## American Thoracic Society Comments on EPA Proposed Carbon Emissions Limits for Existing Power Plants Presented by Ivor Douglas, MD July 29 2015 Denver, CO
I am Dr. Ivor Douglas and I am the Chief, Pulmonary Sciences & Critical Care Medicine Director; Medical Intensive Care; Denver Health Associate Professor, University of Colorado. I am also the chair of the American Thoracic Society Health Policy Committee. Today, I am speaking on behalf of the American Thoracic Society, a medical professional organization of over 14,000 physicians, scientists nurses and allied health professional dedicated to the detection, prevention treatment and cure of respiratory, critical care and sleep related illness. The American Thoracic Society wishes to express our strong support for EPA's proposed carbon emissions standards for power plants.
The research documenting the reality of climate change is comprehensive and compelling. The evidence supporting anthropogenic contribution to climate change is equally clear. As a practicing clinician, I am already seeing some of the health effects of global climate change right here in Denver. The earlier arrival of spring is impacting the health and well being of allergy suffers, the higher summer temperatures and the accompanying code orange and code red air pollution days is adversely effecting patients with asthma, COPD and other respiratory conditions. While my observations are anecdotal at best, they fit the pattern of predicted adverse health impacts associated with climate change. — A -5 A

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## The ATS recently published in the Proceedings of the American Thoracic Society a A) LI-A ` P N

-RIcIsS workshop report: Respiratory Health Effects of Global Climate Change. I will leave a copy of that report with the panel. The workshop report explores the respiratory health effects of global climate change, which include:

• changing pollen releases impacting asthma and allergic rhinitis,

• heat waves causing critical care—related illnesses,

• climate-driven air pollution increases exacerbating asthma and chronic obstructive pulmonary disease,

• desertification increasing particulate matter (PM) exposures,

• and climate-related changes in food and water security impacting infectious respiratory disease through malnutrition (pneumonia, upper respiratory infections).
Because of the strength of the existing data from multiple scientific disciplines, trends in weather patterns, sea temperatures and ice measurements around the globe, and the breadth and severity of likely climate-forced human health issues, the ATS strongly urges EPA to move forward with the proposed carbon emissions limits from existing power plants.

## Source: Peng RD, Bobb JF, Tebaldi C, McDaniel L, Bell ML, Dominici F 2011. Toward

a Quantitative Estimate of Future Heat Wave Mortality under Global Climate Change. Environ Health Perspect 119:701-706. http://dx.doi.org/10.1289/ehp.1002430

# American Thoracic Society Documents

An Official American Thoracic Society Workshop Report: Climate Change and Human Health

Kent E. Pinkerton, William N. Rom, Muge Akpinar-Elci, John R. Balmes, Hasan Bayram, Otto Brandli, John W. Hollingsworth, Patrick L. Kinney, Helene G. Margolis, William J. Martin, Erika N. Sasser, Kirk R. Smith, and Tim K. Takaro; on behalf of the American Thoracic Society Environmental Health Policy Committee

THIS OFFICIAL WORKSHOP REPORT WAS APPROVED BY THE AMERICAN THORACIC SOCIETY BOARD OF DIRECTORS, JANUARY 2012

CONTENTS Executive Summary Introduction Methods Respiratory Health Impacts of Climate Change Heat Research Needs Air Pollution Research Needs Natural (Seasonal) Research Needs Mitigation and Adaptation Recommendations for Clinicians and Researchers Recommendations for Mitigation and Adaptation Issues Affecting Low-Resource Countries Priority Research Infrastructure Needs Monitoring and Alert Systems Summary of Key Findings

This document presents the proceedings from the American Thoracic Society Climate Change and Respiratory Health Workshop that was held on May 15, 2010, in New Orleans, Louisiana. The purpose of the one-day meeting was to address the threat to global respiratory health posed by climate change. Domestic and international experts as well as representatives of international respiratory societies and key U.S. federal agencies convened to identify necessary research questions concerning climate change and respiratory health and appropriate mechanisms and infrastructure needs for answering these questions. After much discussion, a breakout group compiled 27 recommendations for physicians, researchers, and policy makers.These recommendations are listed under main issues that the workshop participants deemed of key importance to respiratory health. Issues include the following: (1) the health impacts of climate change, with specific focus on the effect of heat waves, air pollution, and natural cycles; (2) mitigation and adaptation measures to be taken, with specialemphasis on recommendations for the clinical and research community; (3) recognition of challenges specific to low-resource countrieswhen coping with respiratory health and climate change; and (4) priority research infrastructure needs, with special discussion of international needs for cooperating with present and future environmental monitoring and alert systems.
Keywords: climate change; respiratory; pollen; greenhouse gases; cc:benefits

Proc Am Thorac Soc Vol 9, !is. 1, pp 3-8, Mar 15, 2012 Copyright © 2012 by the American Thoracic Society 10.1513/pats.201201-015ST Internet address: www.atsjoumals.org EXECUTIVE SUMMARYClimate change is due to average global surface temperature increase over the past several decades from greenhouse gases in thetroposphere reflecting infrared radiation back to the earth's surface. Greenhouse gases are dominated by CO2 , but important contributions come from methane, nitrous oxide, carbon black,ozone, and small amounts of chemicals, including hydrofluorocarbons, hydrochlorofluorocarbons, and others. Importantly, the recent increased greenhouse gases chronicled by reports of the Intergovernmental Panel on Climate Change are anthropomorphic in origin. The year 2010 tied 2005 as the warmest year since records began in 1880 and was the 34th consecutive year with average temperatures above the twentieth-century average. The National Oceanic and Atmospheric Administration chronicled seven rising indicators of climate change: (1) air temperature over land, (2) seasurface temperature, (3) air temperature over oceans, (4) sea level, (5) ocean heat, (6) humidity, and (7) tropospheric temperature in the active weather layer of the atmosphere closest to the Earth's surface. Three indicators were declining: (1) Arctic sea ice, (2) glaciers, and (3) spring snow cover in the Northern hemisphere. How will a warming world affect pulmonary, critical care, andsleep physicians? Before the 2010 American Thoracic Society International Conference, the Workshop organizers invited national and international experts to consider these questions and make the following recommendations for research and investigation:

• Epidemiology: Explore how climate changes in heat, humidity, precipitation, and extreme weather events impact the distribution of respiratory disease.

• Heat Stress and Adaptation: Understand how extreme heat affects the individual and the community.

• Vulnerable populations: Increase knowledge of how climateforced heat increases impact the young, impoverished, and those with chronic cardiorespiratory conditions.

• Human Exposure Studies: Conduct chamber studies to understand how the human body responds to airborne exposures in conjunction with heat.

• Climate-Forced Air Pollution: Examine how climate change influences the production, distribution, and interaction with air pollutants, especially heat and ozone.

• Biomass Fuel Cooking: Charcoal, animal matter, and plant matter in indoor cooking and heating increase mortality fromchildren's respiratory infections and chronic obstructive pulmonary disease; explore the impact and control on the release of black carbon into the atmosphere.4 PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY VOL 9 2012

• Seasonal Disease Cycles: Understand how changing climate will impact the seasonal pattern of infectious diseases involving the respiratory system.

• Human Migration: Study how climate change effects on water and food will potentially impact human migration patterns and conflict causing respiratory health challenges (e.g., tuberculosis).

• Allergy: Explore how changing weather patterns, increased CO2 , heat, and changing temperate zones will impact human exposures to pollen in terms of intensity, allergenicity, duration of growing seasons, and expanded pollen range.

• Vector- and Zoonotic-Borne Disease: Investigate how respiratory health will be impacted by climate-induced vectorborne disease and their shifting ranges (e.g., dengue fever).

• Mold: Study how changes in humidity, precipitation, and extreme weather events will impact respiratory exposures to mold, especially those brought on by flooding.

• Desertification: Understand how climate-forced desertification and the long-term transport of mineral dusts will impact respiratory health.

• Forest Fires: Recognize how climate change will impact the frequency and intensity of forest fires and their likely impact on human exposures to respiratory irritants.In addition, the Workshop participants suggested opportunities to mitigate the adverse effects of Climate Change through a variety of approaches:

• Educational Outreach to Clinicians and Public Health Practitioners: Provide information about climate change and itspotential impacts on respiratory health. Clinicians and public health providers can influence public opinion and policy makers on how climate change affects human health.

• Climate Change Research Centers: Develop and fund climate change and Human Health Research Centers. TheseCenters should adopt a multidisciplinary approach and include cross-disciplinary training based in public health and medical schools to foster scientific skills sets for the study of climate change and human health.

• International Research Collaboratives: Incorporate into the mission of existing international research collaboratives the study of how climate change affects human health.

• Build Healthy Buildings and Community: Construct energyefficient healthy buildings located in communities designed to foster exercise and minimize exposure to vehicular emissions.

• Alternative Energy: Identify and protect against any respiratory health risks that new alternative energy processes possess (e.g., acetaldehyde, acrolein).

• Monitoring and Alert Systems: Develop national air quality, pollen, and weather-alert systems; develop potential of personal technologies to alert individuals and communities of climate-related health threats.We, as pulmonary physicians and scientists, currently have minimal capacity to respond to climate change and its impacts onhealth. The extent to which climate change influences the prevalence and incidence of respiratory morbidity remains largely undefined. However, evidence is increasing that climate change doesdrive respiratory disease onset and exacerbation as a result of increased ambient and indoor air pollution, desertification, heat stress, wildfires, and the geographic and temporal spread of pollens, molds, and infectious agents associated with increased allergenicity, temperatures, and atmospheric concentrations of carbon dioxide (1-6). The American Thoracic Society (ATS) Climate Change and Respiratory Health Workshop was held in New Orleans, Louisiana, on May 15, 2010. The purpose of the 1-day meeting was to address the threat to respiratory health posed by climate change (7-9). Domestic and international experts convened to identify necessary research questions as well as appropriate research mechanisms andinfrastructure needs. The ultimate goal was to present recommendations for the health sector to implement efficient approaches tolimit the respiratory health impact of climate change. The proceedings from the workshop are presented below.

METHODSThe workshop cochairs, in consultation with members of the American Thoracic Society's Environmental Health Policy Committee, invited U.S. and international experts on respiratory health andclimate change to participate in the workshop. International respiratory societies and key U.S. federal agencies were also represented.All members of the writing committee submitted Conflict of Interest statements prior to the workshop. No important conflicts of interest were identified or became apparent during the workshop. After viewing a series of expert presentations on the respiratory health effects of climate change, participants were assigned to breakout groups to discuss key research questions and needs. A facilitator and reporter were assigned to each breakout group.All participants were encouraged to express opinions and recommendations. The discussions of the breakout groups were presented to the entire workshop for additional input and thentranscribed, collated, and summarized in this manuscript. Additional recommendations were formulated during teleconferencesamong writing committee members after the workshop. Any disagreement was resolved by discussion and consensus. All workshop attendees had the opportunity to review and revise the manuscript prior to submission. A summary of the methodology is presented in Table 1.

RESPIRATORY HEALTH IMPACTS OF CLIMATE CHANGEPreliminary research has shown climate change has potentially direct and indirect adverse impacts on respiratory health. Publishedstudies have linked climate change to increases in respiratory disease, including the following: changing pollen releases impacting asthma and allergic rhinitis, heat waves causing critical care—related diseases, climate-driven air pollution increases exacerbating asthmaand chronic obstructive pulmonary disease, desertification increasing particulate matter (PM) exposures, and climate-related changes in food and water security impacting infectious respiratory disease through malnutrition (pneumonia, upper respiratory infections). There has been concern about increased aeroallergens and mold exposure associated with allergy and respiratory health after the flooding that occurred from Hurricane Katrina, which deluged the southern United States in 2005 (10-15). The impact of climate change on pollen and mold spores and allergic respiratory diseases is of growing concern (16, 17). Workshop participants suggested links between climate-forced migration, crowding, and tuberculosis, as evidenced in large areas of Africa as deserts spread in this continent. Climate change may also cause seasonal shifts impacting seasonal flu patterns (7, 18, 19). Although all of these factors were discussed at the workshop, the most serious and direct health risk of climate change was believed tobe heat-related disease resulting from increased frequency and severity of heat waves, which have been demonstrated to increase morbidity and mortality (20). Higher surface temperatures, especially in developed urban areas, promote the formation of ground-level5

American Thoracic Society Documents

TABLE 1. METHODOLOGY

Methods Checklist Yes No

Panel assembly Included experts from relevant clinical and nonclinical fields Included individuals who represented patients and society at large Included methodologist with appropriate expertise (documented expertise in development of conducting systematic reviews to identify the evidence base and development of evidence-based recommendations) Literature review Performed in collaboration with a librarian Searched multiple electronic databases Reviewed reference list of retrieved article Evidence synthesis Applied preselected inclusion and exclusion criteria Evaluated included articles for sources bias Explicitly summarized benefits and harms Used PRISMA1 to report systematic review Used GRADE to describe quality of evidence Generation of recommendations Used GRADE to rate the strength of recommendations x
x

x
x

x x

x

x
x

x
x

Definition of abbreviations: GRADE = Grades of Recommendation Assessment, Development and Evaluation; PRISMA1 = Preferred Reporting Items for Systematic Reviews and Meta-Analyses 1.

ozone (4,21), and ozone exposure has been linked to exacerbationsof chronic obstructive pulmonary disease, asthma, idiopathic pulmonary fibrosis, lung cancer, and acute lower respiratory infection.During heat waves, health effects can be due to combined exposures to excessive heat and air pollution. A recent analysis of European heat waves (1990-2004) measured higher respiratory than cardiovascular mortality, although specific causes could not be determined (22). The impacts of climate change on surface ozone, 502, and NO„ concentrations in the United States and elsewhere have been examined in numerous recent studies (23-28), with potentially important morbidity and mortality implications for human health (29-32). In addition, as the demand for air conditioning increases during heat waves, power consumption and the production of fine PM increases, which is a contributor to cardiopulmonary disease. Workshop participants identified key climate change factors— heat, air pollution, and airborne allergens—that they believedpresent significant challenges to respiratory health worldwide. Corresponding research needs and questions for each climate change factor were discussed. The results of the discussion are presented below.

Heat Research Needs

• Epidemiology: Explore how climate changes in heat, humidity, precipitation, and extreme weather events impact the distribution of respiratory disease.

• Heat Stress and Adaptation: Understand how increasedheat, particularly extreme heat, affects a community's ability to adapt.

• Vulnerable Populations: Increase knowledge of how climateforced heat increases impact vulnerable populations (e.g.,old, young, impoverished, those with chronic cardiorespiratory conditions, or chronic disease overall).

Air Pollution Research Needs

• Human Exposure Studies: Conduct chamber studies to understand how the human body responds to airborne exposures in conjunction with heat.

• Climate-Forced Air Pollution: Examine how climate change influences the production and distribution of air pollutants (e.g., how increased ambient temperatures will amplify known hazardous exposures or modify the effect of known exposure-outcome relationships).

• Co-benefits and Trade-offs: Elucidate the interactions between air quality control measures, sustainable development, and climate change mitigation and adaptation measures. Topics include cobenefits research (biomass fuel cooking/heating alternatives), PM reduction and its impact on the atmospheric energy balance, air pollution and cloud formation, urban planning, renewable energy, and energy consumption.

Natural (Seasonal) Research Needs

• Disease Cycles: Understand how changing climate will impact the pattern of infectious disease (i.e., flu, colds).

• Human Migration: Study how climate-forced changes in water/food security, risk of extreme weather events, and heat will potentially impact established and novel human migration patterns as well as how communities and regions will likely adjust to these migration patterns in terms of health care and respiratory disease, such as tuberculosis.

• Allergy: Explore how climate change (increased atmospheric CO2 concentrations and temperatures) will impact human exposures to pollen and mold spores in terms of intensity,allergenicity, duration, and timing of growing and pollenproduction seasons and changed flora and pollen range.

• Vector- and Zoonotic-Borne Disease: Investigate how respiratory health will be impacted by climate change-induced vector-borne diseases and their shifting ranges.

• Humidity, Precipitation, and Mold: Study how climate changes in humidity, precipitation, and extreme weather events will impact respiratory exposures to mold, especially those brought on by flooding of dwellings or high humidity.

• Desertification: Understand how climate-forced desertification and the long-term transport of mineral dusts will impact respiratory health.

• Forest Fires: Recognize how climate change will impact the frequency and intensity of forest fires and its likely impacton human exposures to respiratory irritants along with effective adaptations to lessen or avoid such effects.6 PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY VOL 9 2012

MITIGATION AND ADAPTATIONEfforts to prevent and prepare for climate change include mitigation strategies, defined as actions to limit further climate change byreducing the production of greenhouse gases, and adaptation strategies, defined as actions to lessen adverse impacts by preparing forinevitable changes in climate and climate variability (3, 33). Generally, mitigation and adaptation strategies are being developed independently of each other, and to date, the public health and clinical perspective has not been well represented (34). In this context, the following broad-based and specific recommendations relevant to respiratory health were proposed. Each recommendation has elements that can be implemented in the short term as well as aplanning component for making changes that occur over the medium to longer term (5-10 and 10-100 year time frames).

Recommendations for Clinicians and Researchers

• Educational Outreach to Clinicians and Public Health Practitioners: Provide information about climate change and its potential impacts on respiratory health (11, 18). Medical societies should develop guidelines for medical alerts. Public health measures need to be in place to reach vulnerable populations during specific climate change—related events, such as heat waves or severe air pollution episodes and other extreme weather events (e.g., extreme rainfall and floods) or rising sea levels and storm surges that challenge or threaten community infrastructure. This might include but not be limited to information on how to get to cooling centers, optimal dosing for medications that affect thermoregulation, and access to care (e.g., planning surge capacity).

• Cross-Disciplinary Training Programs: Develop and fund cross-disciplinary training programs based in public health and medical schools to foster the scientific skills sets needed to understand the interactions between climate change andhuman health. Encourage clinicians and researchers to participate in the development of mitigation and adaptation strategies and share their expertise with policy makers at the local, state, federal, and international levels.

• Climate Change Research Centers: Develop and fund climate change/human health research centers. These centersshould adopt a multidisciplinary approach to studying interactions between human health links and climate change.

• International Research Collaboratives: Incorporate into the mission of existing international research collaboratives the study of how climate change affects human health.

Recommendations for Mitigation and Adaption

• Behavior: Understand the factors that impact the capacity and willingness to adopt effective greenhouse gas—mitigationstrategies by individuals and communities and design educational programs to increase communities' awareness of the health benefits (35).

• Power of Clinical Community: Clinicians and health care providers influence the public and policy makers. They should be proactive in identifying and contributing to solutions and capitalize on that power by creating venues and pathways by which their voices can be heard.

• Build Healthy Buildings and Community: Construct energyefficient, healthy buildings (e.g., include adequate ventilationto prevent/reduce indoor mold-fostering moisture and exposure to air pollution, natural light, air conditioned spaces) located in communities designed/modified to foster exercise and minimize exposure to vehicular emissions (36). • Increase Respiratory Resilience to Environmental Stressors: Improve overall population health (e.g., address the globalobesity epidemic in developed countries and nutritional deficiency in developing countries) and reduce exposure to ambient and indoor air pollution.

• Alternative Energy: Identify and protect against any respiratory health risks that new, alternative energy processes possess.

ISSUES AFFECTING LOW-RESOURCE COUNTRIES Although all countries will be affected by climate change, workshop participants acknowledged that low-resource countries are uniquely vulnerable to the respiratory health risks brought on by climate change. This is due to low-resource countries often lacking economic resources, having a close dependence on natural systems for basic food and water provision, and suffering from inadequate housing, energy, and waste management (1) (Table 1). These challenges limit societal adaptation to climate-related shocks (37) or the ability to even consider implementing mitigation strategies.In addition, these countries are often plagued by several respiratory health challenges that defy analysis by simple, linear exposure models, including high rates of childhood pneumonia (38, 39), highlevels of air pollution (40), increasing prevalence of chronic diseases (41), and a range of conditions related to inadequate nutrition and safe water. On a positive note, although climate change makessome health goals more difficult to achieve, it also offers an opportunity to accelerate achievement of health goals through actions that both reduce the risk of climate change and protect health, a "cobenefit."

PRIORITY RESEARCH INFRASTRUCTURE NEEDSWorkshop participants believed that for both low- and highresource countries to benefit from climate change and respiratory health research, improved research infrastructure and concertedinternational cooperation among governments, agencies, scientists, and communities are paramount. Myriad research needs exist in low- and high-resource countries that should be remediedto effectively develop research partnerships that can address major climate-related risks to global respiratory health. A crucial step toward building research infrastructure is to understandthe existing national surveillance systems, augmenting their efficiency and scope, and reinforcing the completeness and reliability in data collection. Considering the variability in currentlyexisting surveillance systems worldwide, implementation of accurate and reliable surveillance systems is necessary to identify, capture, and monitor climate changes that can affect respiratory health and should include the following:

Monitoring and Alert Systems

• Pollen Tracking: Develop national and international pollenmonitoring networks.

• International Air Quality—Monitoring Network: Develop and fund improved national and international air quality— monitoring networks, particularly in rapidly growing cities of the developing world.

• Weather Forecasting: Improve weather forecasting to understand climate-forced change in weather and its impact on human health (heat, humidity, extreme weather events, precipitation, food and water security).

• Weather Alert Systems: Expand or develop effective alert systems to inform communities about pending extreme weather events that can link to air pollution—monitoring systems.American Thoracic Society Documents 7

• Personal Technology Alert and Reporting Systems: Explore the potential of personal technologies as a way to both alert individuals and communities of climate-forced health threats as well as using such personal technologies to collect human health data.

SUMMARY OF KEY FINDINGS The purpose of the ATS Climate Change and Respiratory HealthWorkshop was to identify necessary research questions as well appropriate mechanisms and infrastructure needs for limiting the respiratory health impact of climate change. A crucial step to be taken is improving public health and clinical educational programsto raise awareness of climate change and the potential health consequences and attract more of the work force to this area of study. There needs to be an emphasis on public recognition and earlywarning response to severe climate-related events with the awareness that these effects are likely to have the most impact on susceptible populations: the elderly, infants and children, those with existing respiratory/cardiovascular disease or autonomic dysfunction in temperature control, and those living in low-resource countries. Inaddition, multidisciplinary research efforts involving research scientists, clinicians, public health specialists, sociologists, local—statepartners, climatologists, toxicologists, epidemiologists, and population scientists are required to address unanswered health-relatedconsequences of climate change. Funding agencies should encourage multidisciplinary approaches and introduce newer funding mechanisms, collaborative program project grants, new investigator awards, and training awards to enhance research interest of newerinvestigators in this field. For example, research on climate and respiratory health can be enhanced by greater access to and coordination among existing Earth system science, technology, and data collection efforts underway at organizations such as the World Health Organization (WHO), National Aeronautics and Space Administration (NASA), U.S. Centers for Disease Control and Prevention (CDC), U.S. Environmental Protection Agency(USEPA), U.S. National Institute of Environmental Health Sciences (NIEHS), World Meteorological Organization (WMO), the United Nations (UN), and many others. Critical use of existingresources is likely to enhance cobenefits to several agencies partnering. Last, defined public health cohorts, disease surveillanceprograms, review of existing climate surveillance systems, and environmental tracking and registry systems need to be improved or developed globally. Domestic and international participants in theATS workshop came together to collectively discuss the respiratory health challenges brought about by climate change. These proceedings present their concerns and recommendations to other members of the health, research, and policy sectors, so that they can be informed and act on a challenge that faces us all. This official ATS Workshop Report was prepared by a writing committee of the American Thoracic Society Environmental Health Policy Committee. Members of the Writing Committee: KENT E. PINKERTON, PH.D. (Co

- chair)
WILLIAM N. Rom, M.D., M.P.H. (Co

- chair) MUGE AKPINAR-ELCI, M.D., M.P.H. JOHN R. BALMES, M.D. HASAN BAYRAM, M.D., PH.D. OTTO BRANDLI, M.D. JOHN W. HOLLINGSWORTH, M.D. PATRICK KINNEY, SC.D

. HELENE G. MARGOLIS, PH.D. WILLIAM MARTIN, M.D. ERIKA N. SASSER, PH.D. KIRK R. SMITH, M.P.H., PH.D. TIM K. TAKARO, M.D., M.P.H. Author Disclosure: I.R.B. served as a member of the California Air Resources Board (appointed physician member of state agency; $10,001-50,000) and as a member of panels of the U.S. Environmental Protection Agency's Clean Air Science Advisory Committee ($1,001-5,000). K.E.P., W.N.R., M.A.-E., H.B., 0.B., J.W.H., P.L.K., H.G.M., W.J.M., E.N.S., K.R.S., and T.K.T. reported theyhad no commercial interests or noncommercial, nongovernmental support relevant to subject matter.
Workshop Attendees: JOHN BALBUS, M.D. JOHN R. BALMES, M.D. RUPA BASU, PH.D., M.P.H. HASAN BAYRAM, M.D., PH.D. Otto BRANDLI, M.D. PATRICIA CONRAD, D.V.M., PH.D. DORR DEARBORN, M.D., PH.D. RICHARD DEY, PH.D. KRISTIE EBI, PH.D., M.P.H. STEPHEN B. GORDON, M.D. ANNE GRAMBSCH SHU HASHIMOTO, M.D., M.P.H. JEREMY HESS, M.D., M.P.H. JOHN W. HOLLINGSWORTH, M.D. KAZUHIKO ITO, PH.D. S. K. KATIYAR, M.D. PATRICK L. KINNEY, SC.D. DAVID LEVINSON, PH.D. HELENE G. MARGOLIS, PH.D. WILLIAM J. MARTIN, M.D. YVONNE NJAGE, M.D. KENT E. PINKERTON, PH.D. RAIENDRA PRASAD, M.D. WILLIAM N. ROM, M.D., M.P.H. ERIKA SASSER, PH.D. TORBEN SIGSAARD, M.D. KIRK R. SMITH, M.P.H., PH.D. J. K. SUMARIA, M.D. TONY SZEMA, M.D. TIM K. TAKARO, M.D., M.P.H. KATHERINE WALKER, SC.D. LYDIA WEGMAN, J.D. MARK WINDT, M.D. Ho-IL YooN, M.D., PH.D. DAYA UPADHYAY, M.D.
Acknowledgments: The American Thoracic Society and the workshop co-chairsgratefully acknowledge the support organizations whose support made the workshop possible: The Swiss Lung Foundation, the U.S. Environmental Protection Agency, and the National Institutes of Environmental Health Sciences.

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