems is also being conducted on the water samples obtained from the wells of residences where case families have lived.

The results of these analyses are pending at this time.

We’ve also invited the Centers for Disease Control and Prevention, as well as the Agency for Toxic Substances and Disease Registry, to assist us in identifying and analyzing completed pathways

for other sources of environmental contamination. This would include industrial, agricultural, military, or other sources.

On a parallel tract with these environmental studies, we are also

collecting data on the overall population dynamics of Churchill

County. This includes looking at size of various age cohorts over

the last 10 years, school enrollment information, and military populations. This analysis will help us determine if Churchill County

matches the profile of other communities around the world where

population mixing has been suggested as a possible explanation for

increased rates of childhood leukemia.

In closing, I would like to make some brief comments as to the

importance of cancer registries in the conduct of cancer cluster investigations. Nevada has maintained a population-based cancer

27

registry since 1979. This activity has been funded, in part, through

a grant from the Centers for Disease Control and Prevention since

1995.

I should mention that all disease reporting systems, including

cancer registries, do experience a lag in time between the diagnosis

of a case and the reporting of that case. With a disease such as

cancer, the patient record may not be complete enough to warrant

abstracting information until about 6 months from the date of diagnosis. Additional delays in obtaining information beyond this 6-

month time period relate to workload and staffing. In more rural

parts of Nevada, this situation is made even more difficult due to

the distances involved and the relatively low number of acute hospital beds in each facility, making it costly and time-consuming to

collect rural data. For these reasons, if a cancer cluster is identified

through a cancer registry, it’s likely to have been going on for some

time.

The increased incidence of childhood leukemia in Churchill County was not identified through analysis of cancer registry data. The

local hospital, physicians, and community leaders noted the cases

and perceived the numbers to be unusually high. Nevertheless, Nevada’s cancer registry has been invaluable in helping to place the

observed number of childhood leukemia cases in historical and geographic context. Only through this analysis of cancer registry data

have we been able to calculate the usual rate of childhood leukemia

and determine that the local cases do, in fact, represent a significant excess over the expected.

I’d be happy to entertain any questions the committee might

have.

Senator REID. Dr. Guinan.

Dr. GUINAN. Yes, thank you.

STATEMENT OF MARY GUINAN, NEVADA STATE HEALTH

OFFICER

I’m Mary Guinan, State Health Officer. I’ve been asked to speak

today on the status of the continuing investigation and also Federal

roles in the investigation of cancer clusters.

On February 15, after Dr. Todd had finished the first phase of

the investigation and after the analysis showed no particular environmental or infectious agent that we thought was common among

the cases and would be a likely causative agent, we asked a

panel—we invited an expert panel consisting of experts from the

Centers for Disease Control, the National Cancer Institute, the

University of Minnesota School of Public Health, the University of

California at Berkeley School of Public Health, and others, several

from Nevada, University of Nevada School of Medicine, and we

asked them to review all of the data and to help us plan the next

steps of the investigation. That occurred on February 15.

The committee made six recommendations. The first was to expand case-finding efforts by seeing if you have all of the cases, are

there other cases, and we’re doing that. We’re working with the

Navy to see if there are any Navy families who have been through

Fallon and whose children may have developed leukemia, and that

search is ongoing, and Admiral Naughton will speak to that.

28

We also want to expand our case search with the Children’s Oncology Group. Children’s Oncology Group is a group of treatment

centers around the country. As you know, cancer in children is

rare, and we’re very grateful it’s rare, and so in order to get appropriate treatment protocols, the treatments are concentrated in

groups around the country—California, Utah. We do not have one

in Nevada. So the children with leukemia—over 90 percent of the

children with leukemia in this country are treated at these children’s oncology centers, and they have a data base. So what we

want to do next—and we’re waiting for the funds to do this—is

working with—especially the California oncology groups—working

with them to search their directories to see if we have Nevada patients who were diagnosed in those centers. We have no pediatric

oncologist in Northern Nevada. So that all of the cases would be

referred out. Most of the cases from Fallon are referred to California, and there is a pediatric oncologist that comes from California to Reno on a regular basis and continues their treatment,

but the diagnosis is done in these oncology centers. So we will be

expanding that.

The second recommendation was to categorize the ALL cases by

clinically relevant biomarkers, and Dr. Prescott has mentioned

some of those. What happens is, we need to really look at the leukemia tissue in order to do those studies, to look at the diseased

tissue. So what we have to do now is to—many of the protocols of

these oncology centers require saving tissue specimens. So we are

going to be in the process of identifying each of the centers where

the child was—where the bone marrow biopsy was done and what

kinds of testing were done at that center. There are a number of

tests that can be done.

The first broad test that’s done is to identify two types of

lymphocytes. Which cancer is it? Is it B lymphocyte or is it T lymphocyte? B lymphocyte cancer, or lymphoblastic leukemia, is much

more common than the T cancer, and our cases reflect that. We

have nine B-cell and we have three T-cell cancers. But there are

subdivisions of that. In other words, each of the B cancers have

subdivisions and very distinct analysis, which I think we need to

move forward on, to see if those genetic breaks, those chromosome

breaks are similar. Because if they’re similar, then they’re more

likely to be linked to the same source, and that is a critical issue,

that if we had known in advance and collected, we would know of

specimens. We do not know whether we have those specimens

available at the present time.

No. 3 was to identify potential excess environmental exposures

unique to the community. Dr. Todd has told you that we’re in the

process of that. Next week, members of the Centers for Disease

Control and the Agency for Toxic Substance and Disease Registry

will be here looking at all of the environmental testing that has

been recommended, seeing how we can approach that and who’s

going to do it and how we’re going to do it, and also to do a pathways analysis to say, ‘‘If there are environmental chemicals that

are toxic in the community, by what pathway do they get to people?’’ That’s extremely important for us to analyze.

The next recommendation was to collect and bank biological samples for future study, and we are waiting funds for that. We need

29

to identify a repository for specimens. We would like to collect

specimens from the families, as well as the cases. The technology

is rapidly advancing, as Dr. Prescott said. So maybe in 2 months

we might be able to have a test that would tell us something about

causation. It’s extremely important for us to save those specimens,

and we don’t have a national sort of comprehensive group looking

at that, saying this is what we have to do for every cancer cluster.

The fifth recommendation was determine time course and characteristics of population movement into the Fallon area, and that’s

to address this population mixing theory, which was—it is just a

theory, which came out of Britain after an investigation of a number of clusters, and that is that a rural population has an influx

of people and, for some reason, there’s an increase in leukemia or

cancer in that community, and the reasons for it are very complex.

In Fallon, that particular scenario may exist. In other words, that

we have a small town relatively isolated and then the in-migration

of various groups, either through the military or others, that come

and go. So this is a possibility to test evidence for this population

mixing theory, which go well beyond what the State of Nevada

would do, but something that the National Cancer Institute should

be doing, identifying and—there is no mechanism for the National

Cancer Institute to give us funds for research. Their budgets are

to study months and years in advance. So it’s really important for

there to be a comprehensive plan, as we suggested, for a study to

advance the causation theory.

The last recommendation was to maintain the expert panel,

which they have.

Now, about the lessons learned—all of the panelists serve without—we do not pay for them, they volunteer. They’re wonderful experts, and we have been really blessed to have their interest, and

they are volunteering to be here and help us, and they have done

a tremendous job. One of the lessons that we have learned with regard to Federal agency roles in the investigation of cancer clusters,

although hundreds of cancer clusters have been recognized and investigated during the past 30 years by State and local health departments and Federal agencies, little information is available on

appropriate scientific methods of study, especially with regard to

determining the causative factors or associated risk factors. Well

over 90 percent of these investigations have found no associated

suspect causative agent, and no Federal agency wants to expend

scarce resources for the investigation of cancer clusters that are

likely to show nothing. It’s an investigation which you know that

90 percent of the time you will not find anything. So there is a reluctance to invest resources in something that has such a low probability of an outcome of interest.

Senator REID. Ms. Guinan, I think we’re going to ask you some

questions and you’ll be able to expand on the rest of your statement. I’m going to make your entire statement a part of this

record. You’ve answered one of the questions the panel already

asked directly. We asked Assemblywoman de Braga about what the

Federal Government can do, and you’ve told us very specifically. I

would also just comment that 90 percent is great, but if you’re part

of the 10 percent, you want to make sure that’s investigated also.

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We’re going to turn now to Admiral Naughton. I would say, before you begin your testimony, to explain to Senator Clinton and

some of the audience who may not know, which I’m sure there are

very few—Senator Clinton, in Nevada, we have two very large military installations, of which we’re very proud. In the southern part

of the State, we have an air force base, Nellis Air Force Base. It

is the largest fighter training facility the air force has in the world,

and I’m told by everyone, most important, if you want to have a

Ph.D., so to speak, in the air force and be a pilot, you have to go

through Nellis. The same applies if you’re a Navy pilot. We have

here in Fallon the Fallon Naval Air Training Center, which is

something we’re very proud of. Top Gun is here. It’s something that

has been great for our State, but also certainly for our Nation.

We recognize how important it is to the State of Nevada, but

we’re going to have some tough questions to ask when we get to

the part of this hearing when we ask questions. Admiral Naughton

and Captain Rogers has been through a lot of things in their careers, and they understand we’re only trying to get to the bottom

of things. We’re going to ask questions about when you weren’t

even at the base. So my point is, the directness of the questions

has no bearing on how important we feel your work is here.

Admiral Naughton.

STATEMENT OF ADMIRAL R.J. NAUGHTON, FALLON NAVAL

AIR STATION, FALLON, NV; ACCOMPANIED BY CAPTAIN D.A.

‘‘ROY’’ ROGERS, COMMANDER

Admiral NAUGHTON. Yes, sir.

Senator Reid, Senator Clinton, Senator Ensign, and Representative Gibbons, my name is Richard Naughton. I’m the commander

of the Naval Strike and Air Warfare Center, which is located at

NAS Fallon, NV. Here with me this morning is Captain David Rogers, who’s the base commander. We do welcome this opportunity to

testify before the Environment and Public Works Committee on the

military activity that takes place in Fallon, in particular, how it

may pertain to Churchill County’s recent childhood leukemia cluster. I’ll talk a little bit about the background that the Senator

talked about, about the mission and operations at Fallon, followed

by some remarks that I know are of special interest to the committee, and we look forward to your questions afterwards. Let me

assure the committee and the local community members that the

U.S. Navy is committed to public health and to assisting this investigation in every way possible.

One of the cases in question is the child of a military family

member who was formerly stationed at Fallon. Our base population

is about 7,200 personnel, which includes all the military and civilians and their families, and of that 7,200, three quarters live in the

local community. So we’re very involved in the local community

and we want to be sure that we’re part of this solution. The Navy’s

Bureau of Medicine has just completed extensive screening of naval

medical cases, which might be related to the Fallon cluster. They

reviewed over 12 million records looking for cases of ALL from

1997 to the present, and just the one Navy case that I’ve already

identified was the only one that we came up with.

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The Navy is also committed to exploring the expert panel’s population theory—population mixing theory, and we have shared data

on the transient activity of NAS Fallon with the State. This military data is one of the three transient data collection efforts recommended by the expert panel.

As many of you may know, NAS Fallon began operation in 1942

as an Army Air Corps base. The focus at that time, until about

1984, was unit level air-to-ground combat training. When the Navy

established the Naval Strike Warfare Center in 1984, we began

focusing on entire air wing training of about 1500 people and 70

aircraft in an integrated fashion. The mid-eighties also saw the development of the Fallon Range Complex, an instrumented military

operating area flown over 6.5 million acres east of Fallon. The majority of the land we fly over is unpopulated and managed by the

Bureau of Land Management. The Navy actually only controls

204,000 acres. The third major change in the mid-eighties was the

out-sourcing of many of the functions on the base. As a result, 55

percent of our current base population is civilian contractors.

In 1996, with the closing of NAS Miramar and the Base Realignment and Closure Act, all graduate level aviation flight training

moved to Fallon, with the arrival of Top Gun and Top Dome from

southern California and the establishment of a senior two-star officer on the base as the commander of Naval Strike and Air Warfare

Center. As NSAWC, or Naval Strike and Air Warfare Center, I report directly to the chief of naval operations and provide oversight

of the training of approximately 55,000 personnel a year here at

Fallon and at our weapon centers and weapon schools at other fleet

concentration areas throughout the United States. Over the past 5

years, flight operations have really only increased about 4 to 5 percent at NAS Fallon, with an average of about 40,000 flights per

year. There has been an investment in Fallon infrastructure at

NAS Fallon since 1984 of over $300 million.

I would like to discuss the specifics of our operations out there,

as they may affect this investigation. First, the consolidation of all

our training here in 1996 did not appreciably change the way we

conduct operations. As a matter of fact, our two biggest years of operations at NAS Fallon were in 1990 and 1991, preparing for Operation Desert Storm and Desert Shield. From an environmental perspective, the flight training that NSAWC conducts has changed

very little in the past few years.

Second, NAS Fallon’s environmental, safety, operations, and

weapons departments are responsible for the administration of all

our environmentally-sensitive material. For anything we use, there

is a safety handling program and a way of disposing it properly,

where applicable. We follow the guidelines established by Federal,

State, Department of Defense, and U.S. Navy agencies and are

probably more heavily regulated than anyone in the private sector.

Programs such as our fuel handling, air emissions, hazardous material disposal, electromagnetic radiation effects, and installation

restoration are all inspected on a regular basis. We have received

high marks for compliance, and we’ve shared data on each of these

with the State Health Division and the expert panel. Next week,

when the Agency for Toxic Substance and Disease Registry visits,

we will share our data with them also.

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Third is NAS Fallon’s drinking water supply for the 3,000 personnel who work on the base and the up to 2,000 transients that

we have there at any one time. It is separate from the city of

Fallon’s, but it taps into the same Basalt Aquifer, and the water

chemistry is essentially identical. The base tests our water supply

routinely and monitors for contamination of the 8,000 acres of the

air station property through the use of 218 environmental monitoring wells. No DoD activity-related contaminants have ever been

detected in the Basalt Aquifer or leaving the base property. While

the State and select panel investigations have not established a

link between Fallon water arsenic levels with the leukemia cluster,

these are a matter of concern to our people and to the U.S. Navy,

and we’re working very aggressively with the city to build a DoD/

city of Fallon water treatment facility.

My detailed written statement previously submitted contains lots

of information about NAS Fallon and it may be relevant to this investigation, and it also lists points of contact. I thank you for your

attention.

Senator REID. We would also order that that be made part of the

record.

We’re going to now hear from the mayor of the city of Fallon.

Mayor Tedford.

STATEMENT OF HON. KEN TEDFORD, MAYOR, FALLON, NV

Mayor TEDFORD. Thank you.

Recognizing that my time is brief today, let me begin by saying

that the city of Fallon sincerely appreciates the efforts of the Senators and the Congressman and your staffs, just as we appreciate

the help that we’ve received from the Governor’s office and also

from the State Health Division.

These are trying times for our community, and while we’ve

pulled together in the only way we know how, it is comforting to

know that others want to help. I’m not going to spend any time discussing the cluster’s cause or possible links between the children.

I believe the State Division of Health and others will do that. The

city has cooperated in every way we know. First, as the steward

of the municipal water system and, later, as we began to assess

other city-owned facilities. Thus far, nothing has been found. We

recognize that the health division’s expert panel believes that an

environmental link may not be found, due to the fact that the ALL

found in this cluster generally is not typically caused by environmental triggers. Nonetheless, we will continue to cooperate in that

search in any way we can.

Our efforts, indeed, have been focused on the children, the affected families, and public education. The city council and I have

formed a group called Fallon Families First, which is comprised of

local community leaders and social service providers to coordinate

these efforts. I asked my wife, Jennifer, to chair that committee,

and they’re doing yeomen’s work. Please realize that our city does

not have a social service infrastructure. We’re too small. So we’ve

had to reach out to groups like the FRIENDS Family Resource

Center, the local hospital, mental health professionals, the clergy,

the school district, the county, and others. Fund-raising is handled

through the Mayor’s Youth Fund. You can see the white ribbons

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worn by guests here today. This was a suggestion by a mom of one

of the patients. It’s the latest step in our effort, and we plan to continue raising funds as long as there are needs.

Fallon Families First recently held its first public meeting, a

panel discussion focused on the disease itself. Local physicians, a

mother of a stricken child, a mental health professional—these people, who people know and trust in our community, helped answer

questions that are weighing heavy on the minds of those attending.

Efforts like this will continue, as they are needed. A series of informational mailings is also being coordinated with the county and

the local telephone company. This week, the city launched its first

website. Part of this effort has been driven by not only the need

to communicate about the leukemia cluster, but part of our desire

was also to be generally more accessible.

So what remains to be done? I can tell you without hesitation

that the most frustrating part of this process for me has been the

lack of information. People want answers and I don’t have them.

The investigation’s ongoing, but it’s bound to take a long time.

Where do people go for answers? I believe, in cluster situations like

this, a clear sense of communication needs to be established early

in the process. Perhaps if the State health officer declared a cluster

to be in existence, that could trigger a Federal, State, and local

partnership. The mayor’s office seems to be the place where people

automatically go, but in small towns like ours, we don’t always

have the information people want. I have assembled my own team

of local citizens and other experts who can help the city, but in

other towns, the mayor might not be so fortunate. I think a standard support team should be made available to towns like ours.

Finally, I would be remiss if I didn’t speak briefly about the arsenic in our water. I know the Senators are aware of this situation,

just as I know the experts will testify that arsenic’s probably not

linked to this leukemia cluster, but the two things have become

linked in the media and in earlier meetings. So I feel I, at least,

owe you an update of where we are today. Fallon’s municipal water

supply contains arsenic levels of a hundred parts per billion. The

USEPA has ordered us to remove the arsenic, which is naturally

occurring here in Fallon. As you are well aware, the EPA standard

has long been under review. It was 50 parts per billion. It was temporarily lowered to 10. Now it’s back to 50. We have no idea where

it will finally be set. But for the city of Fallon, it doesn’t matter

anymore. We are proceeding to treat and we will get there.

The city of Fallon, through its environmental engineering firm,

Shepherd Miller, has begun pilot testing of the technology we will

use to remove this arsenic. It appears that a filtration process

called enhanced coagulation is working best. We will finish the

pilot testing by the end of May, then we will design and site a

treatment facility. Our goal is to have construction finished in time

to comply with the EPA order, which gives Fallon until September

2003. This date is significantly earlier than any other public water

system in America, and it’s still not clear how much arsenic we will

have to remove. Nonetheless, we are proceeding, and we are doing

so without regard to cost or where the money will come from. We

also have been in consultation with the U.S. Navy and their officials about a joint treatment plant.

34

My suggestion to this body today is that you make Fallon a test

case. The issue of the EPA standard revolves around the best available science and the fact that there is no off-the-shelf technology

to remove arsenic on our level at our municipal scale. Things like

household reverse osmosis systems won’t work on a system as large

as ours. We believe that since Fallon is required to remove its arsenic more quickly than other municipalities, there may be benefits

to those who follow from learning what we have. Perhaps the Federal Government could pay for the cost of our treatment facility in

exchange for the availability of science and treatment methods resulting here that could be utilized by all those who follow. We’re

dedicated to treating the city water. Others will have to address

the many private county wells that have high arsenic levels, and

all of us will have to address public education issues and outside

media attention that now surround the arsenic. But with your help,

we can put this chapter in our history behind us and focus all of

our energies on this leukemia cluster, the children and their families.

We must maintain our focus on these families. As I’ve said earlier, this is a lonely time for our town. Many people want to speculate, many others are well-intentioned in their scrutiny, others are

just curious, but when the camera lights are off and the media attention fades, our families and our town will be left to care for

these children and assess the long-term impacts of this cluster on

our community. Your presence here today is a chance to change

that. I hope you will be able to stick with us, and I thank you very

much for taking the time to be with us today.

Senator REID. Thank you very much.

Commissioner Washburn.

STATEMENT OF GWEN WASHBURN, COMMISSIONER,

CHURCHILL COUNTY, NV

Ms. WASHBURN. Good morning, Senators, Representative Gibbons.

I’m Gwen Washburn, the chairman of the Churchill County Commission, and I want to tell you that we’ve not had the phone calls,

I’m sure, that the mayor has, but we’ve been working closely with

him. I do want to tell you that the county administration is, first

and foremost, concerned about the health and well-being of its citizens, and I’m happy to have the opportunity this morning to address the leukemia cluster that’s been identified in this community

and also to discuss ways to investigate or mitigate the issue. I’ll

tell you a little bit about Churchill County and what the county

commission is doing. You have several pages of written material in

your packet, and I’ll attempt to summarize those at this time.

Churchill County has sustained a steady growth of about 3 percent over the years and now is home to about 26,000 people. This

population is expected to double in the next 15 years. We’re a progressive small community, boasting modern schools, a community

college, an art center, and the most modern hospital in western Nevada. We have a mix of long-time agricultural-oriented families,

military personnel, young working families, and retired people.

Many people are born here and grow old here with nothing more

35

than average health problems. So, our community is alarmed and

feels helpless in the face of a childhood leukemia epidemic.

This community has reacted to this crisis in a quick and calm

manner, working cooperatively together with all agencies in an attempt to find an answer or a common link between the cases. The

county commission is very concerned about the health and welfare

of not only our 26,000 residents, but those that visit us each year

as military personnel or tourists. Certainly, none of us are experts

in the health field, nor are we research scientists. So we have no

choice but to leave those investigations to those experts, but what

we can do and have done and will continue to do is to support all

scientific and responsible efforts to find the answer. So far, we’ve

actively participated in all efforts of all the agencies in the investigations and in the efforts to educate the residents and to ease the

burden of the affected families. We’ve assisted in reactivation of the

University of Nevada’s Nevada GOLD Program, which is Guard

Our Local Drinking water, and we’ve also tightened some of our

own business permit ordinances for business and industry.

We are anxious to locate and take reasonable and responsible

corrective action for any environmental cause that may be found to

contribute to the incidence of leukemia or any other health risk in

our community. A thorough and scientific study of all the possibilities will take many years and millions of dollars. The medical experts have already expended many resources examining the patients and their families. The community and individuals have all

lent their support. The State of Nevada is considering committing

money. So now I will ask you, on a Federal level, to commit Federal resources, and there are many, but I’m going to list ones that

I think at this point are most important. No. 1 is to provide a funding mechanism to assure proper medical care for the victims; No.

2 is to assure thorough scientific research through Federal grants;

No. 3, grants to the University of Nevada-Reno and Churchill Community Hospital to assure continued public education on health

and nutrition; and No. 4, to assist individual well owners with testing and treatment of water. Best guess, this community has 4,500

domestic wells that our citizens are relying on.

The written comments that you have before you will expand on

these thoughts and cover several others. So for the sake of time,

I won’t go into all those comments, but I hope you’ll take the time

to read and consider those, and I’ll be happy to clarify and expand

upon any of those at your convenience.

On behalf of the Churchill County commissioners, I want to

thank you for taking your time to listen to our concerns and our

ideas. We sincerely hope that you’ll be able to assist our community

in some way to ease the suffering of the leukemia victims and their

families and to help us find the ways and means to lessen or, better yet, prevent more occurrences of this and other cancers.

Senator REID. Thank you very much. Your full statement will be

made a part of the record.

Before moving to questions of this panel, I would like to say to

those people who filled out the forms for asking questions of the

panel, if you’d be kind enough to pass these cards to the center

aisle, they’ll be collected, so they can be given to us following the

third panel.

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Dr. Guinan, we’ve heard testimony about the possibility of this

being a virus. Now, there’s no danger of this being transmitted—

if a child has leukemia that, by chance, is caused by a virus, there’s

no danger of that child transmitting the virus to his friends, is

there?

Dr. GUINAN. No, there is not, there is no danger. Leukemia is not

contagious.

Senator REID. That’s so important, that people here understand

that.

Admiral one of the things I wanted to talk to you about, in the

written testimony that you’ve given and other people from the

Naval Air Station have given, you’ve indicated that in the last 5

years there’s only been 40 gallons of fuel spilled, or words to that

effect. I just want to make sure that the record’s clear, because I

can remember spending a lot of time out there 10 years ago relating to a spill of fuel. There was some dispute as to how much had

been spilled, from a thousand gallons to 30 thousand gallons. We

really never got to the bottom of how much that was. Also, during

that same period of time, people came forward and indicated that

there was fuel contaminated soil that was burned for 5 or 6 days

in a row at the base. This spill and the other information is not

part of this record, it’s simply not there, and much information has

been gathered up to this point.

I would like to have the Navy supply whatever information you

have to Dr. Guinan regarding these prior incidents. It’s my understanding, and I’ve read very clearly the testimony given in the

past, that this information has not been forthcoming in this investigation. I’ll also say, Admiral, that I don’t know if burning soil for

5 or 6 days would have any bearing. I simply don’t know. I don’t

know if the fuel spill would have any bearing on the work that’s

being conducted here, but I think it should be part of the information gathering, so that Dr. Guinan and others will have this at

their fingertips.

Admiral NAUGHTON. Yes, sir, we’ll provide that, the data of the

1988–89 spills. There was lots of discussion on how much was or

wasn’t spilled, where it went, and I know there was much confusion. That’s one of the reasons that we have these 218 environmental monitoring wells there right now, to be sure that there’s

nothing—there’s no pathway off the base. We will provide that

data.

The burning of fuel for 5 or 6 days, I think, perhaps is local legend, sir, but we will find out in much more detail. We can’t find

anybody that has any firsthand knowledge of that, but we will provide all that data. Again, as I say, our strategy is, we want—public

health is our primary concern. We want to be part of the solution,

and we will cooperate fully and provide all data humanly possible.

Senator REID. I appreciate that very much.

It’s my understanding, Admiral, that the Navy has, during the

past 4 or 5 years, used a different kind of fuel for the jet airplanes.

Is that true?

Admiral NAUGHTON. Yes, sir. We’ve moved from JP5 to JP8.

Senator REID. Can you tell me why you did that and what the

difference in fuels is?

37

Admiral NAUGHTON. Well, JP5 has—it’s actually an economic

issue—JP5 has a higher flash point and must be used on the ships.

JP8 is the airforce-based fuel. It’s almost all kerosene, with some

additives. The only difference between JP8 and the jet fuel that’s

used in commercial airliners is that we have an anti-icing ingredient that’s added to it. So it’s essentially identical to what is

burned in every airport around the world, including Reno-Tahoe.

Senator REID. Is it classified information, Admiral, as to how

much fuel is used at this base over a year?

Admiral NAUGHTON. No, sir. We use about 40 million gallons,

about 50 percent of what they use at Reno.

Senator REID. At the airport in Reno.

Admiral NAUGHTON. Reno-Tahoe, yes, sir.

Senator REID. The other question about the monitoring of the

wells—and Dr. Todd, Dr. Guinan, you can chime in here if you feel

it’s appropriate. One of the concerns I have about the monitoring

of the wells is that I’ve been told that there’s really two areas of

water that we need to look at here. The first is the deep water, and

that’s what’s being monitored——

Admiral NAUGHTON. No, we’re monitoring the shallow water. The

deep water in the Basalt Aquifer is where we get our drinking

water, but we monitor the shallow water wells.

Senator REID. It’s the shallow, at least in my opinion, that we

have to be concerned about—— Admiral NAUGHTON. Yes, sir.

Senator REID [continuing]. Because that water moves around.

Admiral NAUGHTON. That’s the pathway that we’re looking for,

and we have not seen one—in the monitoring work between the

Nevada Department of Environmental Protection, they are part

and parcel of what we do there.

Senator REID. The water that you talked about, you have 218

wells that the Navy monitors, itself, as to where the water goes;

is that right?

Admiral NAUGHTON. Yes, sir. If there’s any contamination, we do

test the deep water well routinely, just like the city does.

Senator REID. Senator Ensign.

Senator ENSIGN. Admiral, when they were talking about the mixing, I just thought about something. In your investigation, when

you’re looking at mixing of populations, we’ve heard about the possibility that maybe a virus is one of the environmental causes. During this period of time, when maybe some of the exposures of these

children to some people in the community occurred, was there a

certain part of the world that some of our service personnel came

from? Have they looked at trying to isolate that? We know that

there are very rare diseases in different parts of the world that

Americans are never exposed to, and you can become a carrier

without even knowing you were already exposed. We should look

at all possibilities.

Admiral NAUGHTON. I’m afraid that it’d almost be an infinite set.

You know, you talk about 50,000 people coming through here each

year. We have been everywhere. Of my own personal experience,

I’ve been on almost every continent. The people that come through

here, it would almost be impossible to track where they each have

been. I’m not saying that we can’t look at it, but we can do some

38

analysis with CDC and the naval environmental health agency.

We’ll try and take that on, sir, but I’m a little nervous that it probably would be such a huge set of where they came from and what

they did, and individually tracking each individual is not something that we do because of that, but we’ll certainly look at it.

Senator ENSIGN. Dr. Guinan.

Dr. GUINAN. Yes. I’d just like to say that the theory on population mixing is one that suggests, perhaps, a viral cause, but it’s

not a new virus or an exotic virus. The theory is that it’s a common

virus and a mild virus that, for whatever reason, there’s been an

abnormal immune response to and that follows a community of relative isolation that has been exposed to the virus before and maybe

are a little older and have a different response to the same virus.

That’s why it’s so difficult to find, we think, because it’s a common

virus, but an abnormal response to the virus.

Senator ENSIGN. Has that community mixing theory, then, been

mainly of cancers in older people and not in younger people?

Dr. GUINAN. No, it’s younger people.

Senator ENSIGN. It is.

Dr. GUINAN. In England, there is a cancer cluster in an area

that’s been ongoing for years, and they have put millions and millions of dollars into investigation of causes, and nothing has turned

up. I think one of those things—out of that observational analysis

came the population mixing theory, and as I say, it’s just observational and a theory, but the expert panel felt that we could provide

evidence to support or refute the theory with the cluster in Fallon,

for a number of reasons. No. 1, the timeframe between the cases

was so short, that we are a rural population with an influx of migration, and also that, if we could look at tissue and demonstrate

there was some similarity, the more likely we could possibly say a

virus is more likely.

Senator ENSIGN. You were talking earlier about the B cells

versus the T cells and that even the subtypes of the B cells being

different in some of these cases. Does that not suggest different genetic pathways, or could they all be the same genetic pathway, and

in the end, they branch off?

Dr. GUINAN. Well, I believe that for the B cells—if we thought

they were linked and if they were all the same, we would be much

firmer in our belief that they’re linked. Since we really don’t know

what the cause is, we really don’t know, but I think the lines of

evidence suggest that T-cell may be a different type of etiology

than B-cell, but the evidence is still relatively sparse, and as I say,

there really is no known cause. So if we could come to, at least,

some understanding of the pathway, we would be more likely to

pinpoint a cause, whether it’s environmental or infectious.

Senator ENSIGN. I want you to make one comment. It really has

nothing to do with the particular case today, but it raises a question that we’re dealing with in Congress where we’re talking about

all this epidemiology. When you’re dealing with that whole issue,

privacy is a big concern. We’re hearing about reporting and trying

to make sure—especially for cluster cases—to have rapid reporting.

How do you relate that to the concerns for privacy and how do you

protect people’s privacy? We have to make policy concerning priVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00044 Fmt 6633 Sfmt 6601 H:\DOCS\78069 SENENV1 PsN: SENENV1
39

vacy, but at the same time be able to share information to be able

to solve some of these cases in the future.

Dr. GUINAN. That’s a very important question, and I think that

it’s raised each time we ask that a disease be reported. As you

know, the State has primacy in matters of health, and it’s the State

who decides—the State legislature—what diseases are reported, in

what form. With cancer, there are many people who do not want

to be reported, because they want privacy. All of the information

that’s reported on individuals to health departments is strictly confidential. Nothing about personal identifiers comes out of the

health department. However, in small communities like this, people know who the people are and they’re identified for fund-raising

in the newspapers, but no personal identifiers are ever revealed,

and that is one of the things that we have to do, and as a health

officer, I have to maintain that confidentiality.

We have HIV reporting by name, we have all sexually transmitted diseases, we have cases of leprosy, tuberculosis, all of those

are reported to us, so we can do the appropriate public health work

that needs to be done around these diseases, and they’re all done

and we haven’t had a break of confidentiality. In other words, we

maintain it, we take it very seriously. We have to deal with it now

electronically, since records are being transmitted electronically,

and understanding how you can guard the privacy and confidentiality of records that are being transported over the Internet, there

are large Federal looks at that, on how to protect the confidentiality of data.

Senator ENSIGN. Well, Dr. Guinan, we look forward to continuing

to work with you on this type of issue. I know it is a big concern

for a lot of people—to make sure they have their privacy, but at

the same time, to recognize there are public health concerns.

Senator REID. Senator Clinton.

Senator CLINTON. Dr. Guinan—I don’t know if I should say this

here in Nevada, but I understand you’re actually a native New

Yorker.

Dr. GUINAN. Yes. Could you tell by my accent?

Senator CLINTON. Well, I also know that you’ve worked, in a very

distinguished career, with the CDC and with Dr. Phil Landrigin— who’s at Mount Sinai Hospital in New York—who is very concerned

about many of these issues that we’re speaking about today. Your

written testimony is extremely enlightening and informative, and

I want to, through you, thank the expert panel that served with

you for putting in their time to come up with the recommendations

that they’ve put forth.

Dr. Guinan, as someone who has been on the forefront of public

health as you have and, I know, played a major role back in the

early 1980’s in identifying HIV, AIDS, and recognizing it as a new

disease, what would be your priorities for us to take back to Washington? Because one of the things that I’m concerned about is that

we really come out of this hearing with some real priorities that

all of us can take back to our colleagues and tell them that this

is a pathway for us to follow in trying to get a handle on some of

these issues, because I think there are going to be more of them.

Maybe it’s going to be better identification, better reporting, whatever the explanation. I think we’re going to have more and more

40

of these kinds of environmental health issues raised, clusters, and

other kinds of incidences.

What would you ask us to do and how would you rank the priorities as to how we could respond to Fallon, but more generally to

these issues?

Dr. GUINAN. Well, I have suggestions on two fronts. One is on

cancer cluster investigations. It seems to me that there is no repository of information on this. There should be. We don’t know

whether the clusters are increasing, decreasing, staying the same,

and we really don’t know what the results of most of the investigations of these clusters are, because there’s no mode of reporting, in

other words, there’s no reporting on them. Sometimes they get published, maybe years after; in the Woburn, MA case, for example,

from the identification on the cluster of leukemia to the final report

was 18 years. In the meantime, we cannot benefit from the ongoing

information they have gathered and advance the science. There

may be 10 leukemia clusters being investigated right now, but we

don’t know about them, and I think it’s extremely important to

know that. In other words, if there are similar clusters ongoing, are

they related, is there some relationship?

So the epidemiology of clusters should be done, not with the idea

that some Federal agency has to investigate each one of them, but

that there is some repository of information that the States and

local health departments can go to and know and be able to contact

those other people and find out what they’re doing and not have

to reinvent the wheel, as Senator Reid has said, that we can start

from the most recent scientific evidence and move forward, and we

need resources and we need to be able to identify those clusters

that have the most potential for advancing the science of causation—what are the characteristics—and then some money to be

able to put the resources into those that are most promising.

With regard to environmental substances that are toxic, there is

no standard surveillance system for environmental agents, and it

seems to me that there should be. We’re always being asked about

environmental agents, have we collected information on air quality,

water quality, food quality, who collects it, how do they collect it,

and no agency or group of agencies have come together and said

these are the basic units of environmental surveillance that every

health department should have. We should have air, water, and

these are the things that we should have. Many States have particular environmental health concerns, like Nevada, about radiation, that we should have our own system also, besides the core,

and there is not this kind of thinking. There is the communicable

diseases. We know that there are communicable diseases and everybody agrees that these are the diseases that we should report,

but there’s no agreement on environmental. So I think it’s extremely important that some thought process go into it and then

some funding of infrastructure for the States to be able to develop

those systems.

Senator CLINTON. Thank you very much. That’s very helpful.

Admiral thank you for your being here and for your service. This

reminds me, back in my prior life, in the White House years, I was

asked to head up an investigation into the Gulf War Syndrome, because we had so many service men and women returning from the

41

gulf with unexplained illnesses, and I met with a lot of those veterans, I met with a lot of the people treating them, and we’ve made

a little bit of progress in trying to determine why apparently very

healthy young people after their service—which really was of limited duration, thank goodness, because the operation was so successful so quickly—returned home with terrible rheumatic and

other kinds of diseases. So this is not only something that concerns

cancer, we have other concerns, and oftentimes our people in the

military are on the front lines of a lot of these inexplicable diseases

and conditions, and I appreciate that very much.

One of the things I was curious about, though—it relates to Dr.

Guinan’s point—is that just yesterday the EPA released its new

toxic release inventory data. We’re trying to get a better handle on

what we do release into the air and what kind of emissions and

other contaminants might be available in the environment. I was

wondering, does the Navy and the other services report releases to

DoD and EPA or just to DoD? Do you know that, Admiral?

Admiral NAUGHTON. There’s a lot of things we report. We report

the release of radio-nucleotides from our nuclear power ships to

DoE and DoD, and we report our release of chemicals through

DoD, and I, quite frankly, don’t know for sure if we report to EPA.

I would be surprised—if it’s not, it goes through DoD, because, as

you know, we’re a pyramid structure and we all work for somebody.

It would go through DoD, would be my guess on that, Senator.

You talked about the Gulf War. I’m very familiar with it. I commanded a ship that was in Kuwait City. One of the very first cases

of Gulf War disease was an MS–2 that was on my ship. I don’t

know why. I spent all day on the bridge and I didn’t get sick. He

spent all day inside and he did. So I don’t know. But we do report

all of our emissions and it is collected and it is reported to DoD,

and we work through the Navy, through the Department of Navy

health organization on everything we do.

Senator CLINTON. Thank you.

Senator REID. Congressman Gibbons.

Mr. GIBBONS. Thank you, Senator.

Admiral I want to applaud you and Captain Rogers as well for

your contribution, not only to this Nation in terms of making sure

we are secure in our Nation’s people and our interests abroad, but

also your contribution to this community. The Fallon Naval Air

Station, I think, has been one of the premiere institutions that this

community has oftentimes relied upon for technology, for assistance, for help in times of emergencies or whatever, and I do want

to applaud you for your effort to share the information with the

Naval medical studies that you’re undergoing in this regard. I

think that shows that you’re leading the way and that you’re willing to be a working partner in the solution to this. As somebody

who has also shared the technology of training in some of your facilities, I also want to thank you for being there when we needed

you. It’s always been very important.

I really don’t have any questions for the Navy, other than the

fact that I did want to say that my understanding is that JP4, JP5,

JP8, all very similar, maybe except for, as you say, the flash point

temperature at which they ignite changed, primarily due to safety.

42

Jet Fuel A, without the de-icing additive in it, is essentially the

same as JP8.

Senator REID. Jim, I think you’re just showing off now.

Mr. GIBBONS. I couldn’t keep up with you guys in the medical

field. So I thought I’d tell you where I do have some knowledge.

But, anyway, when you talk about fuel burned and the effect of

having a military aviation operation and comparing it to RenoTahoe International, Reno-Tahoe does burn JP8, with the fact

they’ve got National Guard airplanes there that burn that. So I

think there’s, you know, an interest there, but one which, I think,

will fail in comparison to say that it is the effect of the operation

of the airplanes that is a causal factor in that, unless we start seeing clusters in Nevada in other locations, whether it’s McCarran,

Reno, Fallon, due to the combustion of this fuel.

That would be a question I would ask Dr. Todd. Have you seen

other clusters in Nevada like this that you’ve seen in Fallon?

Dr. TODD. No, we have no other clusters at this time of childhood

leukemia. In fact, when I look at 1999 data statewide, I find only

15 cases of childhood leukemia reported throughout the State. If I

go back over a 5-year period, I find only 53 cases reported statewide. So, clearly, that’s well over half million 0- to 19-year-olds in

my denominator coming to Fallon, with less than a thousand 0- to

19-year-olds in the county population. Having eight cases diagnosed in only 1 year is clearly significant. We’ve not seen that elsewhere throughout the State.

Mr. GIBBONS. Let me turn to the mayor and the county commissioner and thank them for their appearance here as well.

Mayor, I know that oftentimes we have read in the newspaper

that the city of Fallon is dragging its feet with regard to dealing

with arsenic removal, but I know you, I know the work that this

community has done, and just for the record, would you help us by

describing what the city has done in any effort with regard to moving forward on the arsenic removal?

Mayor TEDFORD. Well, as you know, the arsenic issue goes back

to—I was a sophomore in high school in 1969, and the discussion

that began then—I certainly didn’t start it, but I will be the one

that ends it in 2003, that discussion. I think I could go back to the

compliance agreement with the State that we signed in 1990 that

we would meet the permanent standard when it was set. There’s

a lot of history, I think, that doesn’t really need to be gone through

today, but it should suffice to say, when we heard around 1997 that

this standard was finally going to be set, after 10 years of waiting,

we formed an arsenic team with the city. They went to various

venues around the country, to EPA-sponsored meetings on what

the standard might be and what the technology was. We had been

told that there was off-the-shelf technology that we could use, and

after those meetings in a variety of places, we found out there was

no off-the-shelf technology that could be used in a city of our size.

In 1999, we got a violation order from EPA, and in 2000, we

hired Shepherd Miller of Fort Collins, CO, as our consultants, and

they began the chemical testing of the water. They have gone

through bench testing, they’re at pilot testing now, as well as looking for site selection at the same time, as well as design. I think

we’re well on our way to being able to reach the mandate that

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we’ve been given of September 2003. We’ve expended an inordinate

amount of money for a little town. Just probably in the last year

and a half, we’ve spent about $400,000 with arsenic and its study

and its treatment, as well as expanding their work to include

what’s in our water that could cause ALL, of which they have not

found anything.

So a lot has been done, but it’s not an issue to us anymore. Actually in 1990, it wasn’t an issue to us, because the city signed an

agreement that we would do this. Politically, that might be a hard

decision, because there are lots of people in this community who

would prefer that we not do that, who feel that they’re not being

harmed by a hundred parts per billion of pentavalent arsenic, but

that’s not the decision we have to make. Our decision is to lower

the arsenic by September 2003, and that’s what the city council

said to do and that’s what we said to do, and we’re going to do it.

We’re just looking at you all to help us fund that, so we can do it.

There are some issues with an interim standard, because we

tried to seek out several funding sources, and with your help and

Senator Reid’s, we’ve been able to get about $950,000 for help with

design and siting. We are trying to site that on property we own,

to save that money. We’ve been able to get, through AB198, about

$707,000. We have accrued about a million dollars since 1990 to set

aside for arsenic. But the bigger problem is not just the building

of the plant, but also the—what some people lose sight of is, we

spread those dollars over 2,800 hookups in the city of Fallon. This

new standard of 10—that’s our goal to hit—really affects population sizes of 10,000 or less, as the Senator well knows from the

recent legislation of Senator Ensign, where there is probably limited funds to do these sorts of thing. So this is an area where we—

even though out in Fallon, we like to be self-sufficient, we’re probably not going to be able to do that.

Senator REID. Mayor, there’s no question that’s the reason that

Senator Ensign and I introduced the legislation 3 weeks ago. There

are a lot of Fallons around the country. I agree with you. The

standard has been set, and no matter what standard we set, Fallon

has a problem. So we have to get rid of that. You were a sophomore

in high school, I was a freshman in the legislature when this problem came up in the 1969 session, and we need to do something

about it. If there is a thing that will hurt Fallon and the surrounding areas, it’s this arsenic in the water, as far as growth.

We’ve got to take care of that. Whether it has any impact upon this

cancer cluster at this stage—we don’t think so, but we certainly

don’t know—but regardless of that, we’re going to take care of the

problem, because, I repeat, there are a lot of Fallons around the

country, and we need to provide money to allow this water system

to be constructed. We’re fortunate here in Fallon because we have

this great military installation here, and there is simply no reason

for the Navy to build a plant and Fallon to build a plant, we’re

going to do one together.

Mayor TEDFORD. We’re fully supportive of that.

Senator REID. We hope sometime later this year to be able to

have more than just ‘‘the check’s in the mail.’’

44

Mayor TEDFORD. I think you’re absolutely right. I think the cluster’s heightened this and I think we’ve firmed our resolve that we

need to do this.

Senator REID. We realize that Fallon is only a small part of

Churchill County, and we’re going to have to make sure that we

provide some relief for the rest of the county, and that’s something

we’ll talk about later. It may not be done here. We’re not going to

have a third treatment plant either. So we’re going to try to do

something to remedy this problem for the whole county.

One final question I have for you, Dr. Guinan. I don’t want to

ask any questions about epidemiology. I understand over 50 percent of Nevada Health Division’s budget comes from the Federal

Government. While the health division’s total annual budget increased in recent years, do you have sufficient resources to devote

to the cancer investigation and address all the activities for which

the division is responsible? In effect, what I’m saying is, this must

be a tremendous burden on your budget. Is that a fair statement?

Dr. GUINAN. Yes, it is a fair statement, Senator. The Governor

has given us carte blanche and said we will provide resources to

keep this a priority, but Dr. Todd has been taken away from all

his other epidemiologic duties and spends his full time on the investigation, and he has an assistant who also spends full-time on

this, and that takes away from all of our other—and I spend a

great deal of my time also on it. We have a very small health department and we’re a small State. This investigation takes a great

deal of resources, and I can only say, we couldn’t have done it without the Centers for Disease Control, who have been here since we

knew about it, helping us with the steps and finding out, getting

the resources that we need.

Senator REID. It is a factor in your general budget. About 50 percent of it comes from the Federal Government, in some form or

fashion; is that true?

Dr. GUINAN. I believe it’s 85 percent.

Senator CLINTON. Senator, could I just add one final thought to

what the mayor was saying? Because I really appreciate what you

said and the resolve that you’ve shown for resolving this problem,

and certainly both Senators Reid and Ensign are going to stand behind you and try to figure out a way to get some resources to you.

But I just want to reiterate what Senator Reid said, because our

infrastructure needs for clean drinking water around our country

and for waste water treatment are woefully underfunded, and part

of the challenge we face is providing help through Federal resources to communities, such as you have here, so that you don’t

have to go it alone.

It is a very big issue that is really on the horizon. It’s one of

those issues that is not on the front pages of the newspaper, but

if we stop and look at what we need over the next 25 to 50 years

to make sure our drinking water is safe, to deal with problems like

arsenic, to set a standard and stick with it, so that you can plan

and know what you’re supposed to be doing, and to deal with, in

more populated areas, like the many that I represent, the waste

water runoff that takes pesticides and all other kinds of contaminants, as well as sewage, into lakes and rivers and—I was, yesterday, on the Long Island Sound—because beaches that people used

45

to swim in just 10 years ago are now closed permanently because

of pollution, because we don’t have enough treatment for the sewage that is flowing in.

So I think that what you said in your original statement, Mayor,

about Fallon being seen as maybe a model or a pilot project is

something that we ought to take seriously, and we ought to find

some other pilot projects around the country to deal with these infrastructure needs. At the Federal budgetary level, these are not

issues that either individuals or communities can handle on their

own. They really do take all of us to try to pull together to deal

with problems that we know we have. So I really want to thank

you for your testimony and for your response to the questions that

have been asked today.

Senator REID. Senator Ensign.

Senator ENSIGN. I want to discuss something about possible

areas of funding and getting more resources. I know we have heard

once or twice about the way that the water system of Fallon water

is a bit of an issue out here. We know that we have a Superfund

site upriver on the Carson River, between the Truckee River and

the Carson River since the beginning part of the twentieth century.

At least, we have those two rivers coming together and dumping

into Lahontan Reservoir. That was fairly standard practice, I

guess, kind of a ‘‘flushing’’ type of, situation. We don’t want to go

into all the details of what’s happened in the last few years, but

there has been a change, in the way that the rivers flow. The question is: Is there a change in the content of those rivers where they

come together? Can we maybe go after some of the Superfund

money to possibly investigate the possibility? Is that a place where

we could look for funding to investigate what’s going on?

Dr. GUINAN. Well, luckily, Senator Ensign, you have the head of

that agency who does the Superfund investigation, Dr. Henry Falk

from the Agency for Toxic Substance and Disease Registry, on the

next panel.

Senator ENSIGN. I guess we will ask that question to him.

Senator REID. Congressman Gibbons.

Mr. GIBBONS. Just one final brief comment here to the mayor

and the county commissioner. We’re all aware that you have the

welfare of this community, the welfare of this county as your No.

1 priority. The No. 1 priority would be the health and safety of its

individuals. The second priority, of course, would be the economic

welfare of this community. There’ve been reports and people have

called and said there’s been an economic impact, because of the adverse publicity that this issue has given. We’ve heard testimony

today, even Assemblywoman de Braga has indicated, that the No.

1 issue should be the welfare of these children. We all agree with

that, but since there are reports of that, since you’ve probably

heard the same statements, what can the community do, in your

opinions, both from the county and the city perspective, with regard to dealing with the economic issues that are addressed here?

Mayor TEDFORD. Well, you know, Congressman, I believe there

is an impact. There’s no question. It just has not been, in the City’s

view, the foremost issue right now. As you say, it has been the

families, but it is an issue that we know we need to get to. I hear

from people—like Mrs. de Braga said—realtors that housing sales

46

are down, contractors aren’t building houses. So you hear those

concerns, and I think it is something that we, as a city, are trying

to develop now. We’re trying to gather information and knowledge

and data from other places that went through these things, like

what we’re going through. We’ve even preliminarily planned to

make site visits to some of those places to ask, ‘‘How did you handle your economy after you, hopefully, were done worrying about

your families?’’ So I really don’t have a hard answer as to what I think we can

do. I think we’re probably going to need some sort of economic development money to spur—if there is a lag here—to spur growth

back to where it was. But, in all honesty—and the press have

asked me that question many times—it is not an issue I’ve spent

a lot of time on, but that I plan on doing very soon, because that’s

a critical issue. It’s no different than the families. I have four children under 10. So they’re all in Dr. Todd’s factor of 0 to 19. I have

to be worried about every family.

Well, the same is true of business, and my responsibility is to

every business in this community. So that, indeed, is a great responsibility that is going to take a lot of thought. I think one thing

that—if I was thinking of moving a company or moving my family

to a community, I would want to know, first and foremost, this

community had a problem, it addressed it, it didn’t deny it was

there, and it helped those families that were suffering, and, to me,

that would go a long way as far as easing some of the economic

damage that’s maybe being done. Commissioner Washburn may

have a different take on that than I do, but I am hearing those

same comments that I’m sure you’re hearing too.

Senator REID. Commissioner Washburn, do you have anything to

add?

Ms. WASHBURN. Yes. I agree that there definitely is an economic

impact that has come with the notoriety that this issue has

brought to the community. One thing that I think you’ll find in my

written portion here is that I’ve asked that there should be some

Federal funding to underwrite some low-interest, maybe some

longer term loans for the businesses that are being proven to be

hurt by this. That is one possibility. We are attempting to help ourselves as much as we can. The Churchill Economic Development

Authority is working very hard, and I’ve attended many meetings

on this, on what we are calling a visioning program at this point,

but we’re exploring ways to put the community in a more positive

light for people that are looking to put their businesses and small

industries in this area, ways that we can attract those people and

overcome this problem and make it a positive place for them to be.

We are working with that. The other thing that comes to mind is

just basic cooperation between the city, the county, neighboring

counties, legislators on all levels. We just need that cooperation,

and if we can all talk to each other, I think we can get through

this and our business and industry can come back the way it was.

Senator REID. Thank you both very much. The whole panel has

been outstanding. We appreciate your being as candid and forthright and informed as you are.

Senator REID. We’re now going to hear from Panel III, Dr. Henry

Falk, who is the assistant administrator for the Agency for Toxic

47

Substances and Disease Registry. We’re going to hear from Dr.

Thomas Sinks, who’s the associate director for the National Center

for Environmental Health, Centers for Disease Control and Prevention. We’re going to hear from Ms. Ramona Trovato, who’s the director for the Office of Children’s Health Protection, U.S. Environmental Protection Agency. Finally, we’re going to hear from Shelley

Hearne, who’s the executive director of the Trust for America’s

Health.

Dr. Falk heads the Agency, as I’ve indicated, for Toxic Substances and Disease Registry, serves under the director of the Centers for Disease Control. This was established in 1980 under the

Superfund law for the purpose of studying and tracking the health

effects of exposures to hazardous substances at Superfund sites and

other hazardous waste sites and recommending interventions for

public health.

Dr. Falk.

STATEMENT OF HENRY FALK, ASSISTANT ADMINISTRATOR,

AGENCY FOR TOXIC SUBSTANCE AND DISEASE REGISTRY,

ATLANTA, GA

Dr. FALK. Thank you very much, Senator Reid. Good morning to

you, Senator Reid, and members of the committee. My name is

Henry Falk, and I’m the assistant administrator for the Agency for

Toxic Substances and Disease Registry, or ATSDR, as we’ve shortened it. Dr. Aubrey Miller, unfortunately, was detained by a snowstorm coming out of Denver and apparently will not be able to

make it here this morning. I have spoken to him in advance of this

session.

Thank you for inviting us to speak this morning. We share your

concerns about the health and well-being of children and families

in Fallon and across the country. Certainly, the testimony this

morning was very moving, and it must serve as a spur to all of us

in government to do our very best. We also share your desire to

adequately address the concerns expressed about illness and disease that might be associated with the environment.

As you noted, our agency was created by the Superfund legislation. As such, we are an agency charged with determining the nature and extent of health problems at Superfund sites, including

Federal Superfund sites, and advising the USEPA and State health

and environmental agencies on needed clean-up and other actions

to protect the public’s health. ATSDR, of course, works very closely

with the EPA through our Superfund responsibilities. We also work

very closely with our DHHS sister agency, the Centers for Disease

Control and Prevention, and, jointly, we will work with the Nevada

Health Division to assist in investigating the cancer cluster in

Fallon. For our part, ATSDR will assist in the investigation by reviewing all relevant environmental data for toxic substances and

assessing whether people have been exposed to any of these contaminants at levels of concern.

Unfortunately, the cancer cluster in Fallon is not a unique situation. Increasingly, we at ATSDR are being asked by State and local

health departments to help respond to compelling community concerns about apparent outbreaks of serious, noninfectious diseases

with unknown cause. We work closely and collaborate with State

48

health departments and have been funding environmental public

health activities in States since 1987. We currently fund programs

in 28 States to assist in carrying out Superfund responsibilities, including cancer cluster investigations and activities related to concerns about hazardous waste and exposure to toxic substances.

The site work we do directly or through our State partners has

changed somewhat over time. Our original mandate under Superfund called for public health assessments at all National Priorities

List sites, and these constituted the great majority of our workload.

While we still are heavily engaged at NPL sites, increasingly our

site work now is also occurring at immediate removal sites, active

waste sites, occasionally Brownfield sites, and, like Fallon, sites

where communities, States, or congressional officials have asked or

petitioned the ATSDR to participate in the investigation.

I know you are familiar with some of our activities through our

work in Libby, MT, and Elko, NV, where individuals were exposed

to tremolite asbestos through vermiculite mining and its effects,

and I don’t want to review all of that, but we were very actively

involved in the medical screening of over 6,000 people and providing information back to them. In followup to remarks that were

made on the last panel, we have been working—particularly in the

Libby area, but also elsewhere—with local, State, and Federal

health care providers to address health care concerns that arise,

specifically to help local residents obtain medical care. We’ve

worked closely with the Department of Health and Human Services’ regional health administrator and other DHHS agencies, such

as HRSA, to ensure appropriate treatment is available.

Such partnerships are critical to providing needed health services in such areas as Libby, Elko, and now Fallon. Partnerships are

also critical to fully assessing the true existence and potential

cause of disease clusters. ATSDR and CDC, in this respect, are reviewing and responding to the Pew Environmental Health Commission Report. The report recommends strengthening Federal, State,

and local public health capacity to tackle environmental health

problems and establishing a nationwide health tracking network

for chronic diseases and related environmental hazards. We have

made significant progress at ATSDR in developing registries of individuals exposed to specific substances, and we will work on the

issues raised by the Pew Commission as well.

In keeping with the Superfund mandate to establish and maintain a national registry of serious diseases and illnesses, we at

ATSDR see ourselves as having a direct responsibility under

CERCLA to participate with CDC and others in developing disease

surveillance or tracking systems, particularly for diseases with

known or potential relationships to hazardous waste and toxic substances. Because of our close working relationship with EPA, we

are particularly interested in the ability to link health data sets

with environmental data sets.

We recognize that more could be done. The public naturally becomes concerned when they see situations such as half of a class

of third graders needing to bring asthma inhalers to school or children suffering from cancer or other health problems. We at ATSDR

are committed to doing what we can to address these very real concerns. We work every day at sites around the country to address

49

the concerns of communities affected by toxic exposures. We work

with our colleagues at CDC to address the issue of health and disease tracking, and we continue to strengthen our ongoing partnerships with Federal, State, and local agencies.

On a personal note, just briefly, I started my professional career

at CDC as a pediatrician in 1972. My first investigation in 1972

was of a leukemia cluster in Elmwood, WI. I did several such investigations over the next 18 months, none of which revealed an

obvious cause for the clusters. However, my fourth or fifth such investigation was of four cases of liver cancer in a factory, which

turned out to be the first reported cases of vinyl chloride-induced

liver angiosarcoma in polyvinyl chloride polymerization workers.

This subsequently led to much improved and safer working conditions for the entire industry worldwide. I have seen personally how

agonizing and frustrating this work can be, but I also feel that if

we are in the mode of carefully scrutinizing health data, then we

will be positioned correctly to detect new problems as they arise.

This concludes my testimony. Thank you very much.

Senator REID. Doctor, I’m sure it’s a comfort to the parents of the

children who are sick here to recognize someone as well qualified

as you doing the work that you’re doing. So I’m glad that you’re

here.

We’re going to now hear from Dr. Thomas Sinks. Dr. Sinks is a

member of the State Health Division Expert Panel. He’s already

been of great service to the State health division. He represents

other Federal agencies besides ATSDR. He’s most active in assisting cancer cluster investigations and addressing environmentallyrelated community health concerns with the Centers for Disease

Control and Prevention.

Dr. Sinks.

STATEMENT OF THOMAS SINKS, ASSOCIATE DIRECTOR FOR

SCIENCE, NATIONAL CENTER FOR ENVIRONMENTAL

HEALTH, CENTERS FOR DISEASE CONTROL AND PREVENTION, ATLANTA, GA

Dr. SINKS. Good morning, Senator Reid, and other members of

the committee. I would like to say that I’m delighted to speak before you on this issue. This is an issue which is very important to

many people, as can be seen by the media’s attention and all the

people here from the community.

I want to begin by assuring the people of Fallon and the parents

whose children have been diagnosed with cancer that we at CDC

are committed to the health and well-being of children. We are encouraged by the wonderful improvements in the clinical treatment

of childhood cancers. Still, as has been said before, we need to identify the preventable causes of these diseases. Let me assure you,

chance has never caused one case of cancer.

CDC has been providing technical assistance to Nevada since

July 2000, and we will continue to do so, as you heard this morning. I won’t go into the details of that. It’s in my testimony. Perhaps someday we’ll know how to prevent ALL, just like we know

today that folic acid prevents neural tube defects. Whether or not

we identify the cause of ALL, we need to assure the families of

Fallon about the safety of their community.

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I’d like to say a few words about cancer clusters in general. Public health agencies are challenged by the large number of public inquiries. Thousands of perceived cancer clusters have been reported.

More than 2000 published newspaper articles from January 1990

to January 2000 contained the words ‘‘cancer cluster.’’ A survey of

41 State health departments found that they registered about 1900

cancer inquiries in 1996 alone. Public health officials are expected

to identify and remove the cause of each cancer cluster. Yet, only

10 percent to 15 percent of cancer clusters investigated actually

find an excess of cancer cases. Of these, only a handful have led

to discoveries of preventable causes of cancer.

Cancer clusters do provide an opportunity for cancer prevention

and control. Cancer education and screening programs are important tools and can be used effectively in some cancer cluster circumstances. Occasionally, scientific investigations of clusters do

lead to cancer prevention discoveries. I want to point out that most

of these have come from the observations of clinicians working with

patients. Another opportunity to protect human health occurs when

a cluster coexists with a hazardous level of an environmental contaminant. In such circumstances, removal of the health hazard is

prudent, whether or not it’s related to the cluster. Cancer cluster

activities in the CDC have included field investigations, a conference on clustering of health events, and technical assistance to

health departments.

In 1991, CDC published a set of standard investigation procedures for investigating chronic disease clusters, and that has been

distributed to all States and is available on the CDC website. CDC

also funds State-based cancer registries, which is, in my mind, the

essential tool for evaluating inquiries about too much disease. The

Nevada Cancer Registry has received more than $1.4 million from

CDC from 1994 through 2000. CDC also conducts exposure assessments and epidemiologic studies that evaluate how people are exposed to hazards and identify preventable causes of cancer.

I want to emphasize that State health departments are on the

front line of cancer cluster evaluations, and being responsive to the

public is the single most important element to this. Three additional ingredients to enhancing responses include infrastructure,

scientific credibility, and coordination between agencies. Essential

infrastructure elements are timely chronic and childhood disease

registration and linking health and environmental data bases, recommendations supported by the Pew Environmental Health Commission. One significant advance is taking place with the creation

of a national children’s cancer registry through the Children’s Oncology Group and funded by the National Cancer Institute. It will

register all children with cancer at the time of diagnosis and collect

specimens at that time.

Last month, CDC released the first national report on human exposure to environmental chemicals, providing baseline concentrations of chemicals in the blood and the urine of people in the

United States. We plan to use this technology to assist the investigation in Fallon.

Scientific credibility requires staff at the State level having expertise not only in cancer, but also in epidemiology, statistics, toxicology, and other matters. Independent review by expert panels enVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00056 Fmt 6633 Sfmt 6601 H:\DOCS\78069 SENENV1 PsN: SENENV1
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sures the credibility of cluster investigations. Scientific credibility

and direction could be further enhanced by directing priorities for

future cancer cluster investigations based upon hypotheses for why

cancers might cluster. A working group to establish such priorities

is sorely needed. The successful collaboration in Fallon has not only

included State health and environmental agencies, the CDC,

ATSDR, NCI, the Fallon Naval Air Station, and researchers from

the University of Berkeley and Minnesota, but also the willingness

and interest of the people of Fallon and their appointed officials.

Thank you, Mr. Chairman and members of the committee, for

the opportunity to testify before you today, and I’ll be happy to answer any questions you might have.

Senator REID. Thank you, Doctor.

We’re now going to hear from the director of the Office of Children’s Health Protection, Environmental Protection Agency. Ms.

Ramona Trovato is the director and one of the office’s most experienced health officials. She will focus principally on EPA’s activities

relating to the effects of environmental pollution on children, including coordination with the Centers for Disease Control, the National Institute of Health, and the National Institute for Environmental Health Sciences.

Ms. Trovato.

STATEMENT OF E. RAMONA TROVATO, DIRECTOR, OFFICE OF

CHILDREN’S HEALTH PROTECTION, ENVIRONMENTAL PROTECTION AGENCY, WASHINGTON, DC

Ms. TROVATO. Good morning, and thank you.

I am Ramona Trovato, and I’m the director of the Office of Children’s Health Protection at the USEPA. I’d like to start by saying

it’s very distressing to me that 12 children in this community are

suffering with leukemia, and my prayers certainly go out to them

and to their families.

EPA’s mission is to protect human health and safeguard the environment. We do this by controlling the amount of contaminants

that go into the air we breath, the water we drink, and the food

we eat. We can only do this in partnership with the States. We

partner with them on both public health protection and environmental protection, and about half of our budget is sent directly to

the States for their efforts to protect human health and the environment. This partnership is absolutely necessary, we believe, to

address human health issues that are related to environmental factors, and it has to be a partnership at local, State, and Federal levels.

Today, I’d like to discuss the governmental efforts to protect children from environmental risks, I’ll then give an example of how we

responded in the past to a community problem, and, finally, I’d like

to close by offering some thoughts about how we can work together

to help in Fallon.

Over the last 4 years, Federal agencies have joined together to

focus on three specific childhood illnesses that have environmental

links. These are asthma, developmental disorders, and childhood

cancer. Asthma affects about 5 million children and is the leading

cause of hospitalization of children in the United States. Developmental disorders are the leading cause of lifelong disability, and

52

childhood cancer is the leading cause of disease-related mortality

in children. Many of the factors that contribute to asthma, developmental disorders, and childhood cancer are unknown. Therefore,

the Federal Government is focusing on research to better understand how these environmental factors contribute to childhood disease.

The EPA and HHS are funding eight centers for the first time

to investigate the effects of environmental factors on children’s

health.

The National Cancer Institute is conducting a good deal of research into environmental factors that influence childhood cancer

and is developing a national registry of children with cancer.

Congress authorized the Child Health Act of 2000, requiring a

longitudinal cohort study, which is a long-term research study to

examine the impact of environmental pollutants on children. As the

Framingham study provided us most of what we know about heart

disease, this study could be the watershed in understanding how

environmental factors affect children’s health. Where we have sufficient knowledge to act we have developed strategies to address environmental health concerns. These strategies are primarily directed to reducing asthma and lead poisoning in children in the

United States. We’re also working directly with communities and

States to respond to their specific child-related health concerns.

Currently, government agencies work informally together to address cancer clusters. State public health departments are the front

line, and they go out and investigate first. If they want additional

help, they contact CDC or ATSDR, and finally EPA may be contacted if they want an environmental assessment done.

In 1996, due to public concerns about high rates of childhood

cancer in Tom’s River, NJ, ATSDR and the State of New Jersey

conducted a study. They found a contaminant in drinking water

wells from a nearby Superfund site. This contaminant was identified by EPA, and we required the company responsible for that contaminant to put a carbon treatment system on the wells that were

contaminated. There is no detectable amount of this contaminant

in their wells at this time, and we are still conducting and overseeing studies to determine if this contaminant is a carcinogen and

may have contributed to the cancer cluster.

Through the Superfund program, we work closely with ATSDR

to respond to environmental hazards and associated health risks.

Communities petition ATSDR for a community health assessment

and they can request a preliminary assessment through EPA of environmental conditions there. If the environmental assessment indicates a problem, we can take steps to address that problem. EPA

also helps communities address public health threats in drinking

water through the Drinking Water State Revolving Loan Fund.

This fund provides money to States for financing drinking water infrastructure projects. The program recognizes and emphasizes the

needs of small systems, in particular, and those that serve fewer

than 10,000 residents.

On a national level, I would like to suggest five actions to make

environmental health protection a priority. The first is to formalize

the cancer cluster response approach to address cancer, as well as

other environmental health problems. Second, I’d like to see the

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State and local public health infrastructure bolstered to respond to

environmental health threats. I’d like to see a strengthening of the

relationship between environment and health departments at all

levels of government. I strongly support a national tracking system

of chronic diseases. So we can understand where those diseases are

occurring and, if possible, look for associations with contaminants

in the environment. Finally, I think it’s absolutely necessary to

conduct this longitudinal cohort study to understand environmental

factors that affect children’s health.

Finally, I’d like to address how we at EPA can support efforts already underway in Fallon. We would like to work closely with the

city of Fallon, the ATSDR, the CDC, and the State of Nevada to

conduct environmental assessments. We can sample, analyze,

model, and cleanup environmental hazards. In fact, EPA’s Las

Vegas laboratory has already offered to conduct analyses of chemicals that are not typically found in drinking water to help

understand what else may be here. ATSDR and EPA have also

established pediatric environmental health specialty units in nine

locations around the country. These are a first. These units provide

sources of information for doctors, nurses, and parents about

environmental health threats and how they affect their children. In

addition, these units will actually see children who have been affected. The closest one to Fallon is at the University of California

at San Francisco.

Thank you for allowing me to address this committee and the

community of Fallon. I hope that, together, we can make a difference and prevent this in other communities. I’ll be happy to answer any questions.

Senator REID. We will get to some questions in just a minute.

We’re now going to hear from Dr. Shelley Hearne, executive director of the Trust for America’s Health. Dr. Hearne has been involved

with the Pew Environmental Health Commission. Last year, this

commission issued a comprehensive report supporting enhanced

tracking of chronic diseases in this country and the coordinated

and enhanced capacity of the Federal Government to support cancer cluster investigations and to respond to environmentally-related

community health concerns.

The most amazing thing I saw in your testimony is that you’ve

been doing this for more than 20 years. So I think we should notify

the Department of Labor for child labor violations.

STATEMENT OF SHELLEY HEARNE, EXECUTIVE DIRECTOR,

TRUST FOR AMERICA’S HEALTH

Dr. HEARNE. I appreciate that comment, thank you. Thank you

for this opportunity to come to Nevada and have a candid conversation about our Nation’s ability to respond to clusters.

I do serve as the executive director of the Trust for America’s

Health, which is a new health advocacy organization committed to

protecting the health and safety of our communities, and we are

proud that several members of our advisory council are former colleagues of yours—Senator Lowell Weicker, Congressman John Porter, and also Congressman Louis Stokes. They strictly told me not

to use the word epidemiology, you’ll be happy to know.

Senator REID. I’m more happy than you can imagine.

54

Dr. HEARNE. I did recently serve as the executive director of the

Pew Environmental Health Commission at the Johns Hopkins

School of Public Health. It was a blue-ribbon panel charged with

developing recommendations to improve the Nation’s health defenses, and I appreciate all of my colleagues here from EPA,

ATSDR, and CDC for their comments and thoughtful consideration

of how to incorporate those recommendations in the agencies’ activities.

No child or community should suffer like this, and my heart certainly goes out to the families of Fallon, but as a young health scientist, I am growing actually quite angry watching this story repeat itself across the Nation. As Henry Falk noted, Fallon is not

alone. In 1997, there were almost 1100 public requests to investigate suspected cancer clusters in this Nation. My job as the last

panelist, and I guess what holds us all before lunch, is to actually

deliver some of the bad news, that our public health service is actually falling short in its duty to watch the health of this Nation, particularly when it comes to chronic diseases that may be associated

with environmental factors.

We are seeing this all across the country. Back in my home State

of New Jersey, parents in Brinck Township complained to health

officials about a feared autism cluster. It took almost 5 years for

the health officials to confirm a cluster of 60 cases, because no one

tracks autism in this country. In Elmira, NY, 40 students have

been diagnosed with cancer who attend a local high school. I can

go on and on with stories. Chronic diseases account for 7 out of 10

deaths in this Nation, but we still have no adequate system in

place to detect these diseases, nor the ability to effectively respond.

Our health agencies only coordinate tracking infectious diseases,

such as polio and typhoid, diseases that a national tracking and response system helped to eradicate in the nineteenth century. Over

a hundred years later, we still have not updated our public health

system. Our health specialists remain in the dark with no resources and unable to find the solutions to today’s health threats.

Let me give you a few examples of what’s happening here in Nevada. Birth defects are the No. 1 cause of infant mortality. Yet, Nevada does not have a birth defects registry, nor does Nevada track

respiratory and neurological diseases, such as asthma and Parkinson’s. Nevada’s cancer registry consistently fails to meet national

standards. Nevada is the only State that charges its hospitals as

the only forum of reporting cancer cases. It’s a perfect formula for

poor performance.

See why I’m last?

The problem is, Nevada is not unusual. It’s actually quite close

to the norm. To solve this problem, the Pew Commission proposed

a nationwide health tracking network. Here are a few of the basic

components: First, we need to build on the existing infectious disease data systems that track priority chronic diseases and related

environmental factors. This would include diseases such as childhood cancer, asthma, and multiple sclerosis. Next, we need to develop an early warning system that would alert communities to

health crises, such as lead, pesticide, and arsenic poisoning. Third,

we need to improve our response to identify disease clusters by coordinating health officials into rapid response teams to quickly inVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00060 Fmt 6633 Sfmt 6601 H:\DOCS\78069 SENENV1 PsN: SENENV1
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vestigate these health problems. Each State should have a chronic

disease investigator. Most States, like Nevada, do not.

This network is the key to developing prevention strategies, which is the most effective way to reduce the $325 billion a year

that we spend on chronic diseases. The estimated cost of a network

is about 275 million, less than a dollar per person and about .01

percent of our expenditures on chronic disease. The NIH budget is

being doubled. Yet, most of those dollars are not going to discover

the most basic information about why these diseases occur, where

they strike, and how to prevent future diseases. Ironically, the administration is proposing cutting almost a quarter of CDC’s chronic

disease program. Americans care immensely. Nine out of ten registered voters support the creation of a nationwide health tracking

system, and even in today’s economic climate, 63 percent feel that

public health spending is more important than getting your money

back, it’s more important than cutting taxes.

Most local health departments have faced declining funding, inadequate training, and limited laboratory access. In addition, they

receive minimal guidance from Federal agencies on identifying and

responding to clusters. CDC and ATSDR must be directed to aggressively respond to communities like Fallon with modern tracking systems and investigators who can take action, and Congress

must prioritize the real sources to make this happen. Without this

kind of commitment, we’re going to watch asthma, cancer, and

other disease clusters grow and there will be many more Fallons,

and perhaps that’s the greatest tragedy.

Thank you.

Senator REID. Dr. Hearne, thank you very much.

Dr. Falk, I’ll direct this question to you, but perhaps the other

panelists could help. One of the things I’m concerned about and

I’ve heard from the community is that this disease that has stricken these families leaves these families and the rest of the community without any real help to work through these problems. You

know, if there’s a suicide in a school, we have people trained

around the country that come forward and help. Is there anything

that we have on a national level to help communities like Fallon

to meet the emotional needs that families have, in addition to their

physical needs?

Dr. FALK. We at ATSDR do some of this around Superfund sites.

We have very active community education programs. We work both

with members of the community, as well as with professionals in

the community. We even have programs with psychologists in the

sense of stress management programs that we can do, when indicated. So we try to actually do that, but we don’t do that beyond

the Superfund program.

Senator REID. You acknowledge, though, that these families have

a need in addition to making sure their kids get to a physician and

take care of their physical needs. I think it’s something that we

have to keep in mind in this very complex society, that we have

some resource we can call upon for this.

Dr. FALK. I think there are several aspects to this. Probably the

most frequent question we see around hazardous waste sites is,

How will we provide for medical care for those who are affected by

toxic substances? As you know, as far as we are concerned at

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ATSDR, our mandate relates to advising and studying public

health issues, but we have no mandate or no authorization to provide actual medical care. What we are trying to do at the moment

is to creatively partner with other HHS agencies to see whether existing Federal programs, whether regional offices of other Federal

agencies can be applied to situations such as Fallon and elsewhere.

So I think that we would like to see existing programs be able to

be developed so they’ll be applicable in situations such as this.

Senator REID. Yes, Dr. Sinks, please.

Dr. SINKS. If I could just add a brief comment. The day after I

returned to Atlanta from the expert panel meeting, I received from

Dr. Mary Guinan a request to identify resources to help the community deal with the mental health stress that they were having

in terms of dealing with this extraordinarily difficult situation. I

think it is a—— Senator REID. Were you able to identify any?

Dr. SINKS. We tried to look at the National Institute of Mental

Health for resources. We do have a psychologist on our staff who

deals with refugee health issues in the Third World, and Dr. Falk

at ATSDR has a staff person who does help with Superfund communities on these issues and we linked her into the situation. I’ve

not followed up to see where that is. I do know that there are some

mental health professionals in the community working with members of the community.

Senator REID. It’s obvious from watching the movie ‘‘Erin

Brockovich,’’ which was based upon a true story—I spoke to the

lawyer who handled that case, and one of the big problems they

had after they identified there was a problem there is dealing with

the emotional problems of all the families that had, for many,

many years, thought that their disease just came out of the sky

someplace, when in fact it was Chromium 6 that was afflicting

them. So, anyway, that’s a problem we have to acknowledge.

I want to direct a question to you, Dr. Falk, or maybe Dr. Sinks.

I’m fascinated by the studies that we have as to this maybe being

a population mixing problem. There’s no better example of this in

Nevada than in Fallon, unless, perhaps, Nellis. We have people

coming literally from all over the world, we have people staying

here for short periods of time and leaving, and we have population

exposures taking place here. What we heard earlier is that there

simply is no method to do the tracking, and I’m wondering if you

have a reaction to this—in fact, anyone on the panel, other than

Dr. Sinks and Dr. Falk. Is there any way we could do a better job?

I mean—and we’ve got the parents over here—we should find out

about it, it shouldn’t be too difficult to do. We should do it, if it’s

possible to do the tracking. Can we do this?

Dr. FALK. One of the things that I have noted over the years is

that most clusters are identified by members of the community. Occasionally by physicians, but very often the people themselves recognize that a problem is occurring. We are remiss in the sense that

somehow the health care data systems, or tracking systems, call it

what you will, ought to be identifying these kinds of situations

proactively and arranging to deal with them. I assume that many

clusters are not even brought to anybody’s attention, because there

is no system that identifies them. So, yes, I think we could do a

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much more organized effort to actually identify the distribution of

cases, look for clusters or uneven distribution of cases where the

rates are very high and actually explore those in a more systematic

way and in a more uniform way.

Dr. SINKS. Allow me to add to that.

The Kinley hypothesis you’re referring to is extraordinarily interesting. I view it as one of those hypotheses that we ought to be

searching for and targeting for research. This theory is very interesting, but, we’ve not really come up with a way to scientifically

put it to the test—prove it correct or false. Perhaps we might pull

together experts specifically to work at that hypothesis and come

up with a plan for testing. The second is that we fund extramural

research through the National Cancer Institute. I think there is a

role for extramural research in cancer clusters like this. There are

wonderful researchers out there in the academic community, two of

which are on our expert panel.

Senator REID. Senator Ensign.

Senator ENSIGN. Dr. Sinks, when we talk about clusters, statistically, what are we talking about here? What makes something

statistically significant to become a cluster?

Dr. SINKS. I’m always troubled by the word cluster. I get a number of phone calls from the public, from the media, from States, a

variety of places—and let me say that I really enjoy speaking to

those people about their issues. The word ‘‘cluster’’ seems to be

something that is defined differently from one person to the next.

In my mind, in the simplest sense, it’s the concept that we’re observing more cases of some disease than we would expect to see,

given our baseline information, which we hopefully have, and we

do have that for cancer. For many of the cancers, we do have

population——

Senator ENSIGN. But that’s what I’m saying. Then at what level

is it statistically significant?

Dr. SINKS. Well, this is the problem. Statistical significance simply implies the likelihood of chance. The likelihood of chance is

very much influenced by the size of the population and the number

of cases, and it’s not as relevant on the likelihood of cause as other

things. So I, myself, am not so hung up on what the P value is in

terms of, is the probability one in a thousand or one in ten thousand? I’m more concerned about, are there things that make biological sense here in terms of a possible agent that people might

be exposed to?

Senator ENSIGN. Well, isn’t the reason—if it’s possible by random

chance—what Assemblywoman de Braga talked about, one in a

quadrillion? I don’t know if that’s an accurate number, but certain

parts are statistically impossible when you get to a certain level of

a number.

Dr. SINKS. Well, Senator Ensign, I think this is the double-edged

sword of looking at clusters. On the one hand, if we simply go out

and try to draw circles around the population looking for events,

we’re going to find them. Whether the chance is one in a thousand

or the chance is one in ten thousand, if we do a thousand searches,

we’ll find one. We have to be a little cautious, when we start drawing circles, that we have some fundamental understanding of why

58

we’re drawing the circle, that there might be something that we’re

looking for.

I don’t know if I’m answering your question.

Senator ENSIGN. Well, not really.

Maybe, Dr. Falk, you want to take a shot at this. Is this random

chance? Obviously, I think this one is a fairly extreme case. We see

such a small population, and the chances of this being random, I

think, are pretty slim. When we look at other clusters as we’re

forming public policy, and we are not just forming public policy for

Fallon—when we’re developing these type of things, looking at

other cases in the future, we need to know what is significant in

the future. We want to know when to bring these resources to bear.

Dr. FALK. I think this is one of the hardest aspects of dealing

with problems like this. If you think of tens of thousands or even

hundreds of thousands of cases of cancer across the United States,

given the distribution that may occur, even randomly, there would

obviously be many occurrences by chance that look like they’re unusual but may not be, and it’s so very hard to know which ones

to actually focus on. Sometimes, as you pointed out, the statistics

are so striking, as here, that we say ‘‘Oh, definitely, this is where

we should focus.’’ But I think there’s a huge gray area in between

something that looks like a perfectly normal distribution and a situation such as we’re discussing this morning, where there will be

only two or three cases or seemingly unusual distributions, certainly ones that would seem so to people who are concerned. I

think, as Dr. Sinks points out, it will take a lot of judgment to

know where to focus and where the best hypotheses are to pursue

these leads.

Senator ENSIGN. I would just suggest to you that this seems to

be a fundamental question that we need to answer as we’re going

forward. Resources are not unlimited. If we are going to focus resources in the best possible manner, we are going to have to deal

with this question. If we’re going to have a national register or if

we’re going to have a focus, at what point do we ask Federal, State,

and local governments to work together with private entities? You

mentioned in your testimony that 90 percent of them turn out not

to be clusters. Well, what do you mean by that? If you don’t know

what a cluster is, how do you know that it’s not a cluster? That

seems to be a fundamental question we need to have answered. I

would appreciate us giving some thought, as we go forward, to this,

and maybe the Pew Center will give this a great deal of thought

as well.

Senator REID. Senator Clinton.

Senator CLINTON. I’m clustered. I thought I was making progress

understanding all this, but now I feel like I’ve gone 10 steps back.

I think that may be helpful, because, clearly, we have a lot more

questions than we do answers, and I think it’s very important for

us to begin to put into place the capacity to define the questions

clearly and then to begin to answer them. From what I understand

with this panel, that seems to be their recommendations.

Dr. Hearne, I really appreciate the work that the Pew Foundation has done with the report and now following up with the Trust

for America’s Health, and I am very pleased that you got specific

recommendations, that it’s not just an analysis that doesn’t tell us

59

what you think should be done, and they’re pretty hard hitting recommendations, I must say. Maybe, Harry, the reason that Dr.

Hearne is the front woman is because she seems so much less hard

than the recommendations.

Dr. HEARNE. They’re willing to sacrifice their young.

Senator CLINTON. That’s right, sacrifice their young for this.

One thing that you said which really caught my attention is that

the proposed budget from the administration recommends severe

cuts for the Nation’s chronic disease prevention programs. Can you

elaborate on which programs are slated to receive cuts and how

those cuts might impact on what we’re talking about today, which

is to put into effect a health tracking system nationwide that will

assist people at all levels of government?

Dr. HEARNE. As you know, the budget from the administration

was just recently released. So we’re still going through those numbers, but currently the Center for Chronic Disease and Prevention

at CDC has been targeted with a 23-percent cut of its budget. That

is the sentinel spot in this country for work on looking at the prevention opportunities of reducing the No. 1 cause of death in this

country. I highlight that because I think there has been a very

strong bipartisan commitment in this country to really move forward and advance our biomedical research, and I cannot applaud

that effort more as a health scientist.

But I think it’s also important—I think Dr. Prescott actually

noted this earlier on the first panel. We’re at a stage right now

that we need to be starting to apply our knowledge into the clinics,

into the communities on how to actually respond and prevent disease. We can’t simply be investing on the treatment side. We must

stay with that front, but we have the opportunity within our grasp

for preventing disease. I think one of the great examples—Dr.

Sinks mentioned folic acid and how our knowledge of that very

simple vitamin or nutritional addition to our diet has been reducing the cause of neural tube defects, a key birth defect in this country that was actually discovered from a birth defect registry in

Texas. Texas had a terrible birth defects crisis many years back

and couldn’t answer the community’s concerns, because they didn’t

have a tracking system. Texas now has one of the best tracking

systems in the country for birth defects, and it was able to put that

information together, that by adding folic acid to the diet, we can

prevent birth defects. That’s where this entire concept of nationwide health tracking comes from, that we need to have those investments.

Is there a line item for a nationwide health tracking network?

No. We hope, though, through leadership—and that was, yes, the

Pew Commission’s recommendations. We made it as simple but

hard hitting as possible, and thanks to Governor Weicker, Lou

Stokes, and other thoughtful Members of Congress, they’re meant

to be pragmatic, to deal with the concerns that communities have,

with the thoughts that the clinicians have, the agencies. We heard

from the State’s own epidemiologist and health officers—we need

to track.

Senator CLINTON. I hope that out of this hearing, which you

know certainly is receiving a lot of national attention, not just attention here in Nevada, that we’ll take another look at that, beVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00065 Fmt 6633 Sfmt 6601 H:\DOCS\78069 SENENV1 PsN: SENENV1
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cause there has been a very strong push to increase and double the

NIH budget, but if we don’t start applying what we have learned

to prevention, then we’re going to be constantly playing catch-up,

and I don’t think that’s in our best interest.

I also believe it’s important, as you point out in your report, that

there are other diseases or conditions that seem to be increasing

without any real understanding, and you said autism. I recently

met with a group of experts on autism, and it is just astonishing

how much autism we now find among our children. In fact, it

seems to be down to about 1 out of 200 to 250 children who are

being diagnosed with some form of the autistic syndrome. We know

we have an asthma epidemic in many parts of our country. It’s the

leading cause of admission into hospitals, and we haven’t yet figured out what it is we’re doing in our homes and in our communities that is prompting so much asthma.

So I really do hope that the recommendation that Dr. Hearne is

putting forth is going to be given some serious thought in Washington and in the administration, as well as in Congress, so that

we can start to find out more about a lot.

I just had one question, perhaps, to Dr. Falk. Under the toxic

chemicals, the list and the myriad numbers of chemicals that are

out there that have an impact on our well-being and our health,

what predictability are we putting into some of our effort with regard to these diseases that we’re now seeing? Where are we with

regard to that level of predictability? Do we have a high confidence

in that predictability, or is it at an evolving predictability level?

Dr. FALK. I think this is very much evolving. We know that there

are relationships between certain toxic substances and disease,

lead and lead poisoning and so on, but the great bulk of diseases,

in terms of chronic diseases, is really of unknown etiology. We don’t

understand what causes most chronic diseases. There are some—

cigarette smoking, for example, and lung cancer—where we have a

pretty good understanding, but many types of cancer, other types

of disease, we don’t understand really all of the factors that cause

those diseases.

I think one of the important aspects of doing better health tracking would be to identify in a better way what are the likely environmental inputs to disease, what are the environmental factors

that may relate to disease. I also think that we could do a better

job of coordinating the collection of environmental data and the collection of health data. We have a lot of environmental data bases.

The EPA, State health departments, and others have health data

bases, but we probably don’t do a sufficient job of actually linking

those data bases to look for the connections that might help fill in

some of the blanks. So what Shelley Hearne and the Pew Commission have espoused is a better collection of health data, but I think

part of that also is better linkage to environmental data to explore

the potential concerns.

Mr. GIBBONS. Ms. Trovato, thank you for being here. It’s not

often that we get the EPA with such a powerful individual. I would

like to put you on the spot. We do know that the EPA does have

a provision for their safe drinking water infrastructure funding.

Could we get a commitment from you for this community here?

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Ms. TROVATO. We distribute that money to the States, and then

the States make the decisions, so we would have to begin with a

converstion with the State of Nevada.

Thank you, Mr. Chairman.

Senator REID. Thank you, Congressman.

Dr. Falk, I want to thank you and your agency for conducting the

medical screening of approximately 70 people in Elko who had

worked in Montana and been exposed to asbestos-related illnesses.

That brought a sense of relief to those people, some of whom got

bad news, but the vast majority of them got good news. So we’re

going to follow that, but I think it’s important to recognize that the

work that has been done there is extremely important and will

have a long and lasting impact on, I guess, a positive feeling of the

people who have been pulled out of the blue, so to speak, and told

that they need to have these tests conducted, and it was one example that the Federal Government’s here to help.

Dr. FALK. Thank you.

Senator REID. I understand that Nevada’s cancer registry is currently not certified. What does this mean, Dr. Hearne?

Dr. HEARNE. There is a national program with a long title,

NAACCR. I think epidemiology might be in there somewhere, so I

don’t want to tackle that one. But it essentially sets a series of criteria of expectations with minimal performance for a cancer registry, to ensure its timeliness, its accuracy of information, and the

quality of analysis that is conducted with that registry. In the last

few years, that organization has been announcing which States,

which programs actually meet the national standards of quality. It

had been a very small number back in 1995. It’s been increasingly

going up, partly a reflection of the Federal commitment to invest

in cancer registries.

Nevada is probably one of the last States right now that has

failed to meet those national standards. In part, I believe recognition—and I don’t know the details on Nevada’s system, but I think

it reflects that it has a limited ability to collect all of the cancer

cases in the State, because information is limited by being generated from the hospitals. Today, with increasing outpatient care,

there may be many cases that actually slip the radar screen, so

that there would be significant under-reporting in this State. In

addition, lack of resources prevent a timely analysis and dissemination of that information, information that is critical to the communities, to health workers, and many others involved in doing investigative research.

Senator REID. How does anyone on the panel recommend that

Federal and State agencies go about correlating exposure to toxins

in the environment? It seems to me that we have a lot of things

in the environment that we know aren’t good for us, but we don’t

have any way of correlating where they are and what they do.

Dr. SINKS. I’m going to try to answer that by saying, I think

we’ve got a tremendous amount of work before us to truly coordinate all of these data bases into something comprehensive that can

be used, and not only comprehensive but useful, in terms of the

type of information that exists.

From our side at the Centers for Disease Control and Prevention,

we’re only beginning to launch into a new era where we’re colVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00067 Fmt 6633 Sfmt 6601 H:\DOCS\78069 SENENV1 PsN: SENENV1
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lecting national data on levels of contaminants in people, body burdens, if you will, of pesticides, of heavy metals, of chemical contaminants that exist in people. We believe that’s one of the best

ways to determine what’s actually getting into people. But we need

to link that information as well to the type of data that the States

collect on drinking water, air pollution releases, those things, and

we need to make those connections.

Senator REID. My concern is that there was a period of time

when the State of Nevada was required to collect information dealing with people who gamble. We did certain things and collected

all the information, which the Federal Government just dumped in

a warehouse, and no one ever looked at it. It was just collected. For

what reason, I’ve never learned. In this instance, we not only don’t

collect information, but when we do, it’s not correlated.

Let me close by saying this: I know for the parents of these children who are sick, we need some finality. I have heard, during the

time that we’ve heard these three panels—I think there’s an agreement that we could all have that would give some consolation to

these families. First of all, I think there is a consensus among the

panelists on the recommendations of Dr. Hearne for a national system for tracking environmental exposure and chronic diseases. All

four of you agree there, do you not?

Do we also have a consensus among this panel on the recommendation of Dr. Hearne on the need for a coordinated rapid response protocol within the Federal Government, who will work in

conjunction with State and local health officials to address these

clusters or other environmentally-related illnesses. You would

agree with that also. Is that fair?

[Nod in agreement.]

Last, do we have a consensus among the panelists on the recommendation of Dr. Guinan for a Federal blueprint for State investigation of clusters and for environmental monitoring, in conjunction with the Federal Government?

[Nod in agreement.]

So I think those are three things that are very important.

Yes?

Dr. SINKS. Senator, just as a last particular point, I want to emphasize as well the partnership of the States. Most of the States

do have protocols for dealing with these issues, and I think that

whatever we at the national level do, we need to partner with the

States and involve them in these discussions and make sure that

we are doing this together with the States.

Senator REID. I think we’ve learned, in all things—I had a hearing earlier this week dealing with the environment, and it was

clearly established by everybody that no matter how well-meaning

the Federal Government might be, unless the people on the ground,

locally, are involved in what we’re trying to do, it won’t work. So

the same applies here.

Senator Ensign.

Senator ENSIGN. Thank you, Senator Reid.

I think it’s really been an excellent hearing, as far as the information coming forward. It’s really been terrific.

I want to address the three questions, because I want to try to

have an understanding of how to go forward. Senator Reid, I’m

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glad you asked those questions, because that’s exactly where I

wanted to go with my last line of questioning. Dr. Guinan had said

earlier, and you and Dr. Hearne have talked about matters that

seem to have somewhat to do with each other. How do you structure this, and does money come from someplace else? Does a new

bureaucracy need to be set up, and which agency or which entity

is it to be set up in?

Dr. HEARNE. This isn’t rocket science. This is what public health

did with infectious disease back in the 1800’s, and we’ve won those

battles. What we need to do is have CDC in partnership with

ATSDR and the State and local health departments, modernize the

public health system to deal with chronic diseases. This effort must

build on the existing systems. They’re antiquated systems and

they’ve been starved for a long time. It would take both an infusion

of money—and I’ll answer that second part of your question—but

it really is about building on what we already have there, with a

focus on chronic disease and environmental exposures. It really just

takes the vision, as you’ve heard, from all of today’s panelists. We

just now have to have the leadership to make it happen.

We’re not talking about a lot of money. I think the first installment is getting a chronic disease investigator into every State.

There is already a system of EIS officers that could be augmented

to get that to happen. The tracking systems will take an investment, but we’re talking about a fraction of money in comparison to

many of our other investments on both the health and environment

side. I ideally would love to see the health investments in this

country increase, but I know that that’s more of a challenge, and

I’ll throw it back to Congress in terms of where the money comes.

But $275 million—it’s about 200 miles of highway roads—a fraction

of one environmental investigation into ambient air monitoring

programs, is what many people call ‘‘dust’’ in the budget process.

With a little creative thinking, that kind of small investment could

go a long way and really could modernize our public health system.

Senator ENSIGN. Dr. Falk, you wanted to comment?

Dr. FALK. I certainly agree. You know, at ATSDR—the original

CERCLA legislation gave us the name of Agency for Toxic Substances and Disease Registry—though I think that for too long our

agency never really actualized the last part of the name, ‘‘Disease

Registry.’’ So I see that as a direct responsibility under our mandate, and certainly not one just for us, but one that we would work

on with the CDC and others. So I think, for ATSDR, we would be

very interested, willing, and certainly eager to participate in thinking through these issues and developing a better system.

Senator ENSIGN. I’m glad you said that.

Two other comments. One is that, in veterinarian medicine, we

actually focus on prevention. That’s what our whole focus is—diet,

vaccinations, population, medicine. I’ve often said and campaigned

on many times that America has a sick care system, not a health

care system, and we need to change it more to a preventive health

care system. So I’m glad that—and the families, I hope, take some

comfort in—really, some good may come out of this hearing today.

Some profound changes in our health-care system could come from

this hearing today. I think that that’s very exciting. But I can’t get

away without letting Dr. Falk answer a question that I asked of

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the last panel. Regarding the issue of the Superfund site up on the

Carson River, are there funds available that we can possibly get to

use for this situation down here?

Dr. FALK. You know, our role is to advise EPA. We don’t disburse

the clean-up funds, but, in our role of advising EPA, we will take

that question up with them and discuss it.

Senator ENSIGN. I appreciate that.

Dr. SINKS. Let me respond a little bit to the last question, not

in terms of the Superfund site, but in terms of what we’re doing

with Fallon and the State. Everything recommended by the expert

panel, that is being asked of CDC and ATSDR, we will find the resources in our budget to see that it’s done. We are not going to ask

the State of Nevada to provide us resources to help them in that

work. I’m not sure what additional resources we particularly need,

we’ll have to wait to see the exact protocols. Every time I have

asked for help from EPA or ATSDR, it has been forthcoming. We

will get those resources and we will see that they’re delivered to

this issue.

Senator REID. Senator Clinton.

Senator CLINTON. Yes.

Dr. Falk, would you mind submitting for the record what ATSDR

activities and ongoing studies are currently underway in New York,

just so that I have that information?

Dr. FALK. Sure.

Senator CLINTON. I sure appreciate that.

Maybe we’ve got the makings of a Reid-Ensign-Clinton public

health bill that will be, of course, sponsored by Congressman Gibbons in the house. I think that, like John, I am really pleased at

how much information came out, certainly information I was not

aware of, and some of the interactions among the agencies that we

can zero in on and try to create more support for, as we do upgrade

our public health system. One of the real issues, I think, for the

21st century for our entire country is how we build on the successes of the past, because I’m certainly sure that every one of us

want to live and continue to live in a country where the water is

safe to drink and the air is safe to breathe and the food is safe to

eat, and, yet, I think we’ve fallen behind in dealing with some of

the challenges that we’ve now heard very eloquently addressed and

that we have an obligation to try to come up with solutions for.

I appreciate the consensus among this panel and the previous

panelists about what needs to be done. I would just point to, perhaps, some analogous situations. You know, we now have a very

good Federal emergency management assistance program. We

worked on it over the years, and it had to be improved. We now

not only deal with emergencies when they occur, we’ve put in a lot

more on the preventative side, and I hope we continue to do that.

You know, we help people deal with earthquake issues after some

terrible earthquakes, and we really cut the amount of loss of life

and damage from the Seattle earthquakes. We have dealt with hurricanes and tornadoes and other kinds of natural disasters. Certainly we have had a good response to outbreaks of food poisonings,

like E. coli and the like, and I think we need to look at that system. So I believe that we’ve got some good public, private, and

State, Federal, and local partnerships to look at as we address the

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concerns that have been raised at this hearing, and I anticipate

there’ll be a lot of work done in order to be able to come up with

some solutions.

So I really want to thank all of the panelists for coming forward.

I join with the Senators up here in our compliments for the panel

and the testimony that they’ve presented to us today was very enlightening. I do believe, as many of you do, that if we are going to

ever reach parity between treatment and prevention, that we are

going to have to make some significant investments into this system. It is enlightening to hear the testimony, but I also am reminded that over the last 20 years, the evolution of information

technology has made a contribution to the macro side, which is

where I believe each of you is suggesting that we go—to look at the

broad picture, as well as the narrow choices that we have in making some predictability to these diseases that we have affecting us

today.

I just want to thank you again for your presence here today.

Senator REID. I want to thank everyone for being here today. The

audience has been considerate and polite and quiet, for which we

all up here acknowledge and extend our appreciation.

We have here about 20 questions that have been submitted to us.

As you can see by the time, we’re not going to be able to answer

those orally here today, but, as I indicated, everyone here has their

name and address, and we will in detail answer these questions.

I want to extend my appreciation to the Environment and Public

Works staff. They have been working on this hearing for several

weeks. We’ve had people here on the ground. These are your taxpayer dollars being spent to prepare this hearing. You should be

very proud of the work that each of these individuals have done to

allow us to arrive at this point. I want to extend my appreciation

to the staffs of Senator Ensign, Senator Clinton, and Congressman

Gibbons for also working to make this hearing as good as it has

been.

Let me say to the reason that we’re here, the parents and the

children who are afflicted with this disease: This program which

has been conducted today has been helpful, and we are going to do

everything we can to find out if there is some cause that we can

find that has resulted in the illness of your children, but also everyone within the sound of my voice should understand that in the

future we’re going to do a better job with these clusters. We’re

going to have the ability of the Federal Government to respond in

a way that we haven’t responded in the past. As it’s been indicated,

we’re not going to each time reinvent the wheel. Every time, for example, there is an airplane crash in America, we have the National

Air Traffic Safety Board who responds immediately. They know exactly what they’re going to do when an accident occurs. We also

want to be able to respond that quickly and scientifically.

I wish I could express to the panelists how much I appreciate

your time and expertise. From the first witness to the last, it has

just been a feast of information. Now we turn this over, as we do

so many times, to our very responsible staffs and they’re going to

prepare a report based on the testimony—every word has been

taken—and they’re going to report to the committee and to the

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Congress and, hopefully, come up with things that are going to be

beneficial to our country and certainly the community of Fallon.

This committee stands in adjournment.

[Whereupon, at 1:00 p.m., the committee was adjourned, to reconvene at the call of the chair.]

[Additional statements submitted for the record follow:]

STATEMENT OF NEVADA ASSEMBLYMAN MARCIA DE BRAGA

Good morning. It’s a great pleasure to welcome you to Fallon and we want to

thank you for convening these hearings.

In the fall of 1999 I read with sadness a story in our local newspaper about a

fund raiser for a 5-year old who had ALL (Acute Lymphocytic Leukemia). Then

there were a few more cases and more sad stories.

I called the State Health Department and asked if they thought that four cases

of ALL in 3 months was an unusually high number in a small community like ours.

I was told it might just be an isolated cluster, but they would look into it to be sure.

In less than a year eight more cases were discovered. The statistical probability

of this number of cases occurring in an area with our population is one in ten quintillion. In other words, there is almost zero possibility that this cluster happened

by chance.

In mid-February, the Assembly Natural Resources, Agriculture and Mining Committee, which I chair, held 3 days of legislative hearings. The purpose of the hearings was to bring together the experts, data, research, knowledge, funds and other

resources in an effort to expedite the search for any environmental causes or contributing factors.

The hearings also served to attract considerable media attention and with it a

great many offers and promises from individuals and agencies as well as from local,

State and national officials to work together for a common—and urgent—purpose.

Others testifying will give you statistics and progress reports. What I want to

focus on is what I learned through the Legislative hearings and through listening

to the people whose lives have been affected by this tragedy.

As a result of the hearings, we prepared a list of possible causes, created from

our research and the testimony we received. That entire list is in your packet, along

with the names of agencies and individuals our recommendations have been forwarded to. It basically asks those in authority to leave absolutely no stone

unturned.

Our recommendations also include providing information to the public and expanding the scope of the investigation to cover: • A longer period of time; • Other disease groupings; • The analyzing of water, soil and air, and • The testing of the blood, bone, tissue and hair of the children.

I am happy to report that yesterday the Assembly Ways and Means Committee approved $500,000 to be used specifically for those purposes.

In addition, the committee recommends cleaning up the things the community is

concerned about now and not waiting for science to catch up or provide positive

proof. We unanimously agreed that the cancer registry and other data must be processed in a rapid manner so that information is current and readily available to

health and environmental officials and to the general public.

This leukemia cluster may be only a part of the whole picture. An eminent pediatric oncologist has advised us to investigate all marrow diseases and to look for

any increases in other forms of cancer among children and adults.

We know that two additional ALL cases were diagnosed in 1992 and, in 1991, a

5-year old died from Myelodysplastic Syndrome, a less common form of leukemia.

We know that earlier this year, a youngster was diagnosed with aplastic anemia,

another marrow disease. We know there may be additional cases that are connected

to Fallon but were not diagnosed here. And, we know there are clusters of other

diseases that also are suspicious.

I think it is vitally important that everyone involved be proactive and not rely

on old data, that we look beyond the environmental improvements that are already

being done to what needs to be done next, and that we approach our problems with

the hope and optimism that, through determination and perseverance, we can—if

not find a definitive answer—at the very least eliminate possible causes and add

to our information base.

Our legislative committee has sponsored a bill that would require public and private entities, certified to do environmental testing, to report to the Nevada Health

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Division or NDEP any findings of specific values that exceed the established Maximum Contaminant Levels. Those findings would have to be made public if a significant health risk was posed.

I think it’s imperative that we put these protections into law and aggressively

pursue our search for causes. That includes working to eliminate known contaminants. In so doing, obviously we improve the general health of our people and we

very well may destroy some of the ALL contributors.

Why do I feel so strongly that we have a responsibility to move forward in every

way possible?

Because this is about children—children whose lives have been turned upside

down by something terrible that’s beyond their control. This is about a beautiful,

smiling little girl whose hair is gone. This is about a promising young athlete whose

energy now only lasts for minutes. This is about a teenager whose HMO won’t pay

for a bone marrow transplant.

This, as you well know, is about furthering what is known about cancer so that

other communities might be spared what’s happened here. I applaud your efforts

to create a nationwide team to deal with these situations if and when they arise.

Senator Clinton, I read that you said, ‘‘There is no such thing as other people’s children.’’ You, Senator Reid, and Senator Ensign have clearly demonstrated that

belief by coming to Fallon to hold these hearings. We can’t thank you enough for

your concern and your willingness to help our community and communities like this,

everywhere.

Thank you for the opportunity to testify. I would be happy to answer any questions.

REPORT OF THE LEUKEMIA HEARINGS, FALLON LEUKEMIA CLUSTER, FEBRUARY 12– 14, 2001, PREPARED BY LINDA, EISSMANN, SENIOR RESEARCH ANALYST, LEGISLA- TIVE COUNSEL BUREAU

The Nevada State Assembly’s Committee on Natural Resources, Agriculture, and

Mining, and its Committee on Health and Human Services, held a series of hearings

related to a cluster of leukemia cases in Fallon, Nevada, on February 12, 13, and

14, 2001. They were held in the Legislative Building in Carson City. This report

provides a brief overview of the cluster, testimony provided throughout the hearings,

and the recommendations adopted.

BACKGROUND

Acute Lymphocytic Leukemia

Childhood Acute Lymphocytic Leukemia (ALL) is a disease in which underdeveloped lymphocytes (white blood cells) are found in unusually high numbers in

a child’s blood and bone marrow. Under normal conditions, the bone marrow makes

cells known as blasts that mature into several different types of blood cells, including red blood cells that carry oxygen and platelets that help the blood to clot.

However, in ALL the developing lymphocytes become too numerous and fail to

mature. They crowd out the normally-occurring red blood cells and platelets in the

blood and bone marrow. As a result, the bone marrow of children with ALL is unable to make sufficient red blood cells to carry oxygen, and the child may develop

anemia and tire easily. In addition, without sufficient platelets, the child may bleed

or bruise easily.

Acute Lymphocytic Leukemia is the most common form of leukemia found in children, and is the most common kind of childhood cancer accounting for 85 percent

of childhood acute leukemias. Thanks to progress made over the last 50 years in

the diagnosis and treatment of leukemia, there is now an 80 percent survival rate.

Investigation of the Fallon ALL Cluster

A cluster of ALL patients all under the age of 19, has been identified in Fallon,

Nevada. The cluster has been defined by the Health Division as ‘‘medically confirmed diagnosis of ALL, in an individual age 0 to 19 at the time of diagnosis, having resided in the Fallon area prior to diagnosis.’’ At the time of the hearings in

the Nevada State Assembly on February 12, 13, and 14, 2001, the State’s Health

Division was investigating 11 confirmed cases of ALL in the Fallon cluster. Of these,

one was diagnosed in 1997, two in 1999, and eight in 2000. Only a few weeks later,

a 12th case was confirmed (2001) and added to the cluster.

The expected rate of ALL cases statewide is calculated to be 2.78 per 100,000 population per year. With a population of only 7,850 people, the expected rate of ALL

in Fallon would be 0.22 cases annually. However, in the Fallon cluster, eight cases

were diagnosed in a single year (2000), representing a statistically significant event.

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As such, the probability of the Fallon cluster being a random occurrence was determined to be highly unlikely.

The epidemiologic study at the heart of the Health Division’s investigation involves a detailed questionnaire for each affected family, a review of all laboratory

and medical reports, environmental sampling, and consultation with health and disease experts from around the country, in an effort to find a common link between

the cases.

TESTIMONY AT THE LEUKEMIA HEARINGS

Testimony at the leukemia hearings was provided by many State and Federal

agencies; local governments; experts in pediatric oncology, childhood leukemia, arsenic research, and cluster investigations; a leukemia patient’s family; and members

of the general public. Attachment A contains the agendas and topics covered for

each day of the hearings.

For a complete overview of the testimony presented, please refer to the minutes

of the hearings, found in Attachment B of this report.

Although specific causes of ALL are not known, medical experts testified that several environmental and demographic features (as well as predisposing genetic syndromes) have been associated with an increased risk for leukemias in children. Risk

factors for the disease may include (but are not necessarily limited to) ionizing radiation, nonionizing radiation, chemical and toxic exposures, viral and infectious

agents, and parental occupational exposures. Overall, childhood ALL has been classified by scientists as a heterogeneous group of diseases, with varying immunophenotypes. Testimony also revealed that most ALL cases have a genetic link.

Throughout the hearings, the committees heard a great deal of testimony about

a variety of suspected causal factors for the leukemia cluster, including a number

of potentially hazardous materials and environmental contaminants. The possibility

that the leukemia cases are the result of a combination of factors was another common theme throughout the hearings.

Due to the high levels of naturally-occurring arsenic known to exist in the water

supply of Fallon, arsenic was suggested as a possible contributor. However, several

expert witnesses testified that while arsenic has been associated with some cancers

(including lung, bladder, skin, liver, kidney, and prostate cancers), research has not

revealed a clear link between arsenic and leukemia.

In addition to water quality concerns, other factors identified as potential contributors to the ALL cluster were agriculture and domestic chemical uses, military activities associated with the Naval Air Station (NAS) in Fallon, and a variety of environmental contaminants.

The following is a summary of the concerns and possible health risks identified

during testimony:

Agriculture and Domestic Chemical Uses

• Agricultural and other pesticides and herbicides used throughout the region.

• Possible effects of combined agricultural activities, including chemicals and crop

burning.

• Overall inability to monitor uses of appropriate domestic pesticides and herbicides.

• Need to educate the public about reading label directions for domestic chemical

applications.

Water Quality Concerns

• Implications of high levels of arsenic in the Churchill County area water supply.

• Insufficient water quality testing.

• Inadequate laws to require water well testing.

• Need to educate the public about the necessity of water quality testing and possible mitigation activities.

Possible Implications of Military Activities

• Potential contamination/use of hazardous substances at the NAS Fallon, including jet fuel ‘‘dumping’’ or other emissions.

• Stability of the jet fuel line to NAS Fallon.

• Distribution and migration of chaff during military training exercises.

• Microwaves from radar systems.

• Electromagnetic ground waves as a result of the Extremely Low Frequency

radio transmitting station installed in Churchill County by the Navy.

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Other Environmental Contamination

• Surface, subsurface, and airborne radiation and other contaminants as a result

of Project Shoal weapon test conducted 28 miles southeast of Fallon in 1963.

• Adequacy of industrial emissions monitoring (including air, ground, and water

contamination).

• Possible implications of ionizing radiation, depleted uranium, radon, nitrates,

fluoride, MTBE, volatile organic compounds, other industrial contaminants, and the

possibility of other radio nuclides in the Carson and Truckee Rivers.

• Reported PCB contamination at the Fallon Freight Yard.

• Flooding of the Carson and Truckee Rivers in 1997.

In addition to these potential risks to public health, suggestions were also made

to improve or expand the Health Division’s investigation of the Fallon leukemia

cluster:

Cluster Investigation Issues

• Expand the scope of the investigation to determine if there are other leukemia

cases or clusters that should be included in the analysis, or any other related marrow diseases that have a bearing on the investigation.

• Determine if there has been an increase in adult cancers over the last decade.

• Consider any combinations of possible factors and the potential involvement of

past contaminations.

• Test blood, bone, hair, and tissue samples from afflicted children.

• Occurrence of other possible disease clusters in the Fallon area.

• Possible implications of medical procedures including x-rays, ultrasound, and

immunizations.

• Potential role of viral and bacterial infections as a contributing factor.

• Coordination with and guidance to local veterinarians for possible/related animal diseases.

RECOMMENDATIONS

Following the hearings, and upon announcement of the 12th confirmed case of

childhood ALL, Assemblyman Marcia de Braga (Chairman of the Committee on Natural Resources, Agriculture, and Mining) requested an emergency appropriation to

assist the investigation. Assembly Bill 359 would make $1 million available to the

Health Division for expenses relating to:

1. The testing of victims of leukemia;

2. The testing of the environment to determine what factors may be contributing

to this outbreak of leukemia;

3. The compilation of data from the results of such tests; and

4. The dissemination of factual information and health advice to the residents of

Fallon.

A copy of A.B. 359 is found in Attachment C.

A subcommittee was also formed to evaluate and finalize a list of specific recommendations to enhance the sharing of resources among all participants, and to

assist the investigation in finding and addressing the cause of this leukemia cluster

as quickly and thoroughly as possible.

Members of the subcommittee were:

Assemblyman Marcia de Braga, Chairman, Committee on Natural Resources, Agriculture, and Mining (NRAM)

Assemblywoman Ellen M. Koivisto, Chairman, Committee on Health and Human

Services (HHS)

Assemblywoman Sharron E. Angle (HHS)

Assemblyman John C. Carpenter (NRAM)

Assemblywoman Sheila Leslie (HHS)

Assemblyman Harry Mortenson (NRAM)

Assemblyman P.M. ‘‘Roy’’ Neighbors (NRAM)

The subcommittee met twice, on March 6 and 8, 2001, and adopted a formal list

of recommendations. Immediately following adoption of this list, the recommended

Bill Draft Request (BDR) was made (and has subsequently been introduced as Assembly Bill 630), and all recommended letters were sent to the appropriate recipients.

Recommendations to Assist/Address the Leukemia Investigation

1. Committee BDR (40–1456, A.B. 630) should specifically include the following:

a. If a public health risk is detected in an area, the overall results should be made

public; and

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b. Require private or public entities certified to conduct environmental testing (including air, ground, and water testing) to report the results of these tests to the

Health Division when specific values exceed the established Maximum Contaminant

Levels. The intent is to make sure that the Health Division is able to track or detect

any public health risks by having information about contamination or elevated risk

levels reported to them.

2. Letter to the NAS Fallon urging it to:

a. Fully disclose to Nevada’s Health Division all toxic and hazardous materials

historically or currently kept onsite, and all instances of contamination with resulting clean-up measures;

b. Consider any and all other possible contaminates (including those that may

have been previously used) as possible contributors, beyond those currently included

in the investigation;

c. Evaluate medical histories of families formerly assigned to NAS Fallon, insofar

as there may be additional leukemia and other cancer cases in families who have

since been reassigned;

d. Compare results of the Navy’s water testing of the wells on the base, with the

City’s test results and any results of testing from the Fallon PaiuteShoshone Tribe;

e. Address/confirm reports that benzene was found in one of the Navy’s wells, and

if true, explain when and what corrective actions were taken;

f. Address/confirm reports of jet fuel used in diesel trucks and as weed spray;

g. Explain why Halon 1211 is listed on the NAS Fallon Section 311 ‘‘Emergency

Planning and Community Right to Know Act’’ for the 1999 Reporting Year, including how it has been used, is stored, and what ‘‘maintenance activities’’ involved the

use of jet fuel; and

h. Consider any possibility that the general public might have come into contact

with any of the materials listed on the Section 311 report of reportable materials.

3. Letter to Nevada’s Health Division recommending it:

a. Expand the scope of the investigation to determine if there are other leukemia

cases or clusters that should be included in the analysis, or any other related marrow diseases that have a bearing on the investigation;

b. Determine if there has been an increase in adult cancers over the last decade;

c. Consider any combinations of possible factors and the potential involvement of

past contaminations;

d. Test blood, bone, hair, and tissue samples from affected children;

e. Continue to provide information to the general public and coordinate education

efforts about possible public health risks;

f. Continue to solicit input from the public regarding possible causes; and

g. Address/consider the concerns and possible health risks identified during testimony (as previously described on pages 3 and 4 of this report).

4. Letter to the Health Division encouraging it to act as the lead agency to coordinate all educational, research, and investigative efforts.

5. Letter to the Health Division requesting it to proceed with the proposal provided by the University of Nevada, Reno, Department of Civil Engineering, to perform the Ames test on air, water, and ‘‘residue’’ samples collected in the study area,

and to work closely with all parties in research sampling efforts with the primary

goal being to delineate any areas or sources of increased mutagenic activity.

6. Letter to the Health Division requesting it to thoroughly examine Nevada’s

Cancer Registry and the current abstraction process, to determine ways in which

it could be improved and ways in which the lag time might be minimized. Letter

will request the Health Division to undertake necessary steps to improve the registry and report to the Legislature no later than May 1, 2001, what it has learned.

7. Request the Health Division to provide regular updates to the committee(s)

about new developments and the progress of its investigation and research, including any reports of its expert panel.

8. Letter to Nevada’s Division of Environmental Protection; urging it to:

a. Continue its participation with the Health Division in its oversight capacity for

environmental contamination (including air, ground, and water contamination) in

the Fallon area; and

b. Continue to monitor the progress of Project Shoal and the migration of surface,

subsurface, and airborne contaminates from the initial project site.

9. Letter to Nevada’s Department of Agriculture urging it to assist the Health Division in the leukemia investigation, by providing agricultural chemical use data

and by collecting and analyzing additional/necessary environmental samples (including air, ground, and water samples) in an effort to help identify any problems resulting from the use or combined uses of pesticides and herbicides in the Fallon

area.

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10. Letter to Kinder-Morgan requesting information about the jet fuel pipeline, including:

a. The frequency of inspection;

b. Reporting/inspection procedures;

c. Methods used to detect leakage;

d. Precautions used to avoid leakage;

e. History of repairs or upgrades; and

f. Potential to relocate the line if problems are detected.

11. Letter to the University of Nevada, Reno, asking it to assist with the investigation, collaborate with the Health Division, and participate with in-kind contributions to the extent possible.

12. Letters to the City of Fallon and Churchill County, indicating the Legislature

has undertaken hearings and held sequent meetings in an effort to combine resources and expedite a solution to the leukemia investigation. A copy of the recommendations will be enclosed. The letters will further indicate that the committees

wish to assist the City and County in any way possible in their coordination activities and educational efforts.

Recommendations to Assist/Address the Potential Public Health Risk of Arsenic

13. Letter to City of Fallon urging it to:

a. Take whatever steps are necessary to adhere to the new EPA standards for arsenic as soon as possible;

b. Evaluate opportunities for combining efforts of the City, NAS Fallon, and the

Fallon Paiute-Shoshone Tribe to reduce the overall cost of a common filtration system; and

c. Compare its water testing results with those of NAS Fallon and the Fallon Paiute-Shoshone Tribe.

14. Letter of support for Senate Concurrent Resolution No. 5 to the Senate Committee on Legislative Affairs and Operations.

15. Investigate the cost of installing ‘‘point of entry’’ filtration systems at each of

Fallon’s eight schools.

(Note: Subsequent to adoption of this recommendation, staff learned that the

Churchill County School District has determined that ‘‘point of use’’ systems are

more cost effective, including 79 reverse osmosis systems at water fountains and

kitchen faucets throughout the district. These systems are estimated to cost $70,000

to $80,000.)

Other Recommendations

16. Investigate whether community/public notification is made when the WeedMosquito Abatement District undertakes its spraying activities.

(Note: Subsequent to adoption of this recommendation, staff learned that the

Churchill County Weed-Mosquito Abatement District publishes an article once per

month in the local newspaper, informing residents about mosquito and weed problems, general areas targeted, and chemicals that will be used. However, representatives of the Abatement District indicate that it is difficult to notify the public of the

exact time and place to be sprayed because of weather variability. Also, most spraying takes place at the Carson Lake, 10 to 15 miles south of Fallon.)

CONCLUSION

The Committee on Natural Resources, Agriculture, and Mining, and the Committee on Health and Human Services, expresses sincere appreciation to the many

witnesses who testified throughout the leukemia hearings for their interest and participation in this unique and compelling situation. Special appreciation is also extended to the Health Division and members of its expert panel for their dedication

and the thoroughness of this investigation.

ATTACHMENT A

ASSEMBLY AGENDA FOR THE COMMITTEE ON NATURAL RESOURCES, AGRICULTURE,

AND MINING

Day: Monday

Date: February 12, 2001

Time: 1 p.m.

Room: 1214

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SPECIAL HEARING ON FALLON LEUKEMIA CLUSTER

Briefing.—Health Division.

Medical Overview.—Pediatric leukemia specialists; Local physicians experienced

in leukemia and immunology.

Environmental Overview.—Nevada Division of Environmental Protection; Arsenic,

Drinking Water Toxicologist, U.S. EPA.

Day: Tuesday

Date: February 13, 2001

Time: 1 p.m.

Room: 1214

Environmental Overview.—Jet fuel, NAS Fallon; Agriculture, pesticides and crop

spraying, Nevada Department of Agriculture, Mosquito/Weed Abatement District;

Other.

Impacts to the Community.—City of Fallon; Patient families.

Public Testimony.

Day: Wednesday

Date: February 14, 2001

Time: 1 p.m.

Room: 1214

Public testimony.

Medical and Environmental Overview.—Centers for Disease Control; Arsenic research specialist; Oncologist.

Strategies, coordination, and recommendations of the committee.

ATTACHMENT B

MINUTES OF THE MEETING OF THE ASSEMBLY COMMITTEE ON NATURAL RESOURCES,

AGRICULTURE, AND MINING, SEVENTY-FIRST SESSION, FEBRUARY 12, 2001

The Committee on Natural Resources, Agriculture, and Mining was called to order

at 1 p.m., on Monday, February 12, 2001. Chairman Marcia de Braga presided in

room 1214 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All exhibits are available and on file at the Research

Library of the Legislative Counsel Bureau.

Committee Members Present.—Mrs. Marcia de Braga, Chairman; Mr. Tom Collins,

Vice Chairman; Mr. Douglas Bache; Mr. David Brown; Mr. John Carpenter; Mr.

Jerry Claborn; Mr. David Humke; Mr. John J. Lee; Mr. John Marvel; Mr. Harry

Mortenson; Mr. Roy Neighbors.

Committee Members Absent.—Ms. Genie Ohrenschall (Excused)

Guest Legislators Present.—Assemblywoman Sharron Angle, District 29;

Assemblywoman Merle Berman, District 2; Assemblywoman Vivian Freeman, District 24; Assemblywoman Dawn Gibbons, District 25; Assemblywoman Ellen

Koivisto, District 14; Assemblywoman Sheila Leslie, District 27; Assemblywoman

Mark Manendo, District 18; Assemblywoman Kathy McClain District 15;

Assemblywoman Bonnie Parnell, District 40; Assemblywoman Debbie Smith, District 30; Assemblywoman Sandy Tiffany, District 21; Assemblyman Wendell Williams, District 6.

Staff Members Present.—Linda Eissmann, Committee Policy Analyst; Marla

McDade Williams, Committee Policy Analyst; June Rigsby, Committee Secretary.

Others Present..—Yvonne Sylva, Administrator, Nevada State Health; Division;

Dr. Mary Guinan, Nevada State Health Officer, Dr. Randall Todd, State Epidemiologist, Nevada State Health Division; Galen Denio, Manager, Public Health Engineering, Nevada State Health Division; Dr. Ronald Rosen, School of Medicine, University of Nevada, Reno; Dr. Carolyn Hastings, Oncologist, Children’s’ Hospital of Oakland; Dr. Vera Byers, Clinical Immunologist; Dr. Al Levin, Immunologist; Allan

Biaggi, Administrator, Division of Environmental Protection; Paul Liebendorfer,

Chief, Bureau of Federal Facilities; Dr. Bruce Macler, Regional Toxicologist, EPA,

San Francisco.

Chairman de Braga called the Assembly Natural Resources, Agriculture, and Mining Committee to order. Roll was called and a quorum was judged to be in place.

All members were present except for Assemblywoman Ohrenschall who was noted

as an excused absence.

Chairman de Braga welcomed as guests the Assembly Committee on Health and

Human Services. Roll was called, and all members were present, except for Assemblyman Tiffany who was noted as an excused absence.

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Chairman de Braga opened the meeting with a welcome to both committees and

an acknowledgement of the research and support that contributed to the leukemia

hearings. Chairman de Braga stated the purpose of the 3-day special hearings was

to gather information about the recent Acute Lymphocytic Leukemia (ALL) cluster

in Fallon and to explore possible environmental causes. The hearings had been designed to provide a forum for the pooling of research, data, experts, community leaders, agencies, government officials, health and environmental experts, and all other

resources. With the discovery of 11 cases of ALL in the Fallon area within a short number

of years, it had become imperative to address the expected concerns of the residents

as well as be aware of the welfare of the community as a whole. With the extensive

media coverage, Chairman de Braga explained that publicity had served a positive

purpose by bringing attention and resources to the community.

The format for the 3 days was described as a balance of expert testimony and

public input. Following the testimony of witnesses, questions by the two committees

were slated. Guests were encouraged to sign in and participate, and no questions

would be judged as worthless. At the conclusion of the 3 days, a panel would assemble recommendations based on all of the testimony.

Chairman de Braga emphasized that, even if the specific cause of the cluster was

never identified, public concerns would be addressed and environmental improvements made on behalf of the entire community.

Because of the pre-scheduled commitments of the two committees in attendance,

Chairman de Braga stated that, if at any time, a quorum failed to be present, the

hearings would continue uninterrupted under the status of a subcommittee.

Chairman de Braga introduced the opening expert testimony from the Nevada

State Health Division. The committees received two handouts, which were as follows: • A 6-page report entitled State of Nevada Health Division—Leukemia Cluster

Fact Sheet (Exhibit C). • A portfolio of reports which included leukemia fact sheets, a summary of what

constituted a cancer cluster, status reports, an overview of Health Division actions,

and other pertinent background information compiled by the Nevada Health Division (Exhibit D).

Yvonne Sylva, Administrator of the State Health Division, outlined their official

action since being notified in July 2000 of the high number of ALL cases in Fallon.

Their role as the first line of response was recognized. A complete investigation was

initiated, with two employees assigned full time, Dr. Mary Guinan, State Health Officer, and Dr. Randall Todd, State Epidemiologist. By November 2000, it became apparent that additional resources would be required. The calls from the news media

dictated the hiring of a full time media coordinator as well as a bilingual research

assistant to Dr. Todd.

Ms. Sylva summarized the multitude of State and Federal Government agencies

that were engaged for the fact-finding phase of their investigation. These included

the Center for Disease Control in Atlanta, the National Institute of Cancer, EPA,

Department of Energy, the Nevada Department of Agriculture and Nevada Environmental Protection. In January, an additional employee was assigned to field requests from the public and the news media.

According to Ms. Sylva, the investigation had been designed as a partnership with

the community of Fallon and was evidenced by a community presentation made to

Fallon residents in January. A separate community forum at the Naval Air Station

followed, with attendance estimated at 80 residents. A community meeting in early

February provided additional opportunity for more than 250 citizens to ask questions and air their concerns. A community telephone hotline (1–888–608–4623) was

established, with a reported 56 inquiries to date. Ms. Sylva welcomed additional recommendations for addressing public concerns.

Scrutiny of the Health Division’s investigative work had been openly solicited,

with requests made to Federal agencies across the country. This peer review was

designed to be an analytical critique of the soundness of their investigative methods

as well as their findings to date. Recommendations on improvements to their methodology were invited.

In response to Chairman de Braga’s question regarding the nature of hotline

questions, Ms. Sylva replied that citizen concern centered on the safety of continuing to live in Fallon, the chances of other children developing leukemia, and the

safety of drinking the water.

Assemblywoman Gibbons requested clarification of Fallon population figures, the

percentage of ethnic minority citizens, history of residents who had requested testing of their private wells, and data on other cancer cases that were linked to arsenic

in well water in the Fallon area. Ms. Sylva deferred to the upcoming testimony of

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Dr. Todd and Galen Denio. Chairman de Braga clarified that the population of

Fallon was estimated at 8,300 within the city limits and 26,000 within the county.

Dr. Mary Guinan, State Health Officer, resumed testimony for the Nevada State

Health Division. In July 2000 a call had been received from Chairman de Braga regarding the alarming number of leukemia cases at the Churchill Community Hospital. Following a review of the Nevada State Cancer Registry, it became readily apparent that the rate of current ALL cases in Fallon did represent a significant increase from what would be expected statistically.

Phase 1 of their investigative work commenced with consultation among experts

from various schools of medicine and public health agencies. All agreed that phase

1 had to be a thorough interview with each of the affected families for purposes of

determining common exposures. Questionnaires from previously conducted epidemiological studies were reviewed, which resulted in the development of a 32-page

questionnaire customized for the Fallon cluster. The time to conduct each family

interview was estimated at 2–3 hours. The participation by affected families, voluntary in nature, was 100 percent. Scientific methodology was closely followed in

the gathering of the data. Interviews of nine families were completed by November.

The results were analyzed and presented to the families in December by Dr. Todd.

In response to a question by Assemblywoman McClain regarding the place of diagnosis of the nine cases, Dr. Guinan clarified that the definitive diagnosis of leukemia was a bone marrow biopsy. This specialized test had to be done at the hospital where the treatment would occur.

Assemblywoman McClain requested clarification about the Health Division’s ability to track cases in other parts of the nation. Dr. Guinan reported that the publicity

did result in the addition of two cases in individuals who were not residents of

Fallon at the time of diagnosis. Word-of-mouth reports from the citizens of Fallon

contributed to the identification of the first nine cases.

Assemblywoman Leslie inquired about whether the Health Division investigation

included the comparison of physical evidence (e.g., blood test results) that might tie

these cases together. Dr. Guinan explained that questions did focus on discovering

common experiences with the goal of generating hypotheses that could be tested in

the next phase of the investigation. Environmental exposures were a principal focus.

Additionally, each family was invited to speculate about any theory they had about

cause or commonality with other families.

In response to Assemblywoman Leslie’s request for clarification regarding testing

of the children and environment, Dr. Guinan explained that no testing had been

conducted. Phase one was descriptive in nature, and additional testing would be

premature until possible causal agents could be identified. Testing of children (e.g.,

blood, hair analysis) dictated a judicious approach.

Assemblywoman Angle raised the issue of the number of phases of the investigation, any planned efforts to be proactive in uncovering new cases of leukemia, and

a timeline of when the results of the study would be available.

Dr. Guinan explained that the number of phases of the investigation was unknown. There had been hundreds of investigations of clusters, with few resulting

in identification of cause. The Woburn cluster, one of the few with an identified

cause, took 18 years. The Health Division had planned to proceed step-wise. Assurance of public fears had to be the first matter of importance.

In response to Assemblyman Neighbors, Dr. Guinan clarified that an historic review of the health records had been conducted for purposes of comparing the current

cancer rate with historic rates. The rate for Churchill County had been the same

as the State average, with no increase evidenced prior to this cluster. An essential

piece of information was described by Dr. Guinan as the population figures for children up to the age of 9 years in the Fallon area.

Assemblyman Neighbors requested clarification on whether Fallon’s drinking

water had been tested for substances besides arsenic. Dr. Guinan reported that tests

had included radioactive substances and pesticide tests, with no evidence of significant levels. Jet fuel tests of water had been negative as well. It was further noted

that some of the leukemia victims were served by the municipal water system while

others were on private wells.

In response to Assemblywoman Gibbons, Dr. Guinan outlined the expected rate

of cancer versus actual rates of cancer in Fallon. Dr. Guinan reported that the same

rate, 3 per 100,000 cases, would be expected throughout the State of Nevada. Multiple comparisons had been made with cancer registries across the nation, and the

conclusion was that we had a definite increase in Fallon.

Dr. Todd, State Epidemiologist, resumed testimony for the Nevada State Health

Division. Background information regarding communicable disease and cancer reporting practices for Nevada was presented. Dr. Todd referred the committees to his

portfolio of handouts (Exhibit D). Nevada Revised Statutes (NRS) 441 was cited as

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the guideline for their tracking programs for 60 communicable diseases. NRS 457

contained the regulations for tracking cancer. Since 1979, all invasive cancer had

been required to be reported by hospitals, with laboratories and physician offices

being added to reporting requirements in the late 1990’s. It was noted that outpatient management of cancer had interfered with the completeness of data in the

cancer registry. This had been compounded by an almost 2 year reporting lag in updating the data of the cancer registry, a common problem nationwide.

Dr. Todd elaborated on the three principal uses of the registry data, which included research, resource allocation, and program evaluation. The value of the registry data was illustrated by its application in cluster investigation.

The unusual number of ALL cases in a small community like Fallon within a

short timeframe grabbed the attention of the Nevada Health Division. Using population figures of Nevada communities, mathematical calculations of expected rates

and actual rates were scrutinized. Regardless of how the data was sliced, the probability of the Fallon cluster being a random event was judged to be highly unlikely.

For the years 1995 to 1999, Churchill County had expected to see only one case of

childhood cancer. Statistical analyses were alarming and indicated high probability

of a non-random event.

The expected rate in Nevada for residents up to age 10 was calculated at 2.78

cases of Acute Lymphocytic Leukemia (ALL) for a population of 100,000. Churchill

County, with eight actual cases, was judged to be a statistically significant event

given the expected 0.22 cases for its population of 7,850.

Dr. Todd elaborated on the epidemiological investigation, specifically the 32-page

questionnaire. Residential history was examined starting with 2 years prior to the

birth of each victim. Occupational history of both parents, medical history of the

index child, prenatal history, environmental exposure data, types of pets, activities,

and hobbies, household products, types of appliances in the home, and drinking

water sources were all investigated.

A timeline was displayed which captured residency in the Fallon area for all of

the affected families. Data was charted on bar graphs and then examined for overlapping of residency and other significant marker events. The preponderance of

overlapping points was identified as November 1996 through June 1999. This became the timeframe of interest and prompted research questions about coincidental

environmental events in Churchill County.

Scrutiny of water analyses received priority attention, especially synthetic organic

compounds (SOC) and volatile organic compounds (VOC). None were detected in the

municipal water supply that served approximately half of the victim families. Data

for private drinking water wells was not complete. Mercury, arsenic, gross alpha radiation, select components of jet fuel, benzene, and select pesticides and herbicides

were tested, and all were at or below the allowable limits.

Occupational history data included specific questions about chemical, fume, and

radiation exposures on the job. Although some incidents of exposure were discovered, this was judged not to be a common characteristic across all families. The

medical history of each index child was reviewed and revealed no common denominator. Maternal pregnancy questions included many subjects such as alcohol and

food consumption, medications consumed, occupational exposures, and breast-feeding habits. Questions related to family history of cancer revealed no pattern.

The most prominent question fielded by Dr. Todd during his investigation had

been the possible link between leukemia and arsenic in the drinking water. Research did not reveal a preponderance of evidence that linked arsenic with leukemia. Arsenic had always been present in Fallon, which begged the question of

why the recent cluster suddenly emerged. The pathway of exposure, as well as the

biological mechanism through which a suspected agent caused leukemia, were described as essential elements of their epidemiological investigation.

Chairman de Braga requested clarification about the State cancer registry, specifically at what point in time the registry would have revealed a cluster of cancer. Dr.

Todd explained that it would have taken several years before he would have been

confident to draw conclusions about a cluster. The lag time between diagnosis and

reporting was reported to be common for most cancer registries across the nation.

Chairman de Braga urged the Nevada Health Division to submit recommendations

about methods for expediting the cancer reporting process.

Assemblywoman Parnell inquired about substances tested in drinking water, specifically hydrocarbons and chemicals similar to those detected in Woburn. Dr. Todd

explained that trichloroethylenes and tetracholorethylenes were among the substances tested.

Assemblywoman Smith requested clarification on lag time, specifically whether it

was a lag between the initial reporting of the cancer, the completeness, or both. Dr.

Todd explained that lag time was a multifaceted problem, with the first component

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of lag described as the delay between diagnosis and compilation of the patient’s

medical record. The second component of lag was related to the abstraction of the

information from the medical records, a problem that was evident whether the abstraction was performed by the hospital or by a representative of the Nevada Health

Division. Dr. Todd estimated the abstraction time for each medical record at 40 to

60 minutes. The addition of laboratory reporting was anticipated to be a means to

expedite the process. By way of comparison, the Center for Disease Control (CDC)

standard was reported to be 90 percent at the 1-year mark.

Assemblywoman Smith resumed questioning with a request for clarification of

dates of water testing, specifically the inconsistency in the testing schedule and the

reported 2-year gap. Dr. Todd deferred to Galen Denio’s upcoming testimony.

In response to Assemblywoman Smith’s question about private well testing, Dr.

Todd clarified that private well testing had most often occurred when the property

changed ownership. The mortgage companies, not the state, were the requestors of

the water test and reportedly did not routinely order detection of the more complex

chemical substances.

Assemblywoman Smith inquired about the possibility of school commonality. Dr.

Todd reported no clustering or connection to any school site.

Assemblywoman Koivisto pursued the issue of the amounts of synthetic organic

compounds (SOC) and volatile organic compounds (VOC) detected in the water. Dr.

Todd clarified that water analyses revealed zero detection.

In response to Assemblywoman Leslie’s question regarding high levels of other

diseases in the Fallon area, Dr. Todd explained that his review of the cancer registry data through 1999 revealed only the childhood ALL cases in Fallon.

Assemblywoman Gibbons inquired about the probability that the Fallon cluster

could be a statistical anomaly. Dr. Todd replied that it was impossible to State with

absolute certainty that it was not a fluke. Despite the fact that most cluster investigations failed to conclusively identify a causal link, public concerns dictated the

need to continue the investigation.

Assemblyman Mortenson shared his personal experience with recent water testing

and cited a line in his water report which stated that radioactive substances were

not included in the analysis. In response to Assemblyman Mortenson’s request for

clarification, Dr. Todd added that the municipal water data presented were historical in nature and not connected to his current investigation.

Assemblyman Mortenson inquired about possible medical procedures and diagnostic x-ray exposure that the leukemia victims may have experienced. Dr. Todd

clarified that those were precisely the types of questions asked of the victims. No

pattern of exposure, including prenatal ultrasound testing, was revealed. In response to a question of statistical probability, Dr. Todd stated that the projected

statewide probability rate of 0.84 per 100,000 residents had not held up in Churchill

County. Assemblyman Mortenson next requested if the improbability of such events

had been calculated, to which Dr. Todd replied that it had not been determined.

Assemblywoman Berman cited an upcoming bill dealing with the comprehensive

cancer plan in Nevada. She specifically inquired whether her bill should be amended

to address the need for expeditious identification and response to cancer clusters.

Dr. Todd replied that this would require additional thought and that his written response would follow after consultation with his colleagues.

In response to Assemblyman Bache’s question regarding the possible connection

with the 1997 flood, Dr. Todd explained that the flood had been one of the most

prominent events identified for the time period of interest. Initial investigation had

not revealed any evidence of contamination of municipal water supplies. Aquifer

contamination would need further study.

Assemblyman Brown inquired about the geographic boundaries of the investigation. Dr. Todd reported that the cases were distributed throughout the city and surrounding area. Chairman de Braga called the committees’ attention to their information packets and to a copy of the published map which pinpointed the 11 cases.

Galen Denio, Manager of Public Health Engineering, Bureau of Health Protection

Services resumed testimony for the Nevada State Health Division. A handout (Exhibit E), which outlined the procedures for protection of public water systems, was

distributed. Mr. Denio presented an overview of the principal functions of the Bureau, the focus of which was ensuring compliance with drinking water regulations.

In response to earlier questions regarding water testing, Mr. Denio clarified that

the maximum contaminant levels (MCL) had been set by the Environmental Protection Agency (EPA) and adopted by the State of Nevada. The contaminant list was

described as extensive. In regard to private well water, Mr. Denio reported that the

bureau did not test these drinking water sources. In regard to the non-detects referenced by Dr. Todd, current methodology did not allow for detection.

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Chairman de Braga cautioned the committees of the need to maintain open minds

on the issues, especially given the extensive media coverage and speculation about

arsenic as a possible cause. Chairman de Braga requested clarification about the

policy and procedure for alerting the public in cases of high level of contaminants

in the drinking water. She cited the recent case of private well contamination at

Soda Lake and inquired about the follow-up procedure.

Mr. Denio explained that, because it was not a public water system, the Nevada

Health Division had not been advised through formal channels. Chairman de Braga

emphasized that, although not a public water supply covered by law, it was nonetheless a health threat to residents in that area. She expressed concerns over the

lack of a system to alert the residents of the danger.

Mr. Denio clarified that the Federal mortgage lending agencies had required well

water testing when the property changed ownership. The State did not have the responsibility with regard to private wells. Chairman de Braga restated her concern

that the quality of the drinking water should be disclosed as part of the real estate

transactions. This breakdown in communication could be addressed in the final report of recommendations.

Dr. Ronald Rosen, School of Medicine, University of Nevada, Reno commenced testimony. Two handouts, a pamphlet entitled ‘‘Epidemiology of Childhood Leukemia’’ and a one-page summary of comments (Exhibit F), were distributed. Dr. Rosen reviewed the remarkable progress made during the last 50 years in the diagnosis and

treatment of leukemia, with an estimated 85 percent survival rate. Children had accounted for only 1 to 2 percent of all cancers, with Acute Lymphocytic Leukemia

(ALL) the most common malignancy. The projected ALL rate was described as 3 per

100,000. At the point of diagnosis, ALL peaked at 2 to 5 years of age. Gender and

race had been discovered as significant, with a male dominance of ALL and a prevalence in affluent white children.

Dr. Rosen explained the differences between the various forms of leukemia. The

childhood ALL had been classified as a heterogeneous group of diseases, with varying immuno-phenotypes. He further emphasized the point that 80 percent of all ALL

revealed a genetic link. These actual genetic abnormalities within the cells had the

promise of enabling scientists to understand how the genetic and environmental factors linked together.

The trend, as described by Dr. Rosen, was one of increasing rates. Trends also

included striking differences in the international statistics of cancer in children.

Possible explanations were offered by Dr. Rosen and included access to higher quality medical care, a finer ability to diagnose cancer, and better cancer reporting systems.

Dr. Rosen summarized the risk to develop cancer as a complex interplay of inherited predisposition, exogenous exposure to agents with leukomogenic potential, and

chance events. Despite impressive advancements in the treatment of ALL, cause

had evaded science and, when discovered, was predicted to be complex. Dr. Rosen

elaborated by stating that ALL was a genetic disease, but rarely inherited as a genetic syndrome. Of interest was the leukemia rate for children with geneticallybased Down’s Syndrome, where the rate was 20 to 30 times greater than the general

population.

Dr. Rosen restated that little was known about epidemiology and etiologic patterns in childhood cancers compared to adults. A strong causal relationship had

been established with prenatal radiation exposure, albeit connected to a small percentage of ALL cases. Through the decades, documentation from atomic bomb

events had been thorough and included occupational exposure of workers and their

subsequent deaths from cancer. The data for ionizing radiation, overall, had been

conflicting. High dose exposure had been correlated to the high incidence of leukemia among survivors of atomic blasts, while age was strongly correlated to the

type of leukemia.

Non-ionizing radiation research had been extensive but inconclusive. Finding a

control, non-exposed population would be almost impossible. EMF (electromagnetic

fields) research had been largely inconclusive and remained controversial. Research

on chemical exposures to herbicides and pesticides had been associated with certain

forms of leukemia.

Dr. Rosen described the unique population of interest, specifically young children

between the ages of two to five in developed countries. Epidemiological evidence

supported the view that childhood ALL occurred in this age group due to a rare abnormal response brought on by unusual timing in combination with individual genetic susceptibility to a common infection.

This indirect evidence had been judged to be very compelling. The etiologic role

in this infection was described in the context of population mixing. On the subject

of population mixing and herd immunity (e.g., polio virus), Dr. Rosen described an

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increased risk of infection after population mixing and movement. Leukemia clusters occurred when herd immunity was deregulated by population mixing.

In summary, Dr. Rosen highlighted that in the unique population with ALL it was

a delayed first exposure that had been considered to contribute to pathogenesis of

several diseases associated with socio-economic affluence. Decreased breast-feeding

practices in affluent populations had been suggested as a factor and would need

analysis in the Fallon group. An abnormal immunologic response was emphasized

as a probable factor in the development of childhood leukemia.

Dr. Rosen highlighted the distinction between descriptive and analytical statistics

that resulted from epidemiological studies of leukemia. Interpretation of data had

been challenging, with conflicting results between studies. A lack of prevalence of

pediatric malignancies plus confounding circumstances contributed to the chance of

bias in studies.

In closing, Dr. Rosen reiterated that the Fallon cases had great significance and

could contribute to the eventual link of environmental-genetic interactions to the

pathogenesis of the various types and subtypes of childhood leukemia. Prevention

would follow as a realistic goal.

Chairman de Braga expressed her appreciation to Dr. Rosen. She inquired as to

whether the recommendations to which he alluded were in the handouts. Dr. Rosen

clarified that recommendations were not included, however he would be happy to

contribute input.

Dr. Carolyn Hastings, Pediatric Hematologist and Oncologist at the Children’s

Hospital in Oakland, commenced testimony. Dr. Hastings had practiced medicine for

more than 10 years in northern Nevada and had firsthand experience with the

Fallon cluster. It was noted that, because of the relative rareness of childhood leukemia (i.e., 3,000 cases per year), pediatric oncologists across the Nation networked

for purposes of sharing knowledge and experience.

The pooling of knowledge allowed for expansion of research and hypothesis generation. Genetic mutation had been determined to be a significant piece of the puzzle. One mutation that had developed in-utero was thought to be complicated by a

second mutation in early childhood, probably due to some environmental exposure

(e.g., infection). Establishment of the type and subtype of leukemia was described

by Dr. Hastings as essential to scientific comparisons.

Demographics were highlighted as the second essential component of the research. Correlations with age, race, and gender had been established. Children

under the age of 5 years and Hispanic children had been cited as having a higher

incidence.

Assemblywoman Gibbons requested clarification of the role of socio-economic factors and the possibility of the development of another type of cancer. Dr. Hastings

explained that it was impossible to determine with certainty when the leukemia developed in a child.

In response to Assemblyman Carpenter’s question regarding the existence of a diagnostic blood test, Dr. Hastings explained that there was no screening test available to predict the disease. The complete blood count (CBC) was described as the

most common screening tool. There would be no predictive quality to the test, only

diagnostic value. A bone marrow test, described as highly invasive, would alert the

physician in advance of active symptoms. Acknowledged as the most conclusive of

all laboratory tests, Dr. Hastings added that bone marrow testing would be done

only after reasonable suspicion.

Chairman de Braga requested a comparison between suspected environmental

causes of lymphoma and leukemia. Dr. Hastings confirmed the similarity. She

elaborated on the two major hypotheses, genetics and environmental exposures.

Chairman de Braga expressed her gratitude to Dr. Hastings and requested any recommendations.

Following a break, Chairman de Braga called the meeting to order and stated

that, because a quorum was not present, the hearings would continue as a subcommittee. An introduction of Dr. Vera Byers and Dr. Al Levin was made. An outline of their presentation (Exhibit G) was distributed.

Dr. Vera Byers, a physician with a specialty in clinical immunology, commenced

testimony and described with her experiences with the Woburn, Massachusetts cancer cluster case. Woburn was judged to be the prototype for cluster investigation.

Dr. Al Levin, a physician and scientist, interjected with his description of the role

he played in the Woburn case.

Dr. Levin stated with certainty that he believed the Fallon case would be a very

easy case. There had been signature genetic lesions evident in these diseases that

could be connected to etiologic agents. Examination of the siblings, parents and

neighbors promised to be revealing of any common environmental exposure. Dr.

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Levin expressed confidence at discovering the disease process, the causal agent, and

perhaps the pathway.

Dr. Byers resumed testimony with an overview of the Woburn cancer cluster.

Woburn, a town with a significant industrial presence, saw the development of 12

cases between the years 1969 to 1979. The cause was determined to be well water

contamination by tricholoethylene (TCE) and percholoroethylene (PCE).

One of the outstanding features of the Woburn cluster was that the community

itself identified the increased number of cases (as did Fallon) as well as the suspected source of contamination. The close proximity of the affected homes was significant. Since 70 percent of all cancers had been known to have a carcinogenic

cause (as opposed to genetic), water, soil and air sources were tested for chemicals.

Dr. Byers highlighted the value of testing family members and neighbors to uncover similar abnormalities. In Woburn, immune abnormalities were evident and

correlated strongly with TCE contamination. Sources of domestic exposure were

scrutinized because it was known that, increasingly, industrial chemicals were invading households in alarming amounts. The significance was described as being directly related to continuous low dose exposures within the contained atmosphere in

a home.

Dr. Byers reiterated the need to empower the community of Fallon. Historically,

it had been the community (e.g., Woburn) that not only uncovered the cluster but

the source of the environmental contamination. The prolonged investigation over almost two decades was attributed to the failure of the scientific and medical communities’ to believe the residents of Woburn.

Assemblyman Carpenter requested clarification of the map displaying the location

of cases in Woburn. Not all of the dots were included in the Woburn cluster, highlighting the difficulty of cluster identification. In terms of the genetic link, a prenatal exposure compounded by a secondary environmental insult had been the leading theory.

Dr. Levin interjected with an explanation of the role of genetics in the development of all diseases. Disease was described as a function of the individual as he

responded to an etiologic agent.

Chairman de Braga asked if the findings in Woburn had been conclusive. Dr.

Byers replied that the findings were highly conclusive and included the confirmation

of autoimmune abnormalities among family members of the leukemia victims. In response to a question regarding the 20-year timeframe, Dr. Byers clarified that once

the active investigation was instigated and publicized, the answers were apparent

within 3 years. Woburn demonstrated conclusively that it was in-utero exposure and

that when the suspect water wells were closed, new cases ceased within 10 years

(i.e., latency period).

Chairman de Braga acknowledged the contribution of Dr. Byers and Dr. Levin

and requested submission of their recommendations for future action.

Assemblywoman Gibbons summarized the factors that were known to be correlated with leukemia, for example a virus. She also requested clarification on the

socio-economic status of the families in Woburn and the role that Dr. Byers and Dr.

Levin would play in the Fallon investigation. Had they been invited to participate?

Both responded ‘‘no’’ to the question of invitation.

Dr. Byers expanded her explanation of viral etiology by stating that interaction

with a chemical carcinogen was required to trigger the cancer. In terms of socioeconomic class, Dr. Levin stated that all of the Woburn families had great similarity

as well as stability (i.e., long term residence in the area).

In response to Assemblyman Carpenter’s question about the known causes of up

to 70 percent of cancers, Dr. Byers stated that triggers such as smoking and

tricholorethylene exposure had been well established and documented. Assemblyman Carpenter observed that there appeared to be more cases of cancer, despite the

recent medical discoveries. Dr. Byers shared her theory on the movement of industrial chemicals into households and the significant increase in exposure. Dr. Levin

added his observation that pancreatic and brain cancers, once rare, had become

much more common today. Breast cancer appeared to be epidemic.

Assemblyman Carpenter probed for a theory on the increase in cancers. Dr. Levin

explained that brain cancer had been tied conclusively to maternal cigarette smoking and exposure to certain pesticides.

Assemblywoman McClain requested a comparison between Fallon and Woburn,

specifically the compact number of years in the Fallon cluster. Dr. Levin stated emphatically that the circumstances in Fallon suggested an ideal case and great opportunity to learn. Chairman de Braga expressed her hope of the continued involvement of Dr. Byers and Dr. Levin.

Testimony resumed with Al Biaggi, Administrator of the Division of Environmental Protection. A report entitled ‘‘Environmental Conditions Summary of the

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Fallon, Nevada Area’’ (Exhibit H) was distributed to the committees. Mr. Biaggi introduced his staff and then presented an overview of the agency’s principal activities.

Water quality issues received highest priority with Nevada Environmental Protection. Issuance of permits, followed by quarterly compliance reports were, reported

to be the key elements of their water monitoring programs. Periodic inspections had

been conducted by the agency to further ensure compliance with regulations. Mr.

Biaggi referred the committees to the handout, which contained summary tables of

caseload data.

In terms of Fallon, Mr. Biaggi described the area as not being a heavily industrialized area. Fallon had a total of 64 permits, with 14 connected to industrial storm

water and 19 assigned on a temporary basis for cleanup of site contaminations.

Waste management covered solid waste (i.e., landfills), waste generation of hazardous waste, and the oversight of facilities using highly hazardous materials. Mr.

Biaggi added that there were four facilities in Fallon designated as hazardous waste

facilities, one being a chrome-plating operation and the remaining three being geothermal power plant operations. In regard to solid waste management, there had

been a steady decrease in the number of landfills, with only one remaining in the

Churchill area.

Mr. Biaggi outlined the air quality programs which operated in concert with the

permitting processes described above. For Fallon, only two companies at three facilities had been subjected to reporting under the EPA TRI—Toxic Release Regulations.

Statistics for the two companies had been unremarkable.

Strong inspection and enforcement programs ensured compliance with regulations. In Fallon, there were permits issued for six geothermal plaints, six mineral

processing facilities, eight sand and gravel operations, two industrial permits, four

surface area disturbance permits, and two NAS permits (e.g., boilers and power generators).

Data for spills and accidents revealed 86 sites in the Fallon area, with 76 cases

involving petroleum products. Ten cases were reported to be still active.

Mr. Biaggi introduced Paul Liebendorfer, Chief of the Bureau of Federal Facilities, who presented an overview of the Fallon Naval Air Station activity. Mr.

Liebendorfer stated that 26 sites were known at the base and under current scrutiny. Principal contaminants included fuel oil, paints, solvents, and industrial refuse

materials. The upper aquifer had been contaminated to a depth of 20 feet, however

no contaminant had migrated off the base. General ground water flow was known

to be to the southwest direction and away from the Fallon area.

Chairman de Braga requested clarification on the testing of soil and air in addition to water testing. Mr. Leibendorfer explained that all of the contamination had

been determined as subsurface, therefore no air tests were warranted. Chairman de

Braga questioned the follow-up procedures for fuel dumping. Mr. Biaggi interjected

to explain that fuel dumping in the air was considered a distinct activity and not

related to their responsibility to address soil and ground water contamination.

In reply to Chairman de Braga’s question about well contamination with JP8 jet

fuel, Mr. Biaggi acknowledged a problem with groundwater contamination at the

site with JP8.

Assemblywoman Gibbons asked for clarification on the scope of the authority and

the ability of the State Environmental Protection Division to govern environmental

events at the Fallon NAS. Mr. Biaggi characterized the relationship as a cooperative

agreement with the Federal Government.

In response to Assemblyman Carpenter’s question regarding detection of jet fuel

in well water, Mr. Biaggi stated that there had been no indication of hydrocarbon

contamination. Assemblyman Carpenter next asked Mr. Biaggi if other tests had

been conducted which might provide insight to cancer. Mr. Biaggi reiterated that

municipal wells were tested frequently and that hydrocarbons had not been detected.

Chairman de Braga stated that it would be helpful to get a list of recommendations which included what could go wrong. Mr. Biaggi explained that there had to

be an exposure pathway and that the mere presence of a chemical contaminant

would not be enough to cause harm. Water would be suspected as a likely pathway,

however there had been no proof to date.

In response to a question about agricultural activities by Assemblyman Carpenter,

Mr. Biaggi acknowledged the testing of water for agricultural contaminants. He referred the committees to the Nevada Department of Agriculture.

Mr. Biaggi reintroduced Mr. Liebendorfer and the topic of the Shoal Project, an

underground nuclear detonation near Fallon in 1963. Through the years, testing

and remedial efforts were implemented, and Mr. Liebendorfer described the site as

contained today. Ground water wells had been monitored through the years, with

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one well revealing traces of a radionucleide. Any movement of ground water would

be away from the Fallon area.

In response to Chairman de Braga, Mr. Liebendorfer clarified that the wells had

been tested within the last 6 months. The Department of Energy had hired the

Desert Research Institute to conduct a full-scale study of the groundwater movement at the site of Project Shoal.

Mr. Biaggi concluded his presentation with mention of Nevada’s only superfund

site, the Carson River. With known high levels of mercury, the Carson River had

long flowed through the Fallon area, however, links between mercury and cancer

had not been established.

Assemblywoman Gibbons requested clarification of the flow of groundwater to the

east. Mr. Biaggi reiterated that the flow and any potential contaminants from the

navy base would be away from the Fallon community. Mr. Biaggi expressed his appreciation for the opportunity to participate and assist in the investigation.

Chairman de Braga introduced Dr. Bruce Macler, Regional Toxicologist, EPA, San

Francisco. Dr. Macler shared a handout of his presentation (Exhibit 1). Dr. Macler

stated that the focus of his testimony was arsenic and its possible relation to the

Fallon cluster. Exposure routes to arsenic were described as varied. Dr. Macler emphatically labeled arsenic a poison, regardless of ingestion route. Arsenic had been

conclusively linked to lung, bladder, skin, liver, kidney, and prostate cancers, as

well as diabetes and neurological complications. Like other cancers, leukemia occurred when damaged genes caused cells to reproduce uncontrollably.

Dr. Macler elaborated on the quantification of disease rates and associated arsenic

levels. Extrapolation downward from certainty to uncertainty was voiced as a concern. Some cancer risks had been quantified with confidence; however, information

was not abundant on the association with childhood leukemia. International studies

(e.g., Bangladesh) did not reveal an increase in childhood leukemia cases. The mechanism of arsenic damage appeared to be related to the repair mechanisms of chromosomes. Acute Lymphocytic Leukemia (ALL) had been linked to genetic damage

in earlier testimony. Dr. Macler speculated that arsenic did not initiate the leukemia but rather established a toxic background so that the actual causal agent

could trigger the leukemia. Whatever agent triggered the leukemia was amplified

by this toxic background, asserted Dr. Macler.

The question persisted in scientific circles about why Fallon had not witnessed increases in other cancers. Over a lifetime, with an estimated 10,000 residents in

Fallon, 100 people would be expected to get cancers of all types from exposure to

arsenic.

Detoxification of arsenic was described as a methylation process in the human

body and was said to offer some protection to the human. Thinking had changed

drastically in recent years, and the distinction between safe and unsafe forms of arsenic was obliterated. In moving from the known to the unknown in calculating risk,

regulations interfered with risk assessment. Dr. Macler emphasized that toxicology

and epidemiology and risk assessment were described as different processes, but

interrelated fields. Risk assessment was depicted as a process that had been driven

by regulatory needs.

Dr. Macler emphasized that there was no known threshold for arsenic and corresponding adverse effects. It had the status of a nonthreshold carcinogen. In summary, Dr. Macler stated that arsenic posed health risks and regulatory challenges,

however the risks could not be used to link arsenic to the childhood leukemia cases.

He further stated that arsenic had the potential of being a contributing factor.

Chairman de Braga asked if 10 parts per billion was an unrealistic level or excessively low. Dr. Macler replied that he did not agree, and added that 10 was feasible

and a good place to be. Costs were predicted to go down for methods to treat arsenic

in drinking water.

Assemblyman Carpenter referred back to an earlier comment made by Dr. Macler

and requested that he elaborate on any issues that caused him concern during the

day’s testimony. Dr. Macler explained that the nature of childhood leukemia and the

associated chromosomal damage caused him concern. The immunological steps employed by the body to clean up damaged genes and systems needed more research

to fully understand the relationships, especially in relation to arsenic health effects.

Assemblywoman Gibbons asked for clarification about the data that indicated that

methlylated arsenic compounds were as toxic as inorganic arsenic. Dr. Macler explained that the source of the data would be found in the Federal register, in the

literature, and on their Web site. Dr. Macler reiterated that because arsenic had

long been present in Fallon, it was likely to be a background amplifier rather than

the primary cause of the ALL.

In response to Assemblywoman Gibbons question regarding the role of individual

genetics and impaired immunity, Dr. Macler agreed that there was a possibility of

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that association. He did not, however, agree that it could be a fluke. He cautioned

the committee members to remember that everyone had been exposed to arsenic in

Fallon water, but not everyone got sick. Everyone could have been exposed to something else in Fallon that might have initiated childhood leukemia. Testimony did

not indicate compact exposure among these 11 children in Fallon. Variability in susceptibility had to be factored into the investigation.

Assemblywoman Koivisto requested clarification about the calculation of risk, for

adults or for children or for both. Dr. Macler stated that the risks were calculated

for adults and therefore biased. Risks were seldom quantified for childhood cancer.

Chairman de Braga expressed her appreciation for the testimony. The meeting

was adjourned at 5:19 p.m.

Respectfully submitted,

JUNE RIGSBY,

Committee Secretary.

FEBRUARY 13, 2001

The Committee on Natural Resources, Agriculture, and Mining was called to order

at 1:18 p.m., on Tuesday, February 13, 2001. Chairman Marcia de Braga presided

in room 1214 of the Legislative Building, Carson City, Nevada. As there was no

quorum present, Chairwoman de Braga convened the meeting as a sub-committee

of Natural Resources, Agriculture and Mining, and Health and Human Services. Exhibit A is the Agenda. Exhibit B is the Guest List. All exhibits are available and

on file at the Research Library of the Legislative Counsel Bureau.

Committee Members Present.—Mrs. Marcia de Braga, Chairman; Mr. Tom Collins,

Vice Chairman; Mr. Douglas Bache; Mr. David Brown; Mr. John Carpenter; Mr.

Jerry Claborn; Mr. David Humke; Mr. Harry Mortenson; Mr. Roy Neighbors.

Committee Members Absent.—Mr. John J. Lee; Mr. John Marvel; Ms. Genie

Ohrenschall.

Guest Legislators Present.—Assemblywoman Sharon Angle, Assembly District 29;

Assemblywoman Dawn Gibbons, Assembly District 25; Assemblywoman Ellen

Koivisto, Assembly District 14; Assemblywoman Sheila Leslie, Assembly District 27;

Assemblywoman Kathy McClain, Assembly District 15; Assemblywoman Bonnie

Parnell, Assembly District 40; Assemblywoman Debbie Smith, Assembly District 30.

Staff Members Present.—Linda Eissmann, Committee Policy Analyst; June

Rigsby, Committee Secretary.

Others Present.—Captain D.A. ‘‘Roy’’ Rogers, Commanding Officer, Naval Air Station Fallon; Charles Moses, Environmental Scientist, Nevada Department of Agriculture; Mike Wargo, District Manager, Churchill County Mosquito and Weed

Abatement District; Ken Tedford, Mayor, City of Fallon; Mike Mackedon, City Attorney, Fallon; Dr. Donald D. Runnells, Senior Technical Adviser, Shepherd Miller,

Inc.; H. Robert Meyer, Senior Scientist, Shepherd Miller, Inc.; Bjorn P. Selinder,

County Manager, Churchill County; Norman Frey, Commissioner, Churchill County;

Gwen Washburn, County Commissioner; Dr. Bonnie Eberhardt Bob, representing

the Western Shoshone Nation; Leuren Moret, representing Scientists for Indigenous

People; Keith Weaver, a long-term resident of Fallon.

This meeting continued the hearings from February 12, 2001, and was the second

part in a three-part series. Chairwoman de Braga requested that committee members and agency representatives write down recommendations to be included in the

final report to the Congressional committee hearings to be held at a future date.

A work session was planned for February 21 during which no testimony would be

taken unless an expert was available, but final recommendations for any legislation

would be made.

Captain David Rogers, Commanding Officer of Naval Air Station (NAS), Fallon,

Nevada, opened the hearing by reading a statement (Exhibit C) that gave an overview of the history and operations of the base since 1942, and issues which pertained to the investigation of the leukemia cluster.

Chairwoman de Braga asked Captain Rogers to explain a little about the pipeline

that brought fuel to the base, the route it took, who owned it and who was responsible for monitoring it.

Captain Rogers explained that the pipeline was owned and monitored by Kinder

Morgan Co. of Sparks, Nevada; specifically, it was tank 16. A 6-inch pipe ran 70

miles along 1–80, then through Churchill County to the base. NAS assumed responsibility for the fuel when it was on the base. Captain Rogers stated that Kinder

Morgan had an extensive monitoring program for leakage in the pipeline, which included pressure differential testing in the pipe and testing of the soils around the

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pipe. Kinder Morgan had not found any significant problems. Additionally, air and

water sampling done on the base had not indicated any leakage problems.

Assemblywoman McClain asked if any planes came back to Fallon from ‘‘Desert

Storm’’ and if there had been any way contaminants could have come back with

them. She wondered if the cause of the leukemia problems could be airborne and

asked if any investigations had been done to see if that was a possibility.

Captain Rogers replied the airplanes that participated in ‘‘Desert Storm’’ and

‘‘Desert Shield’’ action were not based at Fallon. There was probably a 11⁄2- to 2-

year time lag before any of those aircraft came to Fallon for training. The Navy had

not investigated the possibility of contamination and submitted that it probably was

not warranted.

Assemblywoman Smith inquired if the Navy was doing any follow-up with families that had been in Fallon during this time period to ascertain if they were included in this study.

According to Captain Rogers, the Navy medical community was investigating

whether any families which were no longer based at NAS Fallon had cases of acute

lymphocytic leukemia (ALL) occur since their departure. This investigation would

be completed by the beginning of March. To date, the study was about 60 percent

completed and none had been found.

Assemblywoman Smith asked if the fuel-handling procedures included the dumping of jet fuel, or if there had been a particular precautionary measure that was

covered in the fuel handling.

In response, Captain Rogers declared, generally fuel handling had many aspects:

refueling of aircraft, clean-up of fuel spills which happened either as the airplanes

were refueling or if the fuel inadvertently was jettisoned overboard on the ground,

and in-the-air fuel dumping above 6000 feet of ground level.

There was an extensive spill containment program; the amount that was spilled

was handled in various ways based on the size of the spill. If on concrete, it was

cleaned with absorbent materials that were disposed of in accordance with hazardous materials instructions. If the spill was on soil, the soil was excavated and

burned. The total number of spills was insignificant in terms of the amount. Captain Rogers offered to provide those figures if they were requested.

Captain Rogers continued, the only reason to jettison fuel over land would be during an emergency when the plane must be reduced to landing weight in order to

land. The total number of times this had occurred was perhaps 3 times in the past

15 years. In all three cases, the fuel was jettisoned out to 1he east of the base. As

evidenced in the monitoring, the contaminants moved 10 the east out of the base

area.

Chairwoman de Braga stated that as she read the articles in the newspaper, she

noted a comment that ‘‘they regularly see dumping’’ and asked what might have

been seen.

Captain Rogers submitted that probably these were contrails, an action between

the exhaust product from the airplane and the water vapor in the air which created

a cloud that could appear like fuel. He acknowledged the exhaust from the aircraft

smelled like fuel.

Chairwoman de Braga asked if something had changed in recent years regarding

the dumping at 6,000 feet rather than the 6,000 meters minimum standard of the

Federal Government.

Captain Rogers replied-that the Department of Defense (DOD) regulation is 6,000

feet above ground, unless it was a true emergency.

Chairwoman de Braga, to clarify, stated perhaps it was not a requirement but

that above 6,000 meters was estimated to be the proper range above which fuel dissipated or evaporated before it hit the ground.

Captain Rogers agreed but continued that there had been further study. Six thousand feet was the DOD standard until the introduction of JP8 jet fuel. JP8 did not

disseminate as well as the JP4 and JP5 that were previously used by the Navy. The

Navy and the Air Force were investigating a higher dump altitude. He affirmed that

any fuel that did not dissipate in the air would do so on the ground within 18 to

20 hours.

Assemblywoman Gibbons asked, as 1,800 people lived on base and 6,400 personnel resided off the base, were the two military children diagnosed with ALL living on or off the base? And, was there data to compare a base similar to Fallon,

and were there any acute lymphocytic leukemia cases on those bases?

Captain Rogers answered the first question by stating he was unaware of where

the children lived. Regardless, the water came from the same aquifer. As for the

second question, the Navy had done no comparison of ALL rates in Fallon and other

military areas. The military medical community was ‘‘all over this one’’ and if there

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had been another area with this same rate, that would show up in the investigations.

Assemblywoman Gibbons asked how many of the 8,200 are children. Captain Rogers offered to get the exact number, but estimated it was around a thousand.

Assemblyman Neighbors said that he had seen much of the aluminum foil chaff

that was dropped out of the aircraft in the desert and asked if everyone was comfortable that it was not a problem.

Captain Rogers defended that chaff was expended on the range considerably east

of the town and any chaff migration would tend to drift further east with the prevailing wind. He explained that a select panel of research scientists from eight universities studied the harmful effects of chaff and concluded that there were none

Chaff was a litter issue, not a health issue. The total amount expended at Fallon

equated to one quarter of one ounce per acre per year. This was an amount that

the Navy was willing to use in the name of combat training. Captain Rogers further

affirmed that the combat training done with chaff was essential because it was an

end game maneuver that could save a pilot’s life if a missile was shot at him. Without that three-dimensional training, people would die in combat.

Assemblywoman Parnell assumed that NAS Fallon had material safety data

sheets (MSDS) for toxic wastes and chemicals that they used, and asked if the

Health Division had seen them.

Captain Rogers acknowledged the base had that information but was unaware if

the Health Division had looked at it.

Ms. Parnell requested to know that the Health Division did have that information

in their possession. Ms. Parnell pointed out that in her packet of information she

had a 1999 article from the Las Vegas Sun regarding the citation of the U.S. Navy

by the U.S. EPA for noncompliance and violations of hazardous chemicals that were

noted 2 years prior to 1999. She requested to know the current status of compliance.

Captain Rogers claimed the article, as it appeared in the paper, was ‘‘not exactly

factual.’’ He believed that Mr. Liebendorfer of the State Division of Environmental

Protection was aware of the situation and testified on February 12 that the base

was in compliance, and what was reported on was a difference of opinion between

the State and the base regarding the interpretation of the regulation. That had been

resolved.

Assemblywoman Leslie questioned whether the live or spent ordinance on bombing ranges Bravo 20 and Bravo 16 was swept up and discarded, and did this debris

have any possible connection to the problem? This range scrap was extensive on the

four ranges, Captain Rogers admitted. There were times during the year when it

was swept into large piles until portions were removed. Scientists determined that

contamination from range scrap piled onsite in these dry alkaline lakebeds was not

an issue. Any migration of contaminants would tend to move eastwards.

Ms. Leslie asked if this was checked once or regularly every year. According to

Captain Rogers, the DOD Inspector General prepared a report about this and regular testing of the environment was conducted.

Ms. Leslie’s second question regarded the reaction of the families of the military.

She wished to know if they had asked the Navy for help which had not been touched

on in this hearing. The Captain replied this was an emotional issue. The base had

held town meetings. He affirmed that the Navy did not feel that Fallon was an unsafe place to live nor that this situation warranted moving families out of the area.

Ms. Leslie asked if the community accepted this or were some asking for transfers

out of the area. Captain Rogers believed that the majority accepted this. Just a couple of people asked informally if they could transfer but the Navy would not entertain that until they had been convinced there was a problem. The San Diego-based

Navy Environmental Health Command was intimately involved with the investigation and were as concerned as the local civilian community. The Navy was doing

everything possible to determine a solution. He continued that if the DOD felt there

was an immediate threat, ‘‘they would pull out.’’

Assemblywoman Gibbons questioned whether he knew of any commonality between the two cases with military children and the other nine cases in the civilian

community. The only answer Captain Rogers said he could offer was there was

nothing that was a common trait. The lifestyles and activities were varied.

Assemblywoman de Braga returned to the pipeline issue asking if the Navy could

detect small leakages on the base. Captain Rogers guessed that would depend on

the definition of ‘‘small’’ leakages.

Ms. de Braga restated her question to inquire if the pipeline could be leaking in

such small amounts that it would not be detected anywhere along its route. Captain

Rogers acknowledged that a minute amount of fuel would be detected in any water

source. If fuel leaked from the pipeline, he said, the ‘‘very aggressive’’ water testing

program would detect it. Ground testing was also done. The results of the testing

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were reported to him and to State and Federal agencies that oversaw the base water

quality program. He further explained that Kinder Morgan Co. was obligated to inform NAS Fallon if a problem was detected on the pipeline anywhere off base. The

base received the results of their testing but Captain Rogers did not ‘‘know specifically if there’s a requirement for them to do that or not.’’ He would get that information for Chairwoman de Braga.

Ms. de Braga stated that she wanted to be certain that enough precautions were

in place. She did not feel that there was ‘‘a lot’’ of ground testing being done, but

there was quite a bit of water testing. She questioned again what the Navy was

proactively doing differently to help in this effort; e.g., studies, tests, or other possible environmental causes.

Captain Rogers told the committee that the Navy was more sensitive to the environmental issues on base. NAS Fallon, he said, had much pride in the environmental programs he outlined previously (Exhibit C). He felt the Navy had a good

relationship with the State and Federal agencies which monitored the activities.

Captain Rogers revealed that he had a task force on base that assisted with the

investigation.

Ms. de Braga asked if the State had the authority to test on base. The DOD and

the Navy would give permission if necessary, Captain Rogers replied. Assemblywoman Koivisto asked Captain Rogers about the by-products in contrails that people

were breathing. He responded that the exhaust of a jet airplane was similar to that

of a motor vehicle. Contrails were essentially water vapor, not a hazardous substance.

Ms. Koivisto stated that since automobile emissions were controlled because of

health effects on the population, she found it difficult to believe that a jet airplane

did not have as much exhaust as automobiles. Captain Rogers replied that it had

a similar composition and offered to get that information for her. He continued that

obviously there is a larger amount than a car but State and Federal regulations controlled their air permits.

The next speaker, Charles Moses, an Environmental Scientist of the Nevada

Department of Agriculture (NDOA), stated that goals of the Environmental Compliance Section (ECS) were to protect health and the human environment from the adverse effects of pesticides and to assure that pesticides remained available as valuable tools in an integrated approach to pest management.

He stated that pesticides were used and regulated in a number of applications,

not just associated with agriculture: in ornamental lawns and turf, golf fairways,

household and domestic dwellings, fur- and wool-bearing animals, even pets, wood

protection, swimming pools and hot tubs, airport landing fields, tennis courts, highway right-of-way, mosquito abatement districts, and many more.

The challenge of regulating pesticides existed, he said, basically because of the

dual nature of the products. That is, they were a tremendous benefit for the production of agricultural products and for the protection of human health, but when they

were used inappropriately or inconsistently with label directions, they had adverse

affects.

Mr. Moses indicated that the State of Nevada had a cooperative agreement with

the U.S. Environmental Protection Agency (EPA), that the State received funding

and oversight from the agency to regulate pesticide use, manufacturing, sale, distribution and application.

Mr. Moses continued by giving an overview of the regulatory program that enforced the EPA provisions in the state. This defined a pesticide as any substance

that made a claim of preventing, destroying or repelling a pest or a substance or

mixture of substances used for plant regulators, defoliants and desiccants.

Since the creation of the EPA in 1972, it has been required that all pesticides

must be registered. The law was revised in 1996 to eliminate the benefit factors on

food crops and in areas where children would be exposed. All pesticides, new and

existing, were required to conform to the standards.

Based on the data submitted for pesticide registration, the EPA developed a label

that addressed the hazards of using the products. Mr. Moses emphasized that what

set a pesticide label apart from other hazardous chemical labels was that this label

was the law. An applicator must use this product in accordance with all information

that was printed on the label. A signal word ‘‘CAUTION’’ was used on the label for

the safest type product to give an indication of how acutely toxic the pesticide was.

In other words, with a large dose over a small period of time, the ‘‘CAUTION’’ gave

an indication of whether the victim would experience health effects. For this type

of product, he claimed, it would take quite a bit to actually cause health effects.

However, the signal word would not say how chronically hazardous this product

was, used over an extended period of time.

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Lastly, Mr. Moses continued, the EPA gave the State the responsibility of enforcing the pesticide law and the State had to show that it had similar State laws to

regulate the sale, manufacturing and use of pesticides (Chapters 555 and 586 of the

Nevada Revised Statutes). Commercial applicators and farmers were trained, tested

and regulated. The NDOA required all applicators submit reports of customers,

sites, products and quantities applied. These reports and data have been acquired

since 1970.

Mr. Moses said that the NDOA, as part of the agreement with the EPA, did inspections on Federal property and had been to the NAS Fallon airbase to inspect

the pest control activities. In most cases, he stated, they found that the Navy contracted with private individuals and licensed companies to do the work. According

to Mr. Moses, the Navy asked the contractors ‘‘to go above and beyond’’ what NDOA

required, and concluded that they had been cooperative with the Nevada inspectors.

Next, Mr. Moses showed a sample of a sales report which showed who bought restricted-use products. All of this was public information and was available upon request.

Mr. Moses then shifted gears and explained the ground water monitoring program

for pesticide residue. In 1988, the EPA found that pesticides existed in low levels

in a lot of different areas and in some cases in public drinking supplies and shallow

ground water wells. Since then, the EPA has required every State that had a cooperative agreement with them to have a regulatory program designed to protect

ground water from becoming more contaminated or becoming contaminated from the

applications and use of pesticides.

For a long time, Mr. Moses admitted, it was thought that pesticides could not seep

down 150 to 200 feet to water wells. But even with proper application, he said, it

had been found that pesticides had properties that may allow them to leach down

into ground water. Mr. Moses showed that since the monitoring program was implemented, there had been more detections in urban areas than in rural areas in the

ground water sampling.

Mr. Moses distributed a fact sheet (Exhibit D) done with the U.S. Geological Survey (USGS) that explained the monitoring program. In most cases, the wells were

constructed by the NDOA to look at the shallowest aquifer they could find. If pesticides were to show up in the shallow wells, there would be time to implement regulatory measures before the pesticides leached to the deeper aquifer.

In Churchill County last year, Mr. Moses further explained, water samples from

about 20 wells, many of which were put in by the USGS, but some were irrigation

wells, were examined for about 40 EPA-registered products. The NDOA did not look

for products that the EPA canceled due to health risks because there would be no

regulatory measures that NDOA could take to try to keep the pesticide from getting

worse because it was no longer being used. No contamination was found in Churchill County.

In one other item, Mr. Moses showed that the USGS did some studies ‘‘in that

area’’ of ground water and surface water samples and did find pesticide residues.

The chart he used showed the levels were far below what a health advisory would

be for these products. Many of the products leached into the ground water were a

result of right-of-way applications. These included Atrazine, Prometon and

Simazine. He summarized that most of the cases of leached pesticides were not from

agricultural products but from use around homes, lawns and right-of-ways. But they

were still quite low, far below health advisory levels.

Lastly, Mr. Moses stated that he had information about studies that he had requested the EPA send him. He declared he would be glad to submit them to the

committee because there had been some links to different types of uses where the

mothers were working with the chemicals when their children developed leukemia.

Chairwoman de Braga agreed she would very much like to see that information

because those gaps might lead the committee somewhere in this investigation. She

felt it helped them to know the extent to which the NDOA went to protect people

from chemicals. But, she questioned, what could go wrong? The bottom line was that

there was not complete regulation because you could not know if a housewife mixed

409 and a non-recommended agent which had fine print on the bottle that nobody

read. Maybe education would be the key to this. What she and the committee wanted to know is not what was being done but rather what was missed.

Mr. Moses agreed that one problem they had was assessing the use of pesticides

by homeowners. There was data in some of the studies that suggested that there

were links.

Mrs. de Braga added that even the people who aerial crop-sprayed, who sprayed

your house for spiders or whatever, were they taking the proper precautions? And

what about accidents? The problems might have been entirely different from house

to house.

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Assemblyman Neighbors asked about the ground water level of the 20 wells that

were tested in the Churchill County. Mr. Moses believed that the monitoring wells

averaged about 40 feet. Drinking water and irrigation wells were much deeper.

Mr. Neighbors stated that, as he recalled, Nevada law said you may put a well

and a septic tank on one and a quarter acre. Correct? Mr. Moses was uncertain.

Mr. Neighbors ask about the percolation rate and Mr. Moses replied that he did not

know.

Ms. de Braga suggested that this was not really his area. Mr. Neighbors said it

would be interesting to know because there were areas of Nevada where that had

become a problem. Too many nitrates might be in the water. Mr. Moses believed

that the Health Division had that data and it could easily be obtained from them.

Assemblywoman Gibbons mentioned that the members of the committee were

given maps of the Fallon area that showed where the children with leukemia lived.

She asked if there was a map that showed the areas where pesticides were used.

Could the rainfall or drought years have had an effect on this? Mr. Moses answered

that he could probably come up with a map of the agricultural areas but it would

be tougher to do the residential usage areas. They did not know what homeowners

were using nor how much.

Ms. de Braga inquired about the types of complaints Mr. Moses had received

about pesticide use. They ranged from human health and vegetation damage to possible adverse effects to animals, Mr. Moses replied. He got from 10 to 50 of these

serious investigations per year. At conclusion, Mr. Moses distributed a list of Available Resources for the Leukemia Task Force (Exhibit E).

The next speaker was Michael J. Wargo, District Manager, Churchill County Mosquito and Weed Abatement District (MWAD). He distributed a letter that outlined

the activities of the Mosquito and Weed Abatement District (Exhibit F). With this

he also distributed material safety data sheets for the pesticide used by the District

(Exhibit G). Mr. Wargo stated that he was a biologist more so than a chemist with

a degree in entomology, the study of insects.

Mr. Wargo briefly reviewed the information in the letter that addressed the history of the MWAD, the chemicals they used to control mosquitoes, and the weed activities. To control the mosquitoes, his staff considered the site, the size of the colony, the impact on the area and the population of the natural predators at the site.

With the mosquitoes in an early stage of development, natural agents such as a bacteria or mosquito hormones were used for control. In a later stage, a light petroleum

oil was used in the water to suffocate the pupae. If mosquitoes reached the flight

stage, they were treated with pyrethrum, a compound made from chrysanthemums,

or with Dibrom aerially applied over a large acreage. These latter two applications

were not preferred because of the expense and the difficulty of application. Mr.

Wargo added that most of the mosquito populations were not in Fallon but out in

the rural surroundings.

Next Mr. Wargo spoke about the weed control activities that began in 1987. The

chemicals used were listed on page 3 of his letter (Exhibit F). In 1999 and in 2000,

Pendulum was used as a preemergent along the county roadsides. During the summer, Glyfos and Weedone were used. Arsenal was used to create a bare zone that

protects a road base from emergent weeds that damaged asphalt. Roundup and 2–

4–D were used as needed to eliminate emerging weeds.

Mr. Wargo concluded by saying that, from 1998 to 2000, Tall Whitetop control

along the Carson River required the use of Weedar 64 and Rodeo. Some isolated

patches of Tall Whitetop, Russian Knapweed and African Rue were sprayed with

Tordon.

Chairwoman de Braga asked Mr. Wargo if there had been any substances used

that were now considered unsafe.

Mr. Wargo replied that he was unaware of any. All the chemicals they used, he

said, were approved and were used extensively throughout the United States by

State and county health departments and by other mosquito abatement districts.

Ms. de Braga stated that in the history of the area much was done by aerial

spraying, but if it were intended to kill insects, how could it not be harmful to humans who breathed it?

In reply, Mr. Wargo referred to Mr. Moses’ previous comments that the EPA required tests to be done before the chemical was registered. The end user had no

input into that process.

Right, Ms. de Braga agreed, then mentioned that the committee was back to not

knowing what people were breathing in combination with this chemical and what

deleterious effect this might cause. She asked if Mr. Wargo was aware of any use

of jet fuel, or something with the same components as JP8, for weed killer. She stated she had received a report of this possibility in Churchill County. ‘‘No,’’ Mr. Wargo

replied.

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Ken Tedford, Mayor of the city of Fallon, spoke next. He began his testimony by

stating that Fallon was a tight-knit community, taking seriously the good and the

bad that happened there. As the investigation into the leukemia cases unfolded,

more media attention was paid to the children. He assured the committee that his

focus was not on the town’s image but rather to put the care and comfort of the

children first while preserving their privacy. Mayor Tedford’s goal was to establish

a single point of contact in the community, a place were the families could go if they

had needs that were not met, and a place for those who wanted to give their time,

money or talent to assist.

To avoid fear, rumor and lack of information, the city council prepared fact sheets

and answers to frequently asked questions (Exhibit H) and other information for

distribution throughout the community (Exhibit I). He thanked Governor Guinn, the

State Health Division Administrator Yvonne Sylva, State Health Officer Dr. Mary

Guinan and State Epidemiologist Dr. Randall Todd for their efforts. He declared

that the city would continue to assist in the ongoing investigation.

Mayor Tedford then began to speak about the city water supply that provided

services to approximately 2,900 connections from four city wells pumping water

from the Basalt Aquifer. However, he clarified, not all of the affected families were

on city water—some used private wells and some drank bottled water. He restated

the belief that the city water supply was not the common link in these cases.

He acknowledged that arsenic was present in the water of Lahontan Valley. Many

of the 4000 domestic wells, contained naturally occurring arsenic, as did the water

in the city and Navy wells. Fallon had known of this arsenic for a long time and

had struggled to deal with it. But, there appeared to be no link between arsenic and

leukemia, he held.

The city contracted with Shepherd Miller Inc. (SMI), an environmental and engineering consulting firm, to conduct tests and surveys for arsenic removal from the

water. The public water system would need to comply with the new Federal standards of 10 parts per billion by the year 2006.

Mike Mackedon, Fallon City Attorney, next read from a brief memorandum (Exhibit J) that stated that the city had engaged Shepherd Miller, Inc. in April, 2000,

to provide technical consultation. Within the binder (Exhibit K) were some of the

water reports ‘‘in history’’ that the city had provided to the State as part of its regular reporting duties, under State or Federal law. Additionally, there were numerous studies and analyses conducted by the city in excess of and different from those

required under any reporting requirement, and some in direct response to the pattern of leukemia.

SMI had been asked to examine past data to determine the quality of the data

to the extent possible. They were further instructed to survey the available or innovative technologies that would remove arsenic from drinking water and select a suitable bent-scale test method, to perform tests, to review and analyze the results, and

evaluate the results; to perform pilot-scale testing on the selected treatment technology, evaluate those results, and recommend a final arsenic treatment technology.

The bent-scale tests were completed and pilot-scale testing began on November 30,

2000.

Mr. Mackedon continued that SMI’s work was expanded in July of 2000 when the

city learned of the childhood leukemia cases and that the pattern might have suggested an environmental cause. The mayor instructed Shepherd Miller to: review

the available literature and research to confirm or not confirm a connection between

arsenic and childhood leukemia, to review the available literature and research to

confirm or not confirm a connection between the intake of radon and childhood leukemia, to re-review the historical analysis of the water chemistry of the city of

Fallon, to proceed to develop a list of agents known or suspected to cause leukemia,

and to perform tests of agents not previously analyzed.

Mr. Mackedon introduced SMI representatives Dr. Don Runnells, Senior Technical Adviser, and Dr. H. Robert Meyers, Senior Scientist.

Don Runnells spoke first, introducing the company, its history and himself, a

water geochemist and professor at the University of Colorado. He reiterated that

SMI was hired in April of 2000 to characterize the ground water supply and to provide recommendations on water treatment technology to address the arsenic issue.

From September of 2000 through late January 2001, SMI reviewed and compiled

data from historic groundwater analyses of samples from the city of Fallon water

wells to determine if any regulated constituents were present in concentrations

above the Nevada drinking water standards maximum contaminant limits (MCL).

With the exception of an elevated value of lead in 1989 and the arsenic in all samples, the water had tested below the primary drinking water standards. In the secondary standards, total dissolved solids in the water had exceeded the secondary

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standard of 500 milligrams per liter. It also exceeded the standard for PH that is

6.5 to 8.5, having been around 9.

Based on a very recent literature review for potential leukemia causing chemicals,

Shepherd Miller, Inc. developed a list of chemicals and analytes, some of which

could potentially cause leukemia, for which there had been no previous testing in

Fallon. They excluded from the list pharmaceuticals, analytes for which there were

no analytical methods for testing, chemicals used as part of the water treatment

system, and highly reactive chemicals that had a very short half-life and were gone

quickly when added to water. Those remaining of possible concern included formaldehyde, lead 210, and radium 224. In early February of 2001, the city of Fallon

wells were sampled for these additional chemicals. The results had not yet come in.

SMI also looked at the composition of fuels such as JP8 jet fuel, to determine if

historic water analyses might contain components that could be related back to hydrocarbon fuels. No historic analyses showed a presence of volatile organic chemicals or synthetic organic compounds above detection limits. These were expected to

be found if a fuel supply was, in fact, contaminating the ground water. Dr. Runnells

remarked that the Fallon water was ‘‘remarkably clean’’ with the exception of the

arsenic. The binder (Exhibit K) summarized the findings.

Assemblywoman Koivisto asked for clarification as to why so much emphasis was

placed on the water supply when the children who contracted the leukemia did not

all use the same water source. Dr. Runnells affirmed that Ms. Koivisto’s observation

was correct. SMI was brought in originally specifically for the arsenic issue. Subsequently, with the community awareness of the leukemia cluster, the mayor and the

city council directed them to expand the scope of their work to include a review of

what was known about the relationship between arsenic and leukemia and also to

identify other chemicals that might be related to leukemia. Dr. Runnells avowed

that SMI did not believe that the city water supply was the problem.

Assemblywoman Parnell stated that it appeared that most experts agreed that

the most direct link to childhood leukemia would be that of radiation. She asked

if it was possible to look for a radiation link in the water supply or somewhere else.

Dr. Runnells affirmed that SMI was looking at the water specifically for radionuclides. In the binder (Exhibit K), Table 4 listed the radionuclides and gave the

values they found and the MCL. Gross beta could be composed of a number of radionuclides. Therefore, SMI also analyzed for lead-210 because it contributed to gross

beta and had a high risk factor.

Ms. Parnell asked whether anything on Table 4 alarmed Dr. Runnells, especially

the gross alpha of Wells 2 and 4. He deferred that answer to Dr. Meyer as that was

his field of specialty.

Assemblyman Mortenson asked if the lead-210 was a more energetic beta to

which Dr. Runnells replied that it was attracted to the surface of the bone and

therefore had a high risk factor. Mr. Mortenson also asked about the short half-life

of radium 224 and whether there were products in the decay chain that were stable

enough to analyze and then infer back to the quantity of radium 224.

Dr. Runnells replied that radium 224 was a decay product of thorium that normally was not found in the ground in a natural situation. But SMI was analyzing

specifically for radium 224 to be certain something with a short half-life was not

overlooked. The half-life of radium 224 is about 48 hours.

Mr. Mortenson asked if lead-210 was not a product in the decay chain of radium

224. Dr. Runnells believed that lead-210 came from uranium decay chain not the

thorium decay chain.

Assemblyman Claborn requested to know if any studies were conducted on small

aquatic animals (frogs, fish, even birds). Dr. Runnells responded that he did not

have that knowledge but that perhaps someone from the city or county knew. Mr.

Claborn continued that generally when something happened [in the environment]

it was noticed lower down in the chain of life. Dr. Runnells agreed stating he made

an excellent point.

Robert Meyer, a Senior Scientist (radiation biologist) with Shepherd Miller, Inc.

testified next. He summarized the materials in the handout (Exhibit K). In late July

of 2000, SMI began studies on the potential causes of childhood leukemia. They arranged for Dr. Glyn Caldwell, an epidemiologist, to participate in the health risk

reviews.

Mr. Meyer reiterated that SMI reached the conclusion that no obvious link existed

between the Fallon water supply and the leukemia cases identified in the area, but

the issue was not closed. The literature review summaries were provided in the

binder (Exhibit K). A clear link between arsenic and leukemia was not revealed in

the literature. As it had always been present in the water supply, arsenic did not

seem to explain the recent appearance of childhood leukemia. One factor could be

other sources of radiation, a known cause of leukemia.

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There were a number of possible sources of radiation to which everyone was exposed. Levels of radiation seen in communities were low with respect to the recognized standards for radiation protection. He explained there were different types of

radiation that could impact a human. One would be an external source of radiation,

such as cosmic radiation, gamma rays and other radiation sources from outer space,

and from natural deposits of radioactive materials of the sort analyzed in the Fallon

water supply. These natural deposits were also present, typically in low levels, in

surface soils and rocks. Exposure from these sources included direct exposure and

wind-blown exposure.

Mr. Meyer went on to say that the ‘‘Nevada experience is unique, of course, given

the presence of the test site and the test that was conducted much closer to the city

of Fallon.’’ He had not studied the results of the test nor the weather patterns at

the time, but he knew there were cases in which the circulation of radioactive materials was in other directions.

There were also other possible sources of radioactivity in the environment that

could have influenced this situation. It was not clear, he acknowledged, how an exposure from the 1950’s or 1960’s could impact a cancer that was rapidly developing.

It would be good idea to examine the possibility of other sources of radiation in the

area. Chairwoman de Braga asked if Mr. Meyers and SMI had compared their studies

with those done at the base vis-a ́-vis the water system. Mr. Meyer replied that they

were aware of the findings on the base but had not made comparisons.

Assemblywoman Koivisto asked if the historic levels of arsenic remained the same

or were there spikes and, were there studies of the effects of arsenic on children

rather than just adults? Dr. Runnells answered that the concentrations of arsenic

have been remarkably constant. Mr. Meyer stated that he was not aware of toxicological models that might extrapolate from adult leukemogenesis to childhood

leukemogenesis.

Assemblyman Mortenson related to Mr. Meyer that he recalled reading that

minor earthquakes could produce fissures. As thorium was all over Nevada, he

queried, could a minor tremor release a pulse of radon-224 into the water. Mr.

Meyer submitted that radon-222 and radon-220 were produced as a natural decay

of uranium and thorium. He had read, too, that one of the ways to identify the potential for an earthquake occurrence would be to measure radon. The release of

radon gas then was possible. The total exposure over a period of time would be a

major factor in whether or not cancer might result. He speculated that the release

of this gas prior to or during an earthquake might be quite brief, yet the damage

done to a human body normally accrued over a period of time. A short low-level exposure would be unlikely to increase risk. Risk was proportional to dose.

Mr. Mortenson apologized that he had meant to say radium-224 to which Mr.

Meyer stated that he was unaware of particulate materials released during moderate earthquakes.

Mr. Mortenson continued that he had read recently that with volatile organic

compounds in drinking water, the ‘‘body burden’’ was via three methods: drinking

the water, bathing with it, and through inhalation (steam of showers or cooking).

Even though someone might have consumed bottled water, that was a fraction of

the way the body absorbed water.

Mayor Tedford of Fallon again testified the city began looking at the water first

(Exhibit L) because it was something they had control over. The city had also begun

looking at their landfills, utilities, airport and other lands that they own. He closed

by saying that he hoped the committee would be vigilant in supporting the executive

branch that had made this investigation a priority. Funds and staff were important

to complete the mission. He thanked the committee for the opportunity to speak.

Assemblywoman Leslie thanked the mayor for his testimony and asked him to

briefly describe the plans for the resource center. She hoped that the Fallon Family

Resource Center would be included. Mayor Tedford said this was to be a clearinghouse for assistance that would allow the families to maintain some anonymity. The

hospital would assist and the Family Resource Center was a good idea.

Bjorn Selinder, Churchill County Manager, with Gwen Washburn, Churchill

County Commission Chairman, and Norm Frey, Churchill County Commissioner,

read the following statement from Commissioner Washburn (Exhibit L):

The Churchill County officials are very concerned about the welfare of the

citizens. We want to explore all possible avenues that may attribute to the

cause of leukemia but none of us is willing to point to any one cause. We are

leaving that to the health experts.

Ask 10 people on the street and we’ll get 10 different opinions as to the cause

of the cluster. I will attempt to address what the county is doing about some

of the causes.

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In Churchill County, the first thought is always water. We have been very

concerned about how the reallocation of irrigation water that historically came

into the valley is affecting the quality of the water being pumped from domestic

wells, especially since the passage of Public Law 106–18 known as the Negotiated Settlement.

Churchill County began cooperating with the U.S.G.S. on a ground water

monitoring project in 1994. In 1999, the data collection network included water

level measurements at 19 wells monthly, 39 wells quarterly, and annually at

18 wells. Quality sampling and testing on five wells was done twice during the

year, once during the irrigation season and once during the winter. The water

was sampled for major ions, arsenic and nutrients. In the year 2000, four more

wells were installed in an area slated for development where septic tanks would

be used for sewage disposal to provide background data on the effect of development on water quantity and quality. Also in the year 2000, one isotope sample

was obtained and analyzed at each of the five water quality wells. There’s an attachment that describes some of that activity.

Realizing the potential for growth and the need to supply the community with

a safe and assured water supply in the future, we have for the last several

years been in the process of developing a plan for a community-wide water system. The plan is very tentative at this point and the economic feasibility study

is not yet complete. We are looking at every possible source to supply this system, including Dixie Valley and the Stillwater Mountain Range. In cooperation

with U.S.G.S. and Carson Water Subconservancy District, an injection and recovery experiment storing water for municipal and industrial use from

Lahontan Reservoir in the Dead Camel Mountain alluvial fan will begin soon.

Every aspect of the proposed water system is in the planning and study stage

at this time. For all practical purposes, the water system is many years away.

At this point, the cost to install the system, well over $200 million, is prohibitive for a small community. Obviously, funding is the huge hurdle for the county even after the water source is identified and developed.

In the interim we are faced with the problems here and now. Churchill Economic Development Authority, known as CEDA, is in the process of developing

a vision for Fallon and Churchill County. In this process, CEDA has held three

public workshops and one meeting of a committee made up of citizens from all

business sectors. Water quantity and quality have been identified in every session as the top priority issue.

There is little that Churchill County can do at this juncture to improve the

quantity and the quality of the water but [what] we can do, and are prepared

to do, is to educate citizens about how they can help themselves. It has been

suggested that we, the county, test the well water. That is not something that

we can do. At our best estimate there are over 4,000 domestic wells in the county and it would be not only cost prohibitive and time prohibitive, but there are

private property issues involved as well. What we are doing is telling private

well owners how they can have their water tested.

We are actively encouraging the University of Nevada Extension Service to

reinstate the Guard Our Local Drinking Water program known as Nevada

GOLD. This is a group of volunteers dedicated to educating homeowners about

their water supply. It is funded through the agricultural extension budget but

has been inactive since the local water specialist became ill more than 3 years

ago. At this point it is imperative that the University Extension Service reactivate this water education program. Many people move into the area and purchase their ‘‘dream’’ country home and they have no idea that the water comes

from their own private well and they have the sole responsibility for that well.

We will begin dispensing information about water safety and possible health related issues and testing labs at the local library, extension office, county administrative office, planning office, doctors’ offices, and so forth.

Operations of certain businesses and industries have been blamed. Businesses

and industries including agriculture, pesticide operators and dairies that locate

in the area must have Churchill County business licenses and meet all the local

zoning criteria as well the Nevada Bureau of Health requirements, and have

all necessary permits from the Nevada Department of Environmental Protection. We are looking at ways to make the issuance of a business license contingent upon the company showing current permits from the State of Nevada.

Naval Air Station and jet fuel in particular are suspect. Even though we have

a good relationship with the Navy, we have no control over the Federal facility

and depend upon the Navy to protect its personnel and its neighbors from any

harmful effects of their operation. We must leave investigations of the operations of the Navy in Churchill County to the experts.

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The Churchill County commissioners are as concerned as any one about this

leukemia cluster and will work closely with the local hospital to assist the

health care professionals in the investigation to best of our ability.

Now, I would like to comment as an individual. I know that many people are

quick to point to the water and water quality in the Lahontan Valley as the

culprit in the present leukemia scare. I am not an expert on the water nor in

the medical field, so I will not say that water is or is not the cause. I just would

like to point out that I began using bottled water service at my home in 1995.

This is because I felt that there was a definite deterioration in the quantity,

quality and taste of my well water that like most in the valley comes from the

shallow aquifer. I subscribed to the water service feeling that it was an inexpensive health insurance. At the time, I was more concerned about water-borne

bacteria than heavy metals or minerals. Now, under the changing conditions in

the valley, my concern about the quality of my well water encompasses more

than just bacteria. At this time I can honestly say that I do not advocate anyone

in the valley drinking water from their domestic well unless they have had that

well tested recently and that it tested as safe to use.

The deterioration of our water quantity and quality has been significant since

water right buy-out began. The safety of our water supply must remain the top

priority of the community.

Personally and professionally, I thank you members of the Assembly for adding your support to our community at this especially difficult time.

This concluded the reading of Ms. Washburn’s statement (Exhibit M).

Norman Frey, Churchill County Commissioner, spoke next, and was very concerned about the negative press that the investigation was generating and stressed

that the study must be kept to a scientific and professional level. He felt that the

general public had not separated the presence of arsenic in the water and the leukemia cluster.

Mr. Frey stated the government must deal with the people’s perceptions in order

to ease their tensions. He claimed the county might need assistance from the State

to make well testing easier and more affordable for some 4,500 well owners. The

county might need to set up low interest loans to purchase approved types of filtration systems for individual homes. He concluded by stressing that Churchill County

is a very healthy place to live. Thousands had grown up and grown old there free

of hideous disease.

Chairwoman de Braga stated that she and the committee would do whatever they

could to reinstate the Nevada GOLD program at the Agricultural Extension Service.

She also requested that the commissioners would present the committee with recommendations for educating the public, especially those in the Soda Lake area,

where the arsenic rates were very much higher.

Assemblyman Neighbors requested to know the size of the area that contained the

4,500 wells. About 95 percent of the total population of Churchill County resided

in the Lahontan Valley, which constituted Basin 101, the largest groundwater basin

in the state.

Mr. Neighbors inquired, what was the current cost of testing a well? The cost appeared to be roughly $15 per item for each item on the test, less than $100 per resident. Each property sale required a complete test that cost $120.

In response to Mr. Claborn’s question about increased abnormalities in animals

in the county, Mr. Selinder responded that a veterinarian who had practiced in the

county for many years had seen none.

Testimony came next from Dr. Bonnie Eberhardt Bob and Leuren Moret, representing Scientists for Indigenous People. Ms. Moret revealed that she had worked

at the Lawrence Livermore Laboratory in California (Exhibit N) and had done research on the Yucca Mountain project (Exhibit O) and ran the sampling lab for the

superfund project. She felt these hearings had been good but that air pathways and

sampling of the upper dust layer in Fallon had been overlooked. She stated other

items to investigate included: the incineration of out-dated munitions (some depleted uranium) at Honey Lake Depot that had sent a smoke plume over Nevada;

planes returned to NAS from the Gulf War which might have had radioactive metal;

the increased toxicity of highly complex and mixed compounds such as

radionucleides mixed with hydrocarbons; and, burns in the fallout areas of Nevada

(from the testing of the 1950’s) which remobilized the radionucleides in the upper

dust levels thus recontaminating some populations. Constant exposure to low-level

radiation, she testified, was more dangerous than a flash exposure such as was at

Hiroshima. She concluded by stating that the water in Fallon had not been tested

for tritium (radioactive hydrogen), and that the city should test surface ditches and

drainage for airborne radionucleides.

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Dr. Bonnie Eberhardt Bob, a psycho-biologist, answered Assemblywoman Gibbons’ earlier question saying yes, there was at least one Shoshone child who was quite

young and has contracted leukemia.

Dr. Bob related a story of gathering pine nuts with the Shoshone last Fall in an

area indicated to be ‘‘experimental tree plots’’ and in which the trees had been dying

from the top down. After some research, Dr. Bob found that the BLM had planned

to bum 870,000 acres of pinion trees in Nevada. The chemical that killed the trees,

she claimed, was probably tebuthiuron, a ground sterilizing agent.

Another chemical, picloram, also known as Agent White, was one of the defoliants

used in Vietnam and was now used by the U.S. government in the war against

drugs in Columbia. Picloram was used to make Tordon which when mixed equally

with 2–4–D plus 245T (Weedar) was Agent Orange. She concluded that, in effect, ‘‘we’’ are making Agent Orange again, except perhaps with the dioxins removed.

Furthermore, in the Ely district where there were fires, the fields were sprayed with

Garlon, which when burned ‘‘mimics estrogens and hormones of women and it ruins

the reproductive system.’’ Dr. Bob continued her testimony and described the level of picloram in Nevada’s water and wondered what the reaction was when this chemical was mixed with others and used for weed or insect control. She expressed her concern for: the burning

of parts of Nevada that would release radionuclides into the air; tritium that was

in the tree cellulose and was released into the air from a burning tree; and plutonium that would be released into the air when burning occurred. Dr. Bob gave the

committee a letter she wrote to the Bureau of Land Management (Exhibit P).

Ms. Moret added that the smoke plume from the burning at the Fallon Naval Air

Station should be investigated as well.

Dr. Bob ended her testimony by reading a statement from Corbin Harney, Shoshone Nation, which emphasized the importance of cleaning the earth.

Keith Weaver, a long term Fallon resident and a member of the de Braga family,

delivered the final testimony. Mr. Weaver felt that the link between arsenic and leukemia should not be eliminated from examination at this point, based on a recent

article he had read in the Journal of Epidemiology. Chairwoman de Braga agreed

that the committee did not wish to rule out anything at this point.

The hearing closed at 5:23 p.m. to be resumed February 15 at 1 p.m.

Respectfully submitted,

JUNE RIGSBY,

Committee Secretary.

FEBRUARY 14, 2001

The Committee on Natural Resources, Agriculture, and Mining was called to order

at 1 p.m., on Wednesday, February 14, 2001. Chairman Marcia de Braga presided

in room 1214 of the Legislative Building, Carson City, Nevada. Exhibit A is the

Agenda. Exhibit B is the Guest List. All exhibits are available and on file at the

Research Library of the Legislative Counsel Bureau.

Committee Members Present.—Mrs. Marcia de Braga, Chairman; Mr. Tom Collins,

Vice Chairman; Mr. Douglas Bache; Mr. David Brown; Mr. John Carpenter; Mr.

Jerry Claborn; Mr. David Humke; Mr. John J. Lee; Mr. John Marvel; Mr. Harry

Mortenson; Mr. Roy Neighbors.

Committee Members Absent.—Ms. Genie Ohrenschall.

Guest Legislators Present.—Assemblywoman Sharron Angle, District 29;

Assemblywoman Merle Berman, District 2; Assemblywoman Vivian Freeman, District 24; Assemblywoman Dawn Gibbons, District 25; Assemblywoman Ellen

Koivisto, District 14; Assemblywoman Sheila Leslie, District 27; Assemblyman Mark

Manendo, District 18; Assemblywoman Kathy McClain, District 15; Assemblywoman

Bonnie Parnell, District 40; Assemblywoman Debbie Smith, District 30;

Assemblywoman Sandra Tiffany, District 21; Assemblyman Wendell Williams, District 6.

Staff Members Present.—Linda Eissmann, Committee Policy Analyst; Marla

McDade Williams, Committee Policy Analyst; June Rigsby, Committee Secretary.

Others Present.—Glen Anderson, Policy Specialist, National Conference of State

Legislators; Dr. Thomas Sinks, Epidemiologist, Center for Disease Control; Dr.

Allan Smith, arsenic specialist, University of California, Berkeley; Brenda Gross,

Fallon parent of a leukemia victim; Dr. James Forsythe, Medical Oncologist, Reno;

Dr. Gary Ridenour, Fallon Physician; Diane Hansen, Fallon citizen; Peter

Washburn, Attorney, Senator Harry Reid’s Office; Jerry Buk, University of Nevada,

Reno, Cooperative Extension; Juanita Cox, Citizen Lobbyist; Robert Sonderfan, Citizen Lobbyist.

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Chairman de Braga called the Assembly Natural Resources, Agriculture, and Mining Committee to order. Roll was called, and a quorum was judged to be in place.

All members were present except for Assemblywoman Ohrenschall who was noted

as an excused absence. Chairman de Braga welcomed as guests the Assembly Committee on Health and Human Services. Roll was called, and all members were

present.

Chairman de Braga, in her opening statements, remarked that this was the third

and final day of hearings on the Fallon leukemia cluster. As with the previous 2

days, a balance of expert testimony and public input was scheduled.

Expert testimony commenced with the introduction of Glen Anderson, Policy Specialist, National Conference of State Legislators (NCSL). The role of the NCSL was

described as providing assistance to State legislators on environmental health

issues. Mr. Anderson distributed two handouts that outlined a list of environmental

disease registry legislation by State (Exhibit C) and NCSL environmental projects

(Exhibit D).

Mr. Anderson commenced his testimony with an overview of what was known

about the link between environmental agents and cancer. Scientific investigation of

childhood cancer was complicated by the relative rarity of cases as well as by the

difficulty of estimating past exposure levels for young victims after they developed

cancer. What had been established was that children had less developed immune systems

and were therefore more susceptible to the effects of toxic exposure (e.g., mercury,

lead, pesticide). Childhood cancer was described as the second leading cause of

death in children under age 14, with leukemia the most common type of cancer.

Human research on the link between the environment and cancer lagged behind

animal research. To date, clear causes had evaded scientists in cancer cluster investigations. An extensive list of variables under investigation included long latency periods between exposure and onset of disease, the plethora of potential chemical

agents, and the tendency of families to change residency often.

Disease tracking registries were described as offering the greatest hope for closing

the information gap between exposure data and the cancer data. Nationwide, State

disease registry information would be combined with background data on environmental exposure to promote understanding of cancer causes.

Mr. Anderson reviewed innovations made in other States. Geographic mapping

was described as a significant enhancement to some State registries and promised

to aid in more expeditious detection of future cancer clusters. Some States had

taken a preventative approach through the introduction of children’s environmental

health legislation. Because most law had been designed around protection of adult

health, Maryland and California were cited as two States that enacted specific

health guidelines for children.

Federal efforts in the areas of children’s health, the environment, and disease

tracking (e.g. Center for Disease Control) had paralleled and supported the States’

disease registry efforts. The Food Quality and Protection Act of 1996 resulted in the

restriction of pesticide use that might cause childhood disease.

The Children’s Health Act of 2000 addressed childhood cancer through the requirement of the study of environmental and other risk factors for diseases such as

leukemia. A uniform reporting system to track epidemiological data was described

as an essential success factor.

Mr. Anderson added that the clean up of identified environmental hazards would

always be a positive side benefit to all cancer cluster investigations, even when a

definitive cause for the cluster had never been found.

Chairman de Braga requested recommendations on methods for facilitating the

sharing of registry data between the States. Mr. Anderson explained that there had

not been a lot of work done to connect cancer cluster data. He was unsure of how

a streamlined system would be designed. Chairman de Braga posed a question on

the prevalence of backlog in State registries across the nation. Mr. Anderson clarified that all States had registries in place, however it was unknown about how vigilant each State was in monitoring their registry data. The scrutiny of data by any

State, including the integration of geographical mapping information, would take a

much greater investment of time and resources.

Mr. Anderson reassured Chairman de Braga that his agency did track the research on registry efforts in each State. Most States had not done a lot to make connections between a cancer cluster and environmental exposures. Legislative bills

had been introduced, however few had been passed. On a positive note, Mr. Anderson added that awareness of the need was increasing.

Chairman de Braga expressed her appreciation to Mr. Anderson for his testimony.

Before introducing the next expert, Chairman de Braga made several announcements to the committees. Senator Harry Reid’s Office let it be known that a

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$500,000 Federal fund would be available to help enhance the cancer registry data

gathering. The second announcement was regarding the Nevada GOLD (Guarding

Our Local Drinking Water) program. Jerry Buck would address a positive breakthrough on the future of this program later in the hearings.

Dr. Thomas Sinks, an Epidemiologist with the Center for Disease Control (CDC),

distributed a 6-page handout (Exhibit E) that contained his testimony on the epidemiology of Acute Lymphocytic Leukemia (ALL) and the work of the CDC and their

sister agency, the Agency for Toxic Substances and Disease Registry (ATSDR). Dr.

Sinks commenced testimony with his assurance to the residents of Fallon of the

CDC’s deep concern over the leukemia cluster. Although causes had rarely been

identified in cluster studies, the survival rate for ALL of 80 percent was judged to

be a significant milestone in the cancer battle.

Dr. Sinks emphasized that the highest priorities remained the need to identify

causes and prevent future occurrences. Although described as a relatively rare diagnosis in children, the national rate was known to be one case of ALL per 6,600 children. This translated to an estimated 2,400 new cases of ALL each year in the

United States. Gender, age, race, and socio-economic status were highlighted as significant factors in the profile of a leukemia victim. The peak age was reported for

children between the age of 2 and 5 years, with boys known to be 30 percent more

likely to develop ALL. Genetic and environmental factors were judged to play a significant, but unexplained role, in the development of ALL.

Dr. Sinks continued with a list of suspected cancer-inducing factors, which included ionizing radiation, certain medical conditions (e.g., Down’s Syndrome), high

birth weight, maternal history of fetal loss, and birth order. Other inconsistent evidence included parental smoking, parental occupation exposure, and postnatal infection. In-utero exposure to ultrasound examinations had not been associated with

ALL.

In terms of cancer prevention and control programs at CDC, support of population-based cancer registries and cancer screening efforts were described as in place

across the country. The compilation of the various State registries enabled some longitudinal oversight capabilities by the CDC. Federal support in Nevada was further

illustrated by $1.4 million of funding of the Nevada Cancer Registry between 1994

and 2000.

Dr. Sinks reported that CDC had participated in 108 cancer cluster field investigations, convened a national conference on the clustering of health events, published recommendations, and provided technical assistance to health departments

nationwide. He expressed his concern over the tremendous amount of time and

money required to conduct field investigations, with most studies revealing no conclusive findings. Positive remedial steps, however, were reported as implemented in

most cases.

Chairman de Braga requested clarification of the definition of a cluster and the

number of years typically involved. Dr. Sinks explained that the word cluster, from

an epidemiological point, was defined as being a greater number of cases than expected statistically. The word cluster did not necessarily imply that there would be

a unifying cause. He further emphasized that statistical tests looked only at probabilities of chance occurrence and did not address the likelihood of cause. CDC

treated each suspected cluster as a unique situation.

Assemblywoman Berman requested clarification of the term ‘‘panel of experts’’ on

page 6 of the handout (Exhibit E) and why the Federal Government was not involved in the testing. Dr. Sinks defended the practice of assembling a wide variety

of medical, academic, and scientific experts for purposes of peer review. In response

to the issue of Federal involvement, Dr. Sinks explained that the CDC responded

to numerous requests by the invitation of States facing a public health problem. The

CDC role was described as being supportive, but was not one of assuming ownership

of the problem.

Assemblywoman Leslie expressed her concern that there was no formal national

tracking system in place for cancer clusters. Dr. Sinks agreed that there was need

for a national tracking system, but it would require higher review and authority.

Additionally, it would be a difficult process to implement because of the variability

of defining and identifying clusters. In response to Assemblywoman Leslie’s question

about a cluster being simply one of a high number of cases in a specific geographic

area, Dr. Sinks explained that defining a cluster would only be the first step. It

would be followed by the challenge of establishing the corrective steps needed to

deal with the problem.

Dr. Sinks elaborated that, unlike breast cancer screening programs, there was no

health screening program for childhood ALL. He stated that requests for cancer

cluster investigations were predominantly for the more common, screenable cancers

and, therefore, targeted the adult population.

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To Assemblywoman Leslie’s inquiry about the role of arsenic, Dr. Sinks stated

that it would be impossible to say definitively that it would be associated with the

Fallon cluster. It had been established that the levels exceeded acceptable amounts

and that arsenic was known to be a human carcinogen. He encouraged the investigative team to pursue the examination of other agents, such as volatile organic

chemicals and ionizing radiation.

Assemblywoman Gibbons expressed concern as to whether everything was being

done to minimize risk and exposure. She also asked for clarification on the 20 percent mortality rate among ALL victims and the significance of the demographics

(e.g., age, gender). Dr. Sinks responded that it was unknown if all preventative and

remedial steps were in place. It had been established that the 20 percent mortality

was seen in older victims where chemotherapy was less effective. Late diagnosis was

also a negative for survival. Clarification was requested by Assemblywoman McClain on whether the $500,000

Federal fund would be enough to bring the Nevada Cancer Registry up to date. She

also expressed concern over the reported 2-year lag in the registry data and the possibility that there could be other undetected clusters. Dr. Sinks stated that the Nevada registry was average for reporting lag in comparison to other States. There

were some state-of-the-art systems developed in other States. Dr. Sinks cautioned

that having up-to-date cancer registries would not necessarily be the answer to

early detection of cancer clusters. It would likely result in a multitude of unnecessary investigations. Generally, the registry data had been judged most useful after

attention had been drawn to a suspected cluster.

Assemblywoman McClain commented on the fact that the current ALL cluster in

Fallon had been identified by the smallness of the community and not by the cancer

registry. Dr. Sinks concurred and added that the current study would likely spur

the Nevada Health Division to look at the occurrence of ALL across the entire State.

The most difficult challenge was described as being able to take data from the cancer registry and tie it directly to environmental agents.

In response to Assemblywoman Berman’s question regarding statistical chance,

Dr. Sinks clarified that nobody ever developed cancer because of chances. There was

always a cause, and the challenge in Fallon would be to discover the common denominator among the 11 children. The unifying cause was not yet known, but eventually science would identify the commonality. The probability of the Fallon cluster

being a chance event was described by Dr. Sinks as being unlikely .

Chairman de Braga raised a question about ALL cases that occurred outside of

the identified cluster timeframe of 1995–1999. She requested clarification about the

upcoming assignments of the panel of experts and whether two 1992 cases would

be considered for inclusion in the panel’s discussions. Dr. Sinks explained that the

panel of experts had been assembled by the Nevada Health Division. As such, the

Nevada Health Division would charge the panel with direction and recommendations for action. Dr. Sinks did agree that it would be reasonable to look at the 1992

cases to determine if inclusion would be appropriate. He referred the Chairman to

Dr. Guinan for specific answers.

Assemblyman Collins posed a question about the thoroughness of the health division’s investigation. In response, Dr. Sinks stated that it would be virtually impossible to look at all suspected agents. The accepted process was to narrow the list

of hypotheses to a testable number and then prioritize them based on probability

of involvement.

Assemblyman Collins, using the example of PCB contamination cleanup, reiterated his concern that limiting the investigation could limit the answers. Dr. Sinks

stated that it would be imperative to separate the things that had been known to

be hazardous but had remedial solutions versus the need to answer scientific questions that could not be answered. Preventing the next case of leukemia would remain the primary goal.

Dr. Allan Smith, an arsenic specialist with University of California, Berkeley,

commenced testimony with a review of various domestic and international arsenic

research programs. Dr. Smith reported on his 8-year research project in Nevada,

which included a bladder cancer study. The Nevada Tumor Registry was utilized in

this study as well as in a childhood cancer study.

Dr. Smith explained that most of his cancer research had been with adults and

included cluster investigative work. A leukemia cluster in North Carolina was determined to be related to solvents in a tire producing plant. Most of his cluster investigations did not, however, result in the discovery of a definitive agent.

In his review of the Nevada tumor registry data for Churchill County for the

years 1979 to 1999, Dr. Smith detected only two cases of leukemia. With those statistics in mind, Dr. Smith characterized the current cluster as ‘‘remarkable.’’ Armed

with the knowledge of Fallon’s levels of arsenic for decades, Dr. Smith stated emVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00102 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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phatically that it would be highly unlikely that arsenic would be the cause of the

leukemia cluster.

In response to a question about handouts, Dr. Smith replied that he had not prepared written testimony, and he referred the committees to his Web site

www.socrates.berkeley.edu/-asrg/.

Chairman de Braga inquired about Dr. Smith’s choice of Fallon for his research

studies on bladder cancer. Dr. Smith explained that Fallon was selected because the

area was known to have some of the highest arsenic levels in the nation. The Fallon

population was judged to be a highly exposed group. His researchers looked for genetic damage in bladder cells associated with high cancer rates.

Chairman de Braga asked if his research included the effects of arsenic on the

immune system. Dr. Smith replied that it did not. His research instead focused on

the end result of the cancer. He added that if he had judged it to be a high priority

research question, it would have been done. The evidence was not there to support

arsenic and an adverse effect on the immune system. In response to Assemblyman

Collins’ question regarding the difficulty of discovering combinations of causal

agents, Dr. Smith acknowledged that this was a significant challenge. The synergy

between two agents had been investigated, an example being the combination of

smoking and arsenic. He made the distinction, however that the sudden onset of a

cancer cluster was different and did not fit the classic profile of long-term synergistic effects. The sudden introduction of an environmental co-factor suggested an

infectious agent, for example.

Assemblywoman Gibbons requested clarification of the list of suggested questions

that was included in their information packet. Chairman de Braga explained that

these were supplied as a guideline to the committee members.

Assemblywoman Gibbons posed a question about the levels of arsenic, bladder

cancer rates, and cure rates in Churchill County compared with other areas. Dr.

Smith clarified that typical arsenic levels in the United States were 2 micrograms

per liter. Fallon, Lyon County, and Kings County, California had always tested at

90 to 100 micrograms per liter. The private wells in Churchill County revealed some

of the highest arsenic levels in the world.

In response to the subject of bladder cancer incidence and cure rates, Dr. Smith

described his long-term study as still in the analysis phase. A proposal for the study

of lung cancer in Nevada had recently been submitted to the National Institutes for

Health (NIH). Using a method called ‘‘rapid case ascertainment’’ with data from the

Nevada Tumor Registry, Dr. Smith was optimistic of a more rapid identification of

lung cancer.

Assemblywoman Gibbons requested clarification on the extremely high levels of

arsenic in Fallon’s private wells and the interplay between dosage and individual

immunity. Dr. Smith explained that he had deliberately studied wells with the highest levels of arsenic, selecting 11 families whose wells exceeded 1,000 micrograms

per liter.

Chairman de Braga added that a recurring question among the committees was

the threshold amount at which arsenic became a problem. Dr. Smith elaborated that

in their risk assessment studies, at 50 micrograms per liter, there was an estimated

probability of 1 in 100 people dying of cancer. He concluded that it was an acceptable fact that consumption of water with 90 to 100 micrograms of arsenic was detrimental to public health.

Brenda Gross, a Fallon resident and mother of one of the leukemia victims, commenced testimony. Mrs. Gross shared the heartbreak and stress of dealing with a

devastating illness in the family. She acknowledged the involvement of the Nevada

Health Division and their sharing of information. Her specific concerns were centered on the difficulty of making treatment choices for her son, constantly having

to weigh the side effects of treatment against the chances of death. Mrs. Gross addressed a further concern regarding the tendency to dismiss a cause, such as arsenic. She emphasized that investigation into combination agents (e.g., arsenic plus

another environmental agent) would be imperative.

Mrs. Gross expressed her certainty that there was a definitive cause in Fallon,

and she hoped that the Nevada Health Division would be aggressive in their pursuit

of common denominators. She concluded by saying that, with only one of her four

children affected, she was baffled by what would be so unique about her one son

(e.g., genetic).

On behalf of both committees, Chairman de Braga expressed her sincere appreciation to Mrs. Gross for sharing her personal story. Assemblywoman Leslie reiterated

her appreciation and asked Mrs. Gross if, in her judgment, the State of Nevada

could be doing more for the families and the community. Mrs. Gross added that testing of private well water, soil testing, jet fuel studies and air quality studies in surrounding areas might be helpful.

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Assemblywoman Leslie added that, as a minimum, establishing a central place for

questions would be warranted for the community. It was emphasized that recommendations would be most welcome from the families of Churchill County.

In response to Assemblywoman Gibbons, Mrs. Gross explained that her son’s chemotherapy was being done in Fallon on a weekly basis and at the University of

California, Davis on a monthly basis.

Dr. James Forsythe, Reno Oncologist, was introduced as the next presenter. He

distributed a handout (Exhibit F), a 1979 newspaper article which described a suspected cancer cluster in northern Nevada. At that time, Dr. Forsythe was one of

only two oncologists in the area, the significance being that he had firsthand knowledge of every cancer case in the area. This lead to his discovery of what he considered to be a cancer cluster in the Fallon area. His concern was amplified by the Veteran’s Hospital in Reno.

In 1979, an investigative study was initiated by the University of California,

Berkeley, Public Health Service. Their statistical analyses revealed significant increases in brain and testicular cancer in the Fallon area. The report was delivered

to the chairman of the Northern Nevada Cancer Council, Dr. John Shields, and the

matter was not pursued.

Dr. Forsythe described his ongoing involvement in the diagnosis and treatment

of Fallon cancer patients. He had long speculated on the commonality of the drinking water as the source of the problem, with arsenic levels at 20 times the national

average. Today, Dr. Forsythe stated that his focus was diverted to contamination

of water supplies by petroleum products originating in industries or perhaps the

naval base.

Dr. Forsythe next shared anecdotal stories from various sources which he believed

could have significance. The first point he highlighted was the high water table in

Fallon (i.e., less than 50 feet) in combination with poor water quality. Second, Dr.

Forsythe commented on the reported practice at the Fallon NAS of routinely spraying weeds with jet fuel. His third point centered on reports from utility inspectors

excavating soil on the naval base and their observations of a petroleum stench at

the 4 to 6 foot soil level. In 1995, there was an unofficial report of a large spill of

petroleum products on the base. Although not revealed in the news media, the EPA

did respond with remedial efforts.

Other risk factors included the atomic blast in 1963 (i.e., Shoal Project) and electromagnetic field radiation. Dr. Forsythe stated that, of all of the risk factors on a

long list, childhood Acute Lymphocytic Leukemia (ALL) had been known to be induced, in part, by petroleum byproducts such as benzene and other gasoline substances. Lymphocyte assays of family members, through an analysis called ELISA,

had proven to be revealing. More than 400 chemicals would be detected with ELISA

methodology. Hair and urine analyses for heavy metals were also recommended by

Dr. Forsythe.

Dr. Forsythe encouraged the expansion of testing by the Nevada Health Division

to include the victims and families. He stated with reasonable certainty that petroleum byproducts had leached through the earth and had contaminated the high

aquifers of the Churchill area. In his judgment, this would prove to be significant

in the cluster investigation.

Chairman de Braga requested clarification on the 1979 cluster, specifically regarding the reaction of the medical community. Dr. Forsythe described the event as

being ‘‘clinically suspicious’’ and was not noticed until Berkeley released their report. Chairman de Braga shared her own experience with inquiring about the cancer levels in Fallon. In reply, Dr. Forsythe expressed his disappointment in the apparent inaccuracy of the Nevada Tumor Board records. This was compounded by the

fact that, in a small town like Fallon, many cancer patients left the area for treatment and were not tracked by the registry. Reporting lag time was also cited as a

significant factor in the inaccuracy.

Chairman de Braga inquired about the costs and the process to test families and

neighbors. Dr. Forsythe judged that it would be reasonable if a sampling of families

was used and not the entire population. Hair testing would be non-invasive, and

costs were estimated at $50 to $80. Urine testing for heavy metals was reported to

be approximately $200. The ELISA testing for multiple chemical exposure was described as $300 to $400 per sample, but was the most diagnostic method. The latter

test was based on the detection of antibodies produced by the body in reaction to

various foreign substances.

In response to Chairman de Braga’s question about herbicides and pesticides, Dr.

Forsythe acknowledged that these substances would need to be considered, given

the extensive agricultural activity in the valley. Chairman de Braga requested recommendations for how to proceed with the cluster investigation. Dr. Forsythe summarized his recommendations as: the testing of the victims for chemicals in the hair

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and urine, testing a control group of friends or neighbors, and thoroughly analyzing

the drinking water for all possible pollutants. Dr. Forsythe clarified that he was not

familiar with the list of previously tested substances in drinking water.

Dr. Forsythe reviewed the types of cancers he had handled during the last 10

years in the Churchill County area; 40 cases of breast cancer, 30 cases of colon cancer, 35 cases of lung cancer, 15 cases of Hodgkins/Lymphoma/leukemia, 25 cases of

prostate cancer, 20 cases of skin cancer, 8 cases of brain cancer, 5 cases of ovarian

cancer, and 8 cases of head/neck cancers. It was notable that these were just the

cases handled by Dr. Forsythe and did not include the cancer statistics from 10

other oncologists in Reno.

Assemblywoman Koivisto asked for elaboration on the microwaves from radar systems at the Fallon Naval Air Station (NAS). Dr. Forsythe stated that electromagnetic fields (EMF) must be considered, however EMF research to date was inconclusive.

Chairman de Braga introduced Dr. Gary Ridenour, a Fallon physician. He commenced testimony with the topic of jet fuel, in particular JP8. It was introduced to

Fallon in 1991, and shortly after that, Dr. Ridenour noticed an immediate change

in the liver function tests (e.g., liver damage) in patients. Dr. Ridenour shared his

extensive research on incidents of jet fuel leakage on the base. He further stated

that he had not observed intentional malice on the part of the Navy regarding the

subject of jet fuel. What they know was described by Dr. Ridenour as what they

were told by the Department of Defense.

Often dismissed by the military as similar to kerosene, the high toxicity of jet

fuel, even in minute quantities, had been demonstrated in multiple studies and was

known to provoke serious health effects including skin penetration, decreased immune system response, increase in lung permeability, and headaches, to name a

few. During the 1990’s, medical articles abounded on the subject of the toxicity of

JP8.

In terms of fuel dumping and evaporation, the jet fuel would still exist in some

form when it made contact with the earth. Dr. Ridenour cited a recent example of

a cloud sighting near the base, described as a large brown vapor emitted from the

startup of jets. He added that one of the biggest problems with JP8 was the low

cost of 80 cents per gallon, approximately half of the cost of its predecessor fuel JP5.

JP8 had so far not been allowed on aircraft carriers, a point which Dr. Ridenour

considered significant. It was utilized extensively during the Gulf War, which suggested the need to connect the fuel with the highly publicized health problems

among the military personnel. Even brief contact with JPB fumes resulted in the

immediate detectable presence of fuel in the breath of the person. Dr. Ridenour cited

several recent research articles about the negative health effects of exposure to jet

fuel.

In regard to the 6-inch fuel line that delivered jet fuel to the Fallon NAS, Dr.

Ridenour described it as more than 30 years old, made of steel, and highly susceptible to corrosion and seismic activity in the desert. The integrity of the pipeline

would be highly questionable. A map of Fallon displayed the path of the pipeline,

described as running within 10 feet of schools in Fallon and crossing the parking

lot of the new Baptist Church. The pipeline was further described as coming in contact with the Carson River and every ditch and irrigation channel across the town.

In retrospect, it should have been routed around the city of Fallon, and not through

it. Vents, located along the route, were visibly damaged in certain areas.

Dr. Ridenour expressed his alarm that, despite the plethora of reports and warnings about the hazards of the jet fuel, nothing was done about it. Morgan Kinder,

the operators of the fuel pipeline, had some checks on the integrity of the system.

Dr. Ridenour described a photo of one of the pipeline test locations. It was covered

with spider webs, indicating that it had not been disturbed by personnel assigned

to monitor the pipeline. Morgan Kinder supposedly used pressurization tests to detect leaks, with the problem being the unknown amount of pressure used during the

test. In Dr. Ridenour’s judgment, given the 300-mile length of the pipeline, it would

have to be a sizable leak before it would be detected as a pressure drop. At a leakage rate of one drop per second, the soil contamination in 1 year would be 300 gallons.

Dr. Ridenour summarized by saying it generally would take 8–10 years after introduction of a toxic material before the onset of disease. In terms of what had

changed in Fallon during the last 10 years, Dr. Ridenour summarized that insecticide spraying had actually declined due to fewer fields. He added there had been

no increase in radar nor had there been a change in water quality. Whereas literature searches on the topics of arsenic and leukemia yielded no matches, the topics of bone marrow and JP8 fuel revealed multiple references.

100

Despite the military’s comparison of JP8 fuel to kerosene, Dr. Ridenour cautioned

the committees that it would be akin to comparing plastic explosives to play dough.

He encouraged the committees to consider requesting that JP5 be pumped through

the pipeline from Benecia for an interim period in order to complete testing of JP8.

A determination of the complete integrity of the line was also recommended by Dr.

Ridenour. Finally, the aerosol effects of the fuel should be studied in greater depth.

Air currents in the desert, below 18,000 feet of altitude, were described as highly

unpredictable, and jet fuel particles would be very capable of making contact with

people and soil.

Dr. Ridenour reemphasized that the change in jet fuels had to be considered as

one of the most significant new events during the last 10 years in Churchill County.

He once again stated that the Navy itself would not necessarily be at fault if they

had also been ‘‘sold a bill of goods’’ on the merits of JP8. Morgan Kinder should be

made to reroute the pipeline around the town.

Assemblyman Carpenter inquired about the type of fuel used on commercial jets.

Dr. Ridenour stated that it was Jet A, a fuel that was closer to JP4 in composition.

He cautioned that, because of its economical cost, some airlines were considering

switching to JP8.

In response to Assemblyman Claborn’s comment about the fuel pipeline in Las

Vegas, Dr. Ridenour cited the distinction between the two as being one of age,

namely that the northern Nevada line was much older. The Fallon line also pumped

a greater volume, estimated at more than 400,000 gallons per month.

Assemblyman Neighbors shared his confusion regarding the Helm’s Pit in Reno,

once the site of serious ground contamination and now a family recreational area

for boating and fishing. Dr. Ridenour agreed that it was both suspicious and confusing, and it seemed highly unlikely that the fuel oil would be cleaned up in such

a short amount of time.

Chairman de Braga introduced Diane Hansen, a Fallon resident. Ms. Hansen

sought reassurance from the committees that a systematic and thorough cluster investigation would continue. She spoke candidly and shared her concerns that the

next stage of the Nevada Health Division’s investigation would not happen. Ms.

Hansen expressed her expectations that a team of experts would be assembled and

that this investigative team would receive specific direction and adequate manpower

and funding to do the job right. She further emphasized the need for the team to

ask the right questions and to be forthright in their communication with the residents of Churchill County.

Making reference to a 1996 newspaper article, Ms. Hansen shared her specific

concerns about an industrial plant 12 miles north of Fallon. The New American Tec

Corporation arrived in Nevada after having been cited for severe environmental contamination in Kentucky. Their chemical process, a nickel and chrome plating operation, was known to utilize known carcinogens. Ms. Hansen was especially concerned that there had been no followup publicity on this hazardous industry.

In an effort to get answers to her questions, Ms. Hansen conducted her own research and called various agencies, including NDEP, EPA in San Francisco, the

Lahontan Valley News, the Reno Gazette, and the Churchill County Planning Commission. She was surprised to hear that she had been the only person to request

followup information on New American Tec. What she learned was that Fallon was

the only location in the Nation that utilized a vaporization process to plate copper

using nickel carbonyl, a known carcinogen. There was evidence that New American

Tec had not been totally forthcoming about their history in Kentucky in applying

for a permit in Nevada.

Her inquiries to Nevada Department of Environmental Protection revealed that

New American Tec was permitted to emit 2 pounds of nickel components per hour

into the air. Neither the State nor the county required air monitoring on a regularly

scheduled basis. Any air emission results were self-issued by the corporation. The

possible significance of the New American Tec production startup of November 1996

should not be ignored.

In closing, Ms. Hansen asked for assurance that the investigation would include

these small pieces of the puzzle, for example New American Tec.

Chairman de Braga acknowledged that Ms. Hansen represented widespread community concern and that the serious nature of the cluster dictated a very serious

and thorough approach. It was explained that the role of the legislators would be

to make recommendations. The expert panel, comprised of a variety of medical and

scientific experts, would also make recommendations. Ms. Hansen was reassured

that the Nevada Health Division was committed to doing as much as possible. Congressional, State, and community interest would propel the investigation in the

right direction.

101

Ms. Hansen requested clarification on the issue of NDEP writing a requirement

for monitoring into their permitting process. The New American Tec permit was up

for renewal at the current time, and NDEP was said to be in negotiation with the

attorney for the company to require monitoring activities. Ms. Hansen emphasized

the sincere interest on the part of the Fallon residents to do what ever they could

to help.

Assemblywoman de Braga echoed the words of Ms. Hansen and agreed that

Fallon was, indeed, a wonderful community for families. She gratefully acknowledged the testimony of Ms. Hansen.

The next expert witness called was Peter Washburn, Attorney for Senator Reid’s office in Washington, DC. Mr. Washburn distributed a copy of his written statements (Exhibit G). He commenced his testimony by highlighting Senator Reid’s sen- ior membership with the Senate Environment and Public Works Committee. Mr.

Washburn assured the committees of Senator Reid’s deep concern over the Fallon

cluster. He commended Chairman de Braga on her foresight in scheduling the special legislative hearings and acknowledged the dedication of the two committees and

Dr. Mary Guinan for their participation.

Because of Senator Reid’s dual membership in both the Appropriations and Environmental Committees, he was described as being in a unique position to leverage

Federal resources to aid the investigative work. Senator Reid’s first priority was described as in the areas of communication, participation, and coordination. Because

of the multitude of experts and citizens involved in the process, these hearings were

said to set the stage for the essential communication and coordination of information sharing.

Mr. Washburn described Senator Reid’s second priority as pointing to the issue

of what could and should be done now to reduce environmental risk to the citizens

of Fallon. Because investigative work would likely take years, remedial steps should

be implemented regardless of conclusions about causal agents. He cited the example

of arsenic and stated that Federal grants were forthcoming. The Small Community

Safe Drinking Water Safety Act was slotted for introduction by Senator Reid. This

bill would make Federal grants, not loans, available to small public water systems

for purposes of improving the quality of the water.

Mr. Washburn explained that Senator Reid was planning to schedule hearings in

Nevada for purposes of addressing the leukemia cluster and public health concerns.

Dates and agenda would be announced. Chairman de Braga expressed her thanks

to Senator Reid for his early and on-going involvement in the matter.

Chairman de Braga introduced Jerry Buk, Regional Director for the University

of Nevada Cooperative Extension Service in northern Nevada. Mr. Buk addressed

the Nevada Gold (Guarding Our Local Drinking Water) project in Fallon. This program was designed by a water specialist in Fallon, Mary Reed. The model employed

was a ‘‘train the trainer’’ in which volunteers from the community were trained to

share water safety information with the residents, especially those served by private

wells.

Due to an unexpected illness of the project leader, the Nevada Gold project atrophied and ceased to function by May 2000. Mr. Buk explained that the program

would be reinstated immediately. The first order of business was described as a

compilation of all Nevada Gold information and dissemination of the data to all

agencies and businesses that dealt with residents served by private wells.

Mr. Buk concluded by saying that the program was being reviewed and streamlined for implementation in March 2001. The new program would be tailored to include the leukemia cluster issue and would focus on educating citizens on the need

to have water tested, as well as how and where to procure testing services.

In response to Chairman de Braga’s question regarding the expansion of testing,

Mr. Buk shared his knowledge of some grant money connected to a Ph.D. dissertation. This was described as a possible source of funds for actual water testing for

residents. Mr. Buk cautioned that the breadth of water testing (i.e., number of substances) was overwhelming. The Nevada Gold program had looked specifically at nitrates in water, a relatively cheap and easy analysis. This was contrasted to the

complexity and higher cost of testing newer substances.

The next experts to testify were Juanita Cox and Robert Sonderfan, representatives of People To Protect America and Citizens In Action. Self-described lobbyists,

researchers, and investigative journalists, Ms. Cox and Mr. Sonderfan displayed a

stack of articles and research information (no handouts). Ms. Cox expressed concern

over the lack of discussion of the water contaminant MTBE. Added to gasoline in

the late 1970’s, it had now been known to cause three types of cancer in laboratory

animals, including leukemia. The amount of contamination of drinking water and

recreational water was described as extensive, and therefore, should be added to the

Fallon testing agenda, according to Ms. Cox.

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Internet literature searches revealed the 2001 military construction program for

Fallon NAS, specifically the plan to replace military fuel tanks. Underground fuel

tanks were described by the military as being 45 years old and having known leakage problems. The immersion of the tanks in the area’s saltwater aquifer caused

corrosive effects on the metal. Because contamination by various substances could

be through ingestion, inhalation, or skin contact, Ms. Cox urged the expansion of

testing. Fluoride was cited as an example.

Ms. Cox concluded her testimony with her observations of the 3-day hearings, described as ‘‘CYA’’ and damage control. Because of economic reasons or the threat of

legal ramifications, some answers would never be disclosed. Massive denials and

subsequent legal actions were predicted by Ms. Cox to be unavoidable.

Mr. Sonderfan commenced his testimony with a review of Project Shoal and

Project Faultless. He described the hurdles and red tape he faced in researching

these topics. Project Faultless was a 13-megaton detonation of a classified military

warhead near Fallon. In his judgment, the military had not been forthcoming in revealing harmful practices, such as burying trash for more than 40 years. Nellis Air

Force Base was described as having 30 tons of depleted uranium, with a half-life

of more than four billion years.

Ms. Cox elaborated on the subject of depleted uranium and stated that the Pentagon knew in 1995 about the environmental threats posed by nuclear weapon

waste. The question needed to be asked of the Fallon NAS about their use of plutonium, one of the most toxic substances known to man.

Ms. Cox concluded her testimony with an overview of other agents for investigation and testing, which included electromagnetic radiation (i.e., EMF), Agent White

(i.e., Tordon), DDT, nuclear fallout, fuel dumping from jets, manganese, ethylene

dibromide, and bovine leukemia viruses. Research indicated that veterinarians and

dairy farmers had elevated leukemia rates. Production of milk was reportedly greater in cows infected with bovine leukemia.

Due to the lateness of the hour, Chairman de Braga interjected with a request

of Ms. Cox to leave one copy of her testimony for distribution to the committees.

Ms. Cox concurred and added that having her testimony cutoff would be expected

especially since the topic was milk.

Mr. Sonderfan interjected with a plea for the Fallon NAS to come forward with

a report of chemicals used and stored on the base. His research revealed leaking

storage tanks. Arsenic, according to Mr. Sonderfan, was just a smokescreen. Leukemia was described as resulting from a one-two punch, the first being the lowering

of the immune system and the second punch some exposure to a trigger agent. Bovine leukemia virus in raw milk had the capability of being transmitted to humans.

Ms. Cox interjected with comments about the synergistic effects of chemicals and

environmental toxins. She further cautioned that, even if causes were suggested by

a citizen, it would invite legal entanglement for years. She urged the cessation of

cover-ups and human experimentation. She urged the committees to empower the

community because it was most likely that the answers would come from the people.

The public needed a civilian investigative board and a hotline for public input that

would facilitate the reporting of environmental hazards.

Chairman de Braga explained that there was a hotline in place for citizen input.

In response to Ms. Cox’s concern about reporting an incidence of environmental

dumping, Chairman de Braga assured the witness that the health department in

each community was there to respond to these concerns.

Assemblyman Mortensen inquired if anybody in the room knew with certainty

that the Fallon NAS practiced with depleted uranium shells. Chairman de Braga

elaborated that this had been suggested in several letters from other concerned constituents. It would be included in the list of recommendations. A handout (Exhibit

H) was received from the Department of Energy.

Chairman de Braga adjourned the meeting at 5:46 p.m.

Respectfully submitted,

JUNE RIGSBY,

Committee Secretary.

April, 19, 2001.

Committee on Environment and Public Works,

Washington, DC.

Subject: Fallon Leukemia Cluster

DEAR COMMITTEE MEMBERS: I am writing in response to a request for public testimony concerning factors to consider connection with the Fallon Leukemia cluster.

103

I would like to see this committee carefully consider the role of fire in the disbursal

of hazardous materials through the environment, including fire’s role in remobilized

radioactive isotopes and other contaminates deposited in Nevada as a result of

weapons testing. I would request the committee to consider the dangers associated

with fire as a remobilizing agent of radionuclides from the Nevada Test Site and

other testing ranges in the State.

During the period of above ground testing from 1951 to 1963, radioactive releases

from the Nevada Test Site emitted over 12 billion curies of radioactive material into

the atmosphere, 148 times as much as the nuclear disaster at Chernobyl. Other pre1971 nuclear tests released 25,300,000 curies, and from 1971–1988, 54,000 curies

were released, including the 36,000 curies from the Mighty Oak accident, which was

itself 2000 times greater than the release at Three Mile Island. Over half of all underground tests have leaked radiation into the atmosphere (DOE Report on Radioactive Effluents, 1988). DOE has been out of compliance with Federal and State permit requirements in the areas of air emissions, water releases, and solid waste disposal (DOE Nevada Operations Office Five Year Plan, 1989).

There is contamination in soil, air, ground and surface water. Strong winds, common to this area of Nevada, can carry plutonium-contaminated dust across a large

area. Fallout from above ground nuclear tests in the United States and other countries has radioactively contaminated the atmosphere around the Earth. Project

Faultless in Hot Creek Valley was found to have caused radioactive contamination

in groundwater. According to EPA Publication 520/4–77–016, cumulative deposits of

plutonium (Pu–239 and Pu–240) have been found in soil over 100 miles north of the

NTS at levels of 790 mg per acre. Plutonium has a half-life of 26,000 years, and

plutonium contaminants ingested in microscopic amounts are capable of causing

cancer for 200,000 years. There is no cost-effective technology for decontaminating

such sites. No surveys have been conducted to determine health effects on Native

American or other residents from Nevada Test Site (NTS) releases. Currently the

Nuclear Risk Management for Native Communities project is working to answer

some of these questions.

It is known that plutonium translocates to specific radiosensitive organs, especially reproductive organs.

During the years of 1999 and 2000, almost 3,000,000 acres of Public Lands in the

State of Nevada were subjected to fires, both wild fire and prescribed burns. Fire

remobilizes contaminants. Particles are lifted from the ground into the air, then mobilized through environment on wind currents. The particles are resuspended for an

indefinite time period, finally redeposit onto the earth. This process creates fallout.

As a result of this process, fire can carry containments across the globe.

We understand that the Nevada BLM oversees management of 1,722,330 acres of

public lands considered contaminated with UXO, (unexploded military ordinances).

BLM lands border NTS (Nevada Test Site), Nellis Bombing and Gunnery Range,

Tonopha Air Force Base, together with the Fallon Range. No one knows the amount

or extent of nuclear contamination in the area surrounding the NTS and Nellis Air

Force Base which tests depleted uranium (DU) bombs. In 1997 it was estimated

that 30 tons of DU had already been deposited in the target area (Draft Environmental Assessment Resumption of Use of Depleted Uranium Rounds at Nellis Air

Force Range Target 63–10), a total of 9,500 combat mix rounds (7,900 DU rounds)

being expended annually, there.

Depleted uranium or U–238 has an atomic mass of 238. Its half-life is 4.468 billion years (Rokke, 2001). It’s natural occurrence is 2.1 parts per million. Uranium

is silver white, lustrous, malleable, ductile, and pyrophoric. This makes DU an ideal

metal for use as kinetic energy penetrators, counterweights, and shielding or armor.

High density and pyrophoric (catches fire) nature are the two most significant physical properties that guided its selection for use as a kinetic energy penetrator.

A study performed at Yucca Proving Grounds found DU residues in all components of the environment, that environmental concentrations varied widely, that

corroded DU residues are soluble and mobile in water, that wind dispersal during

testing is the prevalent means of dispersal of DU particles, and that an unknown

degree of risk was posed to human health by DU in the environment. Moreover,

there appears to be no insight into the issue of long-term (100 to 1,000 years and

longer). DU forms of both soluble and insoluble oxides. The inhalation of the insoluble oxides presents an internal hazard from radiation if retained in the lungs.

The long-term effects of internalized depleted uranium are not fully known, but

the Army has admitted that ‘‘if DU enters the body, it has the potential to generate

significant medical consequences.’’ Inhaled DU particles or respirable size may become permanently trapped in the lungs. Inhaled DU particles larger than respirable

size may be expelled from the lungs and ingested. DU may also be ingested via

hand-to-mouth transfer or contamination of water or food supplies. DU, which is inVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00109 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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gested, or enters the body through wind contamination, will enter the bloodstream

and migrate throughout the body, with most of it eventually concentrating in the

kidney, bone, or liver. The kidney is the organ most sensitive to DU toxicity.

More testing of soil and plants needs to be done to determine what radionuclides

might be released into the air in a fire, since a fire and its relationship to the resuspension of contaminants has not been the subject of study. Plutonium and radionuclides concentrate in dust, thus higher concentrations are found in the dust sampling than in regular soil sampling. The standard air monitors and surface water

samplers usually used are not sufficient to measure submicroscopic particles of plutonium. Further, plutonium contamination is not homogeneous, so simplistic sampling methods are inadequate (John Till, President, Risk Assessment Corp; 2000).

Wind-blown particulates must be considered. Debris and gas will go somewhere, but

where? Into the water or the soil?

Radiation detection devices that detect and measure alpha particles, beta particles, x-rays, and gamma rays emissions at appropriate levels from 20 dpm up to

100,000 dpm and from .1 mrem/hour to 75 mrem/hour must be acquired to assess

the distribution of particles. Standard rad-meters or Geiger counters do not measure

these levels.

In order to assess the health risks and damage due to exposure to tritium (radioactive hydrogen), three blood tests must be done. White blood cells must be tested

for the presence of micronuclei, indicating the loss of DNA repair processes and

leading to increased cancer risk. Red blood cells must be examined for genetic modification of surface glycophorin-A molecules, also indicating DNA damage. A study

of Japanese nuclear bombing victims forty years from the time of the blasts showed

DNA codes were still unrepaired. In addition, chromosome painting allows chromosomes to be stained for identification of structural and sequential or numerical

abnormalities linked to radiation and chemical exposure, cancer, and inherited diseases.

In addition to the redistribution of containments, we need to consider the effects

of fire upon other substances. For example, we must consider chemical reactions

which may take place when multiple herbicides are burned together. For instance,

one chemical being most often utilized on public lands is Tordon. But Tordon is also

called Grazon, and the active ingredient is picloram, better known as Agent White,

similar to Agent Orange, and one of several defoliants used in Vietnam. In fact,

Agent White (picloram) appeared in 5 of the 15 defoliants used there. Agent White

is currently being sprayed by the U.S. on the coca fields in Columbia as part of the

drug war. In 1998, Dow Chemical, manufacturer of Agent White (picloram) tried to

halt its use, warning that it does not bind well with soil, easily washes into the

groundwater and could cause irreparable damage to the Amazon Rainforest. Yet,

U.S.G.S. Pesticide 1992 Annual Use Map showed estimated annual agricultural use

of Agent White to be less than 0.370 pounds per square mile per year. The map

shows the entire State of Nevada has been exposed. This is a lot, and has probably

increased since that time. If it’s dangerous to the water and forest areas of Colombia, it is dangerous here in the U.S. The use of Tordon is banned in some countries.

Also commonly used are 2, 4–D which forms poisonous gas in fire. It is on the

Hazardous Substance List because it is regulated by OSHA. The chemical is a

mutagen (changes the genetic structure), a teratogen causing birth defects, and a

carcinogen particularly related to breast cancer. Short term effects of its use include

the death of animals, birds, fish, and plants within 2–4 days after exposure. About

91.7 percent of 2, 4–D will eventually end up in water. In 1990, the Clean Air Act

announced 2, 4–D as a hazardous air pollutant. Run off vapors can kill non-target

plants. Agent Orange was a mix of 2, 4–D and 2, 4, 5–T. Another name for 2, 4,

5–T is Weedar. And both of these chemicals appear on the recommended list of

chemicals used on public lands.

Garlon is also known as triclopyr (both names appear separately on the recommended treatment list as if they are different herbicides). Triclopyr’s chemical

structure is very similar to 2, 4, 5–T. The MSDS sheet includes the following data:

Nitrogen oxides, hydrogen chloride, and phosgene may result under fire conditions

and NIOSH/MSHA requires approved SCBA and full protective equipment for firefighters. Garlon-treated wood that is burned during forest fires, or in wood stoves

at home produces a dioxin, one of the most damaging compounds to living organisms. Garlon is an endocrine disrupter.

It mimics a plant hormone, acting systematically to kill the plant or tree. The hormone that Garlon mimics is perceived by the human body to be estrogen. In women,

this may result in breast cancer, miscarriages, infertility, birth defects, and possibly

ovarian cancer. In men, it can cause prostate or testicular cancer and reduction of

sperm count. It also may aggravate liver and kidney disease. We do not know what

105

1Metabolites result from the interaction of the chemicals with enzymes or other chemicals inside the body.

the effects of burning multiple pesticides and the full extent of the risk to public

health from such events.

I suggest that a more appropriate methodology for determining causation of the

Fallon leukemia clusters would use a multidimensional model for analysis. In other

words, rather considering singular etiologies, as suggested by Prescott from CDC at

the hearings, a more complex multi-factor dynamic process may be in operation. We

might hypothesize very generally that exposure to radionuclides such as tritium,

plutonium, or DU, might cause mitochondrial damage to cells. In addition to other

functions, mitochondria contribute to a sort of ‘‘programmed cell-suicide’’. For example, in certain stages of fetal development, humans have webbed fingers. The mitochondria detect this, and at the appropriate time, seek to destroy the web cells, leaving humans with fully formed fingers. This cell-suicide is necessary.

However, when exposed to an error or to toxins or radionuclides, the mitochondria

engage in a process of ‘‘unprogrammed cell suicide.’’ Thus, healthy cells are destroyed. Such suicides may lead to destruction of critical elements of immune system function, resulting in cancers, leukemia, and the inability to fight the effects

of various viruses and bacteria. The cells may be more vulnerable to effects of exposure to chemicals or pesticides. In addition, adequate production of certain

neurotransmitters and hormones might be disrupted leading to diabetes or neurological damage. These medical conditions have been reported as increasing in the

general population, and though differing in appearance, may be reflecting a basic

underlying cellular assault caused by radiation exposure. I refer you to the work of

Guy Brown.

Thank you for your thoughtful consideration.

Sincerely,

BONNIE EBERHARDT BOBB,

Shundahai Network.

STATEMENT OF GENERAL ACCOUNTING OFFICE, HEALTH, EDUCATION, AND HUMAN

SERVICES DIVISION, WASHINGTON, DC.

TOXIC CHEMICALS—LONG-TERM COORDINATED STRATEGY NEEDED TO MEASURE

EXPOSURES IN HUMANS

State and local officials report continuing public concern over the health risks

posed by exposures to toxic chemicals, ranging from heavy metals such as arsenic

found at national hazardous waste sites to common pesticides used in and around

the home. For example, increasing rates of cancer in various communities have

prompted questions about the potential link to residues from pesticides, indoor air

pollutants, and other toxic chemicals. Historically, estimates of human exposure to

toxic chemicals have been based on the concentration of these chemicals in environmental media—such as air, water, and food—along with assumptions about how

people are exposed. Federal monitoring efforts have primarily focused on this type

of measurement. However, according to public health experts, measurements of internal doses of exposure—actual levels of chemicals or their metabolites1 in human

tissues such as blood or urine—can be a more useful measure of exposure for some

purposes.

Over the past decade, advances in laboratory technology have provided new tools

for measuring a broad range of chemicals in human tissues—tools that can help researchers and health officials assess’ how much of a chemical has been absorbed in

the body and provide more accurate measurements of exposure to relate to potential

health risks. When gathered for the U.S. population, such data can help identify

new or previously unrecognized hazards related to chemical substances found in the

environment, monitor changes in exposures over time, and establish the distribution

of exposure levels among the general population. These data can also help identify

subpopulations—such as children, low-income groups, or ethnic minorities—that

might be at increased risk because they face particularly high levels of exposure.

State and local health officials can use information on typical exposures in the general population to help assess environmental health risks for specific sites or populations within their borders and to keep local residents informed. For example, local

officials in one community collected exposure measurements before, during, and

after the burning of arsenic-contaminated soil and found that no excess exposure—

as compared to typical levels found in the population—had occurred.

106

2The scientific community uses varying terminology when referring to human exposures.

Often, external contacts with chemicals are defined as ‘‘exposures,’’ and internal measurements

of exposure are referred to as ‘‘doses.’’ Doses are also considered a measure of exposure. Our

review focused primarily on efforts to gather internal exposure measurements through human

tissue in the non-occupationally-exposed population. To simplify reporting, we are referring to

such internal exposure measurements as ‘‘human exposure’’ data.

In light of the potential benefits offered by these new technologies, you asked us

to review efforts to collect and use such information at both the State and Federal

levels. Specifically, you asked us to (1) determine the extent to which State and Federal agencies—in particular, the Department of Health and Human Services (HHS)

and the Environmental Protection Agency (EPA)—collect human exposure data2 on potentially harmful chemicals, including data to identify at-risk populations, and (2)

identify the main barriers hindering further progress in such efforts.

We compiled a list of more than 1,400 naturally occurring and manmade chemicals considered by HHS, EPA, and other entities to pose a potential threat to human

health. These included chemicals prioritized for safety testing (based on EPA’s findings that the chemicals may present unreasonable health risks), chemicals linked

to cancer, toxic chemicals frequently found at Superfund sites, and certain pesticides

monitored in foods or thought to be potentially harmful to humans. For these chemicals, we assessed the extent to which major HHS and EPA survey efforts—specifically HHS’ National Health and Nutrition Examination Survey (NHANES) and

EPA’s National Human Exposure Assessment Survey (NHEXAS) phase I (pilot surveys)—were collecting human exposure data. We also surveyed 93 environmental

health officials in 50 States and the District of Columbia, receiving responses from

81 officials in 48 States for a response rate of 87 percent. At the Federal level, we

focused on survey data collected for the general (non-occupationally exposed) population. We excluded federally sponsored academic and private sector research. Appendix I explains our scope and methodology in more detail. We conducted our work

from March 1999 through March 2000 in accordance with generally accepted government auditing standards.

RESULTS IN BRIEF

Federal and State efforts to collect human exposure data are limited, despite some

recent expansions. HHS and EPA have been able to take advantage of improved

technology to measure exposures for more people and for a broader range of chemicals. Still, with existing resources, HHS and EPA surveys together measure in the

general population only about 6 percent of the more than 1,400 toxic chemicals in

our review. For those toxic chemicals that we reviewed, the portion measured

ranged from 2 percent of chemicals prioritized for safety testing to about 23 percent

of those chemicals most often found at Superfund sites and considered to pose a significant threat to human health. Even for those chemicals that are measured, information is often insufficient to identify smaller population groups at high risk, such

as children in inner cities and people living in polluted locations who may have particularly high exposures. At the State level, efforts are similarly limited. Almost all

State officials who we surveyed said they highly valued human exposure data for

populations within their borders, and many provided specific examples of how such

data have provided useful information for interpreting citizens’ health risks and

guiding public health actions. For example, State officials in nine States used

human samples not only to identify who was exposed to a toxic pesticide illegally

sprayed in citizens’ homes, but to identify houses most in need of clean-up. Despite

this perceived value, most officials reported that they were unable to collect or use

human exposure data in most of the cases where they thought it was important to

do so.

Three main barriers limit Federal and State agencies’ abilities to make more

progress. First, Federal and State laboratories often lack the capacity to conduct

measurements needed to collect human exposure data; additionally, for most of the

chemicals on our list, no laboratory method has been developed for measuring the

chemical levels in human tissues. The second barrier, particularly voiced by State

officials, relates to the lack of information to help set test results in context. Public

health officials said they need more information on typical exposures in the general

population so that they can compare this information with people’s levels at specific

sites or with specific populations in their States. They also said they needed more

research to relate exposure levels to health effects for the chemicals of concern in

their States. The third barrier, of particular concern at the Federal level, is that coordinated, long-term planning among Federal agencies has been lacking, partly because of sporadic agency commitments to human exposure measurement and monitoring. HHS and EPA officials indicated that they have been discussing the merits

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3The Role of Monitoring Networks in the Management of the Nation’s Air Quality, National

Science and Technology Council, Committee on Environment and Natural Resources, Air Quality Research Subcommittee (Mar. 1999). 4 According to NRC, human monitoring data alone can signal the need to conduct studies on

specific environmental chemicals, but these data are best viewed as one component of a comprehensive environmental monitoring program. Human measurements are best supplemented

with knowledge of contaminant sources, environmental pathways, environmental concentrations,

time patterns and locations of exposure, routes of entry into the body, material toxicity, and latency. See NRC, Commission on Life Sciences, Monitoring Human Tissues for Toxic Substances

(Washington, DC.: National Academy Press, 1991) . 5Other human biological tissues that might be used for measurements of chemical concentrations include fat tissue, breast milk, semen, urine, liver specimens, hair, fingernails, or saliva.

Human breath has also been used to measure exposure to certain chemicals.

of establishing a coordinated interagency human exposure program, but they have

not yet formalized or agreed upon a long-term strategy. A long-term coordinated

strategy should also ensure adequate linkages between collection efforts and agency

goals, provide a framework for coordinating data collection efforts that considers individual agencies’ needs and expertise, provide a framework for identifying at-risk

populations, and consider States’ needs for information. To address these needs, we

are recommending that the Secretary of HHS and the Administrator of EPA develop

a coordinated Federal strategy for the short- and long-term monitoring and reporting of human exposures to potentially toxic chemicals.

BACKGROUND

EPA projects a continuing upward trend in environmental compliance costs for pollution control measures, amounting to an estimated $148 billion this year. Hundreds of millions of dollars are spent monitoring levels of toxic chemicals in the environment—for example, approximately $139 million of Federal funding supported

national air-quality monitoring networks in the United States in fiscal year 1999.3

Despite these expenditures, what often is not known is the extent to which people

are exposed to potentially harmful chemicals in their daily lives, the chemicals to

which they are most often exposed, the levels of such exposure, how exposures

change over time in relation to regulatory policies, and the sources of exposure. Policymakers, regulators, researchers, and public health officials must often rely on estimates of human exposure levels for the general population or for smaller groups

thought to be at risk. Such estimates are often derived from data showing the extent the chemicals are found in the air, water, food, or other environmental media

and assumptions about how and at what rate the body absorbs the chemicals it contacts. A variety of methods for measuring exposures are considered to be more direct

than those that measure chemicals in the ambient environment. These methods

measure exposures in people’s more immediate environments and include tools such

as personal air monitors, which measure chemicals that may be inhaled. For several

chemicals and purposes, measuring internal exposure levels in human tissues is

considered the most useful and accurate measure and an important piece of the information needed to link contaminants in the environment with adverse health effects.

While officials may be able to collect internal exposure levels at a local level, the

results are difficult to interpret without information such as comparative data to

show what exposure levels might be considered high or research findings linking exposure levels to specific health effects. Because of the need for improved data on

actual human exposures found in the general population, the National Research

Council (NRC), an arm of the National Academy of Sciences, recommended in 1991

that the Nation adopt a new program to monitor chemical residues in human tissues, such as blood. NRC noted that determining the concentrations of specific

chemicals in human tissues could serve to integrate many kinds of human exposures across media such as air, water, or food and over time. As one component of

an effort to manage environmental quality and protect public health, NRC reported

that a well-designed national program for monitoring toxic chemicals in human tissues was needed.4 NRC pointed out that human exposure data could be used to help

monitor changes in the population’s exposure to chemicals and identify population

groups—by factors such as age or geographic location—that might be at increased

risk because they face higher levels of exposure.

Direct biological monitoring of human exposure to chemicals has been made increasingly possible by recent advancements in analytical chemistry and molecular

biology. Methods have been developed to measure smaller levels of toxicants in body

tissues and to do so with smaller sample amounts.5 For example, a few years ago

a laboratory would need 100 milliliters of blood to detect dioxins in the partper-billion range. New test methods use less than 10 milliliters and are capable of

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detecting concentrations in the parts-per-trillion range. Single samples can also now

be used to detect low concentrations of multiple chemicals. Since 1995, for example,

laboratory methods have been developed to detect polycyclic aromatic hydrocarbons,

a group of more than 100 chemicals formed during the incomplete burning of coal,

oil, gas, garbage, tobacco, and other substances.

Lead is an example of a chemical that has been monitored extensively by measuring absorption into human tissues—specifically, lead levels in the blood. Elevated

levels of lead in the blood can cause learning problems and, at extreme levels, result

in serious brain or kidney damage. Data on blood lead levels have been collected

for the national population since 1976. Public health officials, researchers, and others have used lead exposure data from large- and small-scale studies in many ways

to identify at-risk populations, evaluate regulatory actions, improve the models used

to estimate exposure, and identify significant sources of preventable exposure, as

shown in the following examples.

• Identifying at-risk populations: National blood lead data revealed that lowincome children living in houses built before 1946 had a prevalence of elevated blood

lead levels of 16.4 percent as compared to 4.4 percent for all children ages 1 through

5; non-Hispanic black children in similar housing had a prevalence of 21.9 percent—

the highest risk of elevated blood lead levels of any demographic group. Using this

information, State and local health of officials can more effectively target screening

and treatment efforts.

• Establishing and evaluating public health-related policies: In the 1980’s, EPA

was considering whether or not to make permanent a temporary ban on lead in gasoline. National data on lead exposure showed a decline in average blood lead levels

that corresponded to the declining amounts of lead in gasoline. Based on this and

other information, EPA strengthened its restrictions on lead in gasoline and required a more rapid removal of lead from gasoline.

• Improving models used to estimate exposure: Experts indicate that an increasingly important use of human exposure data has been as a ‘‘reality check’’ on other

indexes of exposure, such as questionnaires about activities or work histories, to ascertain whether exposures may have occurred. For example, prior to the decision to

phaseout lead in gasoline, exposure models suggested that eliminating lead in gasoline would have only a slight effect on blood lead levels, while actual testing showed

a more dramatic effect.

• Identifying key sources of exposure: When combined with other exposure data,

exposure measurements can help reveal the source of the exposure—an essential

step in developing and monitoring intervention strategies designed to reduce or

eliminate harmful exposures. For example, when no evidence of lead paint—the

most common source of lead contamination—was found in the home of a child whose

blood showed abnormal levels of lead, public health officials were baffled. Observational data on how and where the child spent time and environmental data from

the surfaces most often encountered revealed that lead-contaminated stuffing in a

toy the child chewed likely accounted for the high exposure. The child’s blood lead

level declined when the contaminated toy was removed.

While lead is unique among chemicals in that it has been extensively studied—

decades of research has shown its harmful effects at increasingly lower levels—such

research has been possible in part because of laboratory advances in measurement

technology. Over the years, as technology improved the ability to measure smaller

and smaller amounts of lead in the bloodstream, researchers have been able to identify increasingly subtle adverse effects by linking blood lead levels and changes in

neurobehavioral functioning.

CURRENT MEASUREMENT EFFORTS COVER FEW CHEMICALS AND SITUATIONS

Although HHS and EPA each are expanding their survey efforts to use new technologies and measure a broader range of exposures in the national population, their

measurement efforts cover a limited portion of the more than 1,400 potentially

harmful chemicals we reviewed. These surveys also remain of limited value for identifying at-risk populations, because in the case of their survey efforts, sample sizes

to date have been insufficient—and, for most chemicals, not representative of the

general population. In addition, Federal efforts to help assess potential disproportionate exposures by collecting data on communities living near Superfund sites

have been limited to few locations. State agencies reported that their efforts are also

limited, despite the importance they place on using such data in their studies of

population- or site-specific situations within their borders. According to State environmental health officials, they are often unable to collect these data.

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6Special reference studies supported by the Agency for Toxic Substances and Disease Registry

were also conducted on nonrepresentative samples of a portion of the people participating in the

most recently completed segment of NHANES (conducted from 1991 through 1994). These special studies assessed exposure to 45 pesticides and volatile organic compounds. 7Specifically, pilot surveys were conducted in Arizona, Maryland, and, EPA’s region 5 (Illinois,

Indiana, Michigan, Minnesota, Ohio, and Wisconsin).

Federal Efforts Are Expanding

In our examination of the HHS and EPA surveys, we found that the types of

chemicals measured have recently increased. For the past 40 years, HHS’ Centers

for Disease Control and Prevention (CDC) has collected through a survey nationally

representative data on the health and nutrition of the U.S. population. Exposure

measurements are one component of this survey. In the mid-1990s, EPA’s Office of

Research and Development initiated a human exposure survey, which is currently

in its pilot phase in three locations across the country. A third more recent effort

to monitor human exposures to select chemicals was initiated in 1996 by HHS’ National Institute of Environmental Health Sciences (NIEHS) of the National Institutes of Health (NIH). For each of these Federal efforts, laboratory measurements

are largely conducted by the laboratory at CDC’s National Center for Environmental

Health, which also developed many of the methods for performing these measurements.

CDC’s National Health and Nutrition Examination Survey

CDC collects human exposure data as part of NHANES, which has been conducted periodically since 1960 and, beginning in 1999, has been conducted annually.

NHANES monitors trends in health status by conducting interviews and physical

assessments on a nationally representative sample of about 5,000 people per year.

NHANES collects blood and urine samples for many purposes, such as assessing

cholesterol levels and the prevalence of diabetes. Since 1976, these samples have

also been used to measure exposure to selected chemicals, and excess samples are

banked for future research. In the past, CDC’s human exposure monitoring efforts

have focused largely on lead, cadmium, and a few pesticides and volatile organic

compounds—chemical compounds which include a number of animal and known or

suspected human carcinogens found in tobacco smoke, building supplies, and consumer products.6 Starting with the 1999 NHANES, CDC proposed to measure up

to 210 chemicals in human tissues as staff and other resources permitted. These

chemicals include metals such as mercury, which at high levels may damage the

brain, kidneys, and developing fetus; polyaromatic hydrocarbons (a group of compounds found in sources such as foods that have been grilled); and volatile organic

compounds, such as benzene. At the time of our review, a CDC official indicated

that resources allowed them to include about 74 chemicals for 1999 and 2000. The

estimated marginal costs for the environmental exposure-related components of the

NHANES 1999 survey were about $5 million.

EPA’s National Human Exposure Assessment Survey

To expand upon and replace its National Human Adipose Tissue Survey

(NHATS)—a tissue monitoring program, which ended in 1992–EPA initiated in 1993

pilot surveys for NHEXAS in three regions of the country.7 A goal of the NHEXAS

pilots is to obtain knowledge on the population’s distribution of total exposure to

several classes of chemicals and to test the feasibility of collecting representative

survey data on people’s total exposures. NHATS focused on monitoring human fat

tissues for persistent organochlorine pesticides and polychlorinated biphenyls (PCB);

NHEXAS has broadened this focus in two ways. First, in addition to measuring

chemical levels in samples such as blood or urine, the NHEXAS pilot surveys included measurements of chemicals in air, foods and beverages, water, and dust in

individuals’ personal external and internal environments. To conduct these measurements, the pilot surveys used tools such as questionnaires, activity diaries, airmonitoring badges worn by the individual or other air-monitoring devices, and tap

and drinking water and food samples. Such data are important for purposes such

as identifying the most important sources or routes of exposure and for taking actions to reduce or prevent exposures. Second, the NHEXAS pilot surveys included

more types of chemicals than pesticides, such as lead and other heavy metals. The

NHEXAS pilots, however, included fewer chemicals than its predecessor—which

measured about 130 pesticides and PCBs in human fat tissue—in part because monitoring levels of any given chemical in personal environments and in human tissues

requires significantly more laboratory measurements for the same chemical. EPA’s

NHEXAS pilot surveys, which have tested biological samples from about 460 participants, have collectively measured up to 46 chemicals, including pesticides, heavy

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8The concern about endocrine disrupters originated from the finding that some synthetic

chemicals in the environment are associated with adverse reproductive and developmental effects in wildlife and mimic the actions of female hormones. According to NRC, although it is

clear that exposures to hormonally active agents at high concentrations can affect wildlife and

human health, the extent of harm caused by exposure to these compounds in concentrations that

are common in the environment is debated. See NRC, Commission on Life Sciences, Hormonally

Active Agents in the Environment (Washington, DC: National Academy Press, July 1999). 9 According to NTP officials, chemicals are tested for cancer and noncancer endpoints—including effects on reproduction, development, nervous system, and immune systems—using traditional bioassays as well as newly validated tests. Validation of new tests is achieved through

an NTP interagency center involving 15 Federal agencies or institutes. 10 CDC officials indicated that, by the end of 1999, it had developed laboratory methods to

measure more than half of the chemicals under the agreement with NIEHS. 11 ‘‘We excluded NHATS and Human Exposure Initiative chemical lists from our analysis.

NRC’s 1991 review of the NHATS program raised questions about the representativeness of the

results and the methods used to handle the tissue specimens, among other questions. The

Human Exposure Initiative measurements were not available at the time of our review and,

thus, which chemicals had been or are currently being measured was not known. 12We selected these lists based on input from program officials and experts at EPA, HHS,

the Association of Public Health Laboratories, and the Pew Commission on Environmental

Health and our assessment that the criteria for listing a chemical demonstrated that exposure

could potentially be harmful to humans. There are many toxic chemical lists maintained by different programs and agencies for different purposes that we did not include in our review and,

metals, and volatile organic compounds in blood, urine, or hair. Once data from

these pilot surveys have been further analyzed, EPA intends to assess the feasibility

and cost of conducting a national effort to collect total exposure data. To date, EPA

has invested about $20 million to support the pilot surveys. Very preliminary estimates by EPA for a national survey range from $20 million to $30 million per year

over 10 years or more.

National Institute Environmental Health Sciences’ Human Exposure Initiative

In 1996, NIEHS began an initiative to collect human exposure data. This initiative was started as a collaboration between NIEHS and CDC to improve understanding of human exposures to hormonally active agents—also called ‘‘environmental endocrine disrupters’’—for the national population.8 The effort was intended

to build upon the chemical monitoring in NHANES by supporting the development

of laboratory methods and measurement of previously unmeasured chemicals in

human tissues collected from NHANES and other studies. NIEHS and CDC signed

an interagency agreement, under which CDC will develop methods for measuring

and will measure in blood, urine, or both up to 80 chemicals thought to be

hormonally active agents. For this effort, CDC obtained samples of about 200 people—most of whom are from the ongoing sampling of the general population under

NHANES.

In 1999, officials of NIEHS and the National Toxicology Program (NTP)—an interagency effort to coordinate toxicological research and testing activities of HHS,

which is administratively housed at NIEHS—proposed to expand upon the initial

collaboration and formalized the undertaking as the Human Exposure Initiative.

Specifically, they proposed a broader interagency effort to quantify human internal

exposures to chemicals released into the environment and workplace. One significant purpose of this effort was to help prioritize those chemicals and chemical mixtures to be studied by NTP, recognizing the limited resources available for toxicological testing and the need for better information to prioritize which chemicals

should be tested. According to NTP officials, although NTP is the nation’s largest

Federal toxicology testing program, it can initiate only 10 long-term cancer studies

and 10 reproductive studies per year.9 NIEHS provided a list of 131 chemicals it

hoped would be measured through this expanded effort. At the time of our review,

however, program officials told us that NIEHS had not published data from the

chemicals CDC had measured under this agreement, and CDC was developing the

laboratory methods needed to measure many of the chemicals identified by NIEHS

as needed.10 (For more information on NHANES, NHATS, NHEXAS, and NIEHS’

Human Exposure Initiative, see app. II.)

Despite Expansion, Chemicals Covered in Exposure Measurements Remains Limited

Despite these expanded efforts, NHANES and the NHEXAS pilot surveys cover

only about 6 percent (or 81) of the 1,456 potentially harmful chemicals in our review. We compared the chemicals measured by these surveys to eight selected lists

of chemicals of concern.11 Our selection was based, in part, on our assessment and

input from experts that these lists contained chemicals of higher concern to human

health.12 However, the listed chemicals represent a small portion of those that are

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as such, the ones we reviewed do not necessarily individually or collectively represent the chemicals of highest concern to human health.

regulated or are of potential public health importance. For example, there are over

7,000 lists of chemical substances and classes that are regulated under the Toxic

Substances Control Act and the Emergency Planning and Community Right-toKnow Act.

For those individual lists that we reviewed, the portion of toxic chemicals measured ranged from 2 percent of chemicals prioritized for safety testing (based on

EPA’s findings that the chemicals may present unreasonable risks) to about 23 percent of chemicals most often found at the nation’s Superfund sites and identified as

posing the most significant threat to human health. See table 1 for each of the lists

reviewed and the extent to which NHANES or the NHEXAS pilots are measuring

these chemicals, and appendix I for a discussion of each list included in our review.

Table 1.—Extent to Which Human Exposure Data Are Collected for Potentially Harmful Chemicals

Through NHANES or the NHEXAS Pilot Surveys

Priority chemicals Chemicals measured or being

measured

Description of list No. in

list No. Percent

Chemicals found most often at the national Superfund sites and of most potential threat to

human health ............................................................................................................................ 275 62 23%

EPA’s list of toxics of concern in air ............................................................................................ 168 27 16

Chemicals harmful because of their persistence in the environment, tendency to bioaccumulate in plant or animal tissues and toxicity ............................................................................ 368 52 14

Pesticides of potential concern as listed by EPA’s Office of Pesticide Programs and the U.S.

Department of Agriculture’s Pesticide Data Program .............................................................. 243 32 13

Chemicals that are reported in the Toxic Release Inventory; are considered toxic; and are

used, manufactured, treated, transported, or released into the environment ........................ 579 50 9

Chemicals that are known or probable carcinogens as listed in HHS’ Report on Carcinogens a 234 17 7

Chemicals most in need of testing under the Toxic Substances Control Act (Master Testing

list) ............................................................................................................................................ 476 10 2

Note: Our analysis was based on human exposure data collected through NHANES or the NHEXAS pilot surveys through 2000.

a The Report on Carcinogens list may also include pharmaceutical agents, substances of primarily occupational concern, and banned substances. According to NIEHS officials, this may account for their lower inclusion in NHANES or the NHEXAS pilots. NIEHS and NTP officials indicated that, in addition to these chemicals, NTP reports results of its chronic bioassays for cancer in its technical report series. There are

now approximately 500 reports, which collectively include nearly 250 chemicals found to cause cancer in rodents. Officials indicated that another useful evaluation would assess the proportion of rodent carcinogens for which human exposure data are collected and that NTP is planning to conduct such an evaluation.

While many potentially harmful chemicals in these lists are not measured in the

population, NHANES or the NHEXAS pilot surveys contain a greater portion of

chemicals considered of higher priority. Two toxic chemical lists we reviewed—one

ranking chemicals frequently found at Superfund sites and one ranking selected

chemicals compiled by EPA—prioritized chemicals based on their potential to harm

human health We examined the highest-ranked chemicals on these lists and found

that higher proportions of these chemicals were or will be measured compared to

the overall list. A CDC laboratory official also indicated CDG was in the process of

developing methods to measure a number of the chemicals on these lists and

planned to measure other chemicals in future efforts if they have adequate resources to do so.

• Ranking of chemicals frequently found at Superfund sites: Developed by EPA

and HHS’ Agency for Toxic Substances and Disease Registry (ATSDR), which conducts public health assessments or other health investigations for populations living

around national Superfund sites, this list ranks substances that are most commonly

found at Superfund sites and pose the most significant potential threat to human

health due to their known or suspected toxicity and potential for human exposure.

Of the top 40 chemicals on this list, CDC indicated that 9 were currently being

measured in NHANES. CDC hopes to include an additional 30 of the top 40 in future efforts; 11 of these 30 chemicals, however, were included in the NHEXAS pilot

surveys.

• Ranking of selected toxic chemicals compiled by EPA: These rankings are based

on a chemical’s persistence, tendency to accumulate in plants and animals, and toxicity. CDC indicated 4 of the top 22 chemicals on this list based on their health hazVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00117 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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13 EPA’s prioritized chemical list ranks chemicals based on the length of time to break down,

the degree to which they accumulate in plants and animals, and their toxicity. Both ecological

and health risk scores are calculated. We used only the health risk scores in our analysis. 14 Executive Order 12898 requires that each agency identify and address as appropriate disproportionately high and adverse human health or environmental effects of its programs, policies, and activities on minority populations and low-income populations in the United States and

its territories and possessions. Executive Order 13045 established similar requirements with respect to children. 15S. Perlin, K. Sexton, and D. Wong, ‘‘An Examination of Race and Poverty for Populations

Living Near Industrial Sources of Air Pollution,’’ Journal of Exposure Analysis and Environmental Epidemiology, Vol. 9, No. 1 (1999), pp. 29–48. 16D. Wagener, D. Williams, and P. Wilson, ‘‘Equity in Environmental Health: Data Collection

and Interpretation Issues,’’ Toxicology and Industrial Health, Vol. 9, No. 5 (1993), pp. 775–95. 17The feasibility of using a representative survey to identify at-risk subpopulations based on

individual characteristics (such as age, race, or income level) or location (such as a city, county,

or State) depends on sample design and size—that is, on how the participants are selected and

how many participants are included. Generally, the lower the percentage of the population in

question in the sample, the less the data can be used to develop precise estimates of exposure

or to distinguish exposure levels between subgroups. 18 Certain groups may be included at a higher rate or oversampled to ensure a greater level

of accuracy. For example, between 1988 and 1994, children ages 2 months through 5 years surveyed in NHANES were oversampled.

ard13 were currently being measured in NHANES. CDC hopes to include the remaining 18 in future efforts; 6 of the 18 chemicals were included in the NHEXAS

pilot surveys.

Federal Efforts Are Limited for Identifying At-Risk Subpopulations

In recent years, Federal agencies have been charged with identifying whether certain populations—including minorities, people with low incomes, and children—disproportionately face greater health risks because they have greater exposure to environmental hazards.14 Researchers increasingly recognize that the scarcity of adequate and appropriate data, especially for exposures and related health effects,

hinders efforts to more systematically identify groups that may be at risk.15 Lacking

such data, past efforts to identify the exposures of certain demographic groups have

often relied on measures of chemical levels in the surrounding environment. For example, some studies around hazardous waste sites and industrial plants have shown

that minorities and low-income subpopulations are disproportionately represented

within the geographic area around the sites. Such studies are limited in identifying

the actual health risk because they must make assumptions about how these substitute measures, such as how close one lives to a hazardous waste site, relate to

actual exposures experienced by people.

To identify groups whose exposure is disproportionately greater than that experienced by the remainder of the population—and thereby provide more definitive assessments of whether certain groups potentially face greater health risks—health officials and researchers might measure exposure levels for (1) a representative sample and analyze the characteristics of subpopulations with the highest exposures or

(2) a population thought to be at high risk and compare it to measurements from

a reference population.16 We examined the extent to which Federal survey data on

human exposures collected to date could be used to assess characteristics of those

groups most exposed. We also examined the extent to which human exposure data

was collected on a population considered to be at higher risk—specifically, those living around national priority hazardous waste sites. In each effort, the information

collected has been limited, as discussed below.

Sampling Not Sufficient to Identify Many Highly Exposed Groups

Representative sampling is required to identify at-risk subpopulations in a nonbiased way—that is, without presupposing that a certain group is at higher risk.

The sample must also be large enough to ensure highly exposed subpopulations can

be objectively identified.17 For nearly all chemicals except lead, however, past Federal collection of human exposure data in NHANES and the NHEXAS pilot surveys

has been insufficient to identify whether disproportionate exposures are occurring

in many demographic groups. In the case of NHANES, the sample is generally

drawn to reflect the national population as a whole.18 Consequently, the sample of

the group of interest may be too small to draw meaningful conclusions about characteristics, such as exposures, of the group. In the past, most NHANES exposure

measurements were conducted among non-randomly-selected samples and from only

a portion of the surveyed participants, thus limiting the ability to identify highly

exposed groups. Lead was an exception. Data for blood lead levels in children have

been the most comprehensively collected, and certain characteristics have been

clearly associated with a higher prevalence of blood lead levels. EPA has concluded

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19 According to CDC officials, children under 12 will not be assessed because the volume of

tissue samples needed to perform the measurement will not be available. Other measurements—

such as those for lead, mercury, and cotinine (a metabolite of nicotine illustrating exposure to

cigarette smoke)—will be performed for many in this age group. 20 According to CDC laboratory officials, other NHANES exposure measurements planned for

1999 and 2000 for a subsample of participants includes volatile organic compounds, mercury,

nonpersistent pesticides, phthalates, and trace metals. Air toxic exposures to selected volatile

organic compounds will be measured in personal measurements—such as chemical levels in the

air, measured through badges, and chemicals in water samples—and in blood samples from a

subsample of people ages 20 through 59. Mercury will be measured in the hair and blood of

participants ages 1 through 5 and women ages 16 through 49. Nonpersistent pesticides or their

metabolites are planned for measurement in one-half of participants ages 6 through 11 and onethird of participants ages 12 and over. Surveys and focused research indicate that household

use of certain pesticides may be extensive, but little information is available concerning residential or household exposures among the general population. Phthalates are planned for measurement in one-third of the participant ages 6 and older. Seventeen trace metals will be measured

in one-third of participants ages 6 and older. Trace metals such as barium and beryllium have

been associated with adverse health effects in occupational or laboratory studies but have not

been monitored in the general population. 21The current design of NHANES samples allows several years of data to be combined. If exposure for chemicals is measured consistently over several years, then assessing risk factors

may be increasingly possible over time. CDC officials indicated that for any annual NHANES

Continued

that the evidence is unambiguous: children of color have a higher prevalence of elevated blood lead levels than white children do, and children in lower-income families

have a higher prevalence than children in higher income families. See table 2 for

the most recent NHANES analysis.

Table 2.—Prevalence of Elevated Blood Lead Levels in Children Ages 1 Through 5, by Selected

Demographic Characteristics (NHANES, 1991 Through 1994)

Characteristic of children in sample

Percentage

with elevated blood

lead levels

Race/ethnicity:

Black, non-Hispanic ................................................................................................................................................ 11.2%

Mexican-American .................................................................................................................................................... 4.0

White, non-Hispanic ................................................................................................................................................ 2.3

Income level:

Low ........................................................................................................................................................................... 8.0

Middle ...................................................................................................................................................................... 1.9

High ......................................................................................................................................................................... 1.0

Age group:

1 through 2 ............................................................................................................................................................. 5.9

3 through 5 ............................................................................................................................................................. 3.5

Total age 1 through 5 ........................................................................................................................................ 4.4%

Source: CDC, ‘‘Update: Blood Lead Levels—United States, 1991–1994,’’ ‘‘Morbidity and Mortality Weekly Report, Vol. 46, No. 7 (1997), pp.

141–5.

CDC officials told us that representative data, such as that collected for lead,

would be collected for a larger number of chemicals starting in 1999. However, CDC

plans indicated that for most chemicals monitored, only a portion of NHANES survey participants—generally one-third or fewer, depending on the type of chemical— would be tested. For some chemicals, only certain groups thought to be at higher

risk may be tested. For example, NHANES will include measurement of certain persistent pesticides known as organochlorines in one-third of the survey participants

ages 12 through 19. Children under 12 will not be assessed.19 CDC officials indicated that people over 19 may be assessed if adequate resources are available to

do so. Although most organochlorines are banned in the United States, some are

still used in home and garden products, such as products for treating lice and controlling agricultural and structural pests and flame retardants used in synthetic fabrics.20 NHANES data from a one-third subsample will be useful for establishing reference ranges within the population and illuminating exposure levels nationally;

they will also be useful for identifying exposures of broad demographic groups, such

as males and females. But these data are not enough to enable researchers to assess

exposure levels of or characterize many potentially at-risk groups, such as the exposures of inner-city children in low-income families.21 According to a CDC laboratory

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full sample, a limited number of estimates for broad population subgroups can be developed.

More detailed measures for smaller subgroups (for example, analyses by age, gender, and race

and ethnicity) will require more years of data, generally 3 through 6 years—and even longer

if a subsample is used—of data collected for all participants. Based on an annual sample of onethird of the participants, CDC indicated that estimates may be possible for very broad subgroups, such as males or females; participants ages 6 through 19 or over 20; or a few major

race and ethnicity groups, depending on the prevalence of the condition examined. 22One assessment of the data from Midwestern States provided some indication of potential

differences in personal exposures between age groups, races, income segments, and house construction dates. Researchers cautioned that the data for some categories examined were small.

This assessment did not report on exposure measurements from biological sampling in this survey. (See E.D. Pellizzari, R.L. Perritt, and C.A. Clayton, ‘‘National Human Exposure Assessment

Survey: Exploratory Survey of Exposure Among Population Subgroups in EPA Region V,’’ ‘‘Journal of Exposure Analysis and Environmental Epidemiology,’’ Vol. 9 (1999), pp. 49–55. 23These participants provided biological samples, such as blood and urine. Larger participant

groups in the study areas provided environmental and food monitoring samples and responded

to questionnaires. This excludes a related but separate study done in Minnesota reviewing pesticide exposures that was not one of the three formal pilot surveys. 24Determining the distribution of chemical exposure among a non-occupationally-exposed population establishes a ‘‘reference range’’ that shows what can be considered background exposure

and what can be considered high. With reference range information, officials concerned about

exposures of groups can compare the groups’ exposures to those of the general population and

determine whether public health action is warranted to prevent or reduce high levels of exposure. 25 ATSDR conducts exposure investigations when (1) people have likely been exposed to a contaminant, (2) more information is needed on the exposure, (3) an exposure investigation will provide that information, and (4) that investigation will affect public health decisions. 26 In its report, panel members suggested many improvements to ATSDR’s exposure investigations, including creating a technical planning group to review emerging and innovative technologies and establishing a national clearinghouse of collected data. ATSDR officials indicated

that they had not been able to act on some of the panel’s suggestions because of limited staff

and resources and other barriers to collecting data, such as the lack of laboratory methods for

testing chemicals of interest ATSDR has nine staff to conduct exposure assessments for sites

across the nation and can only respond to requests from communities or State or local officials

for assistance rather than conducting such assessments as part of every new investigation.

official, targeted studies should be considered for groups that represent a small portion of the population.

Similarly, the NHEXAS pilot surveys included representative samples of participants in the three geographic locations covered. However, because of the smaller

sample sizes, the work to date has also been too limited for much analysis of atrisk populations.22 The pilot surveys included biological measurements for about

200 people in six Midwestern States, about 180 people in Arizona,23 and about 80

people in Baltimore.

Federal Efforts to Identify Communities of Concern Valuable, but Human Exposure

Data Are Limited

A second method to identify a subpopulation disproportionately at risk of adverse

health effects is to compare exposure levels for a group thought to be at high risk

with baseline measurements from a reference population.24 This method can be

used to determine, for example, the extent to which people in a neighborhood, community, or geographic location are exposed relative to others. In cases where exposure levels have been identified as high compared to reference populations but potential health effects associated with those levels have not been researched, public

health actions can help prevent further or increasing exposures, and these groups

can be assessed for any subsequent health outcomes.

One Federal effort, conducted by ATSDR, analyzes risks faced by communities

near hazardous waste sites. ATSDR estimates that 12.5 million people live within

1 mile of the nation’s 1,300 Superfund sites. The agency can collect biological samples through exposure investigations as part of the public health assessment process

or in response to requests from the public.25 ATSDR officials said that human exposure data collected at Superfund sites have been useful in deciding on actions such

as stopping or reducing exposures, relocating residents, referring residents for medical follow-up, reducing community anxiety, influencing priorities on site-specific

clean-up, making referrals to researchers for assessing health links, and educating

community and other health providers. As evidence, they pointed to the conclusions

of an expert review panel, which stated in March 1997 that human exposure data

were as important to exposure investigations and public health assessments as environmental monitoring results at the sites of concern.26 However, the number of investigations that included human exposure data has been limited. Between 1995

and July 1999, ATSDR had gathered biological samples at only about 47 of the more

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27Federal agencies also might fund academic research that is designed to identify communities of concern. Assessing the extent that federally supported academic research included or

focused on human exposure data to identify at-risk population was beyond the scope of our review. 28Since most States conduct surveillance for lead exposure, we asked officials to not include

these efforts in their responses. See app. III for a copy of our survey.

than 1,300 Superfund sites. At least 34 of these investigations detected contaminants in people and 16 found elevated levels.

Other federally conducted efforts designed to monitor or collect data on the exposures of populations within selected communities or geographic regions have also

been infrequent.27 One such regional-scale effort under way is collecting data on exposures within selected communities along the border between Texas and Mexico.

Officials from Mexico and Federal and State agencies in the United States are comparing exposures of people in the border area with those in areas away from the

border. Another study examined the exposures of people along the Arizona border

compared to the exposures of people elsewhere in the State. This study collected environmental samples for pesticides, metals, and volatile organic chemicals. Blood

and urine samples were also tested to relate the environmental measurements to

the measurements in human tissues for these chemicals.

State Officials Value Human Exposure Data for Studies and Investigations but Do

Not Often Include Them

Most State officials who we surveyed highly valued human exposure data. However, most could not include it in their exposure-related health studies, investigations of concerns such as disease clusters, or surveillance efforts. Almost half of the

officials responding to our survey estimated that they had participated in 10 or

more exposure-related studies or investigations since 1996, with about 16 percent

estimating they participated in 50 or more. However, about half of the officials indicated they could seldom if ever collect exposure data through human samples in

their efforts. When data were developed, officials listed five main uses: (1) environmental health epidemiologic studies, (2) surveillance of diseases or conditions with

suspected environmental causes, (3) investigations of citizen concerns, (4) planned

or accidental chemical releases, and (5) disease clusters (see table 3).28 State officials we spoke with noted that human exposure data are often the most valid and

persuasive evidence available to demonstrate whether, and to what extent, exposure

has occurred or changed over time. In highly charged situations, where community

trust has eroded, such data may be the only evidence acceptable to area residents.

Table 3.—Examples of How State Officials Use Human Exposure Data

Purpose Example

Environmental health epidemiologic

studies.

Using blood and urine samples from people who ate sport fish and were concerned about undue exposure to dioxins, pesticides, and other chemicals,

health officials determined these people had exposure to some chemicals

from 2 to 10 times higher than levels in a reference population. Based on

these results, officials will focus a larger health effects study on exposure to

those chemicals.

Surveillance of diseases or conditions

with suspected environmental causes.

Virtually all States collect information on blood lead levels in children to monitor

and prevent lead poisoning. Some also monitor exposure to pesticides and

other chemicals such as mercury and arsenic.

Investigation of citizen concerns ............ Health officials used human tissue measurements and citizens’ reports of illnesses to demonstrate that the combined effect of chemicals released into

the environment posed a health hazard severe enough to warrant evacuating

nearby residents. State and Federal officials subsequently closed a manufacturing plant because of the harmful health effects of its chemical releases.

Investigation of planned or accidental

chemical releases.

Officials in nine States asked CDC to test tissue samples from almost 17,000

individuals thought to have been exposed to methyl parathion, a deadly pesticide. CDC’s ability to measure the pesticide in human tissue and compare

exposures across States was critical to identifying individuals with high exposures and houses most in need of clean-up. Because relocating residents and

removing the pesticide from homes cost up to $250 000 per household, the

exposure data helped officials avoid spending limited funds on houses that

did not pose a health risk to the people living in them. One State official said

the exposure results reduced the number of houses needing pesticide removal

from hundreds to fewer than 10.

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Table 3.—Examples of How State Officials Use Human Exposure Data—Continued

Purpose Example

Investigation of disease clusters ............ State health officials reviewed data on individual cases of cancer in one community and for the entire State. When available data on known risk factors

did not account for the increased incidence of breast cancer, officials began

a more detailed study that included human tissue analysis. Blood samples

were obtained from women before and after treatment began and from

women in a control group. Results will be compared to reference range data

developed by CDC. One goal of such studies is to help identify environmental

factors that contribute to breast cancer risk.

While mercury, arsenic, and pesticides were most often reported as being studied

in human samples, some State officials reported using human exposure data for

chemicals that CDC has since 1991 developed methods to measure. For example,

about 15 percent of officials conducted studies of human exposure to volatile organic

compounds, and almost 30 percent reported studies of exposure to PCBs using data

from tissue analysis.

Regardless of whether State officials had collected or used human exposure data

in the past 4 years, about 90 percent of those officials responding to our survey said

human exposure data from tissue samples was extremely or very important for addressing environmental health concerns. Despite the perceived value of such data,

almost two-thirds of officials said they could include human exposure data in fewer

than half of the exposure-related studies, investigations, and surveillance efforts

where they considered it important. More than one-third said they seldom could include such data.

Several State health and laboratory officials whom we interviewed expressed frustration at the missed opportunities for collecting biological samples as part of their

studies and investigations for reasons such as limited laboratory capacity. For example, health officials in one State could not examine the role played by methyl t-butyl

ether (MTBE)—an additive designed to promote more efficient burning of gasoline— in a major respiratory disease outbreak because State staff lacked the expertise and

CDC staff lacked the time to conduct the needed tests. In 1995, after MTBE was

added to gasoline and thousands of citizens reported becoming ill, State officials

wanted to measure MTBE or its by-products in blood from samples of individuals

with and without symptoms to determine whether MTBE exposure might be the

cause or a contributing factor. Objective measures of individual exposure might have

allowed public health officials to conclusively demonstrate or rule out a link between

the outbreak and exposure, something that was not possible with environmental

data and epidemiologic surveys. The chemicals officials most often cited as wanting

to study using human exposure data, but could not, were pesticides and volatile organic compounds.

SIGNIFICANT INFORMATION AND INFRASTRUCTURE GAPS POINT TO NEED FOR STRATEGIC

PLANNING AND COORDINATION

As part of our survey and interviews, we asked public health experts and State

and Federal officials to identify barriers they considered significant to structure

their efforts to collect and use human exposure data. Officials cited two primary

barriers: the lack of laboratory capacity or methods to analyze tissue samples and

the lack of information to help set exposure test results in context. Addressing these

barriers takes time and resources. In that regard, we identified a third barrier to

more effective use of existing resources: HHS and EPA lack a long-term strategic

plan to address infrastructure and science barriers, coordinate efforts to meet Federal and State needs, and address the many questions about how to set priorities

given their limited resources.

Laboratory Capacity and Methods to Measure More Chemicals Needed

State officials frequently said insufficient laboratory capacity in their States and

at the Federal level hindered their ability to obtain human exposure data in cases

where they thought such data were important. Over half of the officials said their

States lacked sufficient numbers of trained laboratory staff, sufficient laboratory capacity to analyze samples, or sufficient laboratory equipment. Many officials attribute such capacity limitations to funding constraints because tissue analyses can

be time-consuming and expensive to perform. For example, according to a CDC official, each test to measure dioxins in a sample requires (1) a laboratory free from

chemicals that could compromise test results, (2) specialized equipment that costs

about $500,000, and (3) highly trained and experienced staff to complete. Officials

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29This organization actively supports expanding State and local laboratory capacity to participate in a human biomonitoring program to provide human exposure data that would enhance

the effectiveness of environmental policy and regulatory decisions. In addition this group helped

States apply for the four grants CDC offered to increase State and local laboratory capacity to

detect in human fluids and issues chemicals that could be used in a terrorist attack. Illustrating

their interest in developing such laboratory capacity, 31 State and 2 local health departments

applied for the four grants.

of a professional organization representing public health laboratories told us that,

although many State laboratories perceive they have a role in conducting tests to

detect toxic substances in humans, very few currently have such capacity.29

State and Federal officials we interviewed told us that because few State laboratories have the necessary equipment and expertise, they often rely on CDC’s environmental health laboratory staff to analyze tissue samples. Given the specialized

laboratory requirements, CDC’s environmental health laboratory is generally considered the best-suited to analyze tissue samples for a range of chemicals and has, in

fact, developed many of the methods to do so, according to Federal and State officials. CDC’s laboratory performs measurements for most Federal and many State

efforts to gather human exposure data. Many officials said CDC’s laboratory capacity is essential to their efforts and needs to expand to meet growing needs. A few

State officials said CDC’s laboratory consistently returned test results when people’s lives were at risk but was less able to help States assess health risks more generally. An official in one State said that, while CDC’s assistance is invaluable, the

State’s laboratory capacity allowed public health officials to obtain human exposure

data and investigate citizen’s concerns more frequently than they could if they had

to rely soley on CDC’s laboratory capacity.

Another significant issue is the lack of analytical laboratory methods to measure

chemicals of concern. Despite advances over the past 2 decades in analytic chemistry and molecular biology, laboratory methods have not been developed to measure

about 88 percent of the 1,456 chemicals in our review, according to information provided by CDC and EPA officials. Although laboratory staff at CDC have quickly applied scientific and technological advances to develop new and more efficient laboratory methods, they are concerned about the lack of methods to test a single human

sample for several related toxics. For example, a method exists to measure arsenic

in blood but not to measure arsenic and other heavy metals at the same time. Such

methods make more efficient use of the samples that are gathered and greatly reduce the time and money needed to test large numbers of samples. While CDC’s laboratory continuously develops new chemical testing methods, current resources limit

the number to about 10 annually.

Even when analytical methods exist, efforts to gather human exposure data are

sometimes limited by problems with the methods used to gather the samples. This

is especially true for young children, a group thought to be particularly susceptible

to harmful effects from exposure. In some cases, existing laboratory methods require

sample volumes that can only be obtained through invasive techniques. That is,

blood samples must be obtained by puncturing a vein rather than by pricking a finger. Many people will not allow their children to participate in studies that require

such techniques. Similarly, urine samples can be difficult to obtain from children

who wear diapers. For example, substances in the diapers can compromise test results.

Information Needed to Interpret Human Exposure Measurements

To help interpret the results of laboratory analysis and determine what actions,

if any, are needed to protect the public’s health, State and Federal officials cited the

need for two types of context-setting data: comparative (or reference range) information that shows exposure levels among the general population and research that

links exposure to adverse health effects. At the State level, where many of the specific actions regarding at-risk situations are taken, almost three-fourths of responding officials cited the lack of such information as a problem.

State officials said that reference range data, when available, allowed them to determine whether exposures are sufficiently high to merit action to reduce or prevent

further exposure. For example, in one State, public health officials, with help from

CDC, responded to citizens’ reports of foul odors from leaking tanks at a waste

cleanup site by gathering and analyzing blood samples from those living nearby.

CDC’s analysis of the blood samples showed that residents near the site had exposure levels at the high end of a CDC-developed reference range. State and Federal

officials ordered the contractor to move the cleanup operations to another location.

Over 60 percent of State officials responding to our survey said the lack of reference

range data prevented them from using human exposure data in their work. State

officials said the problem for research about adverse health effects was similar.

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30While NRC found EPA in the best position to house a human exposure monitoring program,

it also found that the ambivalence within EPA about the National Human Monitoring program’s

future indicated that the match of program goals, potential benefits, and EPA mandates was

not perfect.

Much of the data linking exposure to health effects concerns high-level occupational

exposures or higher doses administered to laboratory animals. Consequently, translating the results of such research to lower-level exposures of people and determining how best to advise people about potential effects is problematic.

Federal health officials and researchers also cited a need for both types of information in their investigations, particularly for federally supported work in specific

geographic areas. ATSDR officials said the lack of reference ranges was a particular

reason they could not generate human exposure data more often in public health

assessments and exposure investigations. When data allow officials to put exposure

into context, concerns can be investigated and addressed. For example, in one community, where citizens were concerned about exposure to dioxins from nearby chemical manufacturing plants, ATSDR officials had CDC’s laboratory analyze blood

samples and found that some residents had levels of several dioxins above the highest levels in a CDC-ATSDR-developed reference range. In response, ATSDR helped

residents obtain assistance from medical professionals expert in dioxins and, working with State and Federal environmental agencies, began environmental testing to

locate the exposure source.

Stronger Interagency Efforts Needed for Strategic Planning and Coordination

The barriers outlined above present daunting challenges to State and Federal

agencies. The number of chemicals that remain to be investigated and the kinds of

information needed are substantial, the research is often expensive, and progress is

often slow. At the same time, the level of resources available for dealing with the

issue is limited, and responsibilities are fragmented among many State and Federal

agencies. Many studies have pointed to the need for better coordination. While HHS

and EPA efforts have been coordinated through, for example, participation on advisory committees and the use of CDC’s laboratory for performing the actual measurements, such coordination falls short of what is needed for long term planning. This

need is illustrated by the growing convergence of interest in the planned expansions

of NHANES and NHEXAS. To ensure as much progress as possible with available

resources, HHS and EPA need a strategic planning effort that reflects a clear set

of priorities, a framework for coordinating data collection and reporting efforts, and

a tie to performance goals.

Agreement About Need for Better Planning and Coordination of Efforts Is Widespread

In 1991, NRC reported that ‘‘although a successful monitoring program must be

highly relevant to regulatory needs, it could and should serve a wide range of client

programs and must not be dominated by any one of them.’’ NRC reported that the

approaches of EPA, CDC, and ATSDR are each important in the identification and

control of environmental hazards to human health and that coordination among the

programs would enhance Federal monitoring efforts and benefit researchers, health

professionals, and the public.30

Officials and experts agree that interagency interaction is needed to take advantage of all approaches and information available to develop the most cost-effective,

least burdensome approach for collecting needed exposure data. Toward this end,

HHS agencies and EPA have at various times attempted to collaborate in their respective exposure monitoring efforts. For example, EPA solicited broad interagency

input into the design of NHEXAS and established interagency agreements with

CDC and others to assist in performing laboratory measurements, quality control,

and other support functions. Also through interagency agreements, CDC has broadened the exposure monitoring component of NHANES to incorporate the needs of

EPA researchers.

Outside reviews and involved researchers and officials indicate that even with recent efforts, coordination has fallen short in ensuring adequate interaction and linkages between agencies. For example, EPA’s scientific advisers reviewed the

NHEXAS pilot surveys and concluded that, while NHEXAS was an excellent project

and highly relevant for providing needed information, a strategic plan was needed

for follow-up studies. They also urged that EPA link NHEXAS exposure data with

biological data from NHANES, where possible, and develop a more collaborative

process for gathering input for chemical selection. Attendees at a September 1999

NIEHS conference on the Role of Human Exposure Assessment in the Prevention

of Environmental Disease also called for a coordinated interagency effort in assessVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00124 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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31The NIEHS-supported conference addressed many opportunities and challenges in exposure

assessment research including exposure-analysis methodology, exposure-disease relationships,

regulatory and legislative issues, gene-environment interactions, disease prevention and intervention and some current Federal initiatives related to exposure assessment. One area of discussion was the need for and limitations of biological measures of exposure. 32 Because of its emphasis on evaluating total human exposure, NHEXAS emphasized those

chemicals that can be measured In multiple environmental media (for example in air, water,

and food) as well as human tissues. 33 CDC’s laboratory officials indicated that their choice of chemicals is determined by the

availability of high-quality analytical methods with adequate throughput, whether the chemical

is a known or suspected cause of health problems, whether the chemical is on EPA and ATSDR

priority lists, the number of persons likely exposed, and the availability of funding from collaborators. 34Several officials pointed to the importance of developing a breast milk monitoring program.

Many environmental agents are fat soluble and are released into breast milk at significant conContinued

ing human exposure.31 One theme and recommendation from the discussions was

the need to bridge scientific disciplines and agency missions to address knowledge

gaps in assessing human exposure.

State officials and others have also indicated that better linkages and partnering

are needed between Federal, State, and local agencies. For example, an official of

the Association of Public Health Laboratories told us that one way to improve

States’ involvement in a national exposure monitoring program would be to further

their capability to assess levels of toxic chemicals in their own populations relative

to national levels. This would require, in this official’s view, the transfer of new

monitoring technology to State public health laboratories, along with the resources

necessary to support that technology. Improved capacity at the State level would

allow Federal laboratories to concentrate on developing more and faster analytical

methods for measuring chemicals in tissues and on responding to crisis situations.

Other experts have also called for better linkages between Federal efforts and communities and community concerns. For example, the NHEXAS reviewers recommended that EPA improve communication between NHEXAS investigators and

State and local health officials. Another theme of the conference on human exposure

assessment was that efforts to assess human exposure be in line with public health

goals and community concerns.

Individual Priorities Contribute to Difficulties in Coordinating Efforts

The challenges Federal and State agencies face in setting priorities for which

chemicals to assess in their individual programs likely contribute to the difficulties

they have in collaborating with one another. The expense of conducting exposure

measurements in ongoing surveys—especially for the number of samples required

to establish national or regional trends and levels—necessitates that priorities be

set. However, agreeing on priorities—or even agreeing on the process for setting priorities—is challenging and resource-intensive. For example, to identify chemicals to

measure in NHEXAS, EPA undertook an extensive selection process, soliciting input

from regional and program offices.32 EPA’s scientific advisers, while supportive of

the program, cited the criteria for selecting target chemicals as a weakness.

NHANES is even less formal in this regard, with no documented priority-setting

process for chemicals to be measured. Chemicals measured are largely determined

by CDC’s laboratory scientists based on such factors as the availability of analytical

methods for measuring the chemical and the laboratory’s capacity to perform the

measurements.33 According to a CDC official, CDC’s limited staff and laboratory resources cannot develop the administrative infrastructure to establish a scientific review process for selecting priority chemicals.

Another challenge in setting priorities, according to some officials, is the appropriate balance between gathering exposure information on chemicals about which

little is known and gathering information on those already considered to be toxic.

NHANES and NHEXAS, for example, focus largely on chemicals that are considered

to be toxic at some level. By contrast, the National Toxicology Program’s Human Exposure Initiative is intended to help set priorities for chemical toxicological testing

and might gather baseline information on chemicals and chemical mixtures occurring in the population that are not necessarily already known as harmful.

Officials we interviewed raised many other concerns that would need to be addressed when trying to coordinate efforts among multiple Federal and State agencies and programs:

• For what specific purpose(s) will these data be collected?

• What chemicals should be measured, in what order, how frequently, and in

what specific tissues?34

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centrations. Examples include dioxins and PCBs. According to NIEHS researchers, 6 months of

nursing could result in dioxin or PCB concentrations in infants which are 10 times higher than

in the mother. Breast milk monitoring programs operate in several European countries including Sweden, Germany, and the Netherlands. 35 EPA’s scientific advisers’ review of the NHEXAS pilot surveys illustrates some of the tradeoffs in determining the appropriate balance between large population surveys and more targeted

follow-up surveys. The advisers reported that population studies are the only means for collecting baseline information for such uses as trend analysis. NHANES is an example of such

a probability study. On the other hand, more targeted special studies tend to assess high-end

exposure groups more precisely. Additionally, the review illustrated how total exposure data

may be unnecessary to collect for chemicals at a national level, depending on the chemical. The

advisers pointed out that targeted special studies can be used to identify sources and factors

associated with high-end exposures. While identification of major sources, media and pathways

for populations experiencing high exposures are essential to reduce unacceptably high risks, if

the majority of the national population is exposed to pollutants at levels under health-related

benchmarks, source identification for such exposures is not a priority from a health standpoint.

• What chemicals should be measured concurrently with or only through personal

environmental measurements?

• What is the best way to identify populations that might be at higher risk of

exposure?

• What chemicals should be monitored in humans nationally, versus regionally or

locally?35

• How can exposure data be coupled with our increasing knowledge about the effect genetic factors have on risk from exposure to improve the understanding about

an individual’s risk from chemical contaminants?

• What role should State agencies have in conducting human exposure measurements and in planning Federal efforts?

The fragmentation of responsibilities and efforts for assessing human exposure reflect larger issues in the fragmentation of responsibility for environmental health.

For over a decade, a number of studies have pointed to the need for improved coordination between regulatory and health agencies (see table 4).

Table 4.—Examples of Reports Calling for Coordination in Environmental Health

Report Description

Environmental Health Data Needs: An

Action Plan for Federal Public Health

Agencies (Public Health Foundation,

1997).

Called for the Federal Government to facilitate stronger ties between environmental protection and public health agencies, perhaps by strengthening organizational links and coordinating funding for Federal (EPA and HHS) programs. Also indicated that priority environmental health information needs included more complete exposure data, including laboratory data such as biological measurements.

Burke, Shalauta, and Tran, The Environmental Web: Impact of Federal Statutes on State Environmental Health

and Protection (Public Health Service,

Jan. 1995).

Found that progress in understanding the relationship between human health

and the environment will require, among other actions, improved cooperation

between the many health and environmental agendas at the Federal, State,

and local levels.

Researching Health Risks (Office of

Technology Assessment, 1993).

Reported that although agendas are expanding their research efforts, few incentives exist for them to collaborate, and the lack of collaboration can only

hinder progress in applying newly developed techniques and knowledge to understanding the potential links between exposure and adverse health effects.

The Potential for Linking Environmental

and Health Data (National Governors’

Association, 1990).

Reported that linkage of environmental and health data to investigate possible

connections between exposure and adverse health effects cannot occur without interagency communication and cooperation, which rarely evolves naturally.

The Future of Public Health (Institute of

Medicine, 1988).

Found that separating environmental health from public health programs impeded desirable coordination and could limit the depth of analyses given to

the health implications of environmental hazards.

Potential for Convergence of Effort Is Increasing

The importance of planning and coordination is magnified by the possible overlap

in current plans to expand human exposure monitoring efforts. This potential can

be seen in HHS’ and EPA’s plans for NHANES and proposed expansions of the

NHEXAS pilots. Although nearly two-thirds of the chemicals measured in the

NHEXAS pilot surveys are currently measured or planned for NHANES, the two

efforts have taken differing approaches in the past to monitoring the population’s

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36The follow-up to the NHEXAS pilots has not been planned, so the identity of the chemicals

to be measured is not known. 37 At this writing, NHANES’ goals are to (1) estimate the number and percentage of persons

in the United States and designated subgroups with selected diseases and risk factors: (2) monitor trends in the prevalence, awareness, treatment, and control of selected diseases; (3) monitor

trends in risk behaviors and environmental exposures; (4) analyze risk factors for selected diseases; (5) study the relationship between diet, nutrition, and health; (6) explore emerging public

health issues and new technologies; and (7) establish a national probability sample of genetic

material for future genetic research. CDC official told us that the emerging focus in NHANES

on environmental health issues reflects advances in technology as well as the public’s increasing

priority for understanding the impacts of environment on health. Part of CDC’s responsibility

is to report on environmental hazards and determinants of health. Section 306 of the Public

Health Service Act (42 U.S. C. 242k) directs the National Center for Health Statistics, the CDC

agency that conducts NHANES, to collect statistics on subjects such as the extent and nature

of illness and disability of the population; environmental, social, and other health hazards; determinants of health; health resources; and utilization of health care. 38 According to CDC laboratory officials, the first report card will provide data on exposure

levels of the population to 25 chemicals that have not yet been determined. These might include

selected heavy metals, indoor air pollutants, nonpersistant pesticides, and phthalates. 39 Because of the wide range of other health and nutrition questions addressed in NHANES,

environmental measurements currently included are less extensive than those included in

NHEXAS because, for example, food and beverage samples are not conducted.

exposure to these chemicals.36 The NHEXAS pilots have focused on ‘‘total’’ exposure,

which entailed measurements in human tissues, water, air, food, dust, and other potential sources in participants’ living environments, and data-gathering has focused

on three selected regions of the country. Total exposure measurements can help

identify those sources that most contribute to exposure—a critical part of determining how to take action to reduce or prevent exposures. However, measuring total

exposure requires several types of laboratory measurements and is thus more expensive. By contrast, NHANES has focused its exposure monitoring on human biological measurements and on a sample that is generally representative of the Nation

as a whole. Biological monitoring data demonstrate exposure from all sources, but

determining exposure sources usually requires additional environmental measurements. Other than the few chemicals it covered, NHANES has historically been considered an awkward vehicle for including exposure monitoring—in large part because of its wide range of competing goals and lack of a primary commitment to

monitoring tissues for exposures.

Changes to the 1999 NHANES, such as the following, show a greater emphasis

in environmental health. These changes along with EPAs plans to expand NHEXAS

suggest a convergence of the two approaches and a growing and overlapping interest

among agencies in exposure measurement and monitoring. • NHANES now has a goal of monitoring exposures. Starting with NHANES

1999, CDC formalized its commitment to monitoring trends in the nation’s environmental exposures by establishing this as a Stated goal of NHANES.37 In line with

this goal, CDC’s laboratory plans to issue this year a ‘‘National Exposure Report

Card’’ using NHANES samples.38 This goal is similar to EPA’s goal as proposed for

NHEXAS’ follow-up survey—to document the status and trends of the national distributions of human exposure to potentially high-risk chemicals.

• NHANES will include selected environmental measurements. Starting with

NHANES 1999, environmental measurements, such as contaminant levels in water

and house dust, and levels measured through personal air monitors worn by participants will be included in the survey to help identify potential sources of exposure.39

• NHANES will be conducted continuously rather than periodically, allowing for

more flexibility in the measurements it includes. According to CDC officials, the new

annual sampling design will enable them to include emerging and changing priorities in the data collected through the survey and thus allow for a broader collection

of data than in previous surveys, including exposure and measurements in people’s

personal environments.

Other planned changes to NHANES and NHEXAS also indicate a growing overlap

in approaches and interests. For example, pending analysis and evaluation of its

pilot surveys, EPA is proposing to expand NHEXAS beyond the regional focus of its

pilot to include a nationally representative sample similar to the framework of

NHANES. Also, both CDC and EPA would like to eventually include a component

in NHANES and NHEXAS to monitor special populations. EPA’s proposed expansion of NHEXAS would eventually include ‘‘special studies’’ to examine high-end exposures in more detail and with greater precision Small populations for further

study would be identified through the national survey. CDC also plans to add a

component to NHANES that will gather selected NHANES health and nutrition

data, possibly including exposure measurements, on specific subpopulations in geoVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00127 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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40 NIEHS–CDC interagency agreements document that NIEHS had provided about $3.3 million to CDC between fiscal years 1996 and 2000 for performing environmental exposure measurements for its Human Exposure Initiative. No funding was provided in fiscal year 1999. 41 NHANES 1999, for example, received $15.9 million in appropriated funding and, according to CDC officials, an additional $6.8 million from collaborating institutions. Interagency agreements related to environmental measurements performed in conjunction with NHANES document the receipt of about $1.4 million from collaborators at EPA and other agencies for environmental exposure measurements. In addition to EPA’s support for measurement of certain chemi- cals in human tissues, an estimated $125,000 was received from the Department of Housing and

Urban Development for performing dust sampling and an estimated $30,000 from the Mickey

Leland National Urban Air Toxics for personal measurements of volatile organic compounds.

CDC laboratory officials indicated that the increase to their fiscal year 2000 funding for the environmental health laboratory has improved their ability to support needed laboratory measurements for NHANES and other efforts. This funding increased by about $5 million between fiscal

years 1999 and 2000. 42 According to CDC officials, uncertain funding may limit their ability to perform NHANES

measurements for dioxins, furans, coplanercoplanar PCBs, phytoestrogens, certain heavy metals,

phthalates, and polyaromatic hydrocarbons. 43 EPA officials indicated that at the individual study level, approximately $250,000 was allocated for analyses of the NHEXAS pilot data in fiscal year 1999; EPA plans to spend approximately $170,000 in fiscal year 2000.

graphic areas of interest or among specific racial or ethnic minority populations.

This effort to add a subpopulation component to NHANES was initiated in response

to the needs of State health officials and others for local level data.

Funding Is Sporadic, and Funding Priorities Change

Part of the difficulty in collaborating and in planning human exposure monitoring

efforts to meet longer-term needs may also arise from issues of sporadic funding and

resources to support these efforts. As compared to the hundreds of millions spent

on monitoring contaminants in environmental media, we estimate that less than $7

million was spent collectively by CDC (including ATSDR) and EPA on their respective human exposure efforts in 1999.40

Neither CDC nor EPA has provided a dedicated funding stream for their exposure

measurement efforts. Funding for efforts has, to a large extent, depended on priorities established year to year. For example, funding for the exposure and other environmental components of NHANES depends to some extent on the interests of other

Federal agencies and their willingness to pay for related data gathering and analysis.41 CDC estimated it would spend about $4.7 million for laboratory measurements and laboratory staff costs in 1999 for NHANES-related exposure measurements such as lead, mercury, cotinine, heavy metals, pesticides, volatile organic

compounds, and other chemical classes. Interagency agreements document the receipt of about $1.2 million from collaborators for some of those laboratory measurements. If other agencies do not pay CDC to conduct laboratory tests—with the exception of some ‘‘core’’ measurements, such as lead—CDC performs tests as time

and laboratory resources allow. For example, although CDC initially proposed for

the survey starting in 1999 to measure up to 210 chemicals in tissues of a subset

of NHANES survey participants, CDC officials indicated that those chemicals could

be measured only as resources allowed.42 At the time of our review, a CDC laboratory official indicated that resources might allow them to include about 74 chemicals

in 1999 and 2000.

EPA’s commitment to funding NHEXAS also remains uncertain. EPA officials es- timated that approximately $20 million was spent on NHEXAS from 1993 through

1999—with a decreasing amount designated to the project in 1999 and 2000. While

EPA’s independent scientific advisers commended the design for NHEXAS and said

it could be the basis for an effective national program, they expressed concerns

about the limited resources allocated to analyze the data gathered in the pilot

projects.43 At national level, EPA has dedicated approximately three full-time positions to evaluate the data from the NHEXAS pilots and design future expansions.

Better Linkages to Program Goals and Performance Monitoring Needed

The Government Performance and Results Act of 1993 (Results Act) provides Federal agencies a structured frameswork to coordinate efforts in crosscutting programs

when agency missions overlap. The Results Act requires Federal agencies, as part

of their mandated responsibilities, to prepare annual performance plans that discuss

agency goals and performance measures. Past reviews have shown that EPA, HHS,

and other Federal agencies have not fully used the Results Act planning process to

explain how each would coordinate crosscutting efforts with other agencies. Few

agency plans attempt the challenging task of discussing planned strategies for coordination and establishing complementary performance goals and common or complementary performance measures.

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44See Observations on the Environmental Protection Agency’s Fiscal Year 2000 Performance

Plan (GAO/RCED–99–237R) July 20, 1999. 45This effort was coordinated through the White House Office of Science and Technology Policy.46 Executive Order 13045 also indicates such strategies are to include proposals to enhance

public outreach and communication and a statement regarding the desirability of new legislation to fulfill or promote the purposes of the order.

A major weakness of EPA’s fiscal year 2000 Annual Performance Plan was the

lack of sufficient detail describing crosscutting goals and activities or how EPA

planned to coordinate with other Federal agencies on related strategic or performance goals.44 For example, under its plan’s ‘‘safe food’’ objective, EPA discusses coordinating with HHS and other agencies to reduce health risks from pesticides.

However, it did not outline specific projects and strategies, responsibilities, and

products that must be coordinated for EPA to accomplish its goals. Similarly, HHS’ performance plan lacked details regarding how crosscutting activities and goals

would be coordinated with other agencies.

In their fiscal year 2001 performance plans, EPA and CDC make limited use of

human exposure data to measure or validate performance, and neither agency describes how data collection efforts relate to complementary goals of other Federal

agencies. For example, EPA and CDC have the common goal of reducing childhood

lead poisoning, but only CDC uses data on blood lead levels to validate progress toward this goal. Although EPA has goals that are clearly related to reducing human

exposure to other toxic chemicals, the human exposure data collected by EPA and

CDC have largely not been linked with or used to measure progress. Such data

show potential for helping elucidate Federal progress in environmental efforts, but

EPA has not yet acted to fully realize such potential. For example, NHEXAS data

are used to help assess children’s exposure to pesticides. However, a related goal

to reduce public exposure to pesticides does not use human exposure data; instead,

it relies on the number of activities to educate agricultural workers and the public.

The effectiveness of these efforts could be assessed, in part, through measured reductions in actual human exposure to specific pesticides. During 1999, CDC maintained a goal to develop methods to measure toxic substances in humans and added

a goal to measure and report on human exposure to toxic substances. However, neither goal discusses how CDC will coordinate with EPA and other Federal programs

in meeting these goals and ensuring that newly developed methods and measured

substances meet priority data needs.

Successful Models for Planning and Coordination Point to the Need for High-Level

Mandate, Process for Inclusion, and Mechanism for Reporting

Program officials at HHS and EPA told us in early 2000 that they were discussing

the merits of establishing a new interagency program in human exposure monitoring.45 At the time of our review, the proposal was in early stages of discussion

and officials had not clarified how a new program would consider States’ information needs, differ from or relate to NHANES and the NHEXAS pilot surveys, or resolve past issues about differing agency goals and priorities.

Several experts and agency officials have pointed to successful models of interagency collaboration in environmental health issues that could help shape an HHSEPA interagency effort. One such model is the collaboration on children’s environmental health issues. In this case, Executive Order 13045, signed by the President

on April 21, 1997, established a Task Force on Environmental Health Risks and

Safety Risks to Children to develop and recommend Federal strategies for children’s environmental health and safety. Among the elements that have been cited as contributing to success were a clear mandate to collaborate and a process to respond

to the input and data needs of different stakeholders. According to involved officials,

a high-level interagency work group has worked closely to address its charges.

These charges include developing general policy and annual priorities; a coordinated

Federal research agenda; recommendations for partnerships among Federal, State,

local, and tribal governments and the private, academic, and nonprofit sectors; and

identifying high-priority initiatives to advance protection of children’s environmental

health.46

A second model with a top-down mandate and a process to respond to stakeholders is NTP, established in 1978 as an HHS-wide effort to provide regulatory and

research agencies needed information about potentially toxic and hazardous chemicals nationwide and to strengthen the science base in toxicology. According to officials, part of NTP’s success in fostering collaboration are an inclusive executive committee and an established process for decisionmaking. The NTP Executive Committee, which provides policy oversight of NTP, includes agencies outside of HHS,

such as EPA and the Consumer Product Safety Commission. The NTP Executive

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47The Director of NTP issues the Report on Carcinogens pursuant to a 1978 amendment, section 301 (B) (4) of the Public Health Services Act. which requires the Secretary of HHS to publish a list of all substances that are either known to be human carcinogens or may reasonably

be anticipated to be human carcinogens and to which a significant number of persons residing

in the United States are exposed. NTP issues a revised Report on Carcinogens every 2 years.

Committee also serves as a decisionmaking body, in that members cast votes on key

issues, such as prioritization of chemicals for study and for listing in NTP’s Report

on Carcinogens.47 Involved officials believe the voting requirement helps move key

issues forward and provides an effective means of resolving disagreements. NTP

also has an inclusive process for identifying chemicals to be considered by the Executive Committee. NTP’s chemical testing nominations are solicited from sources in

academia, Federal and State regulatory and health agencies, industry, and unions,

as well as environmental groups and the general public.

Several officials indicated that reports on exposures in the national population to

toxic chemicals are needed to help inform policymakers, researchers, and the public.

Specifically, such reports can help identify serious human health risks, help officials

link exposures to sources, determine appropriate interventions to help reduce these

risks, and document the effectiveness of interventions in reducing exposures. Moreover, agencies could use such reports to validate or measure progress in meeting

goals established under the Results Act. A key element of NTP is its biennial reports. As informational scientific and public health documents, these reports are not

only used by Federal and State agencies but are considered an important medium

for informing the public and policymakers on the status of substances considered

likely to be carcinogenic for humans.

CONCLUSIONS

The Nation has a long way to go in measuring human exposures to potentially

harmful chemicals. While Federal efforts are increasingly covering chemicals of

potential concern, there are substantial gaps in current information on exposure

levels, the health risks that result, and those who may be most at risk. Recent advances in laboratory technology show promise for improving the collection and analysis of some of the information needed to understand and measure human exposures. However, a more long-term and concerted effort to address infrastructure and

scientific limitations in measuring exposure will be required if substantive progress

is to be made. Applying and continually improving upon these advances to cover an

increasing number of chemicals and issues will require both time and resources.

CDC’s laboratory to date has been able to meet many demands for human exposure

data for Federal and State measurement and monitoring efforts. However, its capacity, given current resources, will continue to limit progress to develop new methods

and include more people and chemicals in Federal and State efforts.

Federal agencies are currently planning whether and how they can expand existing programs to meet the significant needs for human exposure data. Collaboration

in such planning is essential, because agencies have different capacities and skills,

and separate attempts have fallen short of supporting the large efforts that are

needed. So far, no clear strategy has emerged for how to carry out this major task,

particularly given the growing and overlapping interests among many agencies for

understanding and measuring human exposures to potentially harmful chemicals.

In our view, developing such a strategy is a challenging but necessary first step.

In the meantime, State and local health officials must try to understand and communicate the risks from environmental contaminants to concerned citizens—a difficult, if not impossible, task when information is unavailable to help them interpret

the risks from the exposures citizens face in their daily environments. State officials

indicate they need more of the information that is collected through Federal efforts

to help interpret those levels faced by citizens in their States. And to collect measurements for their studies and investigations, State officials are faced with finding

laboratories that have the equipment and capacity to perform the complex measurements. Federal capacity, largely centered at CDC, cannot meet States’ needs in

many situations, and laboratory capacity is lacking in most States.

To help meet the gaps in environmental exposure data at all levels of government,

EPA and the various HHS agencies with environmental health responsibilities need

to work closely together to forge a strategic plan laying out the necessary next steps

for addressing human exposure information and concerns. In addition to considering

States’ needs and capacities for collecting human exposure data, such a plan could: • provide long-term structure to human exposure monitoring as an interagency

effort, • establish a mechanism for setting program priorities in line with agency goals

and performance measures,

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• clarify agency roles and minimize duplication, and • help agencies share expertise.

Policymakers, agencies, and the public seek many types of information on exposure trends and levels in the national population as well as for groups considered

potentially at risk of disproportionate exposures. Resolution is also needed on what

information should be reported on national trends and levels of exposure. A strategic plan could help agencies resolve the many different informational needs to determine what exposure information should be reported and how agencies can work

together to report such information.

RECOMMENDATIONS TO THE SECRETARY OF HHS AND THE ADMINISTRATOR OF EPA

We recommend that the Secretary of HHS and the Administrator of EPA develop

a coordinated Federal strategy for the short- and long-term monitoring of human

exposures to potentially toxic chemicals. In and the Administrator developing such

a strategy, the Secretary and the Administrator should of EPA assess the need for

an interagency program to collect and report data on human exposures, the extent

current surveys and agency efforts can be used as part of such an effort, and the

funding needs and sources to sustain a viable program for monitoring human exposures to toxic substances.

Such a strategy should:

• address individual agency needs and expertise, • provide a framework for coordinating efforts to gather data needed to improve

understanding of human exposures,

• assess needed Federal and State laboratory capacity,

• establish research priorities for laboratory methods development and a mechanism or process for setting chemical monitoring priorities,

• develop a framework for identifying at-risk populations, and

• consider States’ informational needs.

We further recommend that the agencies identify common or complementary performance goals or measures to reduce, monitor, or develop methods for measuring

human exposures to toxic chemicals. Such goals or measures can be a basis for

structuring and supporting interagency collaborations to collect and use human exposure data.

As part of this coordinated strategy, we recommend that the Secretary of HHS

and Administrator of EPA periodically publish a report on levels and trends in the

national population of exposures to selected toxic substances.

AGENCY COMMENTS

We provided HHS and EPA an opportunity to comment on a draft of this report.

Both agencies generally concurred with our conclusions and recommendations—that

a long-term coordinated Federal strategy was needed for monitoring human exposures to potentially toxic chemicals and that such efforts could be linked through

common or complementary performance goals—and indicated that they would work

together to implement our recommendations. (See apps. IV and V respectively.)

HHS and EPA also both stressed the importance, as discussed in our report, of expanding the scope of their efforts to monitor and measure human exposures to toxic

chemicals beyond the limited number of chemicals covered today. To support such

expansions, HHS noted the importance of additional resources for improving laboratory capacity and methods.

HHS and EPA provided several other comments raising points that one or both

agencies consider important to monitoring human exposures to toxic chemicals.

These included the need to: (1) coordinate any exposure monitoring in the general

population with monitoring of occupational exposures; (2) consider adding the monitoring of breast milk in a national program; (3) depending on the chemical and the

purpose for the data collection, consider measures of human exposure other than the

concentration in human tissues for collection; and (4) consider the option of expanding the scope of NHANES as a means of improving data needed to identify potentially at-risk subgroups. We agree that the points raised in these comments are important and that they should be considered during development of any coordinated

Federal strategy.

EPA also said that additional Federal partners, including the Departments of Defense, Transportation, and Energy should participate in developing and supporting

a coordinated Federal strategy. We agree that it would be appropriate to obtain

input from all involved and interested agencies. HHS and EPA also provided a number of clarifying and technical comments, which we incorporated where appropriate.

We are sending copies of this report to the Honorable Donna E. Shalala, Secretary

of HHS, and the Honorable Carol M. Browner, Administrator, EPA. We are also

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sending copies to Jeffrey P. Koplan, Director, CDC, and Administrator, ATSDR;

Ruth Kirschstein, Acting Director; NIH; Kenneth Olden, Director, NIEHS; Richard

J. Jackson, Director, National Center for Environmental Health; Edward J. Sondik,

National Center for Health Statistics; Norine Noonan, Assistant Administrator for

Research and Development, EPA; and other interested parties. We will make copies

available to others upon request.

If you or your staff have any questions, please contact me at (202) 512–7119.

Other major contributors are included in appendix VI.

JANET HEINRICH,

Associate Director, Health Financing and Public Health Issues.

APPENDIX I

OBJECTIVES, SCOPE, AND METHODOLOGY

Nine Members of the Congress asked us to study the nation’s data collected to

assess human exposure to potentially toxic chemicals in the environment. As agreed

with our requesters, we focused our work primarily on efforts to measure chemical

exposures in human tissue samples, such as blood, hair, and urine. This report discusses (1) the extent to which State and Federal agencies—specifically, HHS and

EPA—collect human exposure data on potentially harmful chemicals, including data

to identify at-risk populations, and (2) the main barriers hindering further progress

in such efforts.

SCOPE OF OUR REVIEW

Although laboratory measurements of chemical exposure are only one part of the

data collected to address environmental health concerns, they merit attention because new technology makes it increasingly easy to measure the degree to which

a chemical has been absorbed into human tissues. Such measurements are often a

more accurate and useful approach to assessing exposure than environmental measurements, according to public health experts.

Because Federal agencies that collect human exposure data collect these data for

different purposes, we were not able to assess the overall adequacy of the nation’s

efforts to address environmental health concerns. Therefore, we focused our work

at the Federal level on the efforts of two agencies—HHS and EPA—and the subcomponents of these agencies involved in exposure measurement and monitoring in

the U.S. population:

• EPA’s Office of Research and Development,

• HHS’ National Center for Environmental Health (NCEH),

• HHS’ National Center for Health Statistics (NCHS),

• HHS’ Agency for Toxic Substances and Disease Registry (ATSDR), and

• HHS’ National Institute of Environmental Health Sciences (NIEHS).

We focused our work mainly on nonoccupational environmental exposure to chemical agents known or thought to pose a health hazard by one or more of these agencies.

To gather information about activities of State officials, we surveyed environmental health officials in State public health agencies and conducted site visits to

six States.

METHODOLOGY OF OUR REVIEW

To assess the extent to which the Federal agencies we reviewed have collected

human exposure data, we met with key officials responsible for efforts intended to

collect human exposure data at each agency. We focused on what we identified as

being the most significant Federal efforts in human exposure assessment at EPA

and HHS related to nonoccupational human exposure to environmental contaminants. We reviewed four major activities: EPA’s National Human Exposure Assessment Survey (NHEXAS), CDC’s National Health and Nutrition Examination Survey

(NHANES), NIEHS’ Human Exposure Initiative, and ATSDR’s exposure investigation activities around hazardous waste and other sites. We also obtained information on EPA’s National Human Adipose Tissue Survey (NHATS), which ended in

1992.

We also interviewed officials and obtained documentation on how these various

programs were planned and organized and to assess the extent data were collected

in a manner that allows the identification of at-risk subpopulations by such factors

as income, race and ethnicity, age, and geographic location. We obtained relevant

budget information for 1999 and reviewed related agency performance plans.

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To assess barriers to progress in collecting or using human exposure data, we

interviewed Federal officials involved in such efforts about past and current views

on such barriers. In addition, we reviewed the general literature on human exposure

to environmental chemicals and interviewed officials from organizations representing State epidemiologists, State public health laboratory directors, local public

health officials, the chemical industry, environmental advocates, and public health

experts.

To gather nationwide data on the views of State public health officials, we surveyed officials with environmental health responsibilities related to chemical exposure in State public health agencies. We identified 93 officials in each of the 50

States and the District of Columbia—referred to collectively as States—with assistance from the Council of State and Territorial Epidemiologists and officials in each

of the 51 States.

We also conducted onsite work at EPA, CDC agencies, and NIEHS and in six

States—California, Louisiana, Massachusetts, North Carolina, Oregon, and Washington. These six States were selected to represent diverse geographic areas and environmental health programs. In the six States, we interviewed State public health

officials. We also interviewed officials in State environmental protection and agriculture agencies, academic and independent researchers, and representatives of

community advocacy organizations.

We excluded efforts to collect human exposure data within occupational settings

from the scope of our review. Similarly, we excluded federally supported academic

and private sector research efforts.

Our work was conducted from March 1999 through March 2000 in accordance

with generally accepted government auditing standards.

Methodology for Chemical List Analyses

To assess the extent to which human exposure data are available for chemicals

of high concern to human health, we analyzed a number of chemical lists maintained by HHS and EPA agencies. We also identified chemicals measured through

HHS and EPA representative surveys. Chemical data were gathered from various

sources, including EPAs Offices of Pesticide Programs, Air and Radiation, Pollution

Prevention and Toxics, and Research and Development; the National Toxicology

Program (NTP) headquartered at NIEHS; CDC’s ATSDR; and NCEH and NCHS

within ATSDR. Several toxic chemical lists were identified through a review of related reports and literature on environmental exposure issues. To narrow the scope,

we also contacted staff in relevant offices within these agencies and asked them to

identify key lists of chemicals of concern. We consulted experts and public health

laboratory officials at the Pew Commission for Environmental Health and the Association for Public Health Laboratories.

From the many available chemical lists, we judgmentally selected eight based on

our assessment that each list contained chemicals thought to have a high potential

for causing harm to human health and input and recommendations from experts.

These eight lists, which contained more than 1,400 unique chemicals, provide a conservative number of the chemicals agency officials consider a concern for human

health. To ensure that chemicals with more than one name were not included more

than once, we used Chemical Abstract Service numbers, a unique identifier. These

lists, whether singly or combined, do not necessarily reflect the highest priorities of

the Federal Government or the agencies or programs we contacted. The lists we reviewed are described below.

• Chemicals found most often at the nation’s Superfund sites: HHS’ ATSDR,

which conducts public health assessments or other health investigations for populations living around national priority hazardous waste sites, and EPA prepare a

list, in order of priority, of hazardous substances. This list contains substances that

are most commonly found at facilities on the National Priorities List (Superfund)

and pose the most significant potential threat to human health due to their known

or suspected toxicity and potential for human exposure.

• EPA’s list of toxics of concern in air: The Congress established the original list

of 188 hazardous air pollutants that EPA would regulate through the Clean Air Act.

EPA periodically must revise the list to add or, when warranted, remove substances.

EPA adds substances that it determines to be air pollutants that are known to

cause or may reasonably be anticipated to cause adverse effects to human health

or adverse environmental effects.

• Chemicals harmful because of their persistence in the environment, tendency to

bioaccumulate in plant or animal tissues, and toxicity: EPA’s Office of Solid Waste

and Office of Pollution Prevention and Toxics created this list of persistent, bioaccumulative, and toxic (PBT) chemicals. PBT chemicals do not readily break down

or decrease in potency after they are released into the environment, even if released

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in quantities that are very small and legally permitted. Over time, these chemicals

are likely to accumulate in soils or other environmental media, be absorbed or ingested by animals and plants, accumulate in animal and plant tissue, pass through

the food chain, and potentially cause long-term human health or ecological problems. • Priority pesticides of potential concern: We combined two lists of potentially

harmful chemicals to develop this list. EPA’s Office of Pesticides Programs provided

a list of pesticides of concern that were classified as organophosphates; carbamates;

or group B1, B2, or C carcinogens. According to a program official, these classes of

pesticides are generally considered among the most potentially harmful to human

health. We combined this list with the U.S. Department of Agriculture’s Pesticide

Data Program list of pesticides that are measured in selected commodities or foods.

Pesticides monitored by the program in 1997 included insecticides, herbicides, fungicides, and growth regulators in fresh and processed fruit and vegetables, whole

milk, and grains. • Chemicals that are known or probable carcinogens: HHS’ Report on Carcinogens includes substances known or reasonably thought to be cancer-causing based

on evaluations of substances performed by scientists from NTP, other Federal health

research and regulatory agencies, and nongovernment institutions. The list of substances in the report represents an initial step in hazard identification. Substances

listed as ‘‘known to be human carcinogens’’ are those for which there is sufficient

evidence of carcinogenicity (cancer-causing potential) in humans to indicate a causal

relationship between exposure to the agent, substance, or mixture and human cancer. Substances listed as ‘‘reasonably anticipated to be human carcinogens’’ are

those for which there is limited evidence of carcinogenicity in humans, insufficient

evidence of carcinogenicity in experimental animals, or both.

• Chemicals that are considered toxic and used, manufactured, treated, transported, or released into the environment: EPA publishes the Toxics Release Inventory containing information on the release and other waste management activities

of toxic chemicals by facilities that manufacture, process, or otherwise use them.

This data base is made available to the public and is considered useful to citizens,

businesses, and governments for purposes of working together to protect the quality

of their land, air, and water and for evaluating the probability that chemical releases could impact human health in communities.

Chemicals most in need of testing required by the Toxic Substances Control Act:

The Master Testing list contains those chemicals that are prioritized for safety testing based on EPA’s finding that (1) a chemical may present an unreasonable risk

of injury to human health or the environment and/or the chemical is produced in

substantial quantities that could result in significant or substantial human or environmental exposure, (2) the available data to evaluate the chemical are inadequate,

and (3) testing is needed to develop the required data.

We compared the combined list of these chemicals, totaling 1,456, and each individual list with those chemicals identified by EPA and CDC officials as measured

in the NHEXAS and NHANES human exposure efforts through 2000. We excluded

NHATS’ and the Human Exposure Initiative’s chemical lists from our analysis.

NRC’s 1991 review of the NHATS program raised questions about, for example, the

representativeness of the results and the methods used to handle the tissue specimens. NIEHS’ Human Exposure Initiative measurements were not complete at the

time of our review and thus it was not known which chemicals had been or are currently being measured.

Survey Development and Distribution and Analysis

To develop survey questions, we reviewed documentation on environmental health

programs prepared by HHS and EPA agencies, professional organizations representing State epidemiology and public health laboratory officials, and public

health experts. We also spoke with officials and representatives from each of these

groups.

We pretested our survey in person with State environmental health officials in

two States and in teleconferences with officials in two additional States. We asked

knowledgeable people in EPA and CDC and in the environmental and public health

fields to review the survey instrument. We refined the questionnaire in response to

their comments to help ensure that potential respondents could provide the information requested and that our questions were fair, relevant, answerable with readily

available information, and relatively free of design flaws that could introduce bias

or error into our study results. We mailed questionnaires to the 93 officials in August 1999. We sent at least one follow-up mailing and conducted telephone followups to nonrespondents. We ended data collection in December 1999; had received

responses from 81 officials in 48 States for a response rate of 87 percent.

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1 NRC, Commission on Life Sciences, Monitoring Human Tissues for Toxic Substances.

2See K. Sexton and others, ‘‘Estimating Human Exposures to Environmental Pollutants:

Availability and Utility of Existing Data bases,’’ ‘‘Archives of Environmental Health, Vol. 47, No.

6 (1992), pp. 398–407.

In preparing for our analysis, we reviewed and edited the completed questionnaires and checked the data for consistency. We tested the validity of the respondents’ answers and comments by comparing them with data we gathered through

interviews with public health experts and other public health officials and with documentation obtained at Federal agencies and in case study States.

The survey and survey results are presented in appendix III.

APPENDIX II

REPORTED GAPS IN HUMAN EXPOSURE DATA AND HISTORY OF FEDERAL EFFORTS

Since the 1980’s, reports reviewing environmental health data needs have recommended the broader collection of human data showing actual human exposures

to chemical contaminants in the environment. Various Federal agencies have collected such human exposure data for a number of purposes; historically, these collection efforts have been limited to selected chemicals, subpopulations, and time periods.

VARIOUS REPORTS DISCUSS THE GAPS IN HUMAN DATA SHOWING MEASURED EXPOSURE

TO CHEMICAL CONTAMINANTS

Data on actual levels of chemicals in humans has been a longstanding gap in the

information needed to establish human health risks from exposures to environmental contaminants. While data on the concentration of chemicals in environmental media—such as air, water, and food—have historically been used to estimate

human exposure to harmful chemicals, this approach to detect or define human

health risks has limitations. According to the NRC, there are too many chemicals,

too many sources, and too many routes of exposure to rely solely on environmental

monitoring. Measurements of internal doses of exposure—actual levels of chemicals

or their metabolites found in human tissues, such as blood or urine—are generally

considered an accurate measure of human exposure. Such measurements can reflect

exposures from all routes and that may be accumulated over time, modified by individual differences in physiology, and difficult or impossible to assess by environmental measurements (such as hand-to-mouth ingestion in young children). In 1991,

NRC reported that a program of human tissue monitoring is critical to the continued improvement of understanding of exposure to toxic chemicals and recommended

that such a program be given high priority for funds and other resources.1

Several other Federal reviews have pointed to information needs in this area. An

interagency assessment of federally supported data bases conducted in the early

1990’s concluded that Federal data systems generally lacked data on actual human

exposures, including information about contact between the chemical and the

human body (personal exposures) and the amount of the chemical absorbed (internal

doses). The review also found substantial value in collecting and analyzing these

data in a comprehensive and systematic manner and that the costs associated with

establishing and maintaining appropriate data bases were justified.2 A discussion

of some of these reviews follow. • HHS, NCHS, Environmental Health: A Plan for Collecting and Coordinating

Statistical and Epidemiologic Data (Washington, DC: Government Printing Office,

1980): This report found that ‘‘acceptable ranges of physiologic measurements and

normal levels of trace elements must be determined before any attempt can be made

to associate health outcomes with environmental exposures. Many of these baseline

data do not exist for particular populations of interest or for specific pollutants. In

addition, early indicators and symptoms of disease that might be environmentally

related are not dearly understood.’’ The report identified a number of research directions to help define the association between health effects and specific environmental exposures, including the establishment of baseline data on physiological

measurements of trace elements in tissue and blood for the population.

• HHS, NIEHS, Issues and Challenges in Environmental Health (Washington,

DC: National Institutes of Environmental Sciences, 1987): This report found that

due to ‘‘gaps in data systems established for monitoring and surveillance of environmental exposure, effort should be made to foster better linkage among existing systems . . . Existing data systems should be expanded to include biochemical and cellular indicators of early stages of disease. . . . The group found there is a need for

more research and more systematic collection of data on the exposure of human popVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00135 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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ulations to harmful substances. Reliable exposure data are necessary for assessing

the probability that exposed populations will develop adverse health effects and the

likelihood of success in intervening to reduce those risks.’’

• K. Sexton and others, ‘‘Estimating Human Exposures to Environmental Pollutants: Availability and Utility of Existing Data bases’’: This report found that while

‘‘the evidence suggests that existing data systems contain a substantial amount of

information that is relevant to exposure estimation . . . the quality of the data is

inconsistent and difficult to assess and that understanding and accessing the information is often difficult. Furthermore, these systems demonstrate a striking absence

of data on actual human exposures, including a lack of information about contact

between the agent and the human body (exposure) and about the amount of the

agent or its metabolites that enters the body (dose).’’

• NRC, Hormonally Active Agents in the Environment: This report found that

‘‘determining the risk of environmental hormonally active agents to humans and

wildlife is difficult because exposure to these agents has not been routinely monitored. . . . Background concentrations of hormonally active agents in humans, particularly in adipose (fat) tissue and blood, and other biota need to be established.

In particular, routes of exposure and the effects of diet need to be assessed to provide a framework for examining the effects of these compounds in the general population and in highly exposed subpopulations.’’

HISTORY OF FEDERAL EFFORTS TO COLLECT HUMAN EXPOSURE DATA

Since 1967, HHS and EPA have conducted Federal surveys to assess the U.S. population’s exposures to toxic chemicals from the analysis of human tissue samples.

While their efforts measured some of the same exposures and covered some of the

same time periods, their goals differed and most did not include a nationally representative sample of citizens. EPA’s efforts first monitored exposure to pesticides

and, more recently, have attempted to link human exposure data to specific routes

of exposure. CDC’s periodic surveys are intended to monitor trends in the health

and nutrition status of the population but, over time, have included exposures to

environmental toxics as one component of the general survey. NIEHS’ Human Exposure Initiative, established in the late 1990’s, is intended to help the agency

prioritize chemicals for further toxicology and carcinogenicity testing. Within these

studies, various subgroups have been used to develop human exposure estimates,

but in most cases, sampling has not been for all participant groups or random. Consequently, the results cannot be projected to the U.S. population as a whole for most

chemicals. See table 5 for the timeframes and numbers of chemicals covered for

major Federal efforts.

Table 5.—Number of Chemicals and Time Frames for Select Federal Efforts

Duration No. of participants providing biological samples

No. of

chemicals

measured

for any

participations

No. of

chemicals

measured

for all participants

(ages 1

and older)

Second National Health and Nutrition Examination Survey (NHANES II):

1976–1980 ................................................................. 20,000 examined a ................................... 36 1

Third National Health and Nutrition Examination Survey

(NHANES III)

1988–1994 ................................................................. 30,000 examined a ................................... 47 1

National Health and Nutrition Examination Survey,

1999 (NHANES)

1999–ongoing ............................................................. 5,000 per year b ....................................... 74 c 2 d

National Human Adipose Tissue Survey (NHATS):

1967–1992 ................................................................. 14,000 ...................................................... 128 20 e

National Human Exposure Assessment Survey (NHEXAS)

Pilot Study:

1995–1999 ................................................................. 460 f ......................................................... 46 c 6

a The number of participants in NHANES II and NHANES III who received physical examinations is used as a proxy for the number providing

biological samples, as the latter number was not readily available. b The number of persons examined in a calendar year is planned to be about 5,000.

c For NHANES, the list of potentially toxic chemicals covered was provided by CDC laboratory officials. For NHEXAS, the list of potentially

toxic chemicals covered was provided by EPA NHEXAS officials. d According to a CDC laboratory official, lead and cadmium are measured in all participants. Cotinine will also be measured in many participants—specifically, those ages 4 and older.

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3Data were not publicly available, as CDC is resolving some methodological issues associated

with data collection. 4The sampling will be conducted on different people, but some questions asked in each survey

will be the same.

e Chemicals analyzed by NHATS varied over time. NHATS collected data on 20 pesticides between 1970 and 1981. NIEHS chemicals are not

included because data were not available at the time of our review. f Excludes a related but separate study done in Minnesota reviewing pesticide exposures that was not one of the three formal pilot surveys.

A description of these Federal efforts to collect human exposure data follows.

• CDC’s National Health and Nutrition Examination Surveys: NHANES, conducted multiple times since 1960 by NCHS, is designed to provide national estimates of the health and nutrition status of the noninstitutionalized civilian population of the United States. Estimates are obtained by examining randomly selected

participants in a manner that accurately reflects the demographic characteristics of

the U.S. population. Participants are given comprehensive physical examinations

(including tissue samples) and are interviewed on issues such as their nutritional

habits, health conditions, and housing characteristics. NHANES data are used for

a number of purposes. For example, in addition to monitoring changes in blood lead

levels, uses of NHANES include development of national standards for blood pressure and cholesterol levels and for determining infection rates for diseases. CDC’s laboratory housed at NCEH performs the measurements of chemicals in human tissues for NHANES. • Second National Health and Nutrition Examination Survey: NHANES II was

designed to provide national estimates of the health and nutritional status of the

civilian noninstitutionalized population of the United States for persons aged 6

months to 74 years. Children, the elderly and people classified as living at or below

the poverty level were oversampled in order to increase the reliability of the estimates for these groups. Measurements of pesticide residues were taken from participants who were between the ages of 12 and 74 years of age.3 Blood lead measurements were taken from participants in all age groups in the survey.

Third National Health and Nutrition Examination Survey: NHANES III was designed to provide national estimates of health and nutritional status of the civilian

noninstitutionalized population of the United States ages 2 months and older. Children ages 2 months through 5 years, blacks, Mexican-Americans, and persons ages

60 or older were oversampled to increase the reliability of the estimates for these

groups. Blood lead measurements were taken from all particiapants ages 1 year or

older. Cadmium measurements were taken from all participants ages 6 years or

older. In addition, some participants ages 20 through 59 years had measurements

taken for volatile organic compounds and pesticides. Participants volunteered for

these additional measurements, so the results cannot be projected to the population

as a whole. However, the results still serve as the reference ranges for these chemicals.

National Health and Nutrition Examination Survey, 1999: In 1999, NCHS

changed the design of NHANES so that it will now be conducted as a continuous

survey of about 5,000 participants annually. Like the previous surveys, NHANES

will yield nationally representative results for the civilian noninstitutionalized population. The NHANES design will allow for oversampling to vary between years; persons aged 12 to 19, persons aged 60 and over, blacks, and Mexican-Americans are

being oversampled. It will be tied to related Federal government data collections

conducted on the general U.S. population, in particular, the National Health Interview Survey.4 NCHS also plans to release results from the survey every year after

the first 3 years of data collection. More than 1 year of data will be required for

many estimates, particularly among detailed subgroups of the population. While

lead and cadmium will be the only potentially toxic chemicals measured for all participants ages 1 and older (although cotinine, a metabolite which illustrates exposure to environmental tobacco smoke, will be measured for most age groups—those

ages 4 and over), NCHS and NCEH plan to get nationally representative data for

specific chemicals for persons in specific demographic groups, such as mercury

measurements in women ages 16 through 49. NCHS will also measure household

lead dust, drinking water contaminants, and exposure to volatile organic compounds

for selected participants. In addition to conducting an annual national survey,

NCHS is developing a smaller, more targeted health survey—the Defined Population Health and Nutrition Examination Survey (DP-HANES). NCHS recognizes

that NHANES cannot collect information that would be directly useful at the local

or State level or for small populations. DP-HANES is intended to address this issue

through the use of small mobile examination centers that would visit areas of interest and examine 2,000 to 3,000 participants for each special study. DP-HANES participants would not receive the full range of tests given under NHANES; rather, the

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5 NRC, Commission on Life Sciences, Monitoring Human Tissues for Toxic Substances.

DP-HANES examination would be tailored to the specific needs of the population

under study.

• EPA’s National Human Adipose Tissue Survey: NHATS was intended to be a

continuously operating survey that would collect, store, and analyze samples of autopsy and surgical specimens of human adipose tissue from major metropolitan

areas of the country. It was established by HHS in 1967 and was transferred to

EPA in 1970. During its existence, NHATS data documented the widespread and

significant prevalence of pesticide exposures in the general population. NHATS data

also showed that reduced use of polychlorinated biphenyls (PCB) and DDT and

dieldrin (common insecticides) resulted in lower tissue concentrations of these compounds. A trend analysis for 1970 through 1981 of NHATS data showed a dramatic

decline in PCB concentrations after the regulation of PCBs in 1976. During the

1980’s, problems with NHATS’ survey design, management, and goals were compounded by insufficient financial support and caused the usefulness and quality of

NHATS to deteriorate. In 1991, NRC conducted a study to review and evaluate the

effectiveness and potential applications of NHATS.5 The study concluded that a

more comprehensive national program of human tissue monitoring was a critical

need for understanding human exposures to environmental toxics. In addition, EPA

needed a human tissue monitoring program in order to evaluate the need and effectiveness of EPA’s regulatory programs. The study recommended that NHATS be

completely redesigned to provide more useful data based on probability samples of

the whole U.S. population and that funding be increased to permit the program to

fulfill its mission. EPA ended the NHATS in 1992 and replaced it with the NHEXAS

pilot surveys.

• EPA’s National Human Exposure Assessment Survey Pilot Surveys: The

NHEXAS pilot surveys were designed to obtain knowledge on the multiple pathways

and media population distribution of exposures to several classes of chemicals and

to test the feasibility of conducting a national survey to provide estimates on the

status of human exposure to potentially high-risk chemicals. NHEXAS was also designed to measure ‘‘total exposure’’—the levels of chemicals participants take in

through the air they breathe; the food, drinking water, and other beverages they

consume; and in the soil and dust around their homes. Measurements have also

been made of chemicals in biological samples (such as blood and urine) provided by

some participants. Participants completed questionnaires to help identify possible

sources of exposure to chemicals. As designed, NHEXAS has three phases. Phase

I is intended to develop and validate NHEXAS methods, phase II is designed to obtain nationally representative exposure data in a manner similar to that used by

NHANES to get health data, and phase III is designed to follow up on information

developed from phase II and will study selected subpopulations. EPA conducted

NHEXAS phase I (pilot) surveys in Arizona, Maryland, and EPA’s region 5 (Illinois,

Indiana, Michigan, Minnesota, Ohio, and Wisconsin). About 460 participants in the

pilot surveys provided biological samples; examinations measured a variety of

chemicals, such as volatile organic compounds, heavy metals, and pesticides. Human

tissue measurements were performed under interagency agreement by CDC’s environmental health laboratory. EPA has completed most of the fieldwork for the

NHEXAS phase I surveys and is now analyzing the results. Based on these results,

EPA will finalize the scope and methods for NHEXAS phases II and III.

ATSDR’s Exposure Investigations: As part of its health assessment process or in

response to requests, ATSDR may conduct limited biological monitoring at hazardous waste sites or other locations through a process called exposure investigations. In response to the recognition that the conclusions drawn from indirect methods of measuring exposures were often not accurate and not reliable for assessing

potential health impacts and the need for more direct measures of exposures,

ATSDR formally established an exposure investigation unit within its Division of

Health Assessments and Consultation. The Exposure Investigation Section was established in 1995 and is comprised of nine staff members who respond to requests

to conduct exposure investigations around hazardous waste sites. These investigations involve gathering biological samples, conducting personal monitoring for siterelated contaminants and their byproducts, and analyzing environmental data using

computational tools.

In 1996, ATSDR convened an expert review panel to comment on ATSDR’s exposure investigation program, including whether ATSDR was on the right track in

providing exposure information to improve public health decisionmaking intended to

address environmental releases from hazardous waste sites. The panelists endorsed

many aspects of ATSDR’s investigative process, including the following:

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• Conducting exposure investigations prior to preparing public health assessments, which makes agency responsibilities easier because information is provided

that enables Federal agencies to take action and respond to community concerns in

a timely manner.

• Considering exposure determinations to be as important as obtaining environmental monitoring results.

• Emphasizing the human element of exposure investigations, which illustrates

that the Federal Government responds to community concerns.

The panel also made several suggested improvements to the process, including establishing a national clearinghouse of exposure investigation data and results and

developing site criteria and a protocol for identifying who will decide onsites to target for exposure investigation.

ATSDR’s exposure investigations have been valuable but limited in scope. ATSDR

used biological monitoring in conducting 47 exposure investigations between 1995

and July 1999. Of these investigations, 17 were done in support of the 460 health

assessments done at that time. Unlike NHANES and the NHEXAS pilot surveys,

exposure investigations usually have a small number of participants (less than 100)

who volunteer to participate in the study. While the exposure investigations are not

intended to be used for generalizations about larger populations, the studies have

proven very useful in ATSDR’s community outreach and intervention activities.

• NIEHS’ Human Exposure Initiative: In 1996, this initiative, a collaboration between NIEHS and CDC, was started to improve understanding of human exposures

to hormonally active agents—also called ‘‘environmental endocrine disrupters’’—for

the national population. CDC’s environmental health laboratory under an interagency agreement is developing methods for and measuring up to 80 chemicals

thought to be hormonally active agents in blood, urine, or both. Human tissue samples used for these measurements are largely obtained from the ongoing sampling

of the general population under NHANES and total about 200 in number.

In 1999, NIEHS and NTP officials proposed to expand the initial collaboration between NEHS and CDC by quantifying human internal exposures to selected chemicals that are released into the environment and workplace. NTP officials indicated

this information would benefit public health and priority-setting in a number of

ways. First, it would strengthen the scientific foundation for risk assessments by allowing (1) the development of more credible relationships between exposure and response in people thereby improving cross-species extrapolation, (2) the development

of biologically based dose-response models, and (3) the identification of sensitive

subpopulations and for estimates of risk based on ‘‘margin of exposure.’’ Second, it

would provide the kind of information necessary for deciding which chemicals

should be studied with the limited resources available for toxicological testing. For

example, there are 85,000 chemicals in commerce today, and NTP can provide toxicological evaluations on 10 to 20 per year. Third, the information could be used to

identify and help focus research on those mixtures of chemicals that are actually

present in people’s bodies. Fourth, the types and amount of chemicals in children

and other potentially sensitive subpopulations would be identified. Determinations

of whether additional safety factors need to be applied to children must rest in part

upon comparative exposure analyses between children and adults. Fifth, this initiative, taken together with the environmental genome initiative, will provide the

science base essential for meaningful studies on gene and environment interactions,

particularly for strengthening the evaluation of epidemiology studies. Finally, efficacy of public health policies aimed at reducing human exposure to chemical agents

could be evaluated in a more meaningful way if human exposure data were available over time, including remediation around Superfund sites and efforts to achieve

environmental equity.

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STATEMENT OF STEPHEN M. PRESCOTT, M.D., EXECUTIVE DIRECTOR, HUNTSMAN

CANCER INSTITUTE

This year, approximately 2,400 children in the United States will be diagnosed

with acute lymphoblastic leukemia (ALL), the most common form of childhood cancer. Their chances for cure are significantly better than they were three decades ago.

Due to breathtaking progress in research, close to 75 percent of these children will

grow up to lead healthy productive lives. The results are improving each year and

childhood ALL is one of the most curable forms of human cancer.

Despite this success, many challenges remain and the first is obvious—the cure

rate isn’t 100 percent. And, until it is we must work toward this goal. A second goal

is to develop treatments with fewer side effects. To achieve these goals we must discover the root causes of childhood leukemia. In this regard, the future is bright. We

are beginning to unravel the events that cause a single cell to become cancerous.

These results can be attributed to significant advances in basic research, especially

in the area of genetics. When we talk about cancer genetics we mean two different

things. The first, which is readily understood, means inheriting a high risk of cancer

from one’s parents. This is only a small minority of all cancer cases and is very rarely the cause of childhood cancer. The second meaning of genetic is that the cancer

cell has acquired damage to its genes, while the rest of the body’s cells have a perfectly normal genetic make-up.

In the case of ALL, we know that a single normal cell, destined to become a normal white blood cell called a lymphocyte, develops a mistake in the genetic code.

In the case of leukemia, this is a swap of genetic material between two chromosomes and is called a translocation. These translocations occur in genes that control growth under normal circumstances. When such growth-promoting genes are

damaged, the cell will continue to grow even when the body is trying to send a message to tell it to stop growing. Through the development of powerful techniques we

now know the location of many of these defects and researchers at many centers

are working to unravel the complexity of the cancer cell to understand specifically

changes that allows the cancer to grow.

Perhaps the most difficult questions for a physician to answer are, ‘‘Doctor, why

did my child get leukemia? And, was there anything I could have done to prevent

it’’? The answer to the second is a resounding ‘‘no.’’ The answer to ‘‘why’’ is that

we don’t yet know the fundamental cause of ALL.

When clusters, or dramatic increases in cancer cases in small geographic areas,

occur, we always revisit the issue of whether a cancer-causing agent from the environment or an infection resulted in the increased number of cases. Unfortunately,

this approach has not identified any causes for ALL. But it is possible that we are

missing subtle relationships if an environmental or infectious cause is present but

only affects individuals with a certain genetic makeup and not all members of the

population.

The recent sequencing of the human genome provides us with unprecedented opportunities to understand cancer and to use that knowledge to develop new treatment and prevention. The major focus of the Huntsman Cancer Institute (HCI) is

to understand this genetic blueprint of cancer. Using a new technology called ‘‘DNA

chips’’ investigators in our childhood cancer program have uncovered genetic pathways that are active in cancer cells but not normal blood cells. Using this information it may be possible to develop drugs that could interfere with these active pathways. Since these changes are limited to the cancer, new drugs targeted to these

pathways might avoid the side effects seen with conventional drugs.

We also now know that certain pathways are unique to groups of patients that

have a greater risk of relapse after treatment. It may be possible to use the genetic

‘‘fingerprint’’ of the leukemia someday to ‘‘tailor’’ therapy so that patients with a

high likelihood of cure can be treated without exposing them to unnecessary more

toxic therapy, while patients with high risk disease can be more effectively treated

before the leukemia comes back. This approach is still experimental and leukemia

samples from children treated at children’s hospitals throughout the United States

will be sent to us to test further this genetic approach to classifying leukemia. We

believe that the same approach could be applied to studies of clusters of ALL to try

to understand why they occur. For example, is there a specific genetic pathway

damaged in children from Fallon who have ALL. If so, this would suggest that an

infection or environmental agent initiated a common form of damage.

The Children’s Oncology Group, a consortium of all major children’s hospitals in

North America, is embarking on a massive effort to identify a subset of patients who

might be especially vulnerable to environmental risks because of inherent susceptibility to damage from chemicals. This effort will use the approach I’ve described and

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will be led by Dr. Bill Carroll, the deputy director of the Huntsman Cancer Institute.

Although these projects are just underway, progress is being achieved at a remarkable rate. By combining sophisticated genetic analysis of patients and their tumors with the best treatments available, we hope to reach that goal of uniform cancer cure and ultimately, prevention.

ENVIRONMENTAL EXPOSURES AND CHILDHOOD CANCER: OUR BEST MAY NOT BE

GOOD ENOUGH

Childhood cancer ranks high among public concerns, evoking the public’s fear of

cancer as well as the special emotional attention that is focused on children. Although it is rare, its priority is elevated on the basis of years of life lost and its

prominence among life-threatening diseases of children. Despite great success in the

treatment of childhood cancers such as Wilms’ tumor and leukemia, cancer continues to be life threatening in children.

For several decades, clusters of childhood leukemia have been investigated, in a

search first for an infectious etiology and then for an environmental etiology,1 both

without success. Childhood cancer clusters continue to generate public concern and

consume health department resources, but there has been little progress in understanding the etiology or identifying preventive measures. The focus often turns to

the role of environmental pollutants such as pesticides, electromagnetic fields, and

chemicals found in hazardous wastes. The rationale for seeking exogenous, modifiable causes of childhood cancer that can be avoided leading to a reduction in the

risk of disease, is compelling. The negative consequence of such public demand and

support for epidemiologic research is the temptation to overinterpret every shred of

fallible evidence that emerges. The public and media tend to place much more faith

than is warranted in isolated findings, to the detriment of sound policy and the

credibility of researchers.

Epidemiologic research into potential environmental contributors to the etiology

of childhood leukemia, brain cancer, and other pediatric malignancies has been pursued intensively for over 20 years. Motivated by scientific interest and public concern, a number of studies have evaluated the role of pesticides,2 ionizing radiation,3

nonionizing radiation,4–5 and a wide range of occupational and environmental expo- sures.6–7 Dozens of epidemiologic studies have been conducted on these topics, some

with sophisticated designs, large populations, and attention to exposure assessment,

such as the report in this issue by Freedman et al.8 on solvent exposure and childhood acute lymphoblastic leukemia.

SCIENTIFIC CHALLENGES TO IDENTIFYING CAUSES OF CHILDHOOD CANCER

The scientific challenges to identifying environmental contributors to the etiology

of childhood cancer are daunting. We are uncertain about the relative importance

of exposures of the mother, father, and child in disease etiology. Although the time

frame is narrower than the half century of potential relevance in the etiology of

adult cancer, the origins of childhood cancer may lie anywhere between conception

and diagnosis. The appropriate disease entities for study cannot be defined with

confidence, so histology, age of onset, and tumor biology are all potential markers

of etiologic heterogeneity. The goal of creating ever-finer case subgroups must be

reconciled with the overall variety of cancers in children. The trade-off is between

potential gains in validity achieved by creating more homogeneous case groups and

a definite loss of precision as the group size is reduced.

Because childhood cancers are so rare, true prospective studies are virtually impossible, necessitating continued reliance on case-control studies. As noted by Freedman et al.,8 the 2 key challenges associated with that design are control selection

and exposure assessment. Except in locations with complete birth registries or population rosters (mostly in northern Europe), identifying and recruiting a sample of

the case-generating study base pose great challenges.

Hospital-based studies make it impossible to define the source of cases, particularly for diseases that result in referrals from a wide geographic area. Because few

children are hospitalized for any reason, finding ‘‘exposure-neutral’’ diagnostic

groups of children as a source of controls is even more challenging than it is for

adults. In population-based studies, nonresponse is inevitable, often reaching levels

of 20 percent to 40 percent of the eligible population. As a reminder that this nonresponse is capable of distorting measures of association, virtually all case-control

studies of childhood leukemia in the United States, including the study by Freedman et al., have found higher risk in the lower social classes, despite there being

an established, though modest, positive correlation between higher social class and

risk for child cancer on the basis of registry information. The overrepresentation of

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upper-social-class controls, stronger than the corresponding trend among cases, appears to be the source of this effect, replicated across studies. Adjustment for social

class can be made, but this consistent observation suggests that other aspects of

nonresponse (particularly among controls) may well have more insidious effects.

The second consequence of conducting case-control studies is the loss of information associated with retrospective exposure assessment. Until the cancer is identified (or the control child reaches the equivalent age), we can not ascertain exposure

and are thus faced with reconstructing exposure throughout the potential etiologic

period. Studies that identify the cases as they are diagnosed, as was done by Freedman et al.,8 avoid the additional time delay associated with recruiting cases diagnosed before the initiation of data collection, but there is still a limit to the accuracy

of exposure assessment for periods extending back as far as 15 years. Biological

markers of exposure are clearly not applicable, and direct measurement of environmental agents in the physical locations of interest is of uncertain relevance owing

to the passage of time. We are forced to relay on memory, which itself is limited

in accuracy and objectivity with regard to the important details about workplaces

and the home environment that can affect exposure.

SOLVENTS AND CHILDHOOD LEUKEMIA

Recognizing all these limitations, the report by Freedman et al. reflects the ‘‘state

of the art’’ in childhood cancer epidemiology with regard to study size (640 cases

included in the analysis), homogeneity of disease classification (all acute

lymphoblastic leukemia), method of control selection (random-digit dialing), and approach to exposure assessment (structured questionnaire addressing frequency and

duration of exposure). As would be predicted, the greatest concerns with bias arise

from nonresponse and exposure misclassification. Only 64 percent of eligible controls

were enrolled, and despite some evidence against the available measures of social

class being associated with solvent exposure, that level of nonparticipation leaves

open the possibility of distorted results. Relative to an ideal measure of actual solvent exposure, as might be obtained through personal monitoring, the effectiveness

of the exposure assessment questions is uncertain. The investigators focus on differential error, which could contribute to elevated measures of association, but nondifferential misclassification is more certain to be present and can be invoked as an

argument that observed associations are more likely to be underestimates of any underlying causal association.

This study advances the hypothesis that solvent exposure may contribute to the

etiology of childhood leukemia, moving it from a plausible hypothesis with no direct

epidemiologic support to one with very limited epidemiologic support. The total evidence supporting the hypothesis that household solvent exposures cause childhood

leukemia nevertheless remains weak but deserving of further study. Perhaps the

most disconcerting challenge posed by the study is how to make progress in evaluating the hypothesis further. The very strengths of the study by Freedman et al.

make it difficult to suggest improvements. Certainly, pure replication, assessing

whether the same study design generates the same results in other settings, would

be welcome. There is clearly some room for refinements in the approach to exposure

assessment, with more detailed query pertaining to exposure determinants. Those

who are already engaged in such studies would do well to include pertinent questions regarding household solvent exposure. However, given the rarity of the disease

and the expense associated with studies of this size, it is difficult to advocate initiating new studies with household solvent exposure as a primary justification.

Even though the epidemiologic studies directly tackle the exposure and disease of

interest, more insight may be generated by strong findings of indirect relevance

than by more weak findings of direct relevance. Research that addresses the impact

of self-reported activities on measured solvent exposure would be highly beneficial

to interpreting this study and could lead to improved methods of retrospective exposure assessment. Toxicologic studies of implicated agents, such as methylene chloride and benzene, focusing on animal models of childhood leukemia may help in the

interpretation of these results. For a possible paternally mediated pathway linking

solvent exposure to childhood leukemia, further work on sperm-mediated genetic alterations associated with solvent exposures could be contributory. With regard to

childhood exposure, focus might shift to endpoints that can measured prospectively

in modest populations, ideally, biomarkers of early effect such as cytogenetic damage. If we are to attain the conclusive results pertaining to solvent exposure (or pesticides, nonionizing radiation, etc.) and leukemia (or other childhood cancers)—an

elusive goal so far—it is very unlikely to come through sheer weight of replicated

findings from conventional epidemiologic studies.

DAVID A. SAVITZ, PHD.

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ACKNOWLEDGMENTS

I would like to thank Dr. Andrew Olshan for his review and helpful comments

on the manuscript.

REFERENCES

1. Alexander FE. Clusters and clustering of childhood cancer: A review, Eur J.

Epidemiol. 1999; 15:847–852.

2. Daniels JL, Olshan AF, Savitz DA. Pesticides and childhood cancers. Environ

Health Perspect. 1997; 105:1068–1077.

3. Laurier D, Bard D. Epidemiologic studies of leukemia among persons under 25

years of age living near nuclear sites. Epidemiol Rev. 1999; 21:188–206.

4. Ahlboin A, Day N, Feychting M. et al. A pooled analysis of magnetic fields and

childhood leukemia. Br J. Cancer. 2000; 83:692–698.

5. Little J. Epidemiology of Childhood Cancer. Lyons, France: International Agency for Research on Cancer; 1999. LARC Scientific Publication 149.

6. McBride ML. Childhood cancer and environmental contaminants. Can J. Public

Health. 1998; 89:S53–S62.

7. Colt JS, Blair A. Parental occupational exposures and risk of childhood cancer.

Environ Health Perspect. 1998; 106:909–926.

8. Freedman DM, Stewart P, Kleinerman RA, et al. Household solvent exposures

and childhood acute lymphoblastic leukemia. Am J Public Health. 2001; 91:564–567.

HOUSEHOLD SOLVENT EXPOSURES AND CHILDHOOD ACUTE

LYMPHOBLASTIC LEUKEMIA

ABSTRACT

Objectives.—This study explored the risk of childhood acute lymphoblastic leukemia (ALL) associated with participation by household members in hobbies or

other home projects involving organic solvents.

Methods.—Participants in this case—control study were 640 subjects with ALL

and 640 matched controls.

Results.—Childhood ALL was associated with frequent (>4 times/month) exposure

to model building (odds ratio [OR]=1.9; 95 percent confidence interval [95 percent

CI]=0.7, 5.8) and artwork using solvents (OR=4.1; 95 percent CI=1.1, 15.1). We also

found elevated risk (OR=1.7; 95 percent CI=1.1, 2.7) among children whose mothers

lived in homes painted extensively (>4 rooms) in the year before the children’s birth.

Conclusions. In this exploratory study, substantial participation by household

members in some common household activities that involve organic solvents was associated with elevated risks of childhood ALL. (Am J Public Health. 2001;91:564-

567)

Little is known about the role of environmental exposures in childhood leukemia.1

Several epidemiologic studies have described elevated risks of childhood leukemia

associated with parents’ exposure to occupational chemicals, 2–10 including solvents 3,6,8,9 and paints.3,5,7,10 Children may also be exposed to solvents and paints at

home through their own or their parents’ hobbies and household maintenance activities. To our knowledge, few studies 10 have examined the risks of childhood leukemia associated with exposures to solvents in the home other than pesticides.

As part of a large comprehensive case-control study of potential risk factors for

childhood acute lymphoblastic leukemia (ALL) conducted by the Children’s Cancer

Group, we undertook an exploratory study to examine the relationship between

childhood leukemia and exposure to selected household chemicals during childhood,

as well as indoor house painting during preconception, pregnancy, and childhood.

We focused on common home activities likely to result in exposures to solvents.11–14

METHODS

Case subjects were children, aged birth to 14 years, who were newly diagnosed

with ALL between 1989 and 1993, resident in any of 9 midwestern and mid-Atlantic

States, and enrolled through the Children’s Cancer Group, a cooperative clinical

trials group.15,16 Eligibility criteria included a residential telephone and an Englishspeaking biological mother available for an in-person interview. Control subjects

were selected through random-digit dialing and were individually matched to the

case subjects by age (within 25 percent of the case’s age at diagnosis), the first 8

digits of the telephone number, and race.17 The overall participation rates were 88

percent for case subjects and 64 percent for control subjects. After exclusion of paVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00160 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
155

tients with Down syndrome, which has been associated with a high risk of ALL,18

there were 640 matched case-control pairs.

For each of 3 hobbies (model building, artwork using solvents, and furniture stripping) and 2 household maintenance activities (motor vehicle and electronic equipment repair), interviewers asked mothers whether household members engaged in

any of the 5 activities in and around their home. Because pretesting revealed that

many mothers could not remember early activities or gave identical answers for

each year of the child’s life, the interview focused on activities during the reference

year (the year preceding the date of diagnosis for the case and its matched control).

Interviewers asked the mother about which household members participated in the

activities, as well as the frequency and duration of each episode. Interviewers also

asked questions about painting inside the subjects’ homes within 3 months of conception, during the pregnancy, and after the subjects’ birth, including the specific

rooms painted, the frequency of the painting, who painted (mother or others), and

whether members of the family remained at home overnight during the house painting.

For each hobby or household activity other than house painting, we analyzed 2

measures of exposure: frequency (defined as the number of times engaged in the activity per month) and cumulative exposure (defined as the product of the frequency

of the activity and its duration per episode). Because fewer control than case mothers provided information about duration, our analysis emphasized frequency as a

more unbiased exposure measure. Before any analysis, we arbitrarily classified frequency and cumulative exposure into common time categories. We categorized frequency of exposure as low (<1 time/month), medium (1–4 times/month), and high

(>4 times/month); we categorized cumulative exposure as low (<10 minutes over a

month), medium (10 minutes–1 hour over a month), and high (>1 hour over a

month). For house painting, exposure was classified by the total number of rooms

painted (1–2, 3–4, >4 rooms), as well as the frequency (1–2, 3–5, >5 times since

birth) among those painting after the child’s birth.

We computed odds ratios by unconditional logistic regression so as to maximize

the number of cases and controls included in this exploratory analysis. We confirmed our main findings by conditional logistic regression. Odds ratios were adjusted for age at the reference date, sex, mother’s education level, and family income. We compared subjects by whether they ever or never participated in a given

activity and by the 2 measures of exposure. We analyzed the total population, as

well as 2 age strata: younger than 5 years (the peak ages are 2–4 years for ALL)

and 5 years and older. Except for model building, there was an insufficient number

of children participating in the various activities to assess the risk of ALL among

child participants. For house painting, we investigated the timing of painting before

and after birth.

We also examined 2 strata based on length of time between diagnosis and interview (≤24 months vs >24 months). We explored trends in risk by entering exposure

variables ordinally into the models.

RESULTS

Case subjects and control subjects were demographically similar, except that the

former came from families with lower income and had mothers with less formal education. Both groups were predominantly White (Table 1).

Exposures From Hobbies, Vehicle Maintenance, and Electronic Repair

No significant excess risk of childhood ALL was observed with ever vs never participation in any of the activities by a household member (Table 2). Moreover, neither automotive and truck maintenance nor electronic repairs reflected a pattern of

risk with increasing exposure.

Elevated risks of childhood ALL, however, were associated with the highest levels

of participation in some activities (Table 2). Risks were elevated for model building

in the highest-frequency category (odds ratio [OR] = 1.9; 95 percent confidence interval [CI]=0.7, 5.8) but did not vary by age group or the child’s involvement. Artwork

requiring solvents was linked with significantly elevated risks of childhood ALL in

the highest-frequency exposure category (OR=4.1; 95 percent CI=1.1, 15.1), and

risks increased as exposure rose (P trend=.07). Although the numbers were small,

similar risks were observed in both age groups (data not shown). The associations

with high cumulative exposure were similar to those with frequent exposures for

both model building and artwork (data not shown).

For furniture stripping, risk was not elevated among children in families with the

highest frequency of exposure. Risk was, however, significantly elevated among children in those families with the highest cumulative exposures (OR=2.9; 95 percent

CI=1.1, 9.1).

156

In general, when the subjects were stratified by time between diagnosis and interview dates, the odds ratios among those interviewed close to the diagnosis date were

about the same as or stronger than the unstratified odds ratios.

TABLE 1.—Characteristics of 840 Children With Acute Lymphoblastic Leukemia and 640 Matched

Controls,a From Interview Data on Use of Household Solvent Exposures

Characteristics Cases N (%) Controls N

(%)

Sex:

Male ................................................................................................................................................ 333 (52.0) 337 (52.7)

Female ............................................................................................................................................ 307 (48.0) 303 (47.3)

Age at diagnosis/reference date, y:

<2 ................................................................................................................................................... 68 (10.6) 85 (13.3)

2–4 ................................................................................................................................................. 312 (48.8) 289 (45.2)

5–9 ................................................................................................................................................. 179 (28.0) 185 (28.9)

5≥10 ............................................................................................................................................... 81 (12.7) 81 (12.7)

Race:

White ............................................................................................................................................... 585 (91.4) 612 (95.8)

Black ............................................................................................................................................... 20 (3.1) 16 (2.5)

Other ............................................................................................................................................... 35 (5.5) 12 (1.9)

Household income during reference year, $:

<20,000 .......................................................................................................................................... 113 (17.7) 77 (12.0)

20,000–29,999 ............................................................................................................................... 122 (19.1) 86 (13.4)

30,000–39,999 ............................................................................................................................... 133 (20.8) 112 (17.5)

40,000–49,999 ............................................................................................................................... 98 (15.3) 105 (16.4)

≥50,000 .......................................................................................................................................... 168 (26.2) 255 (39.8)

Missing ........................................................................................................................................... 6 (0.9) 5 (0.8)

Mother’s education:

<High school .................................................................................................................................. 57 (6.9) 30 (4.7)

High school ..................................................................................................................................... 220 (34.4) 224 (35.0)

Some college ................................................................................................................................... 210 (32.8) 199 (31.1)

College graduate ............................................................................................................................ 153 (23.9) 187 (29.2)

Mother’s occupation:

Professional .................................................................................................................................... 131 (20.5) 148 (23.1)

White collar ..................................................................................................................................... 156 (24.2) 172 (26.9)

Blue collar ...................................................................................................................................... 45 (7.0) 29 (4.5)

Housewife ........................................................................................................................................ 308 (48.1) 291 (45.5)

Father’s occupation:

Professional .................................................................................................................................... 190 (29.7) 200 (31.3)

White collar ..................................................................................................................................... 103 (16.1) 119 (18.6)

Blue collar ...................................................................................................................................... 285 (44.5) 240 (37.5)

Missing ........................................................................................................................................... 62 (9.7) 81 (12.7)

Residential status:

Urban .............................................................................................................................................. 169 (26.4) 136 (21.3)

Suburban ........................................................................................................................................ 271 (42.3) 293 (45.8)

Rural ............................................................................................................................................... 200 (31.3) 210 (32.8)

Time between reference date and interview, mo:

7–12 ............................................................................................................................................... 86 (13.4) 3 (0.5)

13–18 ............................................................................................................................................. 256 (40.0) 107 (16.7)

19–24 ............................................................................................................................................. 134 (20.9) 196 (30.6)

25–36 ............................................................................................................................................. 129 (20.2) 238 (37.2)

≥37 ................................................................................................................................................. 35 (5.5) 96 (15.0)

a Excludes 11 pairs in which 1 member of the air had Down syndrome.

TABLE 2.—Distribution of Cases and Controls by Frequency a of Hobby and Household Maintenance Activity During Year of Diagnosis, With Odds Ratios b (ORs) and 95% Confidence Intervals (Cls)

Cases Controls OR(95% CI)

Hobbies

Model building:

Never c ....................................................................................................................... 549 555 1.0

Ever d ......................................................................................................................... 90 83 1.1 (0.8, 1.5)

Low ........................................................................................................................ 51 60 0.9 (0.6, 1.3)

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TABLE 2.—Distribution of Cases and Controls by Frequency a of Hobby and Household Maintenance Activity During Year of Diagnosis, With Odds Ratios b (ORs) and 95% Confidence Intervals (Cls)—Continued

Cases Controls OR(95% CI)

Medium ................................................................................................................. 29 18 1.5 (.08, 2.8)

High ....................................................................................................................... 10 5 1.9 (0.7, 5.8)

Ptrend ...................................................................................................................... .......... .................. .21

Artwork (using solvents):

Never c ....................................................................................................................... 566 571 1.0

Ever d ......................................................................................................................... 73 65 1.3 (0.9, 1.8)

Low ........................................................................................................................ 34 35 1.1 (0.7, 1.8)

Medium ................................................................................................................. 28 27 1.2 (0.7, 2.0)

High ....................................................................................................................... 11 3 4.1 (1.1, 15.1)

Ptrend ...................................................................................................................... .......... .................. .07

Furniture stripping:

Never c ....................................................................................................................... 574 579 1.0

Ever d ......................................................................................................................... 65 59 1.1 (0.8, 1.6)

Low ........................................................................................................................ 32 35 0.9 (0.6, 1.5)

Medium ................................................................................................................. 24 14 1.8 (0.9, 3.6)

High ....................................................................................................................... 8 8 1.0 (0.4, 2.7)

Ptrend ...................................................................................................................... .......... .................. .33

Household maintenance

Auto/truck maintenance:

Never c ....................................................................................................................... 378 383 1.0

Ever d ......................................................................................................................... 260 255 0.9 (0.7, 1.2)

Low ........................................................................................................................ 121 129 0.9 (0.7, 1.2)

Medium ................................................................................................................. 107 107 0.9 (0.6, 1.2

High ....................................................................................................................... 31 19 1.5 (0.8, 2.7)

Ptrend ...................................................................................................................... .......... .................. .91

Electronic repair:

Never c ....................................................................................................................... 604 612 1.0

Ever d ......................................................................................................................... 35 25 1.4 (0.8, 2.4)

Low ........................................................................................................................ 20 14 1.5 (0.7, 3.0)

Medium ................................................................................................................. 13 5 2.7 (1.0, 7.7)

High ....................................................................................................................... 2 6 0.3 (0.1, 1.5)

Ptrend ...................................................................................................................... .......... .................. .50

a Frequency refers to occasions per moth: ‘‘low’’ is less than once a month, ‘‘medium’’ is 1 to 4 times a month, and ‘‘high’’ is more than

4 times a month. b Adjusted for child’s age at the reference date, sex, household income at the reference date, and maternal education. c Referent category.

d Not all respondents reporting participation specified frequency.

TABLE 3.—Distribution of Cases and Controls by Indoor House Painting in Subject’s Home

During Year Before Birth, With Odds Ratiosa (ORs) and 95% Confidence Intervals (CIs)

Cases Controls OR 95% CI

Ever painted:

No ..................................................................................................... 346 359 1.0

Yes .................................................................................................... 289 278 1.2 0.9, 1.5

No. of rooms painted:

Never painted ................................................................................... 346 359 1.0

1¥2 ................................................................................................. 161 188 1.0 0.8, 1.3

3¥4 ................................................................................................. 62 48 1.4 0.9, 2.1

>4 ..................................................................................................... 64 40 1.7 1.1, 2.7

Ptrend ............................................................................................. .................. .................. .01

Family stayed at home overnight:b

Never painted ................................................................................... 346 359 1.0

Not at home ..................................................................................... 25 17 2.3 0.6, 8.9

At home ............................................................................................ 102 109 1.9 0.6, 6.4

Painter:

Never painted ................................................................................... 346 359 1.0

Mother .............................................................................................. 160 152 1.1 0.9, 1.5

Other ................................................................................................. 128 124 1.3 0.9, 1.7

Note. Not all respondents who reported painting provided information about the number of rooms painted, whether family stayed at home

overnight, or who performed the painting.

158

a Adjusted for child’s age at the reference date, sex, household income at the reference date, maternal education, and painting during

other periods. b Also adjusted for number of rooms painted.

Exposure From Household Painting

We observed no significant overall increase in risk (OR=1.2; 95 percent CI=0.9,

1.5) of childhood ALL associated with interior house painting during the 12 months

before the subject’s birth, although the risk was elevated among children whose

mothers lived in homes in which more than 4 rooms were painted during this period

(Table 3). Risk of ALL was not higher among children whose mothers, rather than

other people, did the painting (Table 3).

When risk was analyzed by 3-month periods in the year before birth, we also

found no significant risk during each period except for a small borderline risk in

the 3 months before conception (data not shown). However, when the study population was analyzed by length of time from diagnosis to interview, this association

appeared to be due to responses from those interviewed at a more distant time from

the reference date.

Among children residing in homes painted after the subject’s birth, a small, but

borderline significant, excess risk was seen (OR=1.3; 95 percent CI=1.0, 1.6). Risk

was elevated for painting more rooms (for >4 rooms, OR= 1.6; 95 percent CI=1.2,2.2)

and painting more frequently (for >5 times, OR=1.8; 95 percent CI=1.1, 2.8). When

the associations among those interviewed close to the diagnosis date were examined,

risk remained about the same, but those associations disappeared among subjects

interviewed later.

DISCUSSION

This study found elevated risks for childhood ALL associated with substantial

postnatal exposure to some household activities and prebirth and postnatal exposure

to indoor house painting. There are, however, several limitations to this study. As

in any retrospective interview study, exposures are likely to be misclassified owing

both to imperfect respondent recollections and to the crudeness of the information

requested. The questionnaire obtained only limited information on the child’s proximity to the activity and none on other activities that may involve solvents, particularly home renovation, such as floor refinishing. Moreover, little is known about the

relevant time frame for exposure—whether exposures occurred before conception

(germ cell mutations), during pregnancy (transplacental fetal exposure), or after

birth. With the exception of house painting, the survey was restricted to postnatal

exposures.

Our greatest concern in interpreting the findings is the possibility that differential

reporting errors by case and control mothers exaggerated estimates of effect.12 The

weaker association with house painting before conception among mothers interviewed near the reference date substantially weakens the credibility of an association with preconception painting. However, the consistency between the other odds

ratios and those limited to mothers interviewed close to the reference date supports

the findings. Unfortunately, the disproportionate delay in interviewing control mothers limited our ability to check the consistency of associations at interview times

very close to the events in question.

Selection bias due to differential socioeconomic status potentially could have resulted from use of random-digit dialing for control selection. Family income, however, was not associated with substantial participation in model building, artwork

using solvents, or furniture stripping. Moreover, indoor house painting was more

common among high-income controls, which suggests that a selection bias could

have underestimated the association with house painting. Finally, socioeconomic factors do not appear to have confounded the relationship between ALL and the activities assessed, because controlling for family income and maternal education did not

appreciably affect the results.

Despite the study limitations, there are several arguments for the plausibility of

the findings. Some epidemiologic studies have shown an association between paternal occupational exposure to organic solvents and childhood leukemia in the postnatal period.2,3,10 Exposure of children could occur through inhalation of solvents

used at home or brought home from the workplace on the parents’ breath.19 Previous epidemiologic studies have found positive associations between childhood leukemia and painting on the job during the prenatal 7,10,20 and postnatal 10 periods.

Each of the activities associated with an elevated risk of childhood ALL involves

exposure to organic solvents, some of which are known or possible human carcinogens. Benzene, a typical constituent in hobby glues in model building11 and in

paints,12 is an established adult leukemogenic solvent.21 There is a case report of

childhood leukemia following intense exposure to toluene-containing glues used in

159

model building.22 Methylene chloride, the main constituent of furniture strippers,13

is also a possible carcinogen,23 and trichloroethylene, which may be found in paints

and varnishes,24 has been found to cause cancer in animals.23

As the first large case—control study of childhood ALL evaluating associations

with hobbies and household activities that may involve carcinogenic solvent exposures, our study is primarily exploratory. Because of the number of exposures examined, confirmation is required to rule out false-positive results. Further study is also

warranted of additional household activities involving solvents, with exposure information for individual chemicals and levels and better delineation of specific time

frames of exposure (prenatal vs. exclusively postnatal) to illuminate the relevant biological pathways.

ACKNOWLEDGMENTS

This study was supported in part by grants from the National Cancer Institute

(R0I CA 48051 and U01 CA 13539) and by the University of Minnesota Children’s

Cancer Research Fund.

The authors gratefully acknowledge Dr. Robert Hoover of the National Cancer Institute for his thoughtful comments on the manuscript.

The study was approved by the National Cancer Institute Special Studies Institutional Review Board and obtained the consent of participants.

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York, NY: Oxford University Press; 1996:1331–1369.

2. Colt JS, Blair A. Parental occupational exposures and risk of childhood cancer.

Environ Health Perspect 1998; 106:909–926.

3. Buckley JD, Robison LL, Swotinsky R, et al. Occupational exposures of parents

of children with acute nonlymphocytic leukemia: a report from the Children’s Cancer Study Group. Cancer Res. 1989;49:4030–4037.

4. Fabia J, Thuy TD. Occupation of father at time of birth of children dying of

malignant diseases. Br J Prev Soc Med. 1974;28:98–100.

5. Hemminki K, Saloniemi I, Salonen T, Partanen T, Vainio H. Childhood cancer

and parental occupation in Finland. J Epidemiol Community Health. 1981;35:11–15.

6. Cocco P, Rapallo M, Turghetta R, Biddau PF, Fadda D. Analysis of risk factors

in a cluster of childhood acute lymphoblastic leukemia. Arch Environ Health.

1996;51:242–244.

7. Van Steensel-Moll HA, Valkenburg HA, Van Zanen GE. Childhood leukemia

and parental occupation, a register-based case-control study. Am J Epidemiol.

1985;121:216–224.

8. McKinney PA, Alexander FE, Cartwright RA, Parker L. Parental occupations

and children with leukaemia in west Cumbria, north Humberside, and Gateshead.

BMJ 1991;302:681–687.

9. Feingold L, Savitz DA, John EM. Use of a job-exposure matrix to evaluate parental occupation and childhood cancer. Cancer Causes Control. 1992;3:161–169.

10. Lowengart RA, Peters JM, Cicioni C, et al. Childhood leukemia and parents’

occupational and home exposures. J Natl Cancer Inst. 1987; 79:39–46.

11. Rastogi SC. Organic solvent levels in model and hobby glues. Bull Environ

Contam Toxicol. 1993;51:501–507.

12. Wallace LA. Comparison of risks from outdoor and indoor exposure to toxic

chemicals. Environ Health Perspect. 1991;95:7–13.

13. Stewart RD, Hake CL. Paint-remover hazard. JAMA. 1976;235:398–401.

14. Thomas TL, Stolley PD, Stemhagen A, et al. Brain tumor mortality risk

among men with electrical and electronics jobs: a case-control study. J Natl Cancer

Inst. 1987;79:233–238.

15. Kleinerman RA, Linet MS, Hatch EE, et al. Magnetic field exposure assessment in a casecontrol study of childhood leukemia. Epidemiology. 1997;8:575–583.

16. Hatch EE, Linet MS, Kleinerman RA, et al. Association between childhood

acute lymphoblastic leukemia and use of electrical appliances during pregnancy and

childhood. Epidemiology. 1998;9:234–245.

17. Robison LL, Daigle A. Control selection using random digit dialing for cases

of childhood cancer. Am J Epidemiol. 1984;120:164–166.

18. Robison LL, Neglia JP. Epidemiology of Down syndrome and childhood acute

leukemia. In: McCoy EE, Epstein CJ, eds. Oncology and Immunology of Down Syndrome. New York, NY: Alan R Liss; 1987:19–32.

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19. Monster A, Regouin-Peeters W, van Schijndel A, van der Tuin J. Biological

monitoring of occupational exposure to tetrachloroethene. Scand J Work Health.

1983;9:273–281.

20. Shu XO, Stewart P, Wen W–Q, et al. Parental occupational exposure to hydrocarbons and risk of acute lymphoblastic leukemia in offspring. Cancer Epidemiol

Biomarkers Prev. 1999;8: 783–791.

21. Linet MS, Cartwright RA. The leukemias. In: Schottenfeld D, Fraumeni JF

Jr, eds. Cancer Epidemiology and Prevention. New York, NY: Oxford University

Press; 1996:841–892.

22. Caligiuri MA, Early AP, Marinello MJ, Preisler HD. Acute nonlymphocytic

leukemia in a glue sniffer. Am J Hematol. 1985;20:89–90.

23. Lynge E, Anttila A, Hemminki K. Organic solvents and cancer. Cancer Causes

Control. 1997; 8:406–419.

24. Tas S, Lauwerys R, Lison D. Occupational hazards for the male reproductive

system. Crit Rev Toxicol. 1996;26:261–307.

AUTHOR NOTE

D. Michal Freedman, PhD, Patricia Stewart, PhD, Ruth A. Kleinerman, MPH,

Sholom Wacholder PhD, Elizabeth E. Hatch, PhD, Robert E. Tarone, PhD, Leslie

L. Robison, PhD, and Martha S. Linet, MD.

D. Michal Freedman, Patricia Stewart, Ruth A. Kleinerman, Sholom Wacholder,

Elizabeth E. Hatch, Robert E. Tarone, and Martha S. Linet are with the Division

of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Md. Leslie L. Robison is with the Division of Pediatric Epidemiology and Clinical Research,

Department of Pediatrics, University of Minnesota, Minneapolis.

Requests for reprints should be sent to D. Michal Freedman, PhD, Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer

Institute, Executive Plaza—South, Room 7087, 6120 Executive Blvd, Bethesda, MD

20892–7238 (e-mail: mf101@nih.gov).

This brief was accepted July 18, 2000.

CONTRIBUTORS

D.M. Freedman was principal author and analyst of the paper. P Stewart and R.

E. Tarone were involved in interpretation of data, analysis, and revisions of the

paper. R.A. Kleinerman was involved in data collection, interpretation of data, analysis, and revisions of the paper. S. Wacholder was involved in the design of the entire study of which this study is a part, interpretation of data, and revision of the

paper. E.E. Hatch was involved in data collection, the design of the study—including

selection of cases and controls—interpretation of data, and revisions of the paper.

L.L. Robison and M.S. Linet were involved in the design of the entire study of which

this study is a part, data collection, interpretation of data, and revisions of the

paper.

Reproduced with permission of the copyright owner. Further reproduction or distribution is prohibited without permission.

STATEMENT OF MARY GUINAN, MD., PH.D., NEVADA STATE HEALTH OFFICER

INTRODUCTION

I am Dr. Mary Guinan, Nevada State Health Officer. I have been asked to speak

today on the status of the continuing investigation and Federal agency roles in the

investigation of cancer clusters.

Status of Investigation

An Expert Panel was convened on February 15, 2001 to guide the next steps of

the investigation. The panel made the following recommendations:

1. Expand case-finding efforts.—In progress with Navy. Health Division continues

to review cases of leukemia, cancer and other bone marrow diseases reported to us.

All reports are kept on file. Expansion of search through the Children’s Oncology

group and California Cancer Registry will proceed when funding becomes available.

(Chronic disease epidemiologist, part time pediatric oncologist).

2. Categorize the Acute Lymphocytic Leukemia (ALL) cases by clinically relevant

biomarkers.—Need services of pediatric oncologist and funding for locating tissue

and determining what phenotypic and genetic tests need to be done and identify laboratory to do testing.

161

3. Identify potential excess environmental exposures unique to the community.—

Test the drinking water of case families whose water supply is from private wells.

Health Division is in process of testing. Nevada State Health Division has requested

assistance from the Centers for Disease Control and Prevention and the Agency for

Toxic Substances and Disease Registry Human. Representatives of these Agencies

will be coming to Nevada during the week of April 16th to review next steps on the

following issues: (a) Collection of blood and urine samples from cases and family

members for testing for environmental chemicals, (b) Advisability of dust studies

from homes of affected families for environmental chemicals, (c) Environmental

pathways assessment, (d) Radiologic assessment of milk produced in Churchill

County.

4. Collect and Bank Biologic Samples for Future Study.—On hold until funding

is made available and storage sites located.

5. Determine time course and characteristics of population movement into the

Fallon area.—This is part of a bigger picture to provide evidence for population mixing theory. Although some efforts have begun, this is much larger research study

than State can support. Federal funding should be made available for this research.

6. Maintain Expert Panel.—Panel members have agreed to continue in an advisory role.

In addition the State Health Division has: (a) Enhanced access to public information about the ALL cluster and environmental concerns through multiple public

community meetings in Fallon, the Health Division website (health2K.state.nv.us)

and a dedicated call-in telephone line. (b) Developed with the Division of Mental

Health a mental health crises counseling and community assistance initiative. This

has received funding from the Nevada Emergency Management Division and the

first steps have been implemented.

LESSONS LEARNED FROM INVESTIGATION OF CLUSTER OF ALL WITH REGARD TO

FEDERAL AGENCIES ROLE

1. Investigation of Cancer Clusters.—Although hundreds of cancer clusters have

been recognized and investigated during the past 30 years by State and local health

departments and Federal agencies, little information is available on appropriate scientific methods of study especially with regard to determining causative factors or

associated risk factors. Well over 90 percent of these investigations have found no

associated suspect causative factor. No Federal agency wants to expend scarce resources in investigation of cancer clusters that are likely to show nothing. However

State (or local) health departments must investigate clusters to ensure that a dangerous environmental agent is not present in the community contributing to the increase in cancer cases.

While several Federal agencies have expertise in some part of cancer cluster investigations, no one agency has a comprehensive mandate. We have identified gaps

in information available to States as follows:

1. No repository of information exists on the occurrence of cancer clusters (i.e.,

surveillance of cancer of clusters) or to record the results of these investigations.

2. Lack of a standard or a ‘‘best-practices guidance’’ for the investigation of cancer

clusters.

3. No information to identify characteristics of clusters that might be most productive to investigate.

4. No resources available to State to implement investigations of clusters with the

most promise of advancing the science of cancer causation.

Bringing together all the relevant Federal Public Health Agencies (National Cancer Institute, Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry) and Environmental agencies to develop a comprehensive approach to the study of cancer clusters (which would include at minimum the

4 activities listed above) would greatly enhance the speed, efficiency and scientific

validity of cluster investigations. A guidance for best practices for investigation of

clusters would reassure the community that standards do exist for these investigations and that health departments efforts can be evaluated in comparison to the

standard. Recognition of clusters that may be most productive in finding evidence

for causation of cancer and providing resources for the appropriate study of such

clusters would prevent lost opportunities and maximize the probability of advancing

the science of cancer causation.

2. Environmental Factors.—The cause or causes of acute lymphocytic leukemia

are largely unknown. Theories of causation have focused on two main theories, (a)

environmental agents such as chemicals or radiation or (b) infection with a virus

or bacteria that results in genetic damage that eventually causes leukemia. Studies

162

of suspect infectious and environmental agents for the most part have not been

fruitful.

What the environmental factors should be monitored by health departments in a

systematic way? No consensus exists on the minimum standards for environmental

surveillance. It would be of immense value to the States if all the involved Federal

agencies could be brought together (perhaps by ASTHO, an organization of State

health officials or another non-governmental agency) and come to consensus on

what constitutes the minimum standard for environmental surveillance for State

health departments.

The Environmental Protection Agency is often in conflict with Federal Public

Health Agencies on assessment of risks to health of environmental contaminants.

This results in a bizarre mixture of conflicting standards for which States are held

accountable. EPA should be required to work with Federal Public Health agencies

to resolve conflicts on interpretation of scientific data before implementing regulations for the States.

In the Churchill County area many environmental agents are present that may

constitute a risk for health, including excess arsenic in the drinking water supply.

A great deal of information is available about arsenic in the water and steps have

been taken by the city of Fallon to reduce the arsenic in the municipal drinking

water. However, community concerns have surfaced about other agents in the environment for which we have much less information. These include jet fuel from

Naval Air Station, radioactive substances that may resulted from nuclear testing

that was done in 1963 about 20 miles away from Fallon (Project Shoal conducted

by Department of Energy), pesticides used for insect control and agriculture, chemical pollutants from industries in the area and air contamination with radioactive

or chemical debris from the Sierra Army Depot in California which is about 3 miles

from the Nevada border. One of the requirements for the explosion or burning of

munitions at this depot is that the wind is blowing toward Nevada at a certain

speed before the explosions can take place. There has been no monitoring of the contamination of the air that blows into Nevada from the depot. Therefore no data are

available on this potential source of environmental contamination. Despite numerous requests the Environmental Protection Agency has not required California to be

accountable to Nevada to ensure that toxic substances are not blown into Nevada

from the operation of this depot.

Like all States Nevada does not have jurisdiction over private well water used for

drinking water, nor does any Federal agency. The safety of drinking water from

these wells is unknown. Churchill County has many households whose water supply

comes from private wells. How to ensure the safety of drinking water from private

wells is a critical issue for all States. Federal agencies may have a role in providing

guidance on solutions to this public health issue.

3. Community Mental Health.—Recognition of a cancer cluster in a community is

associated with increased stress for the community. The need for preventive mental

health services must be assessed. The Nevada Health Division and Mental Health

Division have partnered to begin a community mental health initiative in Fallon to

assess the need for and to provide the necessary mental health services for the affected families and the community at-large.

It would be of great value to have a model for providing such services for communities experiencing cancer clusters. The National Institute for Mental Health and

other Public Health agencies have a role in providing guidance for determining mental health needs and providing resources for these services during crises.

ATTACHMENT

REVIEW AND RECOMMENDATIONS OF THE EXPERT PANEL

The expert panel was convened on February 15, 2001 in Reno, Nevada by Dr.

Mary Guinan, Nevada State Health Officer. The panel reviewed the State health department’s investigation of acute lymphoblastic leukemia (ALL) cases that had been

diagnosed in Churchill County, Nevada. The panel considered possible followup actions and priorities by the Nevada Health Division. The meeting of the expert panel

was attended by panel members and staff from the Nevada Health Division, University of Nevada School of Medicine, Nevada Governor’s Office, U.S. Senate (Senator

John Ensign’s Office and Senator Reid’s staff on U.S. Senate Committee on Environment and Natural Resources), and the Fallon Naval Air Base. This report summarizes the panel’s review and recommendations.

The expert panel recognized the difficulty in evaluating and investigating excess

occurrences of ALL. The panel members acknowledged that the cause(s) of ALL are

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insufficiently understood to single out a specific factor as explaining the observed

excess in Fallon, Nevada. The panel members were familiar with previous investigations of ALL clusters, all of which had failed to uncover an explanation of the cause

of these excesses. At the same time, the panel members confirmed that the excess

occurrence of ALL in Fallon, Nevada is unusual; not only because of it’s large number of observed cases among so small a population-at-risk over a short time period,

but also because further observed ALL cases had been diagnosed after the initial

recognition of the ALL excess. The members of the expert panel acknowledged the

excellent work of the staff of the Nevada Health Division on this investigation.

Scientific understanding of the biology of ALL prevented the committee members

from predicting the cause of the observed excess of cases in Fallon. The committee

is aware of at least three distinct sets of possibilities. The first set of theories collectively point toward a cancer causing chemical contaminant (e.g., human carcinogen)

as the causal agent for the ALL epidemic. Theories about a chemical in the environment have received the greatest amount of public attention and community concern.

The expert panel recognizes the need to address community concern regarding the

presence of a hazardous chemical contaminant. However, the absence of cases of

acute myeloid leukemia, the type of leukemia most commonly associated with toxic

chemical exposure (1–3), argues against the Fallon cases being the result of toxic

exposures. The panel members were skeptical that a chemical exposure could explain the excess cases of ALL in Fallon, Nevada. A second possible explanation relates to the theory of what is called population mixing in which clusters of ALL have

been reported associated with unusual mixing of people, often in relatively isolated

rural areas (4–11). The population mixing theory initially focused on the possibility

of an unidentified infectious agent (i.e., a virus). However, the current consensus is

that exposure to a variety of infectious agents (i.e., viral and bacterial) may trigger

an unusual and rare reaction that affects a very small number of children within

the susceptible population. The hypothesis suggests that ALL is not infectious,

spreading from one person to another; but an unusual complication to a common

infection within a susceptible population. The population-mixing theory is supported

by the observation that excesses of ALL eventually subside, presumably because of

increased population immunity. This theory requires further examination. The panel

believes it reasonable to test this hypothesis by calculating rates of ALL in other

rural areas of the U.S. having significant population mixing. However, such an effort falls outside the mandate of the Nevada Health Division. Finally, the possibility

that the excess of ALL cases is due to random chance cannot be totally excluded

as an explanation. The panel acknowledges, however, that the excess of ALL cases

in Fallon, Nevada is not likely to represent a ‘‘chance’’ occurrence. The expert panel recommends to the Nevada Health Division six followup steps

in the investigation of the excess occurrence of ALL in Fallon, Nevada (see Table

1).

The purpose of these next steps are to: (1) efficiently expand case-finding efforts,

(2) categorize the observed ALL cases by clinically relevant disease biomarkers, (3)

identify potential excess environmental exposures unique to the community by a

cross-sectional exposure assessment of selective contaminants and an evaluation of

contaminant releases into the local environment with assessment of completed pathways for the case families, (4) collect and bank biologic specimens for future scientific investigations, (5) determine the time course and characteristics of population movements into the Fallon area for the period 1990 to 2000, and (6) maintain

an expert panel to peer review investigative protocols and study results, consider

future use of banked specimens, and provide ongoing consultation to the Nevada

Health Division.

The expert panel also discussed the importance of high concentrations of arsenic

in municipal and private drinking water supplies. The panel members expressed

doubt that arsenic consumption in drinking water, by itself, could explain the observed ALL excess for several reasons: (1) The excess occurrence of ALL began in

1999, whereas the arsenic concentrations in drinking water have been consistently

elevated for many years. (2) The case children who make-up the excess occurrence

of ALL differ in respect to their consumption of arsenic contaminated drinking

water. (3) Epidemiologic studies of arsenic exposed populations have not linked arsenic exposure with adult or childhood leukemia. One recent article suggests a weak

association between childhood leukemia risk and exposure to low levels of arsenic

in drinking water (12). The panel has reviewed the article and believes that the

study is inadequate to support a conclusion that ALL is related to arsenic in drinking water. Each panel members expressed concern that the ongoing exposure to excess levels of arsenic in drinking water was a human health hazard, regardless of

its relationship to the excess of ALL. The Fallon municipal water supply is contaminated with arsenic (As) at a level 10 times the EPA recommended standard for arVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00169 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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senic in drinking water. The panel was also aware that an unknown proportion of

Churchill County drinking water wells, unregulated by the Federal Safe Drinking

Water Act (SDWA), are at least as contaminated as the Fallon municipal water supply. Arsenic is recognized by the Report on Carcinogens of the National Toxicology

Program as a known human carcinogen on the basis of epidemiologic studies that

have linked arsenic exposure with an excess of skin, bladder, and lung cancers in

exposed human populations.

The expert panel recommends that arsenic concentrations in the Fallon municipal

drinking water be reduced to a level no more than that currently recommended by

EPA (e.g.; 10 μg/L) as soon as possible. The panel strongly encourages the Nevada

Health Division, and other State agencies, to proceed with recommendations for

testing arsenic in all drinking water wells in Churchill County that are unregulated

by the SDWA. The State health division should work to create a process providing

this service when necessary and develop a set of recommendations for preventing

arsenic exposure based on reported test results. The State health division should

consider maintaining a listing of wells that have been tested along with test results.

Table 1: Investigating the excess occurrence of Acute Lymphoblastic Leukemia in

Fallon, Nevada: Phase II Recommendations of the Expert Panel (February 15, 2001)

Priority Task/Timeframe/Collaborators

1. Efficiently expand case-finding efforts. The panel members encourage the Nevada Health Division to continue limited case-finding strategies. The panel members

recommended limited expansion of case-finding by linking to:

A. The national Childhood Oncology Group (COG) data bases(s) to identify all

children with ALL having a residence at time of diagnosis in the State of Nevada.

The purpose of this would be to evaluate completeness of the Nevada tumor registry

and identify additional ALL cases from Churchill County.

B. An ongoing case-control study of ALL being conducted in California to review

residential history of cases for previous residence in Churchill County, Nevada.

C. The California State Tumor Registry to identify any children with ALL with

a Nevada residence at time of diagnosis.

Timeframe.—These additional steps could be done within 2 months after satisfactory negotiations regarding patient confidentiality are completed.

Potential Collaborators.—Clinical Oncology Group, California Tumor Registry,

California ALL research team.

2. Categorize the observed ALL cases by clinically relevant disease biomarkers.

Cancer cells from each case-child have probably been collected and undergone

immunophenotyping and cytogenetic testing. The health division should collect this

information. If testing has not been done and tumor cells have been stored, the

health division should secure samples and have them tested. These materials could

be reviewed or tested at two independent laboratories. The distribution of these results among the case-children from Fallon can be compared against other children

with ALL to determine if these distributions are similar or if the distribution among

the Fallon case-series is unique.

Timeframe.—The health division should proceed to determine availability of data

or tumor cells as soon as possible.

Potential Collaborators.—Pediatric oncologists, Childhood Oncology Group, National Cancer Institute.

3. Identify potential excess environmental exposures unique to the community.

The health division should conduct limited testing for current exposures in environmental media or human samples as well as evaluate contaminant releases into the

local environment and assess the potential for human exposure to such contaminants. This analysis would be used to identify chemicals that are (and are not) elevated in the community and to consider if additional data collection is required.

A. A cross-sectional exposure assessment of selective contaminants would include

examination of drinking water, human blood and urine of family members, and possibly dust collected from homes where case-children did and did not live. Testing

should be limited to compounds for which normative data are available. The expert

panel recommended testing for volatile organic compounds in drinking water and

human tissues; radioactive isotopes in drinking water; selected heavy metals in

drinking water, household dust, and human tissues; and pesticides in human tissues and in household dust.

B. An evaluation of contaminant releases into the local environment with assessment of completed pathways for the case families. The expert panel recommends collecting environmental release data, including that from local industry and the

Fallon Naval Air Station. An assessment of the potential for environmentally released chemicals to result in human exposure should also be conducted, including

potential for case-children to have been exposed.

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Timeframe.—These activities will require development of survey and sampling

protocols and appropriate review of consent forms and confidentiality agreements.

The committee anticipates startup of these activities during the months of March

or April and available results within 1 year.

Potential Collaborators.—National Center for Environmental Health, Centers for

Disease Control and Prevention; Agency for Toxic Substances and Disease Registries; Jonathan Buckley (University of Southern California) for input on measuring housedust for pesticide residues, heavy metals, PAHs. .

4. Collect and bank biologic specimens for future scientific investigations. The

members of the panel recognize how limited our knowledge is of the cause(s) of ALL

and the difficulty investigators have had in identifying the causes of similar ALL

excesses. The panel members believe that collection of biologic specimens from casechildren and family members may be useful for future research investigations into

the cause(s) of ALL. A small amount of blood and urine, and perhaps buccal cells,

should be collected, maintained, and made available for future research.

Timeframe.—Collection of specimens could occur simultaneously with the exposure assessment (see 3A) or include samples taken during clinical care. A protocol

for collection, storage, and access to samples must be developed and reviewed by an

Institutional Review Board for compliance with human subject research.

Potential Collaborators.—Nevada Public Health Laboratory, National Center for

Environmental Health, Centers for Disease Control and Prevention, National Cancer Institute as possible repositories for the tissue bank.

5. Determine the time course and characteristics of population movement into the

Fallon area for the period 1990–2000. The expert panel recommends collecting demographic data concerning changes in the population of Fallon, specifically looking

for evidence of large migration of new long-term residents into the community during this time period. The appended table illustrates the kind of first-level information that is relevant to this issue.

Timeframe.—Initial data collection within 2 months.

Potential Collaborators.—Public school systems and Fallon Naval Airbase (for information concerning migration patterns), Drs. Les Robison and Malcolm Smith (for

consultation to identify the specific data required).

6. Maintain the expert panel to peer review investigative protocols and study results, review proposals for future use of banked specimens, and provide ongoing consultation to the Nevada Health Division.

REFERENCE LIST

1. Felix CA. Secondary leukemias induced by topoisomerase-targeted drugs.

Biochim Biophys Acta 1998;233–55.

2. Bennett JM, Moloney WC, Greene MH, Boice JD. Acute myeloid leukemia and

other myelopathic disorders following treatment with alkylating agents.

Hematol.Pathol. 1987;99–104.

3. Rothman N, Smith MT, Hayes RB, Traver RD, Hoener B, Campleman S, Li

GL, Dosemeci M, Linet M, Zhang L, Xi L, Wacholder S, Lu W, Meyer KB, TitenkoHolland N, Stewart JT, Yin S, Ross D. Benzene poisoning, a risk factor for

hematological malignancy, is associated with the NQO1 609C—>T mutation and

rapid fractional excretion of chlorzoxazone. Cancer Res 1997;2839–42.

4. Kinlen LJ. Epidemiological evidence for an infective basis in childhood

leukaemia [editorial]. Br. J. Cancer 1995;1–5.

5. Kinlen LJ, Clarke K, Hudson C. Evidence from population mixing in British

New Towns 1946–85 of an infective basis for childhood leukaemia. Lancet 1990;577–

82.

6. Kinlen LJ, Hudson C. Childhood leukaemia and poliomyelitis in relation to

military encampments in England and Wales in the period of national military service, 1950–63. BMJ 1991;1357–62.

7. Kinlen LJ, O’Brien F, Clarke K, Balkwill A, Matthews F. Rural population mixing and childhood leukaemia: effects of the North Sea oil industry in Scotland, including the area near Dounreay nuclear site. BMJ 1993;743–8.

8. Kinlen LJ, Petridou E. Childhood leukemia and rural population movements:

Greece, Italy, and other countries. Cancer Causes Control 1995;445–50.

9. Kinlen LJ. High-contact paternal occupations, infection and childhood leukemia: five studies of unusual population-mixing of adults. Br. J. Cancer 1997;

1539–1545.

10. Alexander FE, Chan LC, Lam TH, Yuen P, Leung NK, Ha SY, Yuen HL, Li

CK, Li CK, Lau YL, Greaves MF. Clustering of childhood leukaemia in Hong Kong:

association with the childhood peak and common acute lymphoblastic leukaemia

and with population mixing. Br. J. Cancer 1997;457–63.

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11. Petridou E, Revinthi K, Alexander FE, Haidas S, Koliouskas D, Kosmidis H,

Piperopoulou F, Tzortzatou F, Trichopoulos D. Space-time clustering of childhood

leukaemia in Greece: evidence supporting a viral aetiology. Br. J. Cancer 1996;

1278–83.

12. Infante-Rivard et al. Drinking water contaminants and childhood leukemia.

Epidemiology 2001; 12:13–19.

STATEMENT OF RANDALL TODD, STATE EPIDEMIOLOGIST, NEVADA STATE

HEALTH DIVISION

Good morning Mr. Chairman and members of the committee. For the record my

name is Dr. Randall Todd. I am the Nevada State Epidemiologist and work for the

Nevada State Health Division. I would like to briefly describe the Health Division’s

investigation into the cluster of childhood leukemia in Churchill County and discuss

the role of Nevada’s Central Cancer Registry.

The initial phase of our investigation consisted of confirming the diagnosis of each

reported case and conducting an interview with each case family to identify any potentially common characteristics or environmental exposures that might point to a

preventable cause. We are indebted to the Centers for Disease Control and Prevention as well as the Massachusetts Department of Public Health for their assistance

in providing us with model interview instruments.

The case family interviews were conducted face-to-face with each family. This involved a detailed review of the family’s residential history from the date of diagnosis

back to a point in time 2 years prior to conception of the ill child. For each residence

we inquired as to the source of water, in-home treatment of water, and uses of

water. We also inquired about known exposures to chemicals from agricultural or

home use of herbicides and pesticides as well as indoor uses of chemicals and solvents. For each parent, we also inquired about occupation and occupation-related exposures to chemicals, fumes, dust, or radiation. We conducted a detailed review of

the child’s medical history and the mother’s pregnancy and breast-feeding histories.

Finally, we asked case families about any hobbies, sports activities, or typical travel

destinations that might have brought them into contact with chemicals, fumes, dust,

or radiation.

From this interview process we learned that half of the case families had spent

2 years or more in the Fallon/Churchill County area. The others had resided in the

area for shorter periods of time. The 12 case families had resided in a total of 88

different homes over their respective time periods of interest. Of these, 22 were located within Churchill County. Of these 22 local residences, half were served by

public water systems while the others obtained their water from domestic wells.

Our initial analysis of the occupational, medical, environmental, and other historical information provided by the case families has not suggested any particular common denominator that would link these cases together. We recognize, however, that

some of our data is subject to recall limitations on the part of the families. Specifically, they may not have known of an environmental exposure that did, in fact,

exist, or may have forgotten about it. For this reason we are currently taking steps

to obtain additional data through objective environmental sampling. This constitutes

a second phase of the investigation.

We are now in the process of obtaining water samples from those current and

former case residences in Churchill County that are served by domestic wells. These

samples are being subjected to the analyses that are routinely done for public water

systems. In other words, any test required by the safe drinking water act for public

water systems is also being conducted on the water samples obtained from the wells

of residences where case families have lived. The results of these analyses are pending at this time.

We have also invited the Centers for Disease Control and Prevention as well as

the Agency for Toxic Substances and Disease Registry to assist us in identifying and

analyzing completed pathways for other sources of environmental contamination.

This would include industrial, agricultural, military, or other sources.

On a parallel tract with these environmental studies we are also collecting data

on the overall population dynamics in Churchill County. This includes looking at

size of various age cohorts over the last 10 years, school enrollment information, and

military populations. This analysis will help to determine if Churchill County

matches the profile of other communities around the world where population mixing

has been suggested as a possible explanation for increased rates of childhood leukemia.

In closing, I would like to make some brief comments as to the importance of cancer registries in the conduct of cancer cluster investigations. Nevada has maintained

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a population-based cancer registry since 1979. This activity has been funded, in

part, through a grant from the Centers for Disease Control and Prevention since

1995.

All disease reporting systems, including cancer registries, experience a lag in time

between the diagnosis of a case and the reporting of that case. With a disease such

as cancer, the patient record may not be complete enough to warrant abstracting

information until about 6 months from the date of diagnosis. Additional delays in

obtaining information beyond this 6-month time period relate to work load and staffing. In the more rural parts of Nevada, this situation is made even more difficult

due to the distances involved and the relatively low number of acute hospital beds

in each facility making it a costly and time consuming process to collect rural data.

For these reasons, if a cancer cluster is identified through a cancer registry it is

likely to have been going on for some time.

The increased incidence of childhood leukemia in Churchill County was not identified through analysis of cancer registry data. The local hospital, physicians, and

community leaders noted the cases and perceived the numbers to be unusually high.

Nevertheless, Nevada’s cancer registry has been invaluable in helping to place the

observed number of childhood leukemia cases in historical and geographic context.

Only through analysis of cancer registry data have we been able to calculate the

usual rate of childhood leukemia and determine that the local cases represent a significant excess over the expected.

I hope this overview of our investigation to date and the role of cancer registries

has been helpful. I would be happy to answer any questions the committee may

have.

STATEMENT OF REAR ADMIRAL RICHARD J. NAUGHTON, U.S. NAVY, COMMANDER,

NAVAL STRIKE AND AIR WARFARE CENTER

Good Morning. My name is RADM Richard J. Naughton and I am the Commander of the Naval Strike and Air Warfare Center located at Naval Air Station,

Fallon, NV. Here with me this morning is CAPT David A. Rogers, the Base Commander. We welcome the opportunity to testify before the Environmental and Public

Works Committee on military activity in the Fallon area, particularly as it may pertain to Churchill County’s recent childhood Leukemia cluster situation.

I will begin with a short discussion of the mission and operations at Fallon followed by some remarks on items I know are of special interest to the committee

members. I will then be happy to entertain questions. Let me assure the committee

members that the United States Navy is committed to public health and assisting

this continuing investigation in any way possible. One of the cases in question is

the child of a military member stationed at Fallon and three fourths of our base

population of 7200 personnel and their family members live off base. The Navy’s Bureau of Medicine has just completed an extensive screen of Naval Cancer cases

which might be related to being stationed at Fallon. Their review of over 12 million

records from 1997 to the present revealed just the one Navy case already identified.

The Navy is also committed to exploring the Expert Panel’s Population Mixing Theory and has shared data on transient activity at NAS Fallon with the State. While

further examination of similar demographic data in other military locales (i.e. small

isolated communities near military bases with large numbers of transients in training) would appear prudent, it will take a coordinated effort by the entire Department of Defense to conduct such a study.

As many of you know, NAS Fallon has been in operation since 1942. The focus

of the base was squadron level air-to-ground combat training until 1984, when the

Navy established the Naval Strike Warfare Center (‘‘Strike University’’) and began

focusing on training entire air wings (1500 personnel and 70 aircraft) in an integrated fashion. The mid-eighties also saw the development of the Fallon Range

Complex—an instrumented Military Operating Area flown over 6.5 million acres

East of Fallon. The majority of the land we fly over is managed by the Bureau of

Land Management, as the Navy only directly controls 204,000 acres. The third

major change in the mid-eighties was the outsourcing of many of the functions on

the base, which is reflected in our current percentage of contractors (55 percent).

1996 saw the consolidation of all graduate level aviation flight programs at Fallon

with the arrival of ‘‘Topgun’’ and ‘‘Topdome’’ from Southern California and the establishment of a senior two-star Flag officer on the base as Naval Strike and Air

Warfare Center, or NSAWC. As NSAWC, I report directly to the Chief of Naval Operations and provide oversight for training of approximately 55,000 sailors a year.

The base has conducted an average of 40,000 flights a year for the past 5 years,

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with a 4 to 5 percent increase over that time. The investment in NAS Fallon since

1984 has been almost $300 million dollars.

I would like to discuss some of our specific operating issues as they might pertain

to this investigation. First, the consolidation of all of our training here in 1996 did

not appreciably change the way we conduct operations. We fly the same aircraft and

the number of flights has only increased by 4 to 5 percent. In fact, our two biggest

years in terms of flight generation at NAS Fallon occurred in 1990 and 1991 in

preparation for Operation’s Desert Shield/Storm. The type of flight training NSAWC

conducts has remained unchanged, particularly from an environmental perspective.

Second, NAS Fallon’s Environmental, Safety, Operations and Weapons Departments are responsible for the administration of all of our environmentally sensitive

materials. For anything we use, there’s a program for safely handling and disposing

of it where applicable. We follow guidelines established by Federal, State, Department of Defense and the U.S. Navy and arguably more heavily regulated than the

private sector. Programs such as Fuel Handling, Air Emissions, Hazardous Materials Disposal, Electromagnetic Radiation Effects and Installation Restoration are

all inspected on a regular basis and have received high marks for compliance. We

have shared the details of each program with the State Health Division and Expert

Panel and are prepared to do the same with the Agency for Toxic Substances and

Disease Registry when they visit next week.

Third, NAS Fallon’s drinking water supply services the 3000 personnel who work

on the base and up to 2000 transients at any one time. It is separate from the city

of Fallon’s but taps the same Basalt Aquifer with the resultant water chemistry

being identical. The base tests our water supply routinely and also monitors for contamination of the 8000 acres of base property through the use of 218 environmental

monitoring wells. No DoD activity-related contaminants have ever been detected in

the Basalt aquifer or leaving base property. While the State and Select Panel investigations have not established a link between Fallon water arsenic levels and the

Leukemia cluster, these levels are a matter of concern to the Navy. We are working

on a joint DoD/city of Fallon water treatment facility.

My detailed written statement previously submitted for the record contains further information on NAS Fallon activity as it might relate to this investigation. It

also lists points of contact for additional information if required. Thank you for your

attention. I will now entertain any questions.

STATEMENT OF RADM RICHARD J. NAUGHTON, USN COMMANDER, NAVAL STRIKE

AND AIR WARFARE CENTER AND CAPT DAVID A. ROGERS, USN COMMANDING OFFI- CER, NAS FALLON 12

The following paragraphs are designed to provide the reader with background on

operational activity at NAS Fallon, NV as it relates to the environment in general

and the leukemia cluster in specific. The Navy is committed to public health and

will assist the State-led investigation in any way desired. Specific points of contact

are listed for further detail if required.

1. MILITARY TRAINING ACTIVITY AT FALLON WITH POSSIBLE

ENVIRONMENTAL CONSEQUENCES

A. Fuels

1. NAS Fallon’s fuel is supplied by the Kinder-Morgan Company of Sparks, NV,

through a 70-mile pipeline. The pipeline is cathodically protected with induced current and monitored. It is also visually inspected by air weekly, visually inspected

by truck bi-weekly and kept under pressure even when fuel is not being pumped

so as to monitor for leakage. No leaks have ever been detected. The point of contact

at Kinder-Morgan is Mr. Girard Gonyeau at 775–358–6971.

2. Spills.—The Nevada Division of Environmental Protection strictly regulates

fuel spills. There are reporting requirements for spills over 25 gallons, spills that

contaminate three cubic yards of soil, or spills of any amount that contaminate surface water.

3. More than 95 percent of fuel spills are confined to paved areas on the flightline,

runways or taxiways. The average spill is about 15 gallons, and there have been

an average of 60 of those per year over the last 10 years. Spills on paved areas are

cleaned-up immediately using absorbent pads or absorbent media. Spills on soil are

cleaned by excavating and subsequent proper disposal of the contaminated soil.

These procedures and amount of spillage are similar to procedures and amounts at

any commercial airport with a similar operating tempo.

4. The largest spill in the last 5 years was approximately 400 gallons. The spill

resulted from a break in an underground fuel delivery pipeline. All soil contamiVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00174 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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nated by the spill was excavated and transported to an authorized treatment facility

near Mustang, NV.

5. Fuel venting.—This is also heavily regulated. We must report all incidents and

must vent fuel above 6000 feet above ground level. Above 6000 feet, 99 percent of

fuel is vaporized. Fuel may be vented/jettisoned below 6000 feet only in an actual

aircraft emergency. The last 15 years worth of data show an average yearly vent

of 3.5 occurrences above 6000 feet (1500 gallons total). There have been three occurrences in 15 years where fuel was vented below 6000 feet (800 gallons total)—each

was east of the base on BLM property and nowhere near population centers (the

nearest settlement East/Southeast of the base is Middlegate Station located 32 miles

East/Southeast.

6. Aircraft mishaps (crashes).—Of the 12 mishaps in the last 15 years, nine were

in the operating area on BLM land or on Navy property, the remaining three were

on private property. Ten of 12 had fire associated with the crash that consumed residual fuel. State Health department personnel have determined that there were no

long term environmental impacts from any of those events.

B. Air Emissions

(1) NAS Fallon has just completed an extensive modeling effort for base air emissions endorsed by the State Environmental Division. The modeling shows that NAS

Fallon meets all Nevada ambient air quality standards.

(2) The base has many detailed reports on the composition of jet exhaust, which

varies by type of aircraft. Each of these is monitored by the Nevada Division of Environmental Protection and United States Environmental Protection Agency to assure public safety. While the quantities of materials released into the atmosphere

vary according to aircraft type, they essentially involve a mix of the following five:

Carbon Monoxide, Nitrogen Oxide, Sulfur Oxide, Hydrocarbons and Particulate Matter, each of which are relatively common at most industrial sites, particularly airports. The total amount of all contaminants released into the atmosphere equates

to 1500 parts per million per day at an average operating tempo (115 flights per

day). This equates to approximately half that of the Reno-Tahoe International Airport. Commercial ‘‘Jet-A’’ fuel is composed of the same basic materials and burns

in an almost identical fashion to that of military ‘‘JP–8’’, the primary difference

being the addition of an anti-icing agent in JP–8.

(3) The fire department open burns approximately 30,000 gallons of jet fuel per

year in training permitted under the Nevada Division of Environmental Protection

Bureau of Air Quality. The fuel is burned no more than four times per month and/

or two times in any week. When it occurs it is also dependent on the winds, which

must be blowing at least five knots from the West to avoid blowing the smoke toward the community. The chemicals contained in fire smoke are roughly twice that

contained in jet engine exhausts. The total amount released into the atmosphere

equates to 1/1000th of that released by the jet traffic at the airfield. Other fire departments around the country routinely burn fuel for training.

C. Other Hazardous Materials (HAZMAT)

Other HAZMATs (cleaning solvents, paints, pesticides, photo processing, vehicle

fluids, etc.) are routinely used on base. An extensive HAZMAT handling facility and

program is managed by the NAS Fallon Supply Department with oversight from the

Industrial Hygiene Office, the Safety Office, the Environmental Office and the

Weapons Department. All hazardous waste generated by station operations is sent

to permitted treatment, storage and disposal facilities. Details are available from

the NAS Fallon Supply Officer, CDR Troy Brannon, 426–2750, or NAS Fallon Environmental Division Head, Mr. Doug Bonham at 426–2772.

D. Electromagnetic Radiation (EMR) Hazards

(1) A survey of electromagnetic radiation hazard for NAS Fallon is conducted approximately every 3 years by the Department of Defense Inspector General Office.

No significant hazards of electromagnetic radiation to personnel situations were detected on the Naval Air Station. The systems used at NAS Fallon include aircraft

navigational aids, radar for aircraft and weather, radios, cell phones, electronic warfare (EW) equipment and aircraft. Equipment used at NAS Fallon adhere to the

DOD radio frequency safety standards and the Institute of Electrical and Electronics Engineers recommended practice for the measurement of potentially hazardous electromagnetic fields and microwave. (The standard developed by representatives of industry, government agencies, scientific communities and the public.)

(2) Standard operating procedures are used to protect Navy personnel and the

public from EMR hazards. These procedures include setting the height and angle

of transmission to avoid direct exposure, posting warning signs, activating warning

lights when the radar are operational, and/or securing sites with fencing. EMR from

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EW systems is the same type as emitted by cell phones, hand-held radios, walkietalkies, commercial radio, and television stations. EMR from a typical EW site averages less and 0.325 milliwatts per square centimeter; EMR from a cell phone is 1.19

milliwatts per square centimeter. Other sources of EMR include navigation aids and

radar. These systems are the same or similar to civilian navigation aids and radars

at airports, TV weather stations, and aircraft navigation aids throughout the United

States. All systems have safety limits to prevent potential hazard. Measures are

also in place to prevent hazards from EMR emitted by military aircraft. The majority of EMR is emitted in the training airspace east of the Naval Air Station.

E. Depleted Uranium (DU) Ammunition.

Depleted uranium is the inert, low-radioactivity uranium which remains after

more-radioactive isotopes have been separated from natural uranium or spent reactor fuel. DU is used globally in private industry as radiation shielding, ballast and

counterweights in commercial and military aircraft. The U.S. Military continues to

use DU projectiles because of their extraordinary effectiveness as anti-armor munitions. Chemically and toxically, DU is no different than the natural uranium found

in air, soil and water everywhere on earth. DU ammunition has never been used,

nor is it authorized for any of the Fallon ranges.

F. Chaff

(1) Radio Frequency (RF) chaff is a glass fiber substrate with a thin coating of

aluminum. Typical chaff rounds contain 200,000 fibers (.001 inches in diameter) and

weigh five ounces. Chaff is expended on our ranges east of Fallon to train aircrew

on vital defensive countermeasures when encountering enemy surface-to-air missiles. As a chaff bundle is deployed from an aircraft, it ‘‘blossoms’’ to attract or decoy

the enemy radar. The fibers will disperse with the prevailing wind.

(2) Historical concerns about chaff have revolved around its potential harm to the

environment. In March 2000, an independent study on the environmental effects of

RF chaff by a team of research scientists from various universities concluded that

existing chaff systems are environmentally benign and not a health hazard. The

chemical composition is very similar to that of desert dust. A copy of this report is

available from the NSAWC Range Department, LCDR Lynn Tawney at (775) 426– 2108.

(3) The total amount of chaff expended on the Fallon ranges amounts to 1⁄4 ounce per acre per year. This amount is several orders of magnitude less than EPA standards for dust, vehicle exhaust, power generation and industry.

2. INSTALLATION RESTORATION (IR) PROGRAM

A site investigation to determine the nature and extent of possible contamination

at NAS Fallon was begun in 1988. Past practices had resulted in contamination by

fuels such as gasoline, diesel and jet fuel; solvents containing PCE and TCE; and

landfills containing garbage, trash, and demolished building materials including asbestos. Fuels and solvents have contaminated the shallow groundwater (between 4′ to 10′ below ground surface) beneath portions of the base. Over 100 wells are systematically sampled to monitor these contaminants and ensure that the contaminants are controlled before they could effect human health or the environment. The

program is designed to prevent contaminated groundwater from leaving the base

boundary and to date none has.

The city of Fallon and the Paiute-Shoshone Tribe pump drinking water from the

deep basalt aquifer near Rattlesnake Hill, over 7 miles northwest of the base. Due

to the nature of the groundwater system in the Carson desert and the location of

NAS Fallon there is no possibility for the contamination beneath NAS Fallon to

reach the drinking water supply used by the City, Navy and the tribe. The closest

drinking water wells to the main base boundary belong to the Navy and they are

located over 3 miles to the northwest of the base, which, is the southernmost point

of the basalt aquifer. The water in the shallow aquifer (ground surface to 50 feet)

underlying the base flows to the south away from drinking water supplies. The

nearest settlement is 32 miles away.

For questions call John Dirickson at (775) 426–3184.

3. WATER INFORMATION UPDATE

The current EPA arsenic standard is 50 parts per billion (ppb). A new EPA arsenic standard was finalized at 10 ppb in January 2001. The EPA Administrator

has announced her intention to review the technical basis for the rule and to extend

the effective date for it. NAS Fallon and the city share the same basalt aquifer

water source with resultant naturally occurring arsenic levels of 90–110 ppb. An

EPA Notice of Violation was issued to NAS Fallon in January 2000 to reduce the

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amount of arsenic in the base’s drinking water system. In September 2000 the EPA

issued an administrative order requiring NAS Fallon to meet at least the current

50 ppb maximum contaminant level for arsenic in drinking water by late 2004. NAS

Fallon has three wells that are each approximately 500 feet deep. The water chemistry for the NAS Fallon wells and the city of Fallon wells is essentially the same.

Arsenic treatment is required for the city of Fallon in 2003 and NAS Fallon in

2004. NAS Fallon is conducting pilot studies to select the best treatment technology.

A joint NAS/City effort to construct a water treatment facility is under consideration. Interim measures at NAS Fallon consist of:

(1) Free Reverse Osmosis (R.O.) filtered water available at 37 locations on base.

All units are tested twice annually to ensure we meet drinking water standards for

arsenic (the R.O. units routinely test to less than 1 ppb for arsenic).

(2) Commercial bottled water is available in work spaces and at the Child Development Center.

(3) A free bottled water machine is available 24-hours a day in the Sierra House

of the BOQ.

(4) Free water testing can be obtained by military members not living in base

housing or on the city water system.

(5) R. O. filtered water systems will be installed in base housing commencing approximately May 1, 2001.

The point of contact for water issues is Mr. Mark Jones (775) 426–2785.

STATEMENT OF KEN TEDFORD, JR., MAYOR, FALLON, NV

Recognizing that my time is brief, let me begin by saying that the city of Fallon

sincerely appreciates the efforts of the Senators, Congressman and your staffs—just

as we appreciate the work being done by the Governor’s Office and the State Health

Division. These are trying times for our community and, while we have pulled together in the only way we know how, it is comforting to know that others want to

help.

I’m not going to spend any time discussing the cluster’s cause, or possible links

between the children. I believe the State Health Division and others will cover that.

The city has cooperated in every way we know, first as the steward of the municipal

water system and later as we have begun to assess other city-owned facilities. Thus

far, nothing has been found. We recognize that the Health Division’s expert panel

believes that an environmental link may not be found, due in part to the fact that

the ALL found in this cluster is not typically caused by environmental triggers.

Nonetheless, we will continue to cooperate in that search.

Our efforts have been focused on the children, the affected families, and public

education. The City Council and I have formed a group called ‘‘Fallon Families

First’’, comprised of local community leaders and social service providers, to coordinate these efforts. I asked my wife Jennifer to chair the committee, and they are

doing a yeoman’s work. Please realize that our city does not have a social service

infrastructure. We are too small. So we have had to reach out to groups like the

FRIENDS Family Resource Center, the local hospital, mental health professionals,

the clergy, the school district, the County and others.

Today there is a single source of assistance for the families, the Family Resource

Center. Patient services are coordinated by the Nevada Health Advocates in Carson

City, and hopefully soon with the National Leukemia and Lymphoma Society Chapter in Sacramento. Fundraising is handled through the Mayor’s Youth Fund. You

can see the white ribbons worn by guests here today, a suggestion by a mom of one

of the patients. It’s the latest step in our effort, and we plan to continue raising

funds as long there are needs.

Fallon Families First recently held its first public meeting, a panel discussion focused on the disease itself. Local physicians, a mother of a stricken child, and a

mental health professional, who people know and trust, helped answer the questions

weighing on the minds of those attending. Efforts like this will continue as they are

needed. A series of informational mailings is also being coordinated with the County

and the local telephone company. This week the city launched its first Web site.

Part of this effort has been driven by the need to communicate about the leukemia

cluster, and part by our desire to be generally more accessible.

So what remains to be done?

I can tell you without hesitation that the most frustrating part of this process has

been the lack of information. People want answers, and I don’t have them. The investigation is ongoing, but it’s bound to take a long time. Where do people go for

answers? I believe, in cluster situations like this, a clear sense of communication

needs to be established early in the process. Perhaps if the State Health Officer deVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00177 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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clares a cluster to be in existence, that could trigger a Federal/State/local partnership. The mayor’s office seems to be the place people automatically go, but in small

towns like ours we don’t always have the information. I have assembled my own

team of local citizens and other experts who can help the city. But in other towns,

the mayor might not be so fortunate. I think a standard support team or ombudsman should be made available to towns like ours.

Finally, I would be remiss if I didn’t speak briefly about the arsenic in our water.

I KNOW the Senators are aware of this situation, just as I know the experts will

testify that the arsenic is probably not linked to the leukemia cluster. But the two

things have become linked in the media and in earlier meetings, so I feel we owe

you at least an update.

Fallon’s municipal water supply contains arsenic at levels of 100 parts per billion.

The U.S.E.P.A. has ordered us to remove the arsenic, which is naturally occurring

here. As you are well aware, the EPA standard has long been under review. It was

50 parts per billion. It was temporarily lowered to 10. Now it is back at 50. We have

no idea where it will finally be set. For the city of Fallon it doesn’t matter any more.

The city of Fallon, through its environmental engineering firm Shepherd-Miller,

has begun pilot testing the technology we will use to remove the arsenic. It appears

that a process called ’‘enhanced coagulation’’ is working best. We will finish the pilot

testing by the end of May. Then we will design and site a treatment facility. Our

goal is to have construction finished in time to comply with the EPA order, which

gives Fallon until September 2003. This date is significantly earlier than any other

public water system, and it’s still not clear how much arsenic we will have to remove. Nonetheless, we are proceeding. And we are doing so without regard to costs,

or where the money will come from. We have also been in consultation with U.S.

Navy officials about a joint plant.

My suggestion to this body today is that you make Fallon a test case. The issue

of the EPA standards revolves around ‘‘best available science’’ and the fact that

there is no ‘‘off the shelf’’ technology to remove arsenic on a municipal scale. Things

like household reverse osmosis systems won’t work on the scale we’re talking about

here. We believe that since Fallon is required to remove its arsenic more quickly

than other municipalities, there may be benefits to those who follow from learning

from what we do. Perhaps the Federal Government could pay for the cost of Fallon’s

treatment facility, in exchange for the availability of the science and treatment

methods resulting here that can be utilized by all those who follow.

We’re dedicated to treating city water. Others will have to address the many private county wells that have high arsenic levels. And all of us will have to respond

to public education issues and outside media attention that now surround the arsenic. But with your help, we can put this chapter in our history behind us and

focus all our energies on the leukemia cluster, the children and their families.

We must maintain our focus on these families. As I said earlier, this is a lonely

time for our town. Many people want to speculate, many others are well intentioned

in their scrutiny. Others are just curious. But when the camera lights are off and

the media attention fades, our town will be left to care for our children and assess

the long-term impacts of this unusual cluster. Your presence here today is a chance

to change that. I hope you will be able to stick with us, and I thank you for taking

the time to come here today.

STATEMENT OF GWEN WASHBURN, CHAIRMAN, CHURCHILL COUNTY COMMISSION

Good morning, Honorable Senators. First, as Chairman of the County Commission, I want to tell you that the County Administration is first and foremost concerned about the health and well being of the people. I am happy to have the opportunity this morning to address the issue of the leukemia cluster identified in this

community, and to discuss ways to investigate and mitigate the problem. I will give

you a little information about Churchill County and what the County Commission

is doing at this time.

Churchill County has sustained a steady growth of about 3 percent over the years

and now is home to about 26,000 people. The population is expected to double in

the next 15 years. We are a progressive small community, boasting modern schools,

a community college, an arts center and the most modern hospital in western Nevada. We have a mix of long time agricultural-oriented families, military personnel,

young working families and retired people. Many people are born and grow old here

with nothing more than average health problems, so the community is alarmed and

feels helpless in the face of a childhood leukemia epidemic.

The community has reacted to this crisis in a quick and calm manner, working

cooperatively together with all agencies in an attempt to find any answer or comVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00178 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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mon link between the cases. The County Commission is very concerned about the

health and welfare of not only our 26,000 residents, but also those that visit us each

year as military personnel or tourists. Certainly, none of us are experts in the

health field, nor are we research scientists. We have no choice but to leave the investigations to the experts. What we can do, have done, and will continue to do is

support all scientific and responsible efforts to find an answer.

We have actively participated in Governor Guinn’s investigation and in

Assemblywoman de Braga’s investigation. We joined forces with the city of Fallon

and Churchill Community Hospital in development and distribution of a fact sheet

(Attachment #1) that attempts to answer the most commonly asked questions about

leukemia and what the community is doing about it. We also support Mayor Tedford

and the Community Hospital in their individual efforts to assist the families of the

victims with the Fallon Families First organization, and the health information center.

I, personally, have spent many hours in consultation with personnel of the University of Nevada, Reno, Extension Service to update and reactivate a drinking

water safety program known as Nevada GOLD (Guard Our Local Drinking water).

The University responded favorably and quickly by hiring a research specialist to

locate and correlate all existing water studies in an attempt to find any possible

cause of cancers in our local (outside the city of Fallon) shallow wells. Studies have

shown that water from the shallow aquifer is variable and may contain Magnesium,

Sulfates, Chloride, Nitrates, Fluoride, Arsenic, Iron, Manganese and other minerals

above levels recommended by EPA. (Attachment #2) Nevada GOLD is also teamed

with the local hospital to provide water sample bottles, instructions and transportation of water samples to the State Health Laboratory giving all well owners the

opportunity to have their water tested for bacteria and heavy metals. (Attachments

#3–7). They also are, rightfully, taking the lead in educating the public about drinking water safety.

Our local water quality, whether the causative agent or not, was immediately

pointed to as the cause of leukemia by the general population, encouraged and perpetuated by the media. The matter has not remained local. We see copies of news

articles from across the Nation with headlines proclaiming Fallon and Churchill

County to be an unhealthy place to live. This press coverage has resulted in damage

to our community. People are turning down jobs, houses go unsold, business has declined, our sales tax revenues are down and we were recently listed as a depressed

area by EDA, (Economic Development Administration). (Attachment #8–11).

One of the first questions raised by the general public concerned the use of chemicals and chemical processes in the county, and what regulations were in effect to

assure public safety. Churchill County relies on the Nevada Department of Environmental Protection to issue any emissions and/or discharge permits relative to any

business or industry that locates in our county. The only county requirement other

than proper zoning, until recently, was a business license. Out of concern for the

health and well being of our citizens we now require a Special Use Permit. This

helps county officials and haz-mat experts know what chemicals are being used in

the community. The information required for a Special Use Permit is also intended

to assist emergency responders, if the need should arise.

We asked ourselves, what has changed in the community since the early 1990’s?

Several things emerged. We have no way of knowing which, if any, of them singly

or in combination are to blame until more research is done. Less irrigation water

in the valley to recharge our shallow aquifers: Are toxins building up in the shallow

aquifer? More people on one-acre lots: Are deep soil disturbances related to building,

more fertilizers and pesticides used for landscaping and lawns, or nitrates from septic leach lines to blame? The 1997 flood: Was more Mercury or some other toxin that

had previously been undisturbed released into the Carson River to end up in

Lahontan Valley? The Gulf War: Was some toxic or carcinogenic substance introduced to the community when personnel and/or equipment returning from the war

came to NAS Fallon? Transportation of hazardous material: How much hazardous

material is being transported through the city of Fallon in trucks traveling the

Highway 95 North/South route, and is it properly contained? Petroleum based products: Were there changes made to the chemical formulations of fuels, paints, tars,

asphalt, fertilizers, lubricants, etc?

We are anxious to locate and take reasonable corrective action for any environmental cause that may be found to contribute to the incidence of leukemia or like

diseases in our community. A thorough and accurate scientific study of all possibilities will take many years and millions of dollars. The medical experts have already

expended many resources examining the patients and their families. The community, and individuals have lent their support. The State of Nevada is considering

committing money. Now I will ask you to do the same.

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• First and foremost is the proper health care for victims of leukemia and related

illnesses. Provide special assistance funds to be administered through Social Service

programs or special insurance underwriting.

• We need to have thorough scientific research underwritten by Federal Grants.

The studies should seek out information on leukemia trends before the cluster appeared for the sake of comparison. There is no doubt that information gathered and

analyzed in this area will provide benefit for other areas also.

• Grants to the University of Nevada and Churchill Community Hospital that

will enable them to continue public education programs in drinking water safety

and nutrition and disease prevention is essential.

• Provide low interest, long-term loans to small business affected by loss of sales

through the leukemia scare.

If water is identified as the cause of ANY health risk to our citizens we need Federal help to build a system to bring safe water to those who live outside the city

limits of Fallon. County Commissioners have been considering this for a long time

and have developed a plan for the system including a source of supply. (A Draft

Copy of the plan was delivered to Senator Reid in the fall of 2000). The estimated

total cost is in the $200,000,000–$250,000,000 range, obviously far beyond the

means of a small community, even if our population doubles as predicted. We know

the government is developing a plan to assist small community water systems for

towns under 10,000 population. Our population outside the city of Fallon is about

16,000, too large to qualify for that assistance, leaving the people who reside in

rural Churchill County in a ‘‘no win’’ situation at this time. As a side note, for many

years qualified Veterans have not been able to exercise their right to guaranteed

home loans in this area because of the water quality. We urge the Federal Government to look at ways to assist areas such as ours to develop safe water supplies.

• In the short term, Federal assistance to help residents with the cost of testing

all existing domestic wells and installing treatment systems if the water test results

deem a system necessary, would be a blessing to this community. It is estimated

that there are about 4500 domestic wells in use at this time, and complete water

analysis costs about $120 or more per sample. Cost of various in-home treatment

systems range from several hundred to several thousand dollars, amounts beyond

the means of many homeowners.

Churchill County Commissioners have approved a proposed hazardous materials

by-pass route for this community, with the idea of beginning to acquire rights-ofway for future construction. (Attachment #12) At this time all trucks that travel

north/south on US 95 must travel about a mile through the city, turn 90 degrees,

travel three blocks and turn 90 degrees again on the three busiest streets in town.

There are no truck stops on this stretch of highway for several hundred miles, so

hungry, tired truckers must stop beside the street in town where thousands of people pass by. This route is very near four schools. The east/west route is US 50,

straight through the heart of town, and passes near two schools and the hospital.

If hazardous waste transportation should prove to cause ANY health hazard to our

community the Federal Government would be obligated to provide assistance to

build a route that keeps the threat of exposure to a minimum.

On behalf of the Churchill County Commissioners, I thank you for taking time

to listen to our concerns and ideas. We sincerely hope that you will be able to assist

our community in some way to ease the suffering of the leukemia victims and their

families and to help us find the ways and means to lessen or better yet, prevent

more occurrences of this and other cancers.

RESPONSES BY KEN TEDFORD, JR., MAYOR, FALLON, NV TO FREQUENTLY ASKED

QUESTIONS ABOUT CHURCHILL COUNTY LEUKEMIA CASES

Question 1. The city of Fallon prepared this document as a public service. The

City is not considered an expert on the subject of leukemia. Sources of information

include the State Health Division, National Cancer Institute, Leukemia &

Lymphoma Society and American Cancel Society. In addition, information was

taken from newspaper articles, Web sites and reports prepared by the City’s own

environmental consultants. This information is not provided as medical advice or as

an official report of scientific research, but as public information.

What are the current findings about the leukemia cases in Churchill County?

Response. A preliminary investigation was conducted by the Nevada State Health

Division to ensure that public health officials were aware of all cases of childhood

leukemia in the area and to identify any common characteristics among the case

families. Case families were asked about their residential history, sources of water

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for drinking and cooking, medical history, family history, and potential sources of

chemical and radiation exposure.

Eight of the eleven cases have been diagnosed in the last 10 months. Patients’ ages at time of diagnosis range from 0 to 19 years old. The cases are scattered

throughout Churchill County. All the patients have acute lymphocytic leukemia

(ALL). Nationally, 2,000 new cases of ALL are diagnosed each year. None of the

children from Churchill County has died from the disease.

State Health officials have completed interviews with 10 case families and data

has been examined for eight of the families. Based on an initial analysis, there does

not appear to be a common characteristic among the case families. All of them lived

in Fallon for varying lengths of time between 1996 and 1999. The families had various sources of drinking water (some drank tap water from the municipal system,

some drank tap water from domestic wells, and some drank bottled water) and reported no consistent exposures to any particular environmental hazard. It is however, important to note that people may not always be aware of their exposure to

an environmental hazard.

Question 2. What is leukemia?

Response. Leukemia is a form of cancer. Childhood acute lymphocytic leukemia

(ALL) is a disease in which too many underdeveloped infection-fighting white blood

cells, called lymphocytes, are found in a child’s blood and bone marrow. ALL is the

most common form of leukemia in children, and the most common kind of childhood

cancer. It is also referred to as acute lymphobastic leukemia.

Question 3. What is a cancer cluster?

Response. A disease cluster of any kind is the occurrence of a greater than expected number of cases of a particular disease within a group of people, geographic

area, or a period of time. Cancer clusters may be suspected when people report that

several family members, friends, neighbors or coworkers have been diagnosed with

cancer. Various statistical methods are used to determine whether the reported number

of cancer cases is really a larger number than would normally be expected to occur.

True clusters are difficult to define and, if they turn out to be real, the causes are

often obscure. Most non-occupational cancer clusters turn out to be the result of the

random nature of the disease.

Clusters have been identified throughout the world but only one case can positively be linked with a contaminant. Some high-profile cancer/leukemia cluster cases

include: Tom’s River, NJ; Hinkley, CA; Woburn, MA; La Hague, France; and

Seascale, Britain.

Question 4. How are cancer clusters investigated?

Response. Epidemiologists, scientists who study the frequency and distribution of

diseases in populations, may investigate reported disease clusters, including suspected cancer clusters. Investigations of suspected cancer clusters can be limited by

the current status of scientific knowledge and tools related to genetics; effects of environmental factors on humans; the availability of statistics on cancer and other diseases by local area; and resources.

Question 5. What causes leukemia?

Response. The cause is unknown.

Question 6. What are the risk factors for childhood leukemia?

Response. For the most part, lifestyle risk factors such as diet and exercise, while

important in adult cancers, are not linked to childhood cancers.

Question 7. What are the symptoms of leukemia?

Response. Early signs of ALL may be similar to those of the flu or other common

diseases. General symptoms can include feeling tired or weak all the time, weight

loss, fever and loss of appetite. Most symptoms of acute leukemia are caused by a

shortage of normal blood cells. Anemia is a result of a shortage of red blood cells.

Anemia causes shortness of breath, fatigue and a pale skin color. Not having enough

white blood cells can increase the risk of infection. Not having enough platelets can

lead to bruising, bleeding, frequent or severe nosebleeds and bleeding from the

gums.

Question 8. What should I do if I think my child may have leukemia?

Response. Immediately consult your physician or healthcare provider for assistance, evaluation, and early intervention. Your physician will complete tests he or

she determines to be needed to make an accurate diagnosis and begin treatment,

if necessary. A blood test is required to diagnose leukemia.

Question 9. How is leukemia treated?

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Response. Treatment decisions for each child are based on a number of individual

factors. It is generally treated with chemotherapy. Chemotherapy refers to the use

of anticancer drugs that enter the bloodstream and spread throughout the body to

kill cancer cells.

More than 95 percent of children with ALL enter remission after 1 month of treatment. Remission means that about 99 percent of the cancer cells have been killed;

but there are still some leukemia cells in the body. That’s why further phases of

treatment are needed.

Bone marrow transplants are also used in the early stages of some types of leukemia.

Question 10. Can children who have leukemia be cured?

Response. The overall 5-year survival rate for children with ALL is 80 percent.

The aim of treatment is to bring about a complete remission. Complete remission

means that there is no evidence of the disease and the patient returns to good

health with normal blood and marrow cells. Relapse indicates a return of the cancer

cells and return of other signs and symptoms of the disease. For leukemia, a complete remission that lasts 5 years after treatment often indicates cure. Treatment

centers are reporting increasing numbers of patients with leukemia in complete remission at least 5 years after diagnosis of their disease.

Question 11. Where can I get more information about leukemia?

Response. State Health Division officials have set up a Community hotline, open

weekdays between 8am and 6pm for inquiries: 1–888–608–4623.

State Health Division Web site, Health2k.state.nv.us

• Leukemia and Lymphoma Society of America, www.leukemia.org or 1–800–955–

4572

• Childhood Leukemia Center, ww.patientcenters.com

• National Cancer Institute, www.nci.nih.gov or 1–800–4–CANCER

• American Cancer Society, www.cancer.org or 1–800–ACS–2345

• Department of Health and Human Services, www.os.dhhs.gov/

• Centers for Disease Control, www.atsdr.cdc.gov/

Question 12. What caused these cases of leukemia in the Fallon area?

Response. The Fallon leukemia cases are the State Health Division’s top priority

and investigators are looking into many theories for the unexpected concentration

of cases. During a public meeting on February 5, officials from the Health Division

stated that they are not ruling out the possibility of a cause, but acknowledged that

this occurrence could be happenstance, a statistical anomaly.

Question 13. Is there an elevated rate of other types of cancer in Fallon?

Response. The State’s Cancer Registry has been analyzed and Churchill County

does not have an increased rate of any other types of cancer.

Question 14. What is being done to investigate these cases?

Response. The State Health Division is conducting an extensive epidemiological

investigation. The investigation, which began 6 months ago, centers on collecting

and analyzing data. Much of the data consists of statewide statistics and information from the 11 children and teens with leukemia as well as their families. The

Health Division is including experts from the Centers for Disease Control and Prevention (CDC) and other States to assist with this investigation. Environmental

sampling and other testing may follow.

The city of Fallon has retained a nationally recognized environmental and engineering consulting firm, Shepherd Miller, to conduct chemistry testing of the city’s

water.

Question 15. Are other government officials getting involved?

Response. The Nevada Legislature is holding hearings in Carson City. The goal

of these hearings will be to unite data, resources and information in an effort to

share information and address concerns. Participating in the effort is the city of

Fallon, the Environmental Protection Agency (EPA), Nevada State Health Division,

Nevada Division of Environmental Protection and the Nevada Department of Agriculture. Also testifying will be experts on arsenic, leukemia, drinking water and pesticides.

U.S. Senator Harry Reid has said that Federal officials, including representatives

of the Centers for Disease Control in Atlanta and a congressional health committee

are expected to get involved in the investigation. Reid said he would send environment committee staff members and an eco-toxicologist to Fallon to conduct preliminary interviews and gather information. An initial investigation is scheduled for

mid-February with a field hearing to be held in the spring.

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Question 16. How long will it take to determine the cause?

Response. Hundreds of cancer clusters have been investigated, some for many

years, and only one clearly identified a cause. Although this is discouraging, the

Health Division believes it is important to properly investigate these cases.

Question 17. Could Navy jet fuel be the cause?

Response. According to the commander of the Fallon Naval Air Station jet fuel

spills and fuel dumping by planes are so rare and well documented that the fuel

cannot be a contribution factor in the childhood leukemia cases. The base has 100

monitoring wells and no fuel contamination has been recorded off Navy property.

No jet fuel has contaminated the municipal water supply.

Question 18. Is there a link between atomic tests and leukemia?

Response. Department of Energy officials say that radiation from the test has not

migrated from the site to Fallon. The test wells have been monitored since 1963 and

the EPA checks the wells annually. Scientists from the energy department, EPA and

Desert Research Institute use eight onsite wells and a dozen offsite wells to search

for radioneuclides like tritium. The ground water below the test site does not connect with the basalt aquifer, Fallon’s source of drinking water. Fallon is 28 miles

from the site of a 1963 nuclear bomb test.

Question 19. Where does the City of Fallon’s water come from and why is arsenic

in the water?

Response. The city’s water source has been an underground basalt aquifer for the

past 58 years. Water is withdrawn from the aquifer through four deep wells. Arsenic

is a naturally occurring mineral. The amount of arsenic in Fallon’s drinking water

is 100 parts per billion.

The city of Fallon Municipal Water System routinely monitors for constituents according to Federal and State laws. The City monitored for 49 synthetic organic compounds and 56 volatile organic compounds and there were no detected quantities of

any of these contaminants.

Question 20. Is there a link between the arsenic and leukemia?

Response. There is currently no evidence that arsenic causes childhood leukemia.

Dr. Randall Todd, the State epidemiologist, says it’s unlikely the longstanding occurrence of arsenic caused a sudden spike in the area’s leukemia rate. The water

has been tapped from the same source for 58 years with no reported clusters of any

type in the past.

Question 21. What is the City doing to take the arsenic out of the water?

Response. In 1990, The city of Fallon entered into a Compliance Schedule Agreement to remove arsenic from its public water supply once a standard was set. The

City has been waiting for a permanent Federal standard on acceptable levels; that

standard appears to have been set by the outgoing Clinton administration.

The City has been distributing quarterly notices to customers that advise using

alternative sources for drinking water, including bottled water, filtered water available for purchase at grocery stores or water filtered at home through a reverse osmosis system.

In April 2000, the City retained a nationally recognized environmental and engineering consulting firm, Shepherd Miller, to conduct chemistry testing of the city’s

water. These tests are ongoing in order to rule out suspected leukemia causing

agents. The next phase includes testing for three other substances in order to exhaust all possibilities.

The City has exceeded required testing requirements, in both the frequency of

testing and the types of contaminants. Additional tests have been completed on contaminants, that are linked, or suspected to be linked, to leukemia. Water tests show

no contamination from fuel, radiation, pesticides, or herbicides.

The City is working with Shepherd Miller to determine which arsenic treatment

technologies are best suited to Fallon’s water chemistry and will be installing a

treatment system to meet all Federal requirements.

The design of a treatment facility is scheduled for completion by June 30, 2002

and startup testing will begin June 15, 2003. Initial compliance for arsenic removal

should commence September 15, 2003. The City is on target to make these EPA

deadlines.

Question 22. Should I have my private well for drinking water tested?

Response. If you don’t know what’s in your well, you should have it tested. You

should know the arsenic levels, bacteria levels, and other contaminants present. You

should contact the Health Division hotline at 1–888–608–4623 or Bureau of Health

Protection Services in the Nevada State Health Division, 775–687–4750 extension

237.

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Question 23. What can I do to help the families?

Response. West End Elementary School is participating in the Pennies for Patients campaign to raise funds for the Leukemia and Lymphoma Society. Additional

information on fundraisers and community support activities will be provided as it

becomes available.

Table 5.2.—Historical Lahontan Valley Underground Water Quality & MCL Exceedence1

Constituent MCL (ppm) No. of Records Which Exceed MCL’s2

Percent of Records

Which Exceed MCL’s

TDS ........................................................................................... 500 1103 40

Magnesium ............................................................................... 150 30 1

Sulfate ...................................................................................... 250 368 13

Chloride .................................................................................... 400 117 4

Nitrate ...................................................................................... 10 590 21

Flouride .................................................................................... 2 203 7

Arsenic:

Current Standard ................................................................. 0.05 955 34

Anticipated EPA Standard ................................................... 0.01 1898 68

Detection Level .................................................................... 0.002 2656 95

Iron ........................................................................................... 0.6 188 7

Manganese ............................................................................... 0.1 810 29

Copper ...................................................................................... 1 2 0

Zinc .......................................................................................... 5 1 0

Barium ..................................................................................... 2 0 0

Color ......................................................................................... 15 342 12

pH ............................................................................................. 6.5–8.5 506 18

1 See Appendix 5.2 which is a tabulation of the water quality records sorted by Township, Range & Section

2 There are a total of 2,792 records in the data base, however some of them are duplicate wells sampled at different dates.

Dixie Valley Ground Water.—Based upon current MCLs, the water quality of the

ground water in the Settlement area within Dixie Valley is good. Based upon 13

well analyses, the average TDS is 264 ppm and individual wells vary from 152 ppm

to 355 ppm. Higher TDS (in the order of 800 ppm to 1000 ppm) is reported in 2

wells located 17 to 20 miles north of the settlement area. (These areas to the north

near the playa are not included in the proposed well field for the Dixie Valley

Ground Water Development Project.).

HOW TO TEST YOUR DRINKING WATER

The Nevada State Health Division recommends that individuals with private

wells do a bacterial analysis every 6 months and a chemical analysis once a year.

When testing for personal reasons, a chemical test costs $100 and a bacterial test

costs $12.

To Prepare Water for Bacterial Testing: 423–2281.—You can get sterile bottles

from the Churchill Community Hospital (Business Office) located at 801 E. Williams

in Fallon or the Nevada State Health Laboratory (address on attached forms). Carefully follow the directions on the form for taking samples. These can be mailed in

a mailer provided with the bottle.

To Prepare Water for Chemical Test.—Use a clean 1-gallon plastic container. You

can purchase a bottle of distilled water in your grocery store, empty it and refill

with your water as outlined in the attached directions.

Where to take Samples: (775) 688–1335.—Take your sample to the State Lab on

the University of Nevada, Reno, campus. The lab is located just west of the Medical

school and north of Lawlor Events Center. The address is 1660 N. Virginia. Take

Virginia Street north to Seventeenth Street, turn right, go 0.1 mile to the second

stop sign, turn left, and the lab is immediately on the left after the left turn.

Reading Your Test.—Enclosed are samples of the report sheets that will have the

results from your test. If you need help understanding the results or have questions,

contact the local health department (423–2281) or your County Extension Office

(423–5121).

When you receive test results compare them with the Federal drinking water

standards found below.

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Federal Drinking Water Standards

[Primary and Secondary Contaminate Levels]

Contaminant Max Level

Primary Regulations:

Inorganic Chemicals

Arsenic .......................................................................................................................... 0.05 mg/L

Barium .......................................................................................................................... 1 mg/L

Cadmium ...................................................................................................................... 0.010 mg/L

Chromium ..................................................................................................................... 0.05 mg/L

Lead .............................................................................................................................. 0.05 mg/L

Mercury ......................................................................................................................... 0.002 mg/L

Nitrate (as N) ............................................................................................................... 10 mg/L

Selenium ....................................................................................................................... 0.01 mg/L

Silver ............................................................................................................................ 0.05 mg/L

Flouride (depending on temperature) .......................................................................... 1.4–2.4 mg/L

Organic Chemicals:

Endrin ........................................................................................................................... 0.0002 mg/L

Lindane ......................................................................................................................... 0.004 mg/L

Methoxychlor ................................................................................................................. 0.1 mg/L

Toxaphene ..................................................................................................................... 0.005 mg/L

2,4–D ............................................................................................................................ 0.1 mg/L

2,4,5–TP Silvex ............................................................................................................. 0.001 mg/L

TTHM ............................................................................................................................. 0.10 mg/L

Turbidity ............................................................................................................................ 1 TU–5 TU

Coliform Bacteria .............................................................................................................. 1/100 ml (mean)

Radiological:

Radium 226 and 228 .................................................................................................. 5 pCi/L

Gross Beta .................................................................................................................... 4 mrem/year

(50 p Ci/L)

Gross Alpha .................................................................................................................. 15 pCi/L

Sodium & Corrosivity ........................................................................................................ Monitoring only

Secondary Regulations:

Chloride ........................................................................................................................ 250 mg/L

Color ............................................................................................................................. 15 color units

Copper .......................................................................................................................... 1 mg/L

Foaming Agents ........................................................................................................... 0.5 mg/L

Iron ............................................................................................................................... 0.3 mg/L

Manganese ................................................................................................................... 0.05 mg/L

Odor .............................................................................................................................. 3 threshold odor number

PH ................................................................................................................................. 6.5–8.5

Sulfate .......................................................................................................................... 250 mg/L

TDS ............................................................................................................................... 500 mg/L

Zinc .............................................................................................................................. 5 mg/L

BACTERIOLOGICAL TEST, NEVADA STATE HEALTH LABORATORY, RENO, NV

DIRECTIONS FOR TAKING WATER SAMPLES

Caution.—Bottle is sterile and contains a bit of necessary powder. Do not open

bottle until Step 5 below and Do not wash out bottle.

Procedure

1. Select sampling outlet closest to the water source (pipe, kitchen faucet, etc.)

2. Remove aerators, hoses, sprinklers, etc., from the fixture.

3. Turn on valve and let water run for 2 to 3 minutes.

4. While water is still running, unscrew the bottle cap carefully. Do not touch

mouth of bottle.

5. Do not rinse bottle, but fill to the shoulders; replace the cap and tighten firmly.

100 mls of water are required for testing.

6. For samples from an open reservoir, make a quick pass with mouth of bottle

forward at a depth of one foot. Tighten cap firmly.

7. Complete information slip with your name, location, county, date, time of sampling, and return mailing address.

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8. Submit sample(s) to laboratory within 30 hours of collection and maintain temperature below 20° C (68°F) during shipment or sample is unsatisfactory. (Do not

allow to freeze.

9. Do not mail sample(s) on Friday, because our laboratory is closed on the weekend. Samples mailed on Friday and received on Monday cannot be tested because

the 30-hour time limit will be exceeded.

10. Please do not bring Fecal Streptococci water samples on Friday.

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STATEMENT OF MARY E. REID, AREA SPECIALIST, WATER RESOURCES, UNIVERSITY OF

NEVADA, COOPERATIVE EXTENSION

INTRODUCTION

• Common Problems with presence of arsenic in drinking water See Health effects below.

• Drinking Water Standards: Federal Standard for Maximum Contaminant Level

(MCL)

0.05 milligrams per liter (mg/l)

0.05 parts per million (ppm)

• Special characteristics (odors, colors, etc.)

None

• To identify. Actions to take if thought to be present.

No simple home test available. If thought to be present, bottled water is an option.

To ascertain presence and levels in water. Sampling procedure.

If known to occur in the general geographical area, an inorganic chemistry test

for presence and level of arsenic present must be done in a laboratory. In Nevada,

a standard inorganic water analysis done by the Nevada State Laboratory includes

testing for arsenic.

• Areas in Nevada where arsenic is found in drinking water

Carson Valley, Cold Springs, Eagle Valley, eastern sides of the Truckee Meadows,

Fallon, Fernley, Hazen, Hidden Valley, Topaz, Verdi, and Virginia Foothills.

SOURCES

Arsenic occurs naturally in rocks, soils and sediments. High levels may occur in

some coals. High levels of arsenic have been found in water from areas with geothermal activity. Marine algae and seaweed usually contain considerable amounts

of arsenic.

Arsenic is used in the manufacture of pesticides and is also used in making glass

and glassware. Other industrial uses for arsenic include copper and lead alloys and

pharmaceuticals. Trace amounts of arsenic may be found in some fertilizers.

The burning of coal and smelting of metals are major sources of arsenic in air.

Industrial waste from electroplating can be a source of arsenic in water. Water used

for geothermal energy production may contain high levels of arsenic.

HEALTH EFFECTS

Arsenic is a poison in humans at 100 milligrams or more and has proved lethal

at 130 milligrams. Health effects of long term exposure to elevated arsenic are

vague and not clearly defined. Acute and chronic toxic effects may include chronic

gastro-intestinal upset and diarrhea, liver damage, nervous system changes, blood

imbalance, and skin changes. Exposure to inorganic arsenic can cause skin cancer,

mainly tumors of low malignancy.

Arsenic has been associated with pulmonary cancer in the manufacture and use

of arsenic-containing pesticides and in the smelting of copper.

REMOVAL FORM DRINKING WATER

Distillation and reverse osmosis are two practical methods of home treatment for

drinking water that contains arsenic.

Treatment type Average Purchase Cost

Distillation ............................................................................................................................................ $100–$800

Reverse Osmosis .................................................................................................................................. $90–$800

SUMMARY

Arsenic has been shown to affect health and is an undesirable constituent in

drinking water. If drinking water exceeds the Federal standard for arsenic, there

are methods for treating the drinking water that will reduce the arsenic level. No

home treatment method should be considered without having a laboratory test of

the water first.

As with any home treatment method for water, it is not possible to install a reverse osmosis or a distillation unit and forget it. Both require ongoing monitoring

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and maintenance. The only way to tell that a unit is functioning properly is to do

regular water tests.

REFERENCE

De Zuane, John. 1990. Handbook of Drinking Water Quality. Van Nostrand

Reinhold, New York.

McGowan, Wes. 1987. Water Processing for Home, Farm and Business. Water

Quality Association, Lisle, Illinois.

Shelton, Theodore B. 1991. Interpreting Drinking Water Quality Analysis; What

Do the Numbers Mean? Rutgers Cooperative Extension, New Brunswick, New Jersey.

U.S. Environmental Protection Agency, Office of Drinking Water. 1982. Manual

of Individual Water Supply Systems.

World Health Organization. 1981. Environmental Health Criteria 18: ARSENIC.

World Health Organization, Geneva, Switzerland.

CHURCHILL ECONOMIC DEVELOPMENT AUTHORITY AND SMALL BUSINESS

DEVELOPMENT CENTER,

Fallon, NV, April 6, 2001.

Hon. GWEN WASHBURN, Chairman,

Churchill County Commissioner,

Fallon, NV.

Ref: Childhood Leukemia Business Impact

DEAR CHAIRMAN WASHBURN: In reply to your questions in regards to impacts to

the Fallon, Churchill County business community.

Our office has received calls from several businessman stating that they see a decline in their business, due to the adverse publicity that has proliferated as a result

of the leukemia cluster in Fallon, Churchill County. they have concerns for the viability of their business if the publicity is sustained over a long period.

It goes without saying that the most important concern of Churchill Economic Development Authority is the welfare of the leukemia victims, however we also have

concerns for our local business community as well. Should the adverse publicity in

regard to our arsenic problems, coupled with the acute lymphocytic leukemia cluster

continue, there is no doubt that some local business will suffer.

In checking with banks, rental estate and title companies there definitely is a

slow down in the sale of homes, and many of the Navy personnel wives do not want

to move to Fallon.

I hope this answers your question. If our office can be of further assistance, please

feel free to contact us at your convenience.

Sincerely,

SHIRLEY G. WALKER,

Executive Director.

FALLON AUTO MALL,

Fallon, NV, February 8, 2001.

Mayor KEN TEDFORD,

City Hall,

Fallon, NV.

DEAR KEN: I am writing you today purely on an informational basis only.

In regards to the recent publicity Fallon has been receiving over it’s water quality,

(arsenic content), child leukemia cases, and now our most dangerous Hwy. 50, I feel

it is important to rely the impact these pubic images are playing on our local economy.

In our dealership, which commonly does 50 to 60 percent of our business to folks

outside our county, we have found this business to be off as much as 40 percent.

In comments we receive regularly we believe much of this loss is directly due to

the new image of Fallon by outsiders.

Now, I am sure you are treating these issues with the highest priority possible,

but I felt that you should know directly the economic impact this publicity is having

on local business.

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I trust you will do everything possible in your power to address these issues and

promote Fallon as a great place to lie and do business.

Sincerely,

KURT HENNING,

President.

[NAME DELETED]

ATTORNEY & COUNSELOR AT LAW,

January 21, 2001.

ARTHUR MALLORY,

THOM STOCKARD,

365 S. Maine Street,

Fallon, NV.

Re: Current Status

DEAR MR. MALLORY AND MR. STOCKARD: I wanted to write this letter so that I

could inform you of my decision as soon as possible. I will be working all day Monday and will not have the chance to speak with you. I am concerned about the water

in Fallon. We addressed it briefly when I was out there but since then I have read

a few other reports, lastly one in our paper here saying that two more cases of childhood illness could be linked to Fallon.

I am concerned because of the possibilities. My wife and I have two kids, she is

pregnant with a third and we anticipate having at least one more. I do not know

that the water is a problem, but I could not live with myself if we moved there

knowing that there was a possibility for problems and then something were to happen.

The problem is I was looking forward to receiving an offer and working out in

Fallon. I wanted to let you know that if something could be worked out I would still

like to work there, I know that you are looking for someone who will live in Fallon.

I understand the reasons and if I was in your position I would want the same thing.

If you cannot find someone that you like, I would propose something else. I could

live in Sparks and commute. I could commit to be there for the months that I am

on call by either renting a place or making other arrangements. I could also commit

to stay for at least 5 years. That would let the water situation sort itself out, and

as an incentive it would also be the time period for any retirement to vest.

I know that your first option is someone to live out there, however if you cannot

work that out please consider this proposal. I will not be coming out on Thursday,

as we have decided that we cannot live in Fallon until we know more about the

water situation and that will probably take some time to sort out. If something cannot be worked out it was a pleasure to have met you both and I appreciate your

hospitality. If there are any questions please do not hesitate to call or write. I hope

to hear from you.

Sincerely,

[NAME DELETED]

STATEMENT OF HENRY FALK, M.D., ASSISTANT ADMINISTRATOR, AGENCY FOR TOXIC

SUBSTANCES AND DISEASE REGISTRY, PUBLIC HEALTH SERVICE, U.S. DEPARTMENT

OF HEALTH AND HUMAN SERVICES

Good afternoon Mr. Chairman and members of the committee. My name is Dr.

Henry Falk, Assistant Administrator of the Agency for Toxic Substances and Disease Registry (ATSDR).

Thank you for inviting ATSDR to speak with you today. We share your concerns

about the health and well being of children and families in Fallon and across the

country. We also share your desire to adequately address the concerns expressed

about illness and disease that might be associated with the environment. In fact,

addressing these types of concerns is at the root of ATSDR’s creation.

ATSDR is a Federal agency created by Congress in 1980 by the Comprehensive

Environmental Response, Compensation, and Liability Act (CERCLA), or what is

more commonly known as Superfund legislation. As such, ATSDR is the public

health agency charged with determining the nature and extent of health problems

at Superfund sites including Federal Superfund sites, and advising the U.S. Environmental Protection Agency (EPA) and State health and environmental agencies

on needed clean-up and other actions to protect the public’s health.

ATSDR works in close collaboration with the EPA, other Federal, State, local, and

tribal governments, health care providers and affected communities. As an agency

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of the U.S. Department of Health and Human Services (DHHS), ATSDR has made

a difference to all of these partners by providing new information to assist in remedial decisionmaking and evaluation. Our work includes answering the health questions of impacted community members, recommending preventive measures to protect public health, and providing diagnosis and treatment information to local

health care providers. ATSDR administers public health activities through: partnerships; public health assessment and consultation activities; exposure investigations;

health studies and registry activities; development of toxicological profiles and attendant research; emergency response; health education and health promotion; and

community involvement.

ATSDR works in particularly close coordination with our DHHS sister agency, the

Centers for Disease Control and Prevention. Jointly we have worked with the Nevada Health Division to investigate the cancer cluster in Fallon. For our part,

ATSDR will assist in the investigation by reviewing all relevant environmental data

for toxic substances and assessing whether people have been exposed to any of these

contaminants at levels of concern.

Unfortunately, the cancer cluster in Fallon is not a unique situation. Increasingly,

ATSDR is being asked by State and local health departments to help respond to

compelling community concerns about apparent outbreaks of serious, noninfectious

disease with unknown cause. As a small agency, responding to these requests would

be impossible for ATSDR alone. To supplement our own staff, ATSDR works in close

collaboration with State health departments, and has been funding environmental

public health activities in States since 1987. ATSDR currently funds public health

activities in 28 States through separate cooperative agreements that provide assistance to conduct public health assessments, health education activities, and epidemiologic studies. Because of our Superfund mandates, most of our cancer cluster

investigations and assistance are related to concerns about Superfund sites, hazardous waste, and exposure to toxic substances.

The site work we do directly or through our State partners has changed over time.

Our original mandate under Superfund called for public health assessments at all

National Priorities List (NPL) sites and these originally constituted the great majority of our workload. While we still actively work at NPL sites, it now constitutes

a smaller proportion of our site activities. Increasingly, our site work now is at immediate removal sites, active waste sites, occasionally Brownfields sites, and, like

Fallon, sites where communities, States or congressional officials have petitioned

ATSDR to investigate or assist in evaluating their health concerns related to toxic

substances.

Activities related to the vermiculite mine in Libby, Montana, provide a very good

example of a current site where ATSDR’s work has made a difference, which also

began with a reported cluster of disease. The situation in Libby offers a dramatic

example of past exposure resulting in serious disease. In 1999, reports from Libby

documented cases of non-occupational asbestos-related pulmonary impairment

among family members of former mine employees as well as others in the community with no connection to the mining operations. They were suffering (or dying)

from asbestosis, mesothelioma, and lung cancers related to their asbestos exposure.

Finding non-occupational asbestos-related pulmonary disease is extremely unusual

and suggests that dangerous levels of asbestos exposure have occurred within the

Libby community. The latency period for mesothelioma, for example, is 40 years.

This means that the health care community could be seeing the effects of exposure

to asbestos-contaminated vermiculite from Libby for an entire generation.

In 2000, ATSDR conducted a medical testing program to assess the public health

implications of past human exposure to tremolite asbestos in Libby. More than

6,100 Libby-area residents and former mine workers were screened. This number

included 70 from Elko, Nevada, who met the screening criteria for Libby. They all

answered an extensive questionnaire about their possible exposures and received

both chest x-rays and pulmonary function tests.

ATSDR recently reported a preliminary analysis of the medical testing results

from the first 1,078 participants, or 18 percent of the total number of participants

in the medical testing program. These results showed a very high percentage of individuals reporting contact with the vermiculite, and evidence of health impacts,

particularly in the form of thickening and scarring of the outer pleural lining of the

lung.

ATSDR will soon complete the evaluation of the Libby medical screening program

and is working with local, State, and Federal health care providers to address

health issues that are identified. Specifically, to help local residents obtain medical

care, ATSDR has worked closely with the DHHS Regional Health Administrator and

other DHHS agencies, such as the Health Resources and Services Administration

(HRSA), and the State of Montana to ensure appropriate treatment is available.

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Such partnerships are critical to providing needed health services at Libby, Elko,

and now Fallon. Such partnerships are also critical to fully assessing the true existence and potential cause of disease clusters. As a part of the latter, ATSDR and

CDC are reviewing and responding to the Pew Environmental Health Commission

Report. The report recommends strengthening Federal, State and local public health

capacity to tackle environmental health problems and establish a nationwide Health

Tracking Network on chronic diseases and related environmental hazards. ATSDR

has made significant progress in developing registries of individuals exposed to specific substances and tracking them over time to assess health status and provide

updated information over time to exposed individuals. At the request of Sen. Baucus

(D-MT) and others, we plan to establish a registry of vermiculite exposed individuals from the Libby area. The agency also has considerable experience working with

State health departments and communities to conduct epidemiologic investigations

of specific health outcomes in communities near environmental sources of hazardous

substances.

In keeping with the Superfund mandate to ‘‘. . . establish and maintain a national registry of serious diseases and illnesses . . .’’, we at ATSDR see ourselves

as having a direct responsibility under CERCLA to participate with CDC and others

in developing disease surveillance or tracking systems, particularly for diseases with

known or potential relationships to hazardous waste and toxic substances. In addition, because of our close working relationship with EPA, we are interested in how

to link environmental data bases with developing health tracking data. Although we

are very far from a comprehensive system at this point, ATSDR does have some ongoing, albeit limited, efforts underway as part of our Superfund work. These include

an epidemiologic study investigating the cause of childhood cancers in conjunction

with Superfund sites in four States, and a pilot program to develop health tracking

of multiple sclerosis in a number of circumstances where concern about the frequent

occurrence of this disease arose in relation to adjacent hazardous waste sites.

But we recognize that more can be done. Mr. Chairman, the public naturally becomes concerned when they see situations such as half of a class of third graders

needing to bring asthma inhalers to school, or when persons compare notes about

their first diagnosis of multiple sclerosis at a 20-year high school reunion, or when

multiple parents within the same neighborhood watch their children suffer from

brain tumors and other severe illnesses, or when women who do not smoke and who

did everything right during their pregnancy give birth to small or sick babies. Sadly,

in a country as large as ours, these unusual occurrences are not so unusual at all.

All over the country, citizens turn to their local, State and Federal health authorities and ask what could be causing these and other types of clusters of health problems. In communities near obvious sources of environmental contamination, people

understandably worry that somehow environmental pollution might be playing a

role.

At ATSDR we are committed to doing what we can to address these very real concerns.

• As I’ve stated earlier, we are working every day at sites around this Nation to

address the health concerns of communities affected by toxic exposures.

• We are working with our colleagues at CDC to address the issue of health and

disease tracking.

• And, we continue to strengthen our ongoing partnerships with Federal, State

and local agencies, which is integral to answering these questions.

Mr. Chairman, on a personal note, I started my professional career as a pediatrician at the Centers for Disease Control in 1972, and my first investigation was of

a leukemia cluster in Elmwood, Wisconsin. I did several more such investigations

over the next 18 months, none of which revealed an obvious cause for the clusters.

However, my fourth or fifth such investigation was of 4 cases of liver cancer in a

factory which turned out to be the first reported cases of vinyl chloride induced liver

angiosarcoma in polyvinyl chloride polymerization workers. This subsequently led to

much improved and safer working conditions for the entire industry worldwide. I

have seen how agonizingly frustrating this work can be; but I also feel that if we

are in the mode of carefully scrutinizing health data, then we will be positioned correctly to detect new problems when they arise.

Mr. Chairman this concludes my testimony. I will be happy to answer any questions that you or members of your committee might have.

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STATEMENT OF THOMAS SINKS, PH.D., ASSOCIATE DIRECTOR FOR SCIENCE, NATIONAL

CENTER FOR ENVIRONMENTAL HEALTH, CENTERS FOR DISEASE CONTROL AND PREVENTION, DEPARTMENT OF HEALTH AND HUMAN SERVICES

Good morning, Mr. Chairman and members of the committee. I am Dr. Thomas

Sinks of the Centers for Disease Control and Prevention (CDC) where I am the Associate Director for Science within the National Center for Environmental Health.

I am pleased to review CDC’s assistance to the Nevada State Health Division’s investigation of acute lymphoblastic leukemia (ALL) in Fallon, Nevada. I will discuss

how CDC provides the technical assistance and infrastructure in responding to disease investigations, and briefly characterize cancer clusters, the roles of State and

Federal agencies in investigating them, and coordination between agencies.

I want to begin by assuring the parents of Fallon, and all parents whose children

are diagnosed with cancer, that we at CDC are deeply concerned about the health

and well being of children. We are encouraged by the wonderful improvements in

the clinical treatment of ALL—today 80 percent of children with ALL will have

healthy and productive lives. However, we need to identify the causes of ALL to prevent it and decrease the number of children who suffer from it.

State health departments are on the front line in responding to cancer clusters

and other disease clusters, and the CDC plays an important role in providing infrastructure and technical assistance. CDC has a close relationship with our sister

agency ATSDR (the Agency for Toxic Substances and Disease Registry) and we coordinate our response to cancer and disease cluster inquiries. Cancer and disease

cluster activities at CDC have included field investigations, convening a national

conference on the clustering of health events, publishing recommendations for the

epidemiologic investigation of disease clusters, and providing technical assistance to

health departments involved in specific cluster investigations.

Last month CDC released the first National Report on Human Exposure to Environmental Chemicals, an important new research tool that will provide better information on levels of exposure to environmental chemicals, and over time what these

levels mean for public health. Using a technology known as biomonitoring, CDC’s

environmental health laboratory measures chemicals directly in blood and urine

samples rather than estimating population exposure using measurements from air,

water or soil samples. By showing what the U.S. population is exposed to under

‘‘normal conditions,’’ the report can become a vital tool for epidemiologists to compare blood and urine levels of chemicals in suspected disease cluster areas to the

baseline exposure data for the general population. We will be using this same type

of biomonitoring technology to assist the Nevada State Health Department in investigating these cases of ALL. We are working to be able to transfer this technology

to State public health laboratories so that they can do their own biomonitoring of

chemical exposures.

TECHNICAL ASSISTANCE TO NEVADA

CDC has worked with the Nevada Health Division since July 2000, providing

technical assistance in each phase of the investigation. CDC helped plan, and participated on, the expert panel review last February 15th. The panel commended the

Nevada Health Division’s work and recommended six followup steps; four of which

involve active assistance from CDC and ATSDR. I recently met with CDC and

ATSDR staff to coordinate our agencies’ assistance to the State. CDC and ATSDR

will help the State complete: (1) a cross-sectional exposure assessment of environmental contaminants in drinking water, house dust, and the blood and urine of

county residents, (2) an assessment of environmental contaminants and possible

pathways leading to human exposure, (3) the establishment of a tissue bank for future research into the causes of ALL, and (4) the continuation of the expert panel

to provide independent review of the investigation.

CANCER CLUSTERS

Cancer clusters provide opportunities as well as challenges for public health agencies. The phrase ‘‘cancer cluster’’ implies that more cancer cases or cancer deaths

have occurred in a specific geographic region than expected. A cancer excess may,

or may not, be the result of an exposure to a unique carcinogen.

Public health agencies are challenged by cancer clusters because of the number

of public inquiries—probably thousands of perceived cancer clusters have been reported. For example, more than 2000 published newspaper articles from January

1990 to January 2000 contained the words ‘‘cancer cluster.’’ A survey of 41 State

health departments found they registered about 1900 cancer inquiries in 1996 alone.

An additional challenge is the unrealistic expectation placed upon public health offiVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00201 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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cials to identify and remove the cause of each cancer cluster. In reality, 85 to 90

percent of evaluated cancer cluster inquiries do not find an excess number of cancer

cases. Although 10 to 15 percent of cancer clusters have involved an excess in cancer

cases, only a handful led to important discoveries of preventable causes of cancer.

Cancer clusters can provide an opportunity for cancer prevention and control.

Cancer education and screening programs are important tools in the fight to prevent

and control cancer and can be used effectively in some cancer cluster circumstances.

Scientific investigations of cancer clusters and local environmental concerns, however, may take years to complete and the findings are often inconclusive. If a cancer

cluster and hazardous levels of an environmental contaminant coexist, removal of

the health hazard seems prudent, regardless of its role in causing cancer.

CDC AND STATE ROLES IN RESPONDING TO CANCER CLUSTERS

At CDC, three centers are involved in responding to cancer clusters. Our National

Center for Chronic Disease Prevention and Health Promotion supports statewide,

population-based cancer registries through the National Program of Cancer Registries (NPCR.) Cancer registries and their use to identify and monitor cancer

trends are an essential tool for evaluating cluster inquiries. The Nevada Cancer

Registry (NCR) received more than $1,480,000 from CDC’s NPCR from 1994

through 2000 to track cancers including ALL. CDC’s National Center for Environmental Health conducts exposure assessments and epidemiologic studies that evaluate how people are exposed to environmental hazards and identify preventable environmental causes of cancer. The CDC’s environmental health laboratory measures

known and suspected cancer causing agents in human blood and urine. CDC’s National Institute for Occupational Safety and Health (NIOSH) addresses exposures to

cancer causing agents in the workplace by conducting laboratory science and epidemiological investigations in fields like toxicology and immunology. NIOSH also responds to requests from employers, employees, and other government agencies for

investigations involving possible work-related cancer. Finally, CDC’s sister agency

ATSDR plays a critical role in responding to clusters as you will hear from ATSDR

Assistant Administrator, Dr. Henry Falk.

ENHANCING CANCER CLUSTER EVALUATIONS

Three key ingredients needed for an adequate response to public concerns about

cancer clusters are sufficient infrastructure, assurance of scientific credibility, and

coordination between agencies. State infrastructure requirements include cancer

registration and tracking, cancer prevention and control, and a mechanism for rapidly identifying hazardous levels of environmental contaminants; recommendations

supported by The Pew Environmental Health Commission. A significant advance in

children’s cancer surveillance is taking place with the consolidation of pediatric cancer specialists within the Children’s Oncology Group with funding from the National

Cancer Institute. Scientific credibility requires that experts from many fields work

together. Independent review by expert panels also ensures the credibility of State

investigations. Scientific credibility could be further enhanced by developing investigative priorities from hypotheses for why certain cancers might cluster. A work

group to establish such investigative priorities is needed.

Coordination between agencies is essential. The successful collaboration in Fallon,

Nevada involves multiple departments within the State, the Federal Government,

and academic institutions. Agencies involved from the Department of Health and

Human Services include not only CDC, but also ATSDR and the National Cancer

Institute. Representatives of the Fallon Naval Air Station have also volunteered

their complete cooperation in the investigation.

CDC is currently in the process of assessing the nation’s public health infrastructure and its needs. CDC has convened an agency-wide workgroup, along with

ATSDR, to review and respond to the Pew Environmental Health Commission Report. This report recommends the strengthening of Federal, State and local public

health capacity to tackle environmental health problems and establish a Nationwide

Health Tracking Network to identify and track chronic disease and potential environmental factors. CDC is working to establish a nationwide laboratory network to

assist communities in evaluating toxic emergencies and human chemical exposure.

This will help communities monitor disease trends and evaluate whether these are

linked to exposures in the environment. In addition, CDC has recently released a

report focusing on a broader perspective of the current status of public health infrastructure. The report is entitled Public Health’s Infrastructure: Every health department fully prepared; every community better protected, and is available on CDC’s

website. Assessment of the nation’s public health infrastructure will help us to determine how to best target resources to build capacity at the State and local level,

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and will enhance our ability to interact with communities to address their local public health needs.

I applaud the people of Fallon for their positive response during this stressful

time. Strong communities are strengthened by people drawing together to help one

another through difficulty. I assure you that the CDC will continue to collaborate

with our Federal partners and assist the State of Nevada. Thank you, Mr. Chairman and members of the committee, for the opportunity to testify before you today.

I would be happy to answer any questions you might have.

STATEMENT OF RAMONA TROVATO, DIRECTOR, OFFICE OF CHILDREN’S HEALTH

PROTECTION, ENVIRONMENTAL PROTECTION AGENCY

Good Morning. My name is Ramona Trovato and I am the Director of the Office

of Children’s Health Protection at the U.S. Environmental Protection Agency. Thank

you for inviting me here today to discuss our response to environmentally-related

health problems. It is deeply distressing to know that a number of children in this

community have developed leukemia. Even one child with leukemia is one too many.

The Environmental Protection Agency’s mission is to protect human health and

safeguard the environment. We protect human health by limiting peoples’ exposure

to contaminants in the air we breathe, the water we drink, and the food we eat.

The Environmental Protection Agency works through the States to protect public

health. About half of the Environmental Protection Agency’s budget is sent directly

to the States for their use in environmental and public health protection. In fiscal

year 2001, the Environmental Protection Agency is providing $3.5 billion to the

States for all environment programs. This same year, Nevada received more than

$6 million in clean water State revolving funds and $7.8 million for drinking water

State revolving funds.

The protection of human health requires a partnership at the local, State and

Federal level. I would like to begin by addressing the government’s response to environmentally-related health problems through some past examples, and then talk

about how we can address some of the issues facing your community. Given the

unique roles of each of the different agencies, it is essential for environmental officials at all levels of government to work with their public health counterparts to

address the environmental health needs of our citizens.

HOW DOES THE ENVIRONMENTAL PROTECTION AGENCY RESPOND TO CANCER CLUSTERS

We currently address potential cancer clusters through an informal agreement

among government agencies. Through this partnership, each agency brings their

particular expertise to the investigation as needed. The current process is as follows:

State public health departments perform the initial phases of cancer cluster investigations according to defined protocols. If further investigation is warranted, the

Centers for Disease Control and Prevention may be asked to provide technical assistance to States on a case-by-case basis. Additional assistance may be provided by

the Agency for Toxic Substances and Disease Registry and the National Cancer Institute.

• If findings indicate a suspected environmental linkage, the National Institute

of Environmental Health Sciences, and/or the Environmental Protection Agency may

be consulted.

Through its participation in this partnership of Federal, State, and local agencies,

the Environmental Protection Agency has a long history of dealing with environmentally-related health problems in communities. I’d like to give you a specific example of how the Environmental Protection Agency has partnered with other agencies to address a real problem.

Case Study: Community Confronts Childhood Cancer

In 1996, due to public concerns about high rates of certain types of cancer among

children in the Dover Township/Toms River area of New Jersey, a study was conducted by the Agency for Toxic Substances and Disease Registry and the New Jersey Department of Health and Senior Services. They found a previously unidentified

contaminant in two drinking water wells. These agencies then asked for the Environmental Protection Agency to identify the contaminant. Through a cooperative effort led by the Environmental Protection Agency’s Las Vegas laboratory, the contaminant mixture, called SAN trimer, was identified. This contaminant was found

in low part-per-billion levels in the two wells already known to have been impacted

by a local Superfund site. The existing treatment system at these wells was not effective at removing the contaminant. Because this area is part of a Superfund site,

the Environmental Protection Agency directed Union Carbide, the site’s potentially

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responsible party, to install a carbon treatment system on the two contaminated

wells to supplement the existing treatment. The new carbon treatment system removes the contaminant to non-detectable levels. The Environmental Protection

Agency, with the National Institute of Environmental Health Sciences, is overseeing

long-term chronic studies to determine if this contaminant causes cancer.

HOW DOES THE ENVIRONMENTAL PROTECTION AGENCY RESPOND TO SUPERFUND SITES

Working under the mandate of the Superfund legislation, the Environmental Protection Agency works closely with the Agency for Toxic Substances and Disease Registry to perform the necessary activities to respond to environmental hazards and

associated health threats in communities. The Agency for Toxic Substances and Disease Registry performs health assessments around Superfund sites, as well as in

communities upon request. The Agency for Toxic Substances and Disease Registry’s public health assessment process determines those potentially exposed and makes

recommendations to reduce exposure and mitigate potential health outcomes. The

Environmental Protection Agency responds to these recommendations and intervenes where possible to stop exposures. Communities can petition the Agency for

Toxic Substances and Disease Registry for a community health assessment and can

petition the Environmental Protection Agency to request a preliminary assessment.

If the preliminary assessment indicates a problem, then the Environmental Protection Agency can take immediate action and begin the process of cleanup.

Case Study: Citizen Complained of Strange Odor—Methyl Parathion (Pesticide)

In 1994, a resident of Lorain County, Ohio, was worried about a strange odor in

his home. He called the local State agriculture department to find out what it was

and what to do about it. The citizen had recently had his home sprayed to eliminate

cockroaches and other pests. State sampling revealed the presence of methyl

parathion in his home. Methyl parathion is a highly potent pesticide used on cotton

and food crops. It was registered only for outdoor use, not for indoor use. The State

agricultural representative turned to the Environmental Protection Agency, who investigated the illegal indoor application of methyl parathion and found an unlicensed applicator had been spraying inside homes and distributing bottles of this

pesticide to homeowners. With help from the media and churches, citizens were

alerted and people who had their homes treated were asked to come forward and

have their homes tested for methyl parathion. The Environmental Protection Agency’s Superfund program, with the Agency for Toxic Substances and Disease Reg- istry, provided $21 million and expertise to decontaminate and restore 233 homes

in Lorain County. Similar incidents turned up in Michigan, Mississippi, Louisiana,

Tennessee, Illinois, Arkansas, and Alabama. After contaminating hundreds of homes

in six States, the individuals responsible for the problem were identified, prosecuted

and convicted.

In these cases, the Environmental Protection Agency and the Agency for Toxic

Substances and Disease Registry issued a joint public health advisory about the

problem, produced public outreach and educational material, and coordinated a Federal response. The two agencies also worked together on procedures for testing the

presence of methyl parathion residues in homes and in the urine of residents, developed criteria for relocation of residents and procedures for cleanup of contaminated

homes. The Agency for Toxic Substances and Disease Registry is still following the

exposed children to determine residual health problems.

On a final note, the Environmental Protection Agency canceled the use of methyl

parathion on many food crops because it was found to present acute dietary risks,

especially in children.

HOW DOES THE ENVIRONMENTAL PROTECTION AGENCY RESPOND TO

WATERBORNE ILLNESS?

The Environmental Protection Agency also responds to cases of illness that are

believed to be associated with contaminated drinking water. The Environmental

Protection Agency works through a formal agreement with other agencies to resolve

the problem that caused the illness. The State health department responds first and

if they need assistance, they call on the Centers for Disease Control and Prevention.

The Centers for Disease Control and Prevention may then request consultation or

participation by the Environmental Protection Agency in detecting, monitoring, sample testing, and providing engineering assistance for water supply pathways or

water treatment plants.

Drinking Water Infrastructure: Meeting the needs of small communities

The Environmental Protection Agency also helps communities address public

health threats through the Drinking Water State Revolving Loan Fund, established

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to provide States with a continuing source of financing for drinking water infrastructure projects. Last year, the Environmental Protection Agency provided more

than $880 million to States to finance the costs of infrastructure improvements. The

program places a particular emphasis on the needs of small systems that serve

10,000 or fewer residents. Congress required that at least 15 percent of the funds

be provided to small systems.

Case Study: Cryptosporidium A waterborne intestinal parasite

In 1993, hospitals and schools in Milwaukee, Wisconsin began reporting widespread absenteeism among employees and students due to gastrointestinal illness.

The medical community and local health departments, together with the Centers for

Disease Control and Prevention recognized that this outbreak was too widespread

for a food-borne illness. The Milwaukee public water system was contacted and high

levels of turbidity were identified in the drinking water. These high levels were estimated to have lasted for 16 days before the problem was identified and corrected.

It was later estimated that during the outbreak, Cryptosporidium levels in treated

water may have exceeded 100 oocytes per 100 liters. During that time, an estimated

400,000 individuals in Milwaukee became ill from Cryptosporidium and at least 50

cryptosporidiosis-associated deaths were reported.

Scientists and water treatment engineers from the Environmental Protection

Agency and the Wisconsin Department of Natural Resources provided assistance by

evaluating and correcting problems with the treatment plant. Together the team

identified that the problem arose from a change in treatment practices, lack of familiarity with these new practices, unusually high levels of Cryptosporidium in the

source water, and delays in correcting the problem when it first occurred. Together

with local, State and Federal Government agencies, experts restored the quality of

the drinking water and introduced additional safeguards to help ensure the future

safety of drinking water for Milwaukee residents. What else are Federal agencies

doing to address environmental health concerns?

Since 1997, the Environmental Protection Agency, the Department of Health and

Human Services, the Department of Housing and Urban Development, and many

other Federal agencies have joined together to focus on environmental health

threats to children. The interagency group first identified those diseases and disorders that affect children’s health and may be associated with an environmental

contaminant. The diseases and disorders selected were: asthma; developmental disorders, including lead poisoning; and childhood cancer. Asthma affects about five

million children and is the leading cause of hospitalization in children. Developmental disorders are the leading cause of lifelong disability. Childhood cancer is the

leading cause of disease-related mortality in children ages 1 to 14. Each year, more

than 8,000 cases of childhood cancer are diagnosed.

The specific causes and confluence of factors that contribute to asthma, developmental disorders, and childhood cancer are generally unknown. Therefore, the decision was made to focus on research to help us better understand the influences,

mechanisms and interactions of environmental factors that contribute to childhood

disease. Where we have sufficient knowledge to act, we have developed strategies

to address environmental health concerns. The national asthma strategy was

launched in January 1999; the national lead strategy was released in 2000; and the

Environmental Protection Agency and the Department of Health and Human Services have jointly funded research centers to investigate children’s environmental

health concerns. (An additional center is funded by the Environmental Protection

Agency). Five of the nine centers conduct research related to asthma; the remaining

four conduct research on development disorders. Also, the National Cancer Institute

is conducting research into childhood cancer and developing a national registry of

all children with cancer.

Asthma Strategy

There is an epidemic of asthma in the United States. Nearly 1 in 13 school-aged

children has asthma. Asthma is one of the leading causes of school absenteeism, accounting for more than 10 million missed school days each year. Asthma is the leading cause of hospitalization for children. Asthma symptoms that are not severe

enough to require a visit to the emergency room can still prevent a child from living

a fully active life.

The Environmental Protection Agency and the Department of Health and Human

Services developed a strategy that focuses on research and public health preventive

programs. Twenty-four million dollars was provided in fiscal year 2000 to expand

the Environmental Protection Agency’s research and public information programs to

address indoor and outdoor asthma triggers. This effort is closely coordinated with

the Department of Health and Human Services program which has committed $128

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million to address asthma. We’ve just begun to work with State environmental and

health departments to address this epidemic.

LEAD STRATEGY

Another collaborative effort on behalf of the Federal Government is the Federal

strategy to eliminate lead paint hazards in homes where children under age six live.

Childhood lead poisoning is entirely preventable, yet today it remains a serious environmental health risk facing children. Lead is highly toxic to young children and

can cause reduced intelligence, impaired hearing, and behavioral difficulties, and at

higher levels can harm a child’s internal organs. In the United States, almost one

million children under the age of six have toxic levels of lead in their bodies. The

strategy attempts to decrease this number to virtually zero in 10 years. It coordinates measures in many Federal departments and agencies aimed at preventing

lead poisoning by:

• Acting before children are poisoned by eliminating and preventing residential

lead paint hazards;

• Identifying and caring for children already poisoned;

• Conducting research to drive down remediation costs; and

• Continuing surveillance and monitoring programs.

The Department of Housing and Urban Development provides grants to cities and

States to address lead paint hazards in low-income housing.

LONGITUDINAL COHORT STUDY

Last year, Congress enacted the Child Health Act of 2000 that authorizes the National Institute for Child Health and Human Development to conduct a longitudinal

cohort study to examine the impact of environmental pollutants on children. This

long term study will evaluate the link between environmental factors and developmental disorders, from conception through early adulthood. It will help the Federal

Government understand how the environment, family, and society interact with the

genetic makeup of the developing fetus and child. The goal is to identify specific

areas where prevention, intervention, and treatment will make a difference for

America’s children. As the Framingham study provided us much of what we know

about heart disease, this study could be the watershed in children’s environmental

health protection. It will require the dedicated and determined effort of all our partners in the environmental and health communities to complete this effort.

HOW CAN EPA HELP

EPA has scientific and technical experts throughout the country experienced in

environmental monitoring, sampling, laboratory analyses, modeling, remediation

and emergency response. We can work closely with the citizens of Fallon, the Agency for Toxic Substances and Disease Registry, the Centers for Disease Control and

Prevention, and the State of Nevada to conduct environmental assessments. Our assessment activities could include environmental testing, surveying industrial, mining, and waste disposal activities in and around Fallon, searching records to understand historical uses of the area and inspecting potential release sites.

Moreover, EPA has more than 40 hot lines and websites, that provide assistance

on a variety of topics, from acid rain to safe drinking water. In addition, the EPA

has a number of websites that provide information for professionals and families regarding a wide variety of environmental topics including pesticides and children’s

environmental health.

In addition, the Agency for Toxic Substances and Disease Registry and the Environmental Protection Agency jointly fund the Pediatric Environmental Health Specialty Units in each of the 10 regions. The pediatric units provide a clinical referral

resource for health care providers and parents. Health care professionals diagnose

and evaluate health threats associated with exposure to hazardous substances. In

addition, children can be seen at these units by health care professionals. These

units serve an important role in the health care community due to their expertise

in recognizing environmental health problems and treating children with these

problems. The closest site to Fallon, NV is located in San Francisco at the University of California. This pediatric unit can be reached at (415) 206–4320.

CONCLUSIONS

Thank you for allowing me to address the committee and the community of

Fallon. I am so sorry that your children are suffering. I hope that together we can

make a difference. I have a few suggestions:

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• Replicate the waterborne disease response model, which I mentioned earlier,

to address other environmental health problems. • Bolster the State and local public health infrastructures to monitor and respond to environmental health threats and put in place preventive health programs

that alert us to problem areas that are likely to occur and to take the appropriate

actions before communities suffer. • Strengthen the partnerships among environment and health agencies at Federal, State, and local levels.

• Establish a national health tracking system for chronic diseases such as asthma, birth defects, cancer and developmental disorders, to ensure a rapid response

to emerging environmental related health concerns.

• Conduct the national longitudinal cohort study on environmental factors affecting child health.

Children are our future and we should do everything in our power to protect

them.

STATEMENT OF DR. SHELLEY HEARNE, EXECUTIVE DIRECTOR, TRUST FOR

AMERICA’S HEALTH

Mr. Chairman, Senator Reid, and members of the committee, thank you for the

opportunity to come to Nevada to provide real perspective to our nation’s ability to

respond to health crises like the pediatric leukemia cluster you are facing here in

Fallon.

My name is Dr. Shelley Hearne and I serve as the executive director of the Trust

for America’s Health—a new nonprofit health advocacy organization committed to

preventing disease and protecting the health and safety of our communities. I am

very proud to have former Governor Lowell Weicker, Representative Louis Stokes,

and Chairman John Porter, along with many other national leaders in public health

serve on our Advisory Council.

By way of background, I am an environmental health scientist—serving for almost

20 years in government, non-profits and as a faculty of the Johns Hopkins School

of Public Health. Most recently, I was the executive director of the Pew Environmental Health Commission—a blue ribbon independent panel charged with developing recommendations to improve the nation’s health defenses against environmental threats.

Let me start by being candid. Our public health service is falling short in its duty

to watch over the safety and health of the Americans, particularly when it comes

to chronic diseases that may be associated with environmental factors.

Chronic diseases are responsible for 7 out of 10 deaths in this country. More than

a third of our population, over 100 million men, women and children suffer from

chronic diseases. These diseases cost our citizens and government, $325 billion a

year. By 2020 chronic diseases are estimated to afflict 134 million Americans and

cost $1 trillion a year. And the CDC estimates that 70 percent are preventable.

But our Federal Government is not actively pursuing how to prevent this epidemic of chronic diseases.

As a Nation, we have been increasing our research into how to treat disease. As

a result, we have some good news here. More children with leukemia survive today

than ever before. But there is bad news. The rates of childhood leukemia have been

steadily rising for the past two decades. As a Nation, we have not invested in preventing chronic diseases.

This health crisis in Fallon is a tragedy. My heart goes out to these families, this

community. But as a health scientist, I grow more angry as I watch this story increasingly repeated in communities all across the country. In 1997, there were almost 1,100 requests by the public to investigate suspected cancer clusters. Many of

these are preventable diseases, preventable tragedies and our public health resources are insufficient to effectively respond to these challenges.

Let me give you an example from my home State of New Jersey. Parents in Brick

Township complained to politicians and health officials for years about a feared autism cluster in their community. But health agencies could not even confirm the

cluster for years because they lacked the most basic investigative tools. New York

has a similar story. In Elmira, New York, the State health officials have been investigating an unusually high incidence of cancer among children who attended the

Southside High School. Fifty-three (53) cases of cancer have been reported from the

7,500 current and former students who attended the high school since it opened in

1979. Thirteen of the cases were reported in the past 3 years. The high school was

built on land that has served as an industrial site since the Civil War. No one

knows why this is happening.

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Even though we know about the increasing numbers of chronic disease clusters

and the staggering human and financial toll they have on our country, we have no

systems in place to detect chronic disease clusters nor do we have the capability to

respond to these health crises. Our Federal, State, and local agencies only coordinate tracking and responding to infectious diseases such as polio, yellow fever and

typhoid. Diseases that a national tracking and response system helped to eradicate

back in the late 1800’s. Over a century later, we never modernized our public health system to respond

to today’s health threats. As a result, we are hamstringing our health specialists

from finding solutions and effectively taking action—regardless if it’s childhood leukemia in Fallon or a nationwide asthma epidemic.

Let me give you some examples of our scattered State health tracking systems

from the State of Nevada. • Even though birth defects are the No. 1 cause of infant mortality, Nevada does

not track birth defects. The Pew Commission gave Nevada and 16 other States an

F in its report, ‘‘Healthy from the Start’’ which was released in late 1999. • Nevada does not track developmental diseases such as cerebral palsy, autism

and mental retardation even though the National Academy of Science estimates

that 25 percent of these diseases in children are caused by environmental factors. • Even though studies have shown autoimmune diseases like Lupus to be increasing, Nevada does not have a system to track these diseases. • Nevada’s cancer registry has been severely neglected for years. It is the only

State that charges hospitals to report cancer cases—a perfect formula to ensure poor

participation.

Unfortunately Nevada is not unusual, it is the norm. This is because our Federal

Government has failed to establish a comprehensive national approach to tracking

and responding to chronic disease.

The Pew Environmental Health Commission based out of the Johns Hopkins

School of Public Health studied our nation’s capacity to identify and respond to

chronic disease clusters for 2 years and proposed creating a nationwide Health

Tracking Network to solve this problem.

The Nationwide Health Tracking Network is based on four principles: (1) building

a coordinated system of tracking chronic diseases and associated environmental factors; (2) providing the resources and training to local health departments to analyze

the data; (3) immediately responding to health problems identified through the system; and (4) providing the national leadership to coordinate health and environmental activities throughout the Federal Government so that these programs do not

operate in isolation of one another.

The Nationwide Health Tracking Network consists of five components:

1. Establishing essential data collection systems.—The first component builds on

existing health and environmental data collection systems and establishes data collection systems where they do not exist. The Network will coordinate with the local,

State and Federal health agencies to collect this critical data.

In all 50 States, the Network would track:

• Asthma and other respiratory diseases;

• Developmental diseases such as autism, cerebral palsy, and mental retardation;

• Neurological diseases such as Alzheimer’s, multiple sclerosis, and Parkinson’s;

• Birth defects; and

• Cancers, especially in children.

The Network also would track exposures to:

• Heavy metals such as mercury and lead;

• Pesticides such as organophosphates and carbamates;

• Air contaminants such as toluene and carbamates;

• Organic compounds such as PCB’s and dioxins; and

• Drinking water contaminants, including pathogens.

Building upon the existing systems for infectious diseases, the Federal Government will establish the standards for the health and exposure data collection necessary to create uniformity throughout the system. With Federal resources such as

funding, training and lab access, State and local public health agencies will collect,

report and analyze the data.

2. Creating an Early Warning System.—The second component is an Early Warning System that would immediately alert communities of health crisis such as lead,

pesticide and mercury poisonings. The existing system of local health officials, hospitals and poison centers that alert our communities to outbreaks like food illness

and the West Nile virus would also alert our communities to these health crises.

3. Improving response to chronic disease emergencies.—The third component consists of improving our response to identified disease clusters and other health crises.

The Network would coordinate Federal, State and local health officials into rapid

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response teams to quickly investigate these health problems, providing the teams

with trained personnel and the necessary equipment.

4. Addressing unique local health problems.—The fourth component is a pilot program consisting of 20 regional and State programs that would investigate local

health crisis and clusters that are currently not part of the Nationwide Health

Tracking Network. These programs would alert the public and health officials to

new developing disease clusters outside of the Nationwide Health Tracking Network. These pilots programs also would serve as models for tracking systems for inclusion in the Network.

5. Creating community and academic partnerships.—The fifth component establishes relationships with five Academic centers and with our communities. Our community relationships would ensure that the tracking data is accessible and useful

on a local level, and our research relationships would train the work force, analyze

data, and develop links between the tracking results and preventive measures.

[The background and basis for this Network and other Commission findings and

recommendations are attached as part of the written testimony. These are also

available on the website at http://pewenvirohealth.jhsph.edu or http://healthtrack.org]

This Network would provide our communities, scientists, doctors, hospitals and

public health officials with missing data on where chronic diseases are clustering

and associated environmental factors that would enable us to develop prevention

strategies. Over 30 key health organizations have endorsed this recommendation,

ranging from Aetna US Health Care to the American Cancer Society to the American Academy of Pediatrics to the Association of State and Territorial Health Officers (ASTHO).

The American Chemistry Council supports the concept, noting that ‘‘. . . data

generated by a national tracking program can shift the focus from debate and speculation about disease trends to intervention and prevention based on scientific evidence.’’ Developing prevention strategies are critical to reducing the $325 billion a year

Americans spend on chronic diseases. In less than 15 years, the estimated cost of

chronic disease is predicted to rise to $1 trillion. The estimated cost of the Network

is about $275 million or less than 1 dollar per every man, woman and child.

These data will allow us to spend our limited treatment and research dollars more

effectively by identifying which chronic diseases are increasing. We have doubled

our research dollars in the National Institutes of Health, yet these scientists do not

have even the most basic information about why these diseases occur, where they

strike, whom they choose as their victims, and how to take action to prevent future

clusters.

Without a Network, we will remain in the dark; still unable to answer these questions.

The most cost effective use of tax dollars today would be to invest in preventing

the leading killers in this country. And the American public agrees. The American

public is so concerned about this issue that 63 percent feel that public health spending is more important than cutting taxes. Seven out of ten registered voters (73 percent) feel that public health spending is more important than spending on a national missile defense system.

A recent public opinion poll by Princeton Survey Research Associates revealed

that nine out of ten (89 percent) registered voters support the creation of a national

system.

Most local health departments face declining funding, inadequate training for

staff, limited or no laboratory access, and outdated information systems. CDC and

ATSDR have not been able to adequately help. For instance, there is no Federal

funding for an environmental health specialist or even chronic disease investigator

in Nevada. This is true for almost all States. Nor could CDC or the Agency for Toxic

Substances and Disease Registries (ATSDR) give Nevada written guidance, standards or protocols on how to investigate this childhood cluster. The health agencies

have never developed a concrete response program to these growing cluster demands.

Due to concerns of Bioterrorism, the CDC is taking many steps toward developing

a public health infrastructure including upgrading computer and communications

systems for collecting and sharing infectious disease data among local public health

departments. We could simultaneously build on these initiatives and enhance these

efforts to ensure a nationwide strategy for chronic disease prevention. These are the

diseases that Americans are dying from today, not tomorrow’s theoretical threats.

On a Federal level, there are a few programs that relate to chronic diseases, but

do not track and respond to the chronic disease clusters. The irony is the Administration’s proposed budget recommends severe cuts for the nation’s chronic disease

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prevention programs. We need to be going in the exact opposite direction. Health

defense should be the country’s No. 1 commitment.

Who is guarding our health? The answer is that the public health service has fallen short of its duty—lacking the tracking, troops and leadership. This is exactly

where our Federal Government is needed—to develop the tracking and monitoring

systems, supply the troops and offer the leadership to prevent chronic disease.

To modernize our public health resources so that we can identify clusters before

they grow, we must take rapid action to control their spread and find solutions to

prevent diseases. CDC must be given the direct mandate to aggressively respond to

communities’ concerns like those in Fallon, with modern tools and health-tracking systems. And Congress must prioritize $275 million per year, less than a dollar per

person to make this happen. It is just a tenth of 1 percent of the overall spending

of health care dollars in this country.

Without this type of investment, we will only watch asthma, certain cancers and

other chronic disease rates continue to rise. There will be many more Fallons. And

that will be the greatest tragedy of all.

SHUNDAHAI NETWORK,

Pahrump NV, April 19, 2001.

COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS,

U.S. Senate,

Washington, DC.

Subject: Fallon Leukemia Cluster

DEAR COMMITTEE MEMBERS: I am writing in response to a request for public testimony concerning factors to consider connection with the Fallon Leukemia cluster.

I would like to see this committee carefully consider the role of fire in the disbursal

of hazardous materials through the environment, including fire’s role in remobilized

radioactive isotopes and other contaminates deposited in Nevada as a result of

weapons testing. I would request the committee to consider the dangers associated

with fire as a remobilizing agent of radionuclides from the Nevada Test Site and

other testing ranges in the State.

During the period of above ground testing from 1951 to 1963, radioactive releases

from the Nevada Test Site emitted over 12 billion curies of radioactive material into

the atmosphere, 148 times as much as the nuclear disaster at Chernobyl. Other pre1971 nuclear tests released 25,300,000 curies, and from 1971–1988, 54,000 curies

were released, including the 36,000 curies from the Mighty Oak accident, which was

itself 2000 times greater than the release at Three Mile Island. Over half of all underground tests have leaked radiation into the atmosphere (DOE Report on Radioactive Effluents, 1988). DOE has been out of compliance with Federal and State permit requirements in the areas of air emissions, water releases, and solid waste disposal (DOE Nevada Operations Office Five Year Plan, 1989).

There is contamination in soil, air, ground and surface water. Strong winds, common to this area of Nevada, can carry plutonium-contaminated dust across a large

area. Fallout from above ground nuclear tests in the United States and other countries has radioactively contaminated the atmosphere around the Earth. Project

Faultless in Hot Creek Valley was found to have caused radioactive contamination

in groundwater. According to EPA Publication 520/4–77–016, cumulative deposits of

plutonium (Pu–239 and Pu–240) have been found in soil over 100 miles north of the

NTS at levels of 790 mg per acre. Plutonium has a half-life of 26,000 years, and

plutonium contaminants ingested in microscopic amounts are capable of causing

cancer for 200,000 years. There is no cost-effective technology for decontaminating

such sites. No surveys have been conducted to determine health effects on Native

American or other residents from Nevada Test Site (NTS) releases. Currently the

Nuclear Risk Management for Native Communities project is working to answer

some of these questions.

It is known that plutonium translocates to specific radiosensitive organs, especially reproductive organs.

During the years of 1999 and 2000, almost 3,000,000 acres of Public Lands in the

State of Nevada were subjected to fires, both wild fire and prescribed burns. Fire

remobilizes contaminants. Particles are lifted from the ground into the air, then mobilized through environment on wind currents. The particles are resuspended for an

indefinite time period, finally redeposit onto the earth. This process creates fallout.

As a result of this process, fire can carry containments across the globe.

We understand that the Nevada BLM oversees management of 1,722,330 acres of

public lands considered contaminated with UXO, (unexploded military ordinances).

BLM lands border NTS (Nevada Test Site), Nellis Bombing and Gunnery Range,

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Tonopha Air Force Base, together with the Fallon Range. No one knows the amount

or extent of nuclear contamination in the area surrounding the NTS and Nellis Air

Force Base which tests depleted uranium (DU) bombs. In 1997 it was estimated

that 30 tons of DU had already been deposited in the target area (Draft Environmental Assessment Resumption of Use of Depleted Uranium Rounds at Nellis Air

Force Range Target 63–10), a total of 9,500 combat mix rounds (7,900 DU rounds)

being expended annually, there.

Depleted uranium or U–238 has an atomic mass of 238. Its half-life is 4.468 billion years (Rokke, 2001). It’s natural occurrence is 2.1 parts per million. Uranium

is silver white, lustrous, malleable, ductile, and pyrophoric. This makes DU an ideal

metal for use as kinetic energy penetrators, counterweights, and shielding or armor.

High density and pyrophoric (catches fire) nature are the two most significant physical properties that guided its selection for use as a kinetic energy penetrator.

A study performed at Yucca Proving Grounds found DU residues in all components of the environment, that environmental concentrations varied widely, that

corroded DU residues are soluble and mobile in water, that wind dispersal during

testing is the prevalent means of dispersal of DU particles, and that an unknown

degree of risk was posed to human health by DU in the environment. Moreover,

there appears to be no insight into the issue of long-term (100 to 1,000 years and

longer). DU forms of both soluble and insoluble oxides. The inhalation of the insoluble oxides presents an internal hazard from radiation if retained in the lungs.

The long-term effects of internalized depleted uranium are not fully known, but

the Army has admitted that ‘‘if DU enters the body, it has the potential to generate

significant medical consequences.’’ Inhaled DU particles or respirable size may become permanently trapped in the lungs. Inhaled DU particles larger than respirable

size may be expelled from the lungs and ingested. DU may also be ingested via

hand-to-mouth transfer or contamination of water or food supplies. DU, which is ingested, or enters the body through wind contamination, will enter the bloodstream

and migrate throughout the body, with most of it eventually concentrating in the

kidney, bone, or liver. The kidney is the organ most sensitive to DU toxicity.

More testing of soil and plants needs to be done to determine what radionuclides

might be released into the air in a fire, since a fire and its relationship to the resuspension of contaminants has not been the subject of study. Plutonium and radionuclides concentrate in dust, thus higher concentrations are found in the dust sampling than in regular soil sampling. The standard air monitors and surface water

samplers usually used are not sufficient to measure submicroscopic particles of plutonium. Further, plutonium contamination is not homogeneous, so simplistic sampling methods are inadequate (John Till, President, Risk Assessment Corp; 2000).

Wind-blown particulates must be considered. Debris and gas will go somewhere, but

where? Into the water or the soil?

Radiation detection devices that detect and measure alpha particles, beta particles, x-rays, and gamma rays emissions at appropriate levels from 20 dpm up to

100,000 dpm and from .1 mrem/hour to 75 mrem/hour must be acquired to sess the

distribution of particles. Standard rad-meters or Geiger counters do not measure

these levels.

In order to assess the health risks and damage due to exposure to tritium (radioactive hydrogen), three blood tests must be done. White blood cells must be tested

for the presence of micronuclei, indicating the loss of DNA repair processes and

leading to increased cancer risk. Red blood cells must be examined for genetic modification of surface glycophorin-A molecules, also indicating DNA damage. A study

of Japanese nuclear bombing victims 40 years from the time of the blasts showed

DNA codes were still unrepaired. In addition, chromosome painting allows chromosomes to be stained for identification of structural and sequential or numerical

abnormalities linked to radiation and chemical exposure, cancer, and inherited diseases.

In addition to the redistribution of containments, we need to consider the effects

of fire upon other substances. For example, we must consider chemical reactions

which may take place when multiple herbicides are burned together. For instance,

one chemical being most often utilized on public lands is Tordon. But Tordon is also

called Grazon, and the active ingredient is picloram, better known as Agent White,

similar to Agent Orange, and one of several defoliants used in Vietnam. In fact,

Agent White (picloram) appeared in 5 of the 15 defoliants used there. Agent White

is currently being sprayed by the U.S. on the coca fields in Columbia as part of the

drug war. In 1998, Dow Chemical, manufacturer of Agent White (picloram) tried to

halt its use, warning that it does not bind well with soil, easily washes into the

groundwater and could cause irreparable damage to the Amazon Rainforest. Yet,

U.S.G.S. Pesticide 1992 Annual Use Map showed estimated annual agricultural use

of Agent White to be less than 0.370 pounds per square mile per year. The map

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shows the entire State of Nevada has been exposed. This is a lot, and has probably

increased since that time. If it’s dangerous to the water and forest areas of Colombia, it is dangerous here in the U.S. The use of Tordon is banned in some countries.

Also commonly used are 2, 4-D which forms poisonous gas in fire. It is on the

Hazardous Substance List because it is regulated by OSHA. The chemical is a

mutagen (changes the genetic structure), a teratogen causing birth defects, and a

carcinogen particularly related to breast cancer. Short term effects of its use include

the death of animals, birds, fish, and plants within 2–4 days after exposure. About

91.7 percent of 2, 4-D will eventually end up in water. In 1990, the Clean Air Act

announced 2, 4-D as a hazardous air pollutant. Run off vapors can kill non-target

plants. Agent Orange was a mix of 2, 4-D and 2, 4, 5-T. Another name for 2, 4, 5-

T is Weedar. And both of these chemicals appear on the recommended list of chemicals used on public lands.

Garlon is also known as triclopyr (both names appear separately on the recommended treatment list as if they are different herbicides). Triclopyr’s chemical

structure is very similar to 2, 4, 5-T. The MSDS sheet includes the following data:

Nitrogen oxides, hydrogen chloride, and phosgene may result under fire conditions

and NIOSH/MSHA requires approved SCBA and full protective equipment for firefighters. Garlon-treated wood that is burned during forest fires, or in wood stoves

at home produces a dioxin, one of the most damaging compounds to living organisms. Garlon is an endocrine disrupter.

It mimics a plant hormone, acting systematically to kill the plant or tree. The hormone that Garlon mimics is perceived by the human body to be estrogen. In women,

this may result in breast cancer, miscarriages, infertility, birth defects, and possibly

ovarian cancer. In men, it can cause prostate or testicular cancer and reduction of

sperm count. It also may aggravate liver and kidney disease. We do not know what

the effects of burning multiple pesticides and the full extent of the risk to public

health from such events.

I suggest that a more appropriate methodology for determining causation of the

Fallon leukemia clusters would use a multidimensional model for analysis. In other

words, rather considering singular etiologies, as suggested by Prescott from CDC at

the hearings, a more complex multi-factor dynamic process may be in operation. We

might hypothesize very generally that exposure to radionuclides such as tritium,

plutonium, or DU, might cause mitochondrial damage to cells. In addition to other

functions, mitochondria contribute to a sort of ‘‘programmed cell-suicide’’. For example, in certain stages of fetal development, humans have webbed fingers. The mitochondria detect this, and at the appropriate time, seek to destroy the web cells, leaving humans with fully formed fingers. This cell-suicide is necessary.

However, when exposed to an error or to toxins or radionuclides, the mitochondria

engage in a process of ‘‘unprogrammed cell suicide.’’ Thus, healthy cells are destroyed. Such suicides may lead to destruction of critical elements of immune system function, resulting in cancers, leukemia, and the inability to fight the effects

of various viruses and bacteria. The cells may be more vulnerable to effects of exposure to chemicals or pesticides. In addition, adequate production of certain

neurotransmitters and hormones might be disrupted leading to diabetes or neurological damage. These medical conditions have been reported as increasing in the

general population, and though differing in appearance, may be reflecting a basic

underlying cellular assault caused by radiation exposure. I refer you to the work of

Guy Brown. Thank you for your thoughtful consideration.

Sincerely,

Dr. Bonnie Eberhardt Bobb.

[Pew Environmental Health Commission Report, September 2000]

COMPANION REPORT ON AMERICA’S ENVIRONMENTAL HEALTH GAP: WHY THE

COUNTRY NEEDS A NATIONWIDE HEALTH TRACKING NETWORK

FOREWORD BY COMMISSION CHAIRMAN LOWELL WEICKER, JR.

With the mapping of the human genome, we are on the verge of a new wave of

advances in health. With this remarkable achievement, researchers will be able to

shed new light on the links between genetic predisposition and such factors as behavior and exposures to pollutants in the environment in order to prevent many of

the chronic diseases that today cause so much suffering.

But there is a catch. We must have the basic information about the health of

Americans and our environment before we can make the fullest use of this exciting

genetic knowledge. The way to get this basic data is to track it—systematically,

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comprehensively, on a coordinated basis at all levels from the local community to

the Nation as a whole. We have to track what and where the hazards are in the

environment, whether people are at risk from exposures to these hazards, and the

health of our communities. Our information about environmental factors must run

as deep and comprehensive as our knowledge of the genome.

This report examines our current public health response capabilities to environmental threats, and recommends the establishment of a Nationwide Health Tracking Network. The Pew Environmental Health Commission is charged with developing a blueprint to rebuild the Nation’s public health defenses against environmental threats. We know there are pollutants entering our air and water each year

with suspected or known adverse effects on the health of our communities. What

we are limited in knowing if there is a link between that pollution and the increases

we are seeing in chronic diseases because we aren’t tracking environmental health

factors.

We need to gather the facts now. Americans have a right, and the need, to know.

EXECUTIVE SUMMARY

At the dawn of the 21st century, America is facing an environmental health gap.

This is a gap in critical knowledge that hinders our national efforts to reduce or

eliminate diseases that might be prevented by better managing environmental factors. This is especially true for chronic diseases and conditions, such as birth defects, asthma and childhood cancer, which strike hundreds of thousands of American

families each and every year.

What is the environmental health gap? It is the lack of basic information that

could document possible links between environmental hazards and chronic disease.

It is the lack of critical information that our communities and public health professionals need to reduce and prevent these health problems. While overt poisoning

from environmental toxins has long been recognized, the environmental links to a

broad array of chronic diseases of uncertain cause is unknown.

The national cost of chronic disease is staggering: 4 of every 5 deaths annually,

100 million people suffering each year and $325 billion in annual healthcare and

lost productivity. While our healthcare system is one of the best in the world in

treating disease, the environmental health gap is crippling our ability to reduce and

prevent chronic disease and help Americans live longer, healthier lives.

The Pew Environmental Health Commission proposes a Nationwide Health Tracking Network to close this critical gap. With a comprehensive tracking network, we

can advance our ability to:

• Identify populations at risk and respond to outbreaks, clusters and emerging

threats;

• Establish the relationship between environmental hazards and disease;

• Guide intervention and prevention strategies, including lifestyle improvements;

• Identify, reduce and prevent harmful environmental risks;

• Improve the public health basis for policymaking;

• Enable the public’s right to know about health and the environment; and

• Track progress toward achieving a healthier Nation and environment.

The proposed Network would be comprised of five key components:

(1) national baseline tracking network for diseases and exposures;

(2) nationwide early warning system for critical environmental health threats;

(3) State pilot tracking programs to test diseases, exposures and approaches for

national tracking;

(4) Federal investigative response capability; and

(5) tracking links to communities and research.

Investing in prevention through these five components is estimated to cost the

Federal Government $275 million annually—less than 0.1 percent of the current annual economic cost of treating and living with chronic disease—a very modest investment in a healthier America.

THE GRIM PICTURE—AN ENVIRONMENTAL HEALTH AND PREVENTION GAP

Americans today are sophisticated about their health. More of us are asking if

there is something in the air, water or diet that could be making us sick. Is it our

behavior—or something in our genes? Unfortunately, we are left with too many unanswered questions.

Recently, a major research study found that most types of cancer are not inherited

genetic defects, but are explained mainly by environmental factors. Environmental

factors include environmental tobacco smoke, toxic chemicals, dietary habits and

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1Published in the July 13, 2000, edition of the New England Journal of Medicine, the study

examined the medical histories of 44,788 pairs of twins listed in the Swedish, Danish and Finnish twin registries in order to assess risks of cancer at 28 anatomical sites for the twins of persons with cancer. It concluded that genetic factors make a minor contribution to susceptibility

to most types of neoplasms, and the environment has the principal role in causing sporadic cancer.

viral infections.1 Despite many years of effort, scientists still are searching for answers about the relationship among the factors in our behavior, genes and the environment that cause disease and disability.

Earlier this year, it was announced that researchers have mapped the human genome, a breakthrough that is expected to open new doors to understanding chronic

disease. Scientists will use this emerging genetic knowledge to fight disease. But if

we are going to prevent disease, researchers also need more complete information

about environmental factors, their effect on people, and the resulting health outcomes. In this way, scientists will have the capability to link genetic and environmental information and could begin to answer our questions about the complex

causes and prevention of chronic disease.

Few would dispute that we should keep track of the hazards of pollutants in the

environment, human exposures, and the resulting health outcomes—and that this

information should be easily accessible to public health professionals, policymakers

and the public. Yet even today we remain surprisingly in the dark about our Nation’s environmental health.

We have as a Nation invested heavily in identifying and tracking pollutants in

the environment, particularly for regulatory and ecological purposes, but only minimally in tracking exposures and the distribution of disease and its relationship to

the environment. As a result of decades of neglect, we have a public health system

that is working without even the most basic information about chronic disease and

potential environmental factors. The Commission found that information on trends

in health conditions potentially related to the environment is largely unavailable.

Here are a few illustrations of what this environmental health gap means: • Only four States report tracking autoimmune diseases, such as Lupus, even

though there is increasing evidence to believe rates of these diseases are rising and

the environmental links remain unknown.

• Despite evidence that learning disabilities have risen 50 percent in the past

10 years, only six States track these disorders and we have no answers about causes

or possible prevention strategies. Most States do not track severe developmental disabilities like autism, cerebral palsy and mental retardation. A recent report of the

National Academy of Sciences estimates that 25 percent of developmental disorders

in children are caused by environmental factors.

• Endocrine and metabolic disorders such as diabetes, and neurological conditions such as migraines and multiple sclerosis, have increased approximately 20

percent between 1986 and 1995, based on surveys by the Centers for Disease Control and Prevention (CDC). Most States do not systematically track these diseases

and conditions.

• For most of the United States, there is no systematic tracking of asthma despite the disease having reached epidemic proportions and being the No. 1 cause of

school absenteeism. Between 1980 and 1994, the number of people with asthma in

the United States jumped by 75 percent. Without prevention efforts that include a

strong tracking component, the Commission has estimated that the number of asthma cases will double by 2020.

• Birth defects are the leading cause of infant mortality in the United States,

with about 6,500 deaths annually. Since the mid-1980’s, rates of low birth weight

and pre-term births have been rising steadily despite increased prevention efforts.

The causes of 80 percent of all birth defects and related conditions remain elusive

even as evidence mounts that environmental factors play an important role. The

Commission found that less than half the Nation’s population is covered by State

birth defect registries, which inhibits our ability to find solutions.

The tracking programs that do exist at the State and local levels are a patchwork

because there are no agreed-upon minimum standards or requirements for environmental health tracking. The Commission found different standards, created to meet

different objectives or regulatory requirements, and little synchronization in the collection, analysis and dissemination of information. In addition, much of the data

that is collected is never analyzed or interpreted in a way that could identify targets

for further action. Most of this data is never released to the public.

There is limited ability to take action at the State level without additional resources and leadership from the Federal Government. For decades, State and local

health agencies have faced declining resources, with the result that many now face

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2 Health-Track is a project supported by The Pew Charitable Trusts through a grant to

Georgetown University. The survey, by Princeton Survey Research Associates, was conducted in

April 2000 of 1,565 registered U.S. voters and has a margin of error of ±3 percent for results

based on a full sample.

the 21st century with outdated information systems, limited laboratory access, inadequate staff training and an inability to develop viable tracking programs. The Commission’s survey of State and local agencies found a critical lack of funding for these

activities despite unprecedented public demands.

Environmental tracking for pollutants is crucial, because often the hazards can

be removed or abated before they cause harm. But such monitoring is not sufficient

by itself. Tracking actual human exposures to hazards in the environment is frequently the missing link between public health efforts to evaluate a risk nationally

and the ability to respond to a health threat in a specific community. This should

include improving national efforts to track population exposures to contaminants

and providing the investigative tools for local health officials.

Finally, there is a national leadership void, resulting in little or no coordination

of environmental health activities. As a result, public health prevention efforts are

fragmented and too often ineffective at reducing chronic and disabling diseases and

conditions.

The CDC and EPA have some basic building blocks of a tracking network in place,

but much more needs to be done. Currently 50 infectious diseases are tracked on

a national basis. We need a comparable modern network to track chronic diseases

and discover the environmental contributions to them.

THE PUBLIC’S EXPECTATIONS

The public understands that we are not doing enough to protect our communities.

A recent national survey of registered voters found that the majority are concerned

about risks to their health from pollutants in the environment, and believe that government is tracking these hazards and possible links to chronic health problems.2

When they learn that in reality there is no disease tracking, they are concerned— seriously concerned. Most Americans surveyed say that taking a national approach

to tracking environmental health should be a priority of government at all levels.

Without comprehensive environmental health tracking, policymakers and public

health practitioners lack information that is critical to establishing sound environmental health priorities. In addition, the public is denied the right to know about

environmental hazards, exposure levels and health outcomes in their communities—

information they want and have every reason to expect.

At the same time Americans demand a right to know about these hazards, they

also expect government to gather health information in a way that protects citizens’

privacy. Americans understand the importance of population-based health tracking

as well as the need to keep individual health records private. Fortunately, public

health agencies have an outstanding track record for zealously guarding the public’s

confidentiality and privacy. To ensure this continued balance, the Pew Commission

established a set of principles for Protecting Privacy and Confidentiality and Our

Environmental Health Right-to-Know (listed in the back of this report). The Commission believes that adherence to these principles will enable public health agencies to continue their traditional commitment to the confidentiality of individually

identifiable health records without significantly hampering their obligations to the

public health.

The Federal Government tracks many things all the time. It knows how many

women dye their hair every year (three out of five), but has only rough estimates

of how many people have Parkinson’s disease, asthma, or most other chronic diseases that cause four of every five deaths in the U.S. each year. We have the right

to know more.

THE PEW ENVIRONMENTAL HEALTH COMMISSION’S RECOMMENDATION—A RIGHT TO

KNOW OUR ENVIRONMENTAL HEALTH

To fill the Environmental Health Gap, the first step is to establish a tracking capacity for chronic diseases and environmental exposures that also link to hazard

data. To this end, the Commission offers the following comprehensive recommendation:

Create a federally supported Nationwide Health Tracking Network with the appropriate privacy protections that informs consumers, communities, public health

practitioners, researchers, and policymakers on chronic diseases and related environmental hazards and population exposures. This will provide the capacity to better understand, respond and prevent chronic disease in this country.

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This tracking network would be a tiered approach, with a national baseline of

high-priority disease outcomes and exposures that allows flexibility at the State and

local level for specific concerns. At a minimum, all information would include race,

ethnicity, gender, age and occupation. The blueprint for the Nationwide Health

Tracking Network involves five components of information and action:

Tier 1: National Baseline Tracking of Diseases and Exposures

This will be a nationwide network of local, State and Federal public health agencies that tracks the trends of priority chronic diseases and relevant environmental

factors in all 50 States, including Washington, DC, Puerto Rico and U.S. territories.

The information will allow us to identify populations at high risk, to examine health

concerns at the State level, to recognize related environmental factors, and to begin

to establish prevention strategies.

The Federal Government will have the responsibility to establish minimum national standards for health and exposure data collection. The State and local public

health agencies, with Federal support and guidance, would be responsible for the

collection, reporting, analysis and response.

As a starting point, the Commission identified certain diseases and exposures that

should be collected by all 50 States, based on review of the scientific literature, environmental data, reported health trends and targets identified by public health agencies. These are:

Diseases and Conditions: Birth defects; Developmental disabilities such as cerebral palsy, autism and mental retardation; Asthma and chronic respiratory diseases

such as chronic bronchitis and emphysema; Cancer, including childhood cancers;

and Neurological Diseases, including Parkinson’s, Multiple Sclerosis and Alzheimer’s. Exposures: Persistent organic pollutants such as PCBs and dioxin; Heavy metals

such as mercury and lead; Pesticides such as organophosphates and carbamates; Air

contaminants such as toluene and fine particles; and Drinking water contaminants,

including pathogens.

To translate this information into action will require a revitalization of the public

health infrastructure by providing adequately trained health professionals to collect

and interpret the data at the local, State and national levels; to respond to concerns

and to ensure a healthy environment. The information produced by the network will

be widely disseminated and easily accessible—simultaneously protecting both the

public’s right to know and individuals’ privacy.

Finally, all of these efforts will be coordinated and made available to our communities and public health researchers. To ensure the information is accessible and

useful in evaluating the progress of disease prevention efforts, a National Environmental Report Card should be jointly developed by CDC and EPA by 2003. It would

provide an annual overview of key environmental factors and health outcomes, allowing all interested parties to track progress and shape national goals. It should

be adaptable so that State and local agencies can build on this for their own Environmental Health Report Cards.

Tier 2: National Early Warning System

This early warning system would act as a sentinel to allow rapid identification

of immediate health problems, including chemical catastrophes. This would build on

the existing infectious disease monitoring network around the country by including

environmental sentinel exposures and health outcomes. The existing partnership of

hospitals, poison centers and public health agencies that make up the tracking network for outbreaks like food and waterborne illnesses and bioterrorism attacks also

should identify and track early warning signs of outbreaks of health effects that

may result from environmental factors. This would be the first stage in an environmental outbreak response capability. At minimum, the Commission recommends

that this should include: Acute sensory irritation such as eye and respiratory problems, Heavy metal poisoning, and Pesticide poisoning.

For example, if a terrorist or accidental event occurred involving misuse or release

of toxic chemicals, an early warning system with environmental capacity could

quickly recognize the episode, identify the chemical exposure and more rapidly initiate effective treatment and response.

Tier 3: State Pilot Tracking Programs

The Network also would support a coordinated series of 20 State pilot programs

in order to respond to regional concerns and test for exposures and disease outcomes

that could be tracked on a national level. These pilots would be ‘‘bellwethers’’ for

better understanding potential health and environmental problems.

Selecting appropriate health and environmental indicators is essential to the success of a national network. This requires systematic development of tracking methVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00216 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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ods that are flexible, practical and adaptable to the unique public health needs of

States.

States may be interested in developing pilot tracking capacity for certain disorders, diseases and exposures in order to strengthen the response to local health

concerns. For example, there have been increasing concerns about environmental

links to attention deficit disorder, lupus and endocrine disorders, such as diabetes.

Pilot programs covering specific health problems also would provide the Network

with a broad reach for rapidly addressing many different health concerns, while at

the same time testing methods and evaluating the need for broader tracking of certain health problems.

Tier 4: Public Health Investigative Response

Trained public health officials at the Federal, State and local level need to be able

to respond to health concerns that are identified through this network. The Federal

Government must provide States and localities with the support and capacity to assure a coordinated response to investigate threats linked to the environment.

By developing the capacity to track trends at the national level and conduct investigative surveys anywhere in the nation, the Network would be prepared to respond

to outbreaks, clusters and emerging threats. While this is a routine response for infectious outbreaks, we presently lack a similar ability to respond to chronic disease

investigations.

There are many needs for a response capacity. For example, the recent National

Academy of Sciences study on mercury and its neurodevelopmental effects on children exposed in utero underscored the need to study exposures and health outcomes

of pregnant women across America. This capability also would permit quick response at the local level to citizens’ concerns about potential problems, such as spontaneous abortions among women who live near hazardous waste sites.

Tier 5: Tracking Links to Communities and Research

The Network would depend on a strong community and scientific foundation to

ensure its relevance, effectiveness and vitality.

The public has a right to know the status of our environmental health at the national, State and local level. It is paramount that the Network be grounded in community groups so that local concerns are adequately addressed in the design of the

system, that tracking data is readily accessible and that this information is useful

for local level activities. To insure this interaction, the Network should support community-based organizations to routinely evaluate the tracking systems with regard

to individual and local needs and to ensure dissemination and interpretation of the

Network data.

ACTION STEPS NEEDED TO DEVELOP THE NETWORK

To establish this Nationwide Health Tracking Network, the Commission calls on

the Administration, Congress, the Secretary of Health and Human Services, and the

Administrator of the Environmental Protection Agency to support and implement

the following action plan:

• The Administration and Congress should provide funding support within 1 year

to develop and establish the Nationwide Health Tracking Network. This should include support and incentives for State and local agencies, healthcare providers, community-based agencies and insurers to become active partners in tracking population health and identifying, treating, and preventing health problems related to

the environment. The Commission estimates that the annual cost for a Nationwide

Health Tracking Network is $275 million.

• The Administration and Congress should guarantee public access to the Nationwide Health Tracking Network to better understand community environmental exposure and health outcome information. As part of this right-to-know requirement,

the EPA, CDC and the Surgeon General should jointly develop a National Environmental Health Report Card by 2003, which will give all Americans an annual overview of key hazards, exposures, and health outcomes in order to gauge progress and

shape national goals. The approach should be adaptable to the needs of State and

local agencies to facilitate similar report cards at the State and local levels.

• The Secretary of Health and Human Services, in collaboration with the EPA

Administrator, should by 2001:

• Designate a national lead authority for environmental health tracking to

oversee development of a nationwide network and coordinate all related

health and exposure monitoring activities, including those of EPA, CDC and

the Agency for Toxic Substances and Disease Registry (ATSDR); and

• Establish a Council on Environmental Health Tracking to work with the

HHS, EPA and State tracking leadership to set up science-based criteria,

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minimum State standards and privacy and confidentiality guidelines for a

tiered approach that supports both national priorities and State flexibility.

• Every Governor should appoint an environmental health lead in the State

health department.

• CDC/ATSDR should help build State capacity to launch the Network, monitor

the data, and respond to potential health concerns by:

• Placing an Environmental Health Investigator in every State;

• Expanding the CDC Epidemic Intelligence Service and Public Health Prevention Service to recruit and train public health officers in environmental epidemiology and tracking;

• Working with the National Association of County and City Health Officials

to develop similar leadership capacity at the local level with support and

guidance from HHS; and

• Providing technical resources to local and State public health agencies, including improvement of regional, State and local laboratory capacity to evaluate community exposures and complement State investigative abilities.

THE CASE OF LIBBY, MONTANA

Last November, Federal agencies began investigating what is believed to be the

single most significant source of asbestos exposure in the United States. Residents

of the small town of Libby, Montana, have watched for decades as neighbors,

friends, and loved ones fell ill with respiratory problems. Many died. Townspeople

thought it might have something to do with the vermiculite mine that was the

town’s largest employer from its opening in the 1920’s until it was shut down in

1990. But until the Federal health investigation this year, no one knew for certain.

As far back as the mid-1950’s, State health officials had reported on the toxic asbestos dust in the mine, but no one followed up on possible exposures or health impacts

to the town’s 2,700 residents.

It turned out that along with vermiculite, the mine also was releasing tons of

tremolite, a natural but rare and highly toxic form of asbestos, into the region’s environment. It takes 10 to 40 years for asbestos exposure to manifest in chronic, and

often fatal, respiratory diseases, including asbestosis, rare cancers and emphysema.

Therefore, early intervention as soon as potential or actual exposures were detected

could have prevented these long-term harms.

So far, nearly 200 people reportedly have died from diseases connected to the

asbestos-tainted vermiculite. Newspapers account that another 400 have been diagnosed with asbestos-related disease, including mesothelioma, a rare and fatal cancer

of the lung lining associated with asbestos exposure. Every month, more Libby area

residents are diagnosed with asbestos-related diseases. As many as 5,000 people are

expected to undergo medical testing for asbestos-related diseases by Fall 2000.

‘‘Active [tracking] of asbestos-related disease might have picked this up much

sooner, and started preventive activities 10–20 years ago,’’ said Dr. Henry Falk, administrator of the Agency for Toxic Substances and Disease Registry. In that case,

more lives would have been saved and the severity and possible spread of the outbreak reduced.

Now, public health officials have to cope not only with ensuring that Libby residents are protected from this environmental hazard, but also investigating other

sites and possible worker exposures around the country where this asbestos-laden

vermiculite was shipped, processed and used in large quantities.

Clearly, this case illustrates the tragedy of not tracking the environmental health

of our communities. Every year there are towns and cities across the United States

where residents are asking themselves, their health officials and elected leaders,

why they or their children are getting sick. Until we establish a national tracking

network capable of bringing together in a coordinated fashion the information about

environmental hazards in the community, the exposures of people, and data on

health problems, we will risk having more cases like Libby, Montana.

THE CASE OF PESTICIDES IN MISSISSIPPI

In November 1996, one of the nation’s worst and most costly public health disasters involving pesticide misuse was discovered in rural Jackson County, Mississippi.

The event in Jackson came on the heels of similar events in Ohio and Michigan.

Initially, health officials became aware of a possible problem when church members reported a noxious odor and yellowed walls in their church after fumigation.

Before long, numerous residents began complaining of various symptoms, mainly reVerDate 11-MAY-2000 11:19 Jun 28, 2002 Jkt 078066 PO 00000 Frm 00218 Fmt 6633 Sfmt 6621 H:\DOCS\78069 SENENV1 PsN: SENENV1
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sembling influenza. Suddenly, officials were facing a possible pesticide threat potentially larger than any in Mississippi’s history.

The initial investigation revealed that illegal pest control spraying in homes and

businesses had taken place, potentially exposing thousands of residents in the area

to methyl parathion (MP), an organophosphate insecticide intended for outdoor use

that attacks the central nervous system, causing nausea, dizziness, headaches, vomiting and in severe cases, death. EPA officials began considering relocation of residents and decontamination of homes at what would be a staggering cost.

Fortunately, public health officials had a health-tracking tool that was able to pinpoint who was at immediate risk and allowed for a more targeted, rapid response.

Using biomonitoring—the direct measurement of human exposure to a contaminant

by measuring biological samples, such as hair, blood or urine—health officials could

determine individuals’ exposure levels to MP. In this case, biomonitoring allowed

scientists to identify the residents who were most at risk and prioritize evacuation

and cleanup in the most dangerous situations, not just every house suspected.

Armed with this information, EPA, ATSDR and State health officials were able

to implement an effective health defense plan. In Mississippi and Alabama, over

1,700 residents had to be temporarily relocated and nearly 500 homes and businesses had to be decontaminated at a cost of almost $41 million. While no one died

or was seriously injured in the short term, many of the early victims were

misdiagnosed with the influenza virus—a fact that only underscores the need for a

nationwide health tracking network to monitor environmental threats.

A national early warning system for pesticide poisoning might have detected this

problem sooner and led to a quicker halt of the illegal pesticide applications in other

States. In turn, this would have prevented widespread exposures, and in some

cases, evacuations, and higher human and financial costs. This case also points to

the importance of another feature of a network—the laboratory resources and other

infrastructure to conduct rapid and effective biomonitoring to protect the health of

our communities.

THE COMMISSION’S HEALTH TRACKING ANALYSIS

In the 1970’s and 1980’s, the nation’s environmental regulatory infrastructure was

built, fueled by the passage of Federal laws aimed at cleaning up the environment.

Unfortunately, these same laws failed to support core public health functions of environmental health. More than a decade ago, the Institute of Medicine report, The

Future of Public Health sounded a warning, saying the Nation had ‘‘lost sight of its

public health goals’’ and allowed the public health system to ‘‘fall into disarray.’’

With diminishing authority and resources, public health agencies at all levels of

government grew detached from environmental decisionmaking, and the infrastructure failed to keep pace with growing concerns about health and environment.

The Commission’s study of health tracking found that today, there still is no cohesive national strategy to identify environmental hazards, measure population exposures, and track health conditions that may be related to the environment. Just as

important, there is a national leadership void, resulting in little or no coordination

of environmental health tracking activities.

The few existing environmental health tracking efforts are a widely varied mix

of programs across multiple Federal, State and local agencies. These programs have

evolved, often in isolation from each other, to respond to disparate regulatory mandates or program needs. Unfortunately, there are no identifiable linkages between

hazard, exposure and outcome tracking, and there is limited coordination in the collection, analysis, or dissemination of information. The combination of lack of leadership, planning, coordination and resources have left important questions about the

relationship between health and the environment unanswered. For example:

• Are environmental exposures related to clusters of childhood cancer and autism?

• What are the impacts of pesticide exposure on children’s health?

• What proportion of birth defects is related to environmental factors?

• Are changes in the environment related to the dramatic increase in asthma?

• Are adult-onset diseases like Parkinson’s and Alzheimer’s related to cumulative

environmental exposures?

• Are there increases in Systemic Lupus Erythmetosis (SLE) and multiple sclerosis (MS) in communities with hazardous waste sites?

• Are learning disabilities related to environmental factors?

• Is attention deficit disorder (ADD) related to exposures that occur in a child in

the womb?

• Are endocrine disrupting pollutants in the environment related to the increasing incidence of breast and prostate cancers?

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• How does particulate air pollution increase the risk of death in the elderly?

• What is the relation of diet and lifestyle to chronic disease?

With the exception of childhood blood lead screening, there have been few systematic efforts to track individual levels of exposure to any hazardous substance. CDC

and EPA have developed the methodologies for biological and environmental monitoring of a wide range of substances. However, inadequate support and inconsistent

funding have restricted their application and availability. These findings were underscored in a recent report of the U.S. General Accounting Office that calls for a

long-term coordinated strategy to measure health exposures to pollutants. With the

goal of improving the public health response to environmental threats, the Pew Environmental Health Commission conducted an examination of the national capacity

for tracking environmental hazards, exposures and health outcomes. The study had

the following objectives:

• To examine the existing public health capacity for environmental health tracking;

• To identify the environmental health priorities of the nation’s public health

agencies;

• To examine the coordination among agencies, healthcare providers and researchers on environmental health tracking efforts; and

• To develop recommendations for implementing an effective national strategy for

environmental health tracking.

The complete study is available at the Commission’s website: http://

pewenvirohealthJhsph.edu.

A LOOK AT NATIONAL CAPACITY FOR TRACKING

‘‘Tracking’’ is synonymous with the CDC’s concept of public health surveillance,

which is defined as ‘‘the ongoing, systematic collection, analysis and interpretation

of health data essential to the planning, implementation, and evaluation of public

health practice, closely integrated with the timely dissemination of these data to

those who need to know (Thacker et al., 1988).’’ Effective environmental health

tracking requires a coordinated approach that identifies hazards, evaluates exposures, and tracks the health of the population.

Figure 1 provides a schematic representation of the steps in environmental health

tracking.

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3This analysis includes both suspected and recognized toxicants. An agent is listed as a recognized toxicant if it has been studied by national or international authoritative and scientific regulatory agency hazard identification efforts. Suspected agents are included if they are shown to

have target organ toxicity in either humans or two mammalian species by a relevant route of

exposure.

Hazard Tracking

What are the hazards to health in our environment? Environmental hazard tracking identifies potential hazards and examines their distribution and trends in the

environment. It is an essential component in prevention strategies, particularly in

the absence of definitive knowledge about the health impacts of environmental exposures. EPA and the State environmental agencies have primary responsibility for

hazard tracking, which includes networks for data collection on water and air quality, environmental emissions, hazardous and radioactive waste generation, storage,

and disposal, and the use of toxic substances and pesticides. These efforts are the

foundation of our national environmental protection efforts.

The EPA Toxics Release Inventory (TRI) is an example of an effective and publicly

accessible hazard tracking program. The TRI contains data on annual estimated releases of over 644 toxic chemicals to the air and water by major industries. Data

are reported as annual total releases by chemical. TRI is an innovative way to provide communities with information about the nature and magnitude of pollution in

their neighborhoods. While there are many pollution sources not covered and a 2-

year time lag in making the data public, TRI provides the best snapshot of local

and national environmental releases of key toxins by major industries.

The Commission analyzed the 1997 TRI data to determine the ranking of 11 categories of associated possible toxicological effects (Table 1)3. Substances with potential respiratory effects were released in the largest amount in 1997. Neurotoxicants

and skin toxicants were next highest in total pounds released. Actual population exposures to these toxicants are not currently tracked and their relationship to disease

is unclear. This approach to hazard tracking provided the Commission with an important starting point for identifying needs for tracking exposure and health outcomes.

Table 1.—Ranking of Toxicants based on 1997 Toxics Release Inventory (TRI)3

Types of health effects Ranking based on 1997 TRI

release

Total Air & Water Releases

(pounds)

Respiratory .............................................................................................. 1 1,248,977,984

Neurologic ............................................................................................... 2 1,211,458,945

Skin or sense organ ................................................................................ 3 1,109,718,312

Gastrointestinal or liver .......................................................................... 4 1,086,264,404

Cardiovascular or blood .......................................................................... 5 823,375,664

Developmental ......................................................................................... 6 811,686,192

Reproductive ........................................................................................... 7 498,142,705

Kidney ...................................................................................................... 8 488,554,582

Immunological ......................................................................................... 9 234,713,891

Carcinogenesis ........................................................................................ 10 209,271,142

Endocrine ................................................................................................ 11 173,331,065

Reference: Environmental Defense Scorecard (www.scorecard.org)

While the Nation has developed a hazard tracking network, little has been done

to link these findings to efforts to track actual population exposure levels or track

the health of communities where these releases occur.

EXPOSURE TRACKING

Are communities being exposed to harmful levels of pollutants? Understanding exposure levels is essential in understanding and preventing environmentally-related

disease. Ideally, exposure tracking includes the systematic measurement of harmful

environmental agents to which individuals are exposed. Exposure tracking also

helps evaluate the effectiveness of public health policies. It should be closely coordinated with ongoing hazard tracking.

The National Health and Nutrition Examination Survey (NHANES) illustrates a

national approach to exposures. The survey examines a nationally representative

sample of about 5,000 Americans each year. Environmental exposure measurements

are only one part of NHANES, a broad-based national survey of nutrition and

health.

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One of its strengths is that it allows policymakers to evaluate public health intervention policies. For example, NHANES data showed a drop in average blood lead

levels between 1976 and 1980, a period that corresponded with the removal of lead

from gasoline. These data enabled policymakers and regulators to determine that

the ban on leaded gasoline was effective. NHANES has also provided a national profile of exposure to environmental tobacco smoke, thus supporting initiatives to reduce exposures.

Unfortunately, NHANES is not designed to track exposures at the State and local

level, and so does little to help public health professionals in responding to a community’s local concerns about a possible cluster of health problems related to the

environment.

There is potential for progress, however, given advances in sampling and detection for a broad array of human monitoring techniques. But the failure to develop

and support a national capacity for exposure tracking and coordinate with ongoing

environmental hazard tracking has left a large gap in our approach to environmental protection. The GAO underscored the need to close this gap in a report that

called for a national approach to measuring Americans’ exposures to pollutants in

order to strengthen prevention efforts.

HEALTH OUTCOME TRACKING

Are environmental exposures and population exposures related to increased disease? Understanding trends in the incidence of diseases that may be related to environmental exposures is fundamental to protecting public health. The Commission

reviewed a number of national health outcome data bases to examine the availability of information on diseases that may be linked to the environment. Three are

particularly worth noting:

• The National Hospital Discharge Survey (NHDS) conducted since 1965 is a continuous survey based on a sampling of patient medical records discharged from hospitals. The survey collects demographic information, admission and discharge dates,

diagnoses and procedures performed.

• The National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) are national surveys designed to

provide information on the types and uses of outpatient health care services for office-based physicians, emergency rooms and hospital outpatient centers, respectively. This allows us to measure the number of doctor visits pertaining to specific

health concerns that may be environmentally-related, such as asthma.

• The National Health Interview Survey (NHIS) is a multistage sample designed

to represent the civilian, non-institutionalized population in the United States. The

survey is conducted by the CDC’s National Center for Health Statistics (NCHS). It

has been conducted continuously since 1957. Due to budget reductions, the survey

was redesigned in 1997 to track a much more limited set of health problems.

These data bases are not designed to describe either State and local communities

or environmentally-related health outcomes, but they provide warning signals or

‘‘big picture’’ level information on the prevalence and trends of health outcomes in

need of closer study. For instance, the NHIS data show the 10-year national trend

in rising rates of asthma and clearly established it as an epidemic chronic disease.

From 1986–1995, the surveys of about 5,000 people annually found that endocrine

and metabolic disorders increased by 22 percent, while neurological and respiratory

disease increased by 20 percent.

However, the role of the environment in these health outcomes remains unknown.

Without an adequate tracking process, such links are difficult to clarify. This type

of snapshot data does not provide the full panoramic view needed by health professionals to identify clusters, uncover risks or guide the prevention programs that

make people healthier.

A LOOK AT STATE AND LOCAL CAPACITY FOR TRACKING

The Commission interviewed environmental health leaders from public health

agencies in the 50 States and a sample of local health departments as part of its

examination of State and local public health capacity for environmental health

tracking. While some States and localities have well-developed programs, others

have virtually no capacity for environmental health tracking. Overall, the survey

found that the State and local infrastructure for environmental health tracking has

been neglected; with the result that today many have outmoded equipment and information systems, and lack technical and laboratory support. As a result, fundamental information about community health status and environmental exposures is

not available.

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In a Commission survey of State health officials, it was found that while over

three quarters of State health departments track blood lead levels, biomonitoring for

other substances, including hazardous pesticides, is very limited. Only about 25 percent said their departments can measure human exposure to environmental contaminants by monitoring the air in a person’s breathing zone, an important investigative capability in responding to a health threat. Most of the chronic diseases and

health problems that the Commission identified as priorities are not being tracked.

Even for health problems that most States do track—cancer, infectious disease

and birth defects—tracking efforts have significant problems. For instance, an earlier Pew Commission report found that while 33 States have birth defect registries,

the majority was inadequate in terms of generally recognized standards for an effective tracking program. Another Commission study found similar gaps in State efforts.

Finally, information that is tracked according to current standards is often not usable for intervention, policy, and scientific purposes. First, State data sets commonly

lack enough samples from more refined geographic areas to make it possible to characterize health hazards, exposures and outcomes at the local level. In addition, the

Commission’s survey found that many departments lack the staffing, expertise, or

technology to analyze and in some cases even to access existing data sets relevant

to local environmental health. Rather, local health practitioners find themselves focusing on enforcement and reacting to complaints. Another concern is the absence

of national standards to ensure consistent data collection.

State and local public health agencies are the foundation of the nation’s health

tracking capacity. The first requirement for an effective, integrated network is

strong State and territorial public health organizations with linkages to strong local

health agencies, as well as Federal agencies, healthcare providers, State environmental agencies and communities. While the States and localities may have the

will, this vision of a Nationwide Health Tracking Network will only come together

with the support, guidance and leadership of the Federal Government.

THE TIME IS RIGHT

Advances in hazard identification, exposure assessment health outcome data collection and information technology provide unprecedented opportunities for advancing

tracking and improving our understanding of the environment and health.

Despite the challenges, there are unprecedented opportunities to strengthen the

national infrastructure for environmental health information, expand public access

to this important information and protect the privacy of individuals. New technologies in biomonitoring have the potential to transform the nation’s capacity to

track exposures to pollutants and understand their impacts on health. Advances in

communication and information technology have expanded opportunities for public

access and given us new tools to analyze, map and disseminate health data. New

technology also can improve safeguards to protect the confidentiality of identifiable

personal health information. We have better tools than ever before to meet the public health missions of protecting Americans’ health and privacy.

New initiatives at CDC and EPA have the potential to address tracking needs, including information technology development and State and local capacity-building,

along with exposure measurement, interagency coordination and public access to

health information. Opportunities exist, but we need to do more to advance the

science and support for inclusion of environmental health components.

The integration of public health information and tracking systems is listed as a

top priority of the CDC. Spurred by concerns about bioterrorism, a Health Alert

Network is being developed to improve tracking and information sharing on key infectious diseases and priority chemical and poison agents that may be used in terrorist attacks. In addition, there are several other data systems being developed by

CDC and EPA that could be building blocks in a national tracking network. However, national vision and leadership to bring this all together on behalf of environmental health issues will be required if any of these current initiatives are to become building blocks for a national environmental health tracking network.

Environmental health tracking will give us an unprecedented opportunity to ensure

our environmental policies are successfully reducing exposures in our communities

and safeguarding public health.

Reduction of risks from hazards in the environment and people’s exposures and

the improvement of public health are fundamental goals of environmental regulations. At present, tracking activities are focused primarily on hazard identification

for regulatory permitting and enforcement. Improved capacity to measure peoples’

exposures to hazards and track health outcomes will strengthen the scientific basis

for these important policy decisions. In addition, environmental health tracking will

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give practitioners and policymakers better indicators of progress, and assure that

benefits of healthier communities continue well into the future.

The public increasingly wants and demands more credible environmental health

information so that they can make independent and fully informed decisions. The

Internet explosion has further fueled this desire.

Recent public opinion research confirms that Americans want to have access to

national, State and community level health data. In fact, they are incredulous when

informed that health tracking information is not readily available. The Internet now

allows the public quick and highly accessible information on most facets of their

lives. There is a widespread belief that health tracking information should be and

needs to be available to the public. With growing concerns about environment and

health, this public demand should help support the Network.

Recently, a group of environmental health leaders held a summit co-sponsored by

the Pew Environmental Health Commission, the Association of State and Territorial

Health Officials, the National Association of County and City Health Officials, and

the Public Health Foundation at which they strongly endorsed the Commission’s efforts to strengthen environmental health tracking.

Summit participants endorsed a tiered approach to national environmental health

tracking that is consistent with the Commission’s five-tier recommendation. It includes: national tracking for high-priority outcomes and exposures; a sentinel network to identify acute and emerging hazards; a coordinated network of pilot regional, State and local tracking programs; and aggressive research efforts to guide

and evaluate tracking.

WHY WE NEED A HEALTH TRACKING NETWORK NOW

Earlier this year, a scientific breakthrough was announced that has incredible potential to help us understand the links between people, their environment and behaviors, genetic inheritance and health.

As researchers begin to apply this new genetic knowledge to the study of disease,

we will have more information than ever before to use in revealing the connections

between environmental exposures, people’s behaviors and genetic predisposition to

health problems. But only if we have the basic information about what is going on

in our communities—the hazards, the exposures and health problems that Americans are experiencing.

The ‘‘building blocks’’ of knowledge provided by the Nationwide Health Tracking

Network will enable scientists to answer many of the troubling questions we are

asking today about what is making us sick. The Network will provide the basis for

communities, health officials, businesses and policymakers to take action for making

this Nation healthier. The result will be new prevention strategies aimed at reducing and preventing many of the chronic diseases and disabling conditions that afflict

millions of Americans.

The Commission is calling upon our national leaders to take the steps outlined

in this report, and with a minimal investment, revitalize our nation’s public health

defenses to meet the challenges of this new century. It is time to close America’s

environmental health gap.

THE PEW COMMISSION PRINCIPLES FOR PROTECTING PRIVACY AND CONFIDENTIALITY

AND OUR ENVIRONMENTAL HEALTH RIGHT-TO-KNOW

Without a dynamic information collection and analysis network, public health

agencies would be ineffective in protecting health. The Commission recognizes the

substantial benefits that accrue from personally identifiable health information and

provides these principles to assist agencies in addressing privacy and confidentiality

concerns associated with collection and use of this information in environmental

health investigations.

The Commission is aware of the sensitivity of individually identifiable health information and is committed to protecting the privacy of such information and to preventing genetic and other sensitive health information from being used to discriminate against individuals. The Commission believes that the values of public health

activities and privacy must be reasonably balanced.

The Commission also is aware of the need to increase public confidence in our nation’s public health system by making nonidentifiable health information and trends

widely available and providing access to the analyses of collected data. This also will

serve to better inform communities about the value of public health data.

The Commission believes that adherence to the following principles will enable

public health agencies to honor their traditional commitment to the confidentiality

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of individually identifiable health records without significantly hampering execution

of their obligations to the public health:

• Recognize that it is largely possible to balance the protection of individually

identifiable health information and the acquisition, storage and use of that information for environmental health purposes;

• Protect individuals’ privacy by ensuring the confidentiality of identifiable health

information;

• Disclose only as much information as is necessary for the purpose in cases

where the public health requires disclosure of identifiable information;

• Require that entities to which identifiable information has been disclosed take

the same measures to ensure confidentiality that are taken by the disclosing agency;

• Utilize the best available organizational and technological means to preserve

confidentiality of information (includes such measures as limiting access, staff training, agreements and penalties as well as updating of security measures);

• Provide individuals the opportunity to review, copy and request correction of

identifiable health information.

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