Drinking water can come from either groundwater sources, via wells, or from surface water sources, such as rivers, lakes, and streams. All sources of drinking water contain some naturally occurring contaminants. As water flows in streams, sits in lakes, and filters thorough layers of soil and rock in the ground, it dissolves or absorbs the substances that it touches. Some of these contaminants are harmless, but others can pose a threat to drinking water, such as improperly disposed-of chemicals, pesticides, and certain naturally occurring substances. Likewise, drinking water that is not properly treated or disinfected, or which travels through an improperly maintained water system, may pose a health risk. However, the presence of contaminants does not necessarily indicate that water poses a health risk—all drinking water may reasonably be expected to contain at least small amounts of some contaminants. As of July 2006, EPA had set standards for approximately 90 contaminants in drinking water that may pose a risk to human health. According to EPA, water that contains small amounts of these contaminants, as long as they are below EPA’s standards, is safe to drink. However, EPA notes that people with severely compromised immune systems and children may be more vulnerable to contaminants in drinking water than the general population. Camp Lejeune covers approximately 233 square miles in Onslow County, North Carolina, and includes training schools for infantry, engineers, service support, and medical support, as well as a Naval Hospital and Naval Dental Center. The base has nine family housing areas, and families live in base housing for an average of 2 years. Base housing at Camp Lejeune consists of enlisted family housing, officer family housing, and bachelor housing (barracks for unmarried service personnel). Additionally, schools, day care centers, and administrative offices are located on the base. Approximately 54,000 people currently live and work at Camp Lejeune, including about 43,000 active duty personnel and 11,000 military dependents and civilian employees. In the 1980s, Camp Lejeune obtained its drinking water from as many as eight water systems, which were fed by more than 100 individual wells that pumped water from a freshwater aquifer located approximately 180 feet below the ground. Each of Camp Lejeune’s water systems included wells, a water treatment plant, reservoirs, elevated storage tanks, and distribution lines to provide the treated water to the systems’ respective service areas. Drinking water at Camp Lejeune has been created by combining and treating groundwater from multiple individual wells that are rotated on and off, so that not all wells are providing water to the system at any given time. Water is treated in order to remove minerals and particles and to protect against microbial contamination. (See fig. 1 for a description of how a Camp Lejeune water system operates.) From the 1970s through 1987, Hadnot Point, Tarawa Terrace, and Holcomb Boulevard water systems provided drinking water to most of Camp Lejeune’s housing areas. The water treatment plants for the Hadnot Point and Tarawa Terrace water systems were constructed during the 1940s and 1950s. The water treatment plant for the Holcomb Boulevard water system began operating at Camp Lejeune in 1972; prior to this time, the Hadnot Point water system provided water to the Holcomb Boulevard service area. In the 1980s, each of these three systems had between 8 and 35 wells that could provide water to their respective service areas. In 1987 the Tarawa Terrace water treatment plant was shut down and the Holcomb Boulevard water distribution system was expanded to include the Tarawa Terrace water service area. Generally, housing units served by the Tarawa Terrace and Holcomb Boulevard water systems consisted of family housing, which included single- and multifamily homes and housing in trailer parks. Housing units served by the Hadnot Point water system included mainly bachelor housing with limited family housing. Based on available housing data for the late 1970s and the 1980s, the estimated annual averages of the number of people living in family housing units served by these water systems at that time were: 5,814 people in units served by the Tarawa Terrace water system, 6,347 people in units served by the Holcomb Boulevard water system, and 71 people in units served by the Hadnot Point water system. In addition to serving housing units, all three water systems provided water to base administrative offices. The Tarawa Terrace, Holcomb Boulevard, and Hadnot Point water systems also served schools and other recreational areas. Additionally, the Hadnot Point water system also served an industrial area and the base hospital. Certain Navy entities provide support functions for Marine Corps bases such as Camp Lejeune. Two entities provide support for environmental issues: The Naval Facilities Engineering Command began providing environmental support for bases in the 1970s. The Naval Facilities Engineering Command, Atlantic Division (LANTDIV) provides environmental support for Navy and Marine Corps bases in the Atlantic and mid-Atlantic regions of the United States. For example, LANTDIV officials work with Camp Lejeune officials to establish environmental cleanup priorities and cost estimates and to allocate funding to ensure compliance with state and federal environmental regulations. The Navy Environmental Health Center (NEHC) has provided environmental and public health consultation services for Navy and Marine Corps environmental cleanup sites since 1991. NEHC is also designated as the technical liaison between Navy and Marine Corps installations and ATSDR and, as a part of this responsibility, reviews and comments on all ATSDR reports written for Navy and Marine Corps sites prior to publication. Prior to 1991, no agency was designated to provide public health consultation services for Navy and Marine Corps sites. In 1980, the Department of the Navy established the Navy Assessment and Control of Installation Pollutants (NACIP) program to identify, assess, and control environmental contamination from past hazardous material storage, transfer, processing, and disposal operations. Under the NACIP program, initial assessment studies were conducted to determine the potential for environmental contamination at Navy and Marines Corps bases. If, as a result of the study, contamination was suspected, a follow- up confirmation study and corrective measures were initiated. In 1986 the Navy replaced its NACIP program with the Installation Restoration Program. The purpose of the Installation Restoration Program is to reduce, in a cost-effective manner, the risk to human health and the environment from past waste disposal operations and hazardous material spills at Navy and Marine Corps bases. Cleanup is done in partnership with EPA, state regulatory agencies, and members of the community. Congress passed the Safe Drinking Water Act in 1974 to protect the public’s health by regulating the nation’s public drinking water supply. The Safe Drinking Water Act, as amended, is the key federal law protecting public water supplies from harmful contaminants. For example, the act requires that all public water systems conduct routine tests of treated water to ensure that the water is safe to drink. Required water testing frequencies vary and range from weekly testing for some contaminants to testing every 3 years for other contaminants. The act also established a federal-state arrangement in which states may be delegated primary implementation and enforcement authority for the drinking water program. For contaminants that are known or anticipated to occur in public water systems and that EPA determines may have an adverse impact on health, the act requires EPA to set a nonenforceable maximum contaminant level goal, at which no known or anticipated adverse health effects occur and that allows an adequate margin of safety. Once the maximum contaminant level goal is established, EPA sets an enforceable standard for water as it leaves the treatment plant, the maximum contaminant level. A maximum contaminant level is the maximum permissible level of a contaminant in water delivered to any user of a public water system. The maximum contaminant level must be set as close to the goal as is feasible using the best technology or other means available, taking costs into consideration. The North Carolina Department of Environment and Natural Resources and its predecessors have had primary responsibility for implementation of the Safe Drinking Water Act in North Carolina since 1980. In 1979, EPA promulgated final regulations applicable to certain community water systems establishing the maximum contaminant levels for the control of TTHMs, which are a type of VOC that are formed when disinfectants—used to control disease-causing contaminants in drinking water—react with naturally occurring organic matter in water. The regulations required that water systems that served more than 10,000 people and that added a disinfectant as part of the drinking water treatment process begin mandatory water testing for TTHMs by November 1982 and comply with the maximum contaminant level by November 1983. TCE and PCE were not among the contaminants included in these regulations. In 1979 and 1980, EPA issued nonenforceable guidance establishing “suggested no adverse response levels” for TCE and PCE in drinking water and in 1980 issued “suggested action guidance” for PCE in drinking water. Suggested no adverse response levels provided EPA’s estimate of the short- and long-term exposure to TCE and PCE in drinking water for which no adverse response would be observed and described the known information about possible health risks for these chemicals. Suggested action guidance recommended remedial actions within certain time periods when concentrations of contaminants exceeded specific levels. Suggested action guidance was issued for PCE related to drinking water contamination from coated asbestos-cement pipes, which were used in water distribution lines. The initial regulation of TCE and PCE under the Safe Drinking Water Act began in 1989 and 1992, respectively, when maximum contaminant levels became effective for these contaminants. (See table 1 for the suggested no adverse response levels, suggested action guidance, and maximum contaminant level regulations for TCE and PCE.) The Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) of 1980 established what is known as the Superfund program to clean up highly contaminated waste sites and address the threats that these sites pose to human health and the environment, and assigned responsibility to EPA for administering the program. CERCLA was amended by the Superfund Amendments and Reauthorization Act (SARA) of 1986. Among other things, SARA requires that federal agencies, including DOD, that own or operate facilities on EPA’s CERCLA list of seriously contaminated sites, known as the National Priorities List, enter into an interagency agreement with EPA. The agreement is to specify what cleanup activities, if any, are required and to set priorities for carrying out those activities. SARA also established the Defense Environmental Restoration Program, through which DOD conducts environmental cleanup activities at military installations. Under the environmental restoration program, DOD’s activities addressing hazardous substances, pollutants, or contaminants are required to be carried out consistent with the provisions of CERCLA governing environmental cleanups at federal facilities. Based on environmental contamination at various areas on the base, Camp Lejeune was designated as a National Priorities List site in 1989. EPA, the Department of the Navy, and the state of North Carolina entered into a Federal Facilities Agreement concerning cleanup of Camp Lejeune with an effective date of March 1, 1991. ATSDR was created by CERCLA and established within the Public Health Service of HHS in April 1983 to carry out Superfund’s health-related activities. These activities include conducting health studies, laboratory projects, and chemical testing to determine relationships between exposure to toxic substances and illness. In 1986, SARA expanded ATSDR’s responsibilities to include, among other things, conducting public health assessments, toxicological databases, information dissemination, and medical education. SARA requires that ATSDR conduct a public health assessment at each site proposed for or on the National Priorities List, and that ATSDR conduct additional follow-up health studies if needed. Potentially responsible parties, including federal agencies, are liable for the costs of any health assessment or health effects study carried out by ATSDR. SARA requires that ATSDR and DOD enter into a memorandum of understanding to set forth the authorities, responsibilities, and procedures between DOD and ATSDR for conducting public health activities at DOD Superfund sites. Based on the memorandum of understanding signed between ATSDR and DOD, ATSDR is required to submit an annual plan of work to DOD, in which it must describe the public health activities it plans to conduct at DOD sites in the following fiscal year, as well as the amount of funding required to conduct these activities. After the annual plan of work has been submitted, DOD has 45 days to respond and negotiate the scope of work to be conducted by ATSDR. The memorandum of understanding states that DOD must seek sufficient funding through the DOD budgetary process to carry out the work agreed upon. From 1991 to 1997, ATSDR conducted a public health assessment at Camp Lejeune that was required by law because of the base’s listing on the National Priorities List. The health assessment evaluated several ways in which people on base had been exposed to hazardous substances, including exposure to the VOC-contaminated drinking water. In its 1997 report, ATSDR recommended that a study be carried out to evaluate the risks of childhood cancer in those who were exposed in utero to the contaminated drinking water and also noted that adverse pregnancy outcomes were of concern. In 1995, while the health assessment was being conducted, ATSDR initiated a study to determine whether there was an association between exposure to VOCs in drinking water and specific adverse pregnancy outcomes among women who had lived at Camp Lejeune from 1968 through 1985. The study, released in 1998, originally concluded that there was a statistically significant elevated risk for several poor pregnancy outcomes, including (1) small for gestational age among male infants born to mothers living at Hadnot Point, (2) small for gestational age for infants born to mothers over 35 years old living at Tarawa Terrace, and (3) small for gestational age for infants born to mothers with two or more prior fetal losses living at Tarawa Terrace. However, ATSDR officials said they are reanalyzing the findings of this study because of an error in the original assessment of exposure to VOCs in drinking water. While the study originally assessed births from 1968 to 1972 in the Holcomb Boulevard service area as being unexposed to VOCs, these births were exposed to contaminants from the Hadnot Point water system. An ATSDR official said the reanalysis may alter the study’s results. In 1999, ATSDR initiated its current study examining whether certain birth defects and childhood cancers are associated with exposure to TCE or PCE at Camp Lejeune. The study examines whether individuals born during 1968 through 1985 to mothers who were exposed to the contaminated drinking water at any time while they were pregnant and living at Camp Lejeune were more likely than those who were not exposed to have neural tube defects, oral cleft defects, or childhood hematopoietic cancers. The current study began with a survey to identify potential cases of the selected birth defects and childhood cancers. The study is also using water modeling to help ATSDR determine the potential sources of past contamination and estimate when the water became contaminated and which housing units received the contaminated water. The water modeling data will help ATSDR identify which pregnant women may have been exposed to the contaminated water, and will also help ATSDR estimate the amount of TCE and PCE that may have been in the drinking water. ATSDR officials said that the study is expected to be completed by December 2007. According to ATSDR’s Toxicological Profile, inhaling small amounts of TCE may cause headaches, lung irritation, poor coordination, and difficulty concentrating, and inhaling or drinking liquids containing high levels of TCE may cause nervous system effects, liver and lung damage, abnormal heartbeat, coma, or possibly death. ATSDR also notes that some animal studies suggest that high levels of TCE may cause liver, kidney, or lung cancer, and some studies of people exposed over long periods to high levels of TCE in drinking water or workplace air have shown an increased risk of cancer. ATSDR’s Toxicological Profile notes that the National Toxicology Program has determined that TCE is reasonably anticipated to be a human carcinogen and the International Agency for Research on Cancer has determined that TCE is probably carcinogenic to humans. Unlike TCE, the health effects of inhaling or drinking liquids containing low levels of PCE are unknown, according to ATSDR. However, ATSDR reports that exposure to very high concentrations of PCE may cause dizziness, headaches, sleepiness, confusion, nausea, difficulty in speaking and walking, unconsciousness, or death. HHS has determined that PCE may reasonably be anticipated to be a carcinogen. Efforts to identify and address past drinking water contamination at Camp Lejeune began in the 1980s, when the Navy initiated water testing at Camp Lejeune. In 1980, one water test identified the presence of VOCs and a separate test indicated contamination by unidentified chemicals. In 1982 and 1983, water monitoring for TTHMs by a laboratory contracted by Camp Lejeune led to the identification of TCE and PCE as the contaminants in two water systems at Camp Lejeune. Sampling results indicated that the levels of TCE and PCE varied. Former Camp Lejeune environmental officials said they did not take additional steps to address the contamination after TCE and PCE were identified. The former officials recalled that they did not take additional steps because at that time they had little knowledge of TCE and PCE, there were no regulations establishing enforceable limits for these chemicals in drinking water, and variations in water testing results raised questions about the tests’ validity. In 1984 and 1985, the NACIP program identified VOCs, including TCE and PCE, in 12 of the wells serving the Hadnot Point and Tarawa Terrace water systems. Camp Lejeune officials removed 10 wells from service in 1984 and 1985. Additionally, information about the contamination was provided to residents. Upon investigating the contamination, DOD and North Carolina officials concluded that both on- and off-base sources were likely to have caused the contamination in the Hadnot Point and Tarawa Terrace water systems. Since 1989, federal, state, and Camp Lejeune officials have partnered to take actions to clean up the sources of contamination and to monitor and protect the base’s drinking water. The presence of VOCs in Camp Lejeune water systems was first detected in October 1980. On October 1, 1980, samples of water were collected from all eight water systems at Camp Lejeune by an official from LANTDIV, a Navy entity that provided environmental support to Camp Lejeune. The water samples were combined into a single sample, and a “priority pollutant scan” was conducted in order to detect possible contaminants in the water systems. The results of this analysis, conducted by a Navy- contracted private laboratory and sent to LANTDIV, identified 11 VOCs, including TCE, at their detection limits, that is, the lowest level at which the chemicals could be reliably identified by the instruments being used. Separately, in 1980 the Navy began monitoring programs for TTHMs at various Navy and Marine Corps bases, including Camp Lejeune, in preparation for meeting a future EPA drinking water regulation. LANTDIV arranged for an Army laboratory to begin testing the treated water from two Camp Lejeune water systems, Hadnot Point and New River, in October 1980. At that time, these two water systems were the only ones that served more than 10,000 people and therefore would be required to meet the future TTHM regulation. From October 1980 to September 1981, eight samples were collected from the Hadnot Point water system and analyzed for TTHMs. Results from four of the eight samples indicated the presence of unidentified chemicals that were interfering with the TTHM analyses. Reports for each of the four analyses contained an Army laboratory official’s handwritten notes about the unidentified chemicals: two of the notes classified the water as “highly contaminated” and notes for the other two analyses recommended analyzing the water for organic compounds. The exact date when LANTDIV officials began receiving results from TTHM testing is not known, and LANTDIV officials told us that they had no recollection of how or when the results were communicated from the Army laboratory. Available Marine Corps documents indicate that Camp Lejeune environmental officials learned in July 1981 that LANTDIV had been receiving the results of TTHM testing and was holding the results until all planned testing was complete. Subsequently, Camp Lejeune environmental officials requested copies of the TTHM results that LANTDIV had received to date, and LANTDIV provided these results in August 1981. The next documented correspondence from LANTDIV to Camp Lejeune regarding TTHM monitoring occurred in a February 1982 memorandum in which LANTDIV recommended that TTHM monitoring be expanded to all of Camp Lejeune’s water systems and noted that Camp Lejeune should contract with a North Carolina state-certified laboratory for the testing. Current and former LANTDIV officials recalled that their agency played a limited role in providing information or guidance regarding environmental issues at Camp Lejeune, and that this assistance generally would have been at the request of Camp Lejeune officials. However, former Camp Lejeune environmental officials recalled that at that time they had little experience in water quality issues and relied on LANTDIV to serve as their environmental experts. Following LANTDIV’s recommendation to expand TTHM monitoring to all base water systems, Camp Lejeune officials contracted with a private state-certified laboratory to test samples of treated water from all eight of their water systems. According to an August 1982 memorandum, in May 1982 a Camp Lejeune official was informed during a telephone conversation with a private laboratory official that organic cleaning solvents, including TCE, were present in the water samples for TTHM monitoring from the Hadnot Point and Tarawa Terrace water systems. In July 1982, additional water samples from the two systems were collected in an effort to investigate the presence of these chemicals. In August 1982 the contracted laboratory sent a letter to base officials informing them that TCE and PCE were identified as the contaminants in the May and July samples. According to the letter, the testing determined that the Hadnot Point water system was contaminated with both TCE and PCE and the Tarawa Terrace water system was contaminated with PCE. The letter also noted that TCE and PCE “appeared to be at high levels” and were “more important from a health standpoint” than the TTHM monitoring. Sampling results indicated that the levels of TCE and PCE varied. The letter noted that one sample taken in May 1982 from the Hadnot Point water system contained TCE at 1,400 parts per billion and two samples taken in July 1982 contained TCE at 19 and 21 parts per billion. Four samples taken in May 1982 and July 1982 from the Tarawa Terrace water system contained levels of PCE that ranged from 76 to 104 parts per billion. (See table 2 for the May and July 1982 sampling results.) Former Camp Lejeune environmental officials recalled that after the private laboratory identified the TCE and PCE in the two water systems, they did not take additional steps to address the contamination for three reasons. First, they had limited knowledge of these chemicals; second, there were no regulations establishing enforceable limits for these chemicals in drinking water; and third, they made assumptions about why the levels of TCE and PCE varied and about the possible sources of the TCE and PCE. The former Camp Lejeune environmental officials told us that they were aware of EPA guidance, referred to as “suggested no adverse response levels,” for TCE and PCE when these contaminants were identified at Camp Lejeune. However, they noted that the levels of these contaminants detected at Camp Lejeune generally were below those outlined in the guidance. One Camp Lejeune environmental official also recalled that at the time they were unsure what the health effects would be for the lower amounts detected at the base. Additionally, in an August 1982 document and during our interviews with current Camp Lejeune environmental officials, it was noted that EPA had not issued regulations under the Safe Drinking Water Act for TCE and PCE when the private laboratory identified these chemicals in the drinking water. The former Camp Lejeune environmental officials also said that they made assumptions about why the levels of TCE and PCE varied. For example, they attributed the higher levels to short-term environmental exposures, such as spilled paint inside a water treatment plant, or to laboratory or sampling errors. Additionally, in an August 1982 memorandum, a Camp Lejeune environmental official suggested that based on the sampling results provided by the private laboratory, the levels of PCE detected could be the result of using coated pipes in the untreated water lines at Tarawa Terrace. The former Camp Lejeune environmental officials told us that in retrospect, it was likely that well rotation in these water systems contributed to the varying sampling results because the contaminated wells may not have been providing water to the Hadnot Point and Tarawa Terrace systems at any given time. However, both they and current Camp Lejeune environmental officials said that at that time the base environmental staff did not know that the wells serving both systems were rotated. After August 1982, the private laboratory continued to communicate with Camp Lejeune officials about the contamination of treated water from the Hadnot Point and Tarawa Terrace water systems. All eight of Camp Lejeune’s water systems were sampled again for TTHMs in November 1982. In a December 1982 memorandum, a Camp Lejeune environmental official noted that during a phone conversation with a chemist from the private laboratory the chemist expressed concern that TCE and PCE were interfering with Tarawa Terrace and Hadnot Point TTHM samples. The chemist said the levels of TCE and PCE were “relatively high” in the November 1982 samples, though the specific levels of TCE and PCE were not provided to Camp Lejeune officials. The private laboratory report providing the November 1982 results said that the samples from Tarawa Terrace “show contamination” from PCE and the samples from Hadnot Point “show contamination” from both TCE and PCE. All eight of Camp Lejeune’s water systems were sampled again for TTHMs in August 1983, and the private laboratory report providing these results said that the samples from Tarawa Terrace “show contamination” from PCE and the samples from Hadnot Point “show contamination” from both TCE and PCE. Former Camp Lejeune environmental officials recalled that they did not take any actions related to these findings. In 1982, Navy officials initiated the NACIP program at Camp Lejeune with an initial assessment study, which was designed to collect and evaluate evidence that indicated the existence of pollutants that may have contaminated a site or that posed a potential health hazard for people located on or off a military installation. The initial assessment study determined that further investigation was warranted at 22 priority sites and a confirmation study to investigate these sites was initiated in July 1984. As a part of the confirmation study, a Navy contractor took water samples from water supply wells located near priority sites where groundwater contamination was suspected. Current and former Camp Lejeune officials told us that previous water samples usually had been collected from treated water at sites such as reservoirs or buildings within the water systems rather than being collected directly from individual wells at Camp Lejeune. In November 1984, Camp Lejeune officials received sampling results for one Hadnot Point well located near a priority site, which showed that TCE and PCE, among other VOCs, were detected in the well. This well was removed from service, and in December 1984, water samples from six Hadnot Point wells that were located in the same general area and treated water samples from the Hadnot Point water plant were also tested. Results of the analysis of the well samples indicated that both TCE and PCE were detected in one well, TCE was detected in two additional wells, and other VOCs were detected in all six wells. Results for the treated water samples also detected TCE and PCE. Four of these six wells were removed from service in addition to the original well removed from service. For the two wells that were not taken out of service, while initial results indicated levels of VOCs, including TCE, other test results showed no detectable levels of VOCs. Documents we reviewed show that continued monitoring of those two wells indicated no detectable levels of TCE. During December 1984, seven additional samples were taken from the treated water at Hadnot Point water plant and revealed no detectable levels of TCE and PCE. According to two former Camp Lejeune environmental officials, once the wells had been taken out of service and the samples from the water plant no longer showed detectable levels of TCE or PCE, they believed the water from the Hadnot Point water system was no longer contaminated. Although the December 1984 testing of water from the Hadnot Point water system showed no detectable levels of TCE or PCE, in mid-January 1985 Camp Lejeune environmental staff began collecting water samples from all wells on the base. Sampling results were received in February 1985 and detected VOCs, including TCE and PCE, in 3 wells serving the Hadnot Point water system and 2 wells serving the Tarawa Terrace water system. As a result, those 5 wells were removed from service. According to current Camp Lejeune officials, all 10 wells had been removed from service by February 8, 1985. According to memoranda dated March 1985 and May 1985, 1 of the 2 wells removed from service at Tarawa Terrace was used on 1 day in March 1985 and on 3 days in April 1985 for short periods of time to meet water needs at the base. See table 3 for the dates that wells were removed from service and for the levels of TCE and PCE that were detected in the wells prior to their removal from service in 1984 and 1985. See app. I for the levels of all VOCs that were detected in the wells prior to their removal from service in 1984 and 1985. In addition, while base officials were waiting for sampling results from January 1985 of samples collected from wells serving Hadnot Point, water from this system was provided to a third water system for about 2 weeks. In late January 1985, a fuel line break caused gasoline to leak into the Holcomb Boulevard water treatment plant. During the approximately 2-week period the treatment plant was shut down, water from the Hadnot Point system was pumped into the Holcomb Boulevard water lines. Former Camp Lejeune environmental officials said that they used water from the Hadnot Point water system because it was the only water system interconnected with the Holcomb Boulevard water system, and because they believed the water from the Hadnot Point water system was no longer contaminated. Prior to restarting the Holcomb Boulevard water system, samples of treated water were tested and no gasoline was detected in any of these samples. However, the samples were found to contain various levels of TCE; these results were attributed to the use of water from the Hadnot Point water system. About 5 days after these samples were taken, the Holcomb Boulevard water system was restarted because the fuel line had been repaired. “Two of the wells that supply Tarawa Terrace have had to be taken off line because minute (trace) amounts of several organic chemicals have been detected in the water. There are no definitive State or Federal regulations regarding a safe level of these compounds, but as a precaution, I have ordered the closure of these wells for all but emergency situations when fire protection or domestic supply would be threatened.” The notice asked residents to reduce water use until early June, when the construction of a new water line was to be completed. In May 1985, another article in the base newspaper stated the number of wells that had been removed from service, stated why the wells were removed from service, and noted the potential for water shortage at Tarawa Terrace as a result. In addition, the Marine Corps provided us with copies of three North Carolina newspaper articles published from May 1985 to September 1985 discussing contamination at Camp Lejeune. All three articles included information about the drinking water contamination and noted that 10 wells serving two water treatment systems at Camp Lejeune had been removed from service. The sources of past contamination for the Hadnot Point water system have not been conclusively determined. However, DOD officials have estimated that eight contaminated on-base sites in the proximity of the Hadnot Point water system may be the sources of contamination for that water system. These eight sites were contaminated by leaking underground storage tanks containing fuel, by degreasing solvents, by hazardous chemical spills, and by other waste disposal practices. Efforts by ATSDR are ongoing to conclusively determine the sources of past contamination in the Hadnot Point water system, as well as when the contamination began. For the Tarawa Terrace water system, North Carolina officials determined that the contamination likely came from a dry cleaning solvent that had been released into a leaking septic tank at an off-base dry cleaning facility— ABC One Hour Cleaners—which built its septic system and began operation in 1954. Both the dry cleaning facility and its septic tank were located off base but adjacent to a supply well for the Tarawa Terrace water system. Based on the environmental contamination at this site, ABC One Hour Cleaners was designated as a National Priorities List site in 1989. As part of its current health study, ATSDR has estimated that beginning as early as 1957 individuals were exposed to PCE in treated drinking water at levels equal to or greater than what became effective in 1992 as EPA’s maximum contaminant level of 5 parts per billion. Since 1989, officials from Camp Lejeune, North Carolina, and federal agencies, including EPA, have taken actions to clean up the suspected sources of the contamination in the Hadnot Point and Tarawa Terrace water systems. Because the contamination is thought to have come from both on- and off-base sources, and because those sources are part of two separate National Priorities List sites—Camp Lejeune and ABC One Hour Cleaners—cleanup activities for the suspected sources of contamination are being managed separately. Cleanup activities have included the removal of contaminated soils and gasoline storage tanks and the treatment of contaminated groundwater and soils. Since ATSDR began its Camp Lejeune-related work in 1991, the agency did not always receive requested funding and experienced delays in receiving information from DOD entities. Although concerns have been raised by former Camp Lejeune residents, ATSDR officials said these issues have not significantly delayed its work and that such situations are normal during the course of a study. ATSDR received funding from DOD for 13 of the 16 fiscal years during which it has conducted its Camp Lejeune-related work, and ATSDR provided its own funding for Camp Lejeune-related work during the other 3 years. Under federal law and in accordance with a memorandum of understanding between DOD and ATSDR, DOD is responsible for funding public health assessments and any follow-up public health activities, such as health studies or toxicological profiles related to DOD sites as agreed to in an annual plan of work. For fiscal year 1997, funding for ATSDR’s Camp Lejeune-related work came from the Navy. From fiscal year 1998 through fiscal year 2000, no funding was provided to ATSDR by the Navy or any DOD entity for its Camp Lejeune-related work because the agencies could not reach agreement about the funding for Camp Lejeune. In June 1997, ATSDR proposed conducting a study of childhood leukemia and birth defects associated with TCE and PCE exposure at Camp Lejeune during fiscal years 1998 and 1999 at an estimated cost of almost $1.8 million. In a July 1997 letter to the Navy, an ATSDR official noted that during a June meeting the Navy appeared to be reluctant to fund the proposed study; however, the official noted that DOD was liable for the costs of the study under federal law. In an October 1997 letter responding to ATSDR, a senior Navy official stated that the Navy did not believe it should be required to fund ATSDR’s proposed study because the cause of the contamination was an off-base source, ABC One Hour Cleaners. The Navy official said that it was more appropriate for ATSDR to seek funding for the study from the responsible party that caused the contamination. However, ATSDR officials told us that while they expected that the study would focus primarily on contamination from the dry cleaner, the study was also expected to include people who were exposed to on-base sources of contamination. An ATSDR official reported that the agency submitted its funding proposals for the Camp Lejeune study to DOD in each of the annual plans of work from fiscal year 1998 to fiscal year 2000, but that during that time period the agency received no DOD funding and funded its Camp Lejeune-related work from general ATSDR funding. In fiscal year 2001 the Navy resumed funding of ATSDR’s Camp Lejeune- related work. We could not determine why the Navy decided to resume funding of ATSDR’s work at that time. Since fiscal year 2003, funding for ATSDR’s Camp Lejeune-related work has been provided by the Marine Corps. According to a DOD official, the Marine Corps has committed to funding the current ATSDR study. The DOD official also noted that per a supplemental budget request from ATSDR for fiscal year 2006, the Marine Corps agreed to fund community assistance panel meetings and portions of a feasibility assessment for future studies that will include computerization of Camp Lejeune housing records. ATSDR has experienced some difficulties obtaining information from Camp Lejeune and DOD officials. For example, while conducting its public health assessment in September 1994, ATSDR sent a letter to the Department of the Navy noting that ATSDR had had difficulties getting documents needed for the public health assessment from Camp Lejeune, such as Remedial Investigation documents for Camp Lejeune. The letter also noted that ATSDR had sent several requests for information, and Camp Lejeune’s responses had been in most cases inadequate and no supporting documentation had been forwarded. ATSDR also had difficulty in obtaining access to DOD records while preparing to conduct its survey, the first phase of the current ATSDR health study. In October 1998, ATSDR requested assistance from the Defense Manpower Data Center, which maintains archives of DOD data, in locating residents of Camp Lejeune who gave birth between 1968 and 1985 on or off base. An official at the Defense Manpower Data Center initially did not provide the requested information because he believed that doing so could constitute a violation of the Privacy Act. Between February and April 1999, Headquarters Marine Corps facilitated discussion between ATSDR and relevant DOD entities about these Privacy Act concerns and some information was subsequently provided to ATSDR by DOD. In April 2001, Headquarters Marine Corps sent a letter to the Defense Privacy Office suggesting that the Defense Manpower Data Center had only provided a limited amount of information to ATSDR. However, in a July 2001 reply to Headquarters Marine Corps, the Defense Privacy Office noted that it believed that relevant data had been provided to ATSDR by the Defense Manpower Data Center in 1999 and 2001. In December 2005, ATSDR officials told us that they had recently learned of a substantial number of additional documents that had not been previously provided to them by Camp Lejeune officials. ATSDR then sent a letter to Headquarters Marine Corps seeking assistance in resolving outstanding issues related to delays in the provision of information and data to ATSDR. In an attachment to the letter, ATSDR provided a list of data and information needed from the Marine Corps in order to complete water modeling activities for its current study. In a January 2006 response, a Headquarters Marine Corps official noted that a comprehensive review was conducted of responses to ATSDR’s requests for information and that the Marine Corps believed it had made a full and timely disclosure of all known and available requested documents. The official also noted that while ATSDR had requested that the Marine Corps identify and provide documents that were relevant or useful to ATSDR’s study, the Marine Corps did not always have the subject matter expertise to determine the relevance of documents. The official noted that the Marine Corps would attempt to comply with this request; however, the official also noted that ATSDR was the agency with the expertise necessary to determine the relevance of documents. Despite difficulties, ATSDR officials said the agency’s Camp Lejeune- related work had not been significantly delayed or hindered by DOD. Officials said that while funding and access to records were probably slowed down and made more expensive by DOD officials’ actions, their actions did not significantly impede ATSDR’s health study efforts. The ATSDR officials also stated that while issues such as limitations in access to DOD data had to be addressed, such situations are normal during the course of a study. The officials stated that ATSDR’s progress on the study has been reasonable in light of the complexity of the project. Nonetheless, as some former residents have learned that ATSDR has not always received requested funding and information from DOD entities, they have raised questions about DOD’s commitment to supporting ATSDR’s work. For example, when some former residents learned during a community assistance panel meeting that it took about 4 months for DOD to respond to a supplemental budget request from ATSDR for fiscal year 2006, they questioned DOD entities’ commitment to ATSDR’s Camp Lejeune-related work. However, DOD and ATSDR officials described this delay in responding as typical during the funding process. The seven members of an expert panel convened by NAS at our request generally agreed that specific parameters of ATSDR’s current study were appropriate, including the study population, the exposure time frame, and the selected health effects. The expert panel members had mixed opinions on ATSDR’s projected completion date. The seven panel experts concurred that ATSDR logically limited its study population to those individuals who were in utero while their mothers were pregnant and lived at Camp Lejeune during the 1968 through 1985 time frame, and who may have been exposed to the contaminated drinking water. The current study follows recommendations from the agency’s 1997 public health assessment of Camp Lejeune, which noted that studies of cancer among those who were exposed in utero should be conducted to further the understanding of the health effects in this susceptible population. Panel experts said that ideally a study would attempt to include all individuals who were potentially exposed, but that limited resources and data availability were practical reasons for limiting the study population. Additionally, panel experts agreed that those exposed while in utero were an appropriate study population because they could be considered at higher risk of adverse health outcomes than others, such as those exposed as children or adults. In addition, two panel experts said that studying only those who lived on base was reasonable because they likely had a higher risk of inhalation exposure to VOCs such as TCE and PCE, which may be more potent than ingestion exposure. Thus, pregnant women who lived in areas of base housing with contaminated water and conducted activities during which they could inhale water vapor—such as bathing, showering, or washing dishes or clothing—likely faced greater exposure than those who did not live on base but worked on base in areas served by the contaminated drinking water. The seven panel experts agreed that the 1968 through 1985 study time frame was reasonable, based on limitations in data availability. This time frame was adopted from ATSDR’s 1998 study of adverse pregnancy outcomes, which limited the study population to include those potentially exposed between 1968 and 1985. According to ATSDR’s study protocol, these years were chosen because 1968 was the first year that birth certificates were computerized in North Carolina and 1985 was when the affected water wells were removed from service. Four of the panel experts said they did not see any benefit in using an earlier start date than 1968 because collecting birth records before 1968 could require a significant amount of resources to collect data. In addition, while the initial exposure to contaminated drinking water may have occurred as early as the 1950s, at the time the ATSDR study time frame was selected officials were unable to determine precisely when the contamination began. Four of the panel experts commented that exposure was likely highest in the latter part of the study time frame—presumably, they said, as a result of a higher accumulated level of contamination over time—thus making the uncertainty of when the contamination began less significant and supporting ATSDR’s decision to study the later time frame. The five panel experts who discussed health effects said that those selected for the study were valid for individuals who were potentially exposed in utero at Camp Lejeune. Based on previous ATSDR work and existing literature, the health effects chosen for the study were neural tube defects, oral cleft defects, and childhood hematopoietic cancers, including leukemia and non-Hodgkin’s lymphoma. Two panel experts said that ATSDR had limited its study to health effects that are rare and that generally occur at higher levels of exposure to VOCs such as TCE and PCE than are expected to have occurred at Camp Lejeune. They said that this may result in ATSDR not identifying enough individuals with these health effects to determine meaningful results in the study. ATSDR has projected a December 2007 completion date for the study, which would include activities such as identifying and enrolling study participants, conducting a parental interview, confirming each reported diagnosis, modeling the water system to quantify the amount and extent of each individual’s exposure, analyzing the data, and drafting a final report. Panel experts had mixed opinions regarding ATSDR’s completion date. Of the five panel experts who commented on the proposed completion date, three said that the date appeared reasonable, and two others said that based on the complexity of the water modeling the projected completion date might be optimistic. Mr. Chairman, this completes my prepared statement. I would be happy to respond to any question you or other Members of the Subcommittee may have at this time. For further information about this testimony, please contact Marcia Crosse at (202) 512-7119 or crossem@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this testimony. Bonnie Anderson, Assistant Director; Karen Doran, Assistant Director; Danielle Organek; and Christina Ritchie made key contributions to this testimony. Concentrations of chemicals in parts per billion4 and 195 and are one-time sampling results. We did not find documentation that tied the decision to remove the wells from service to any particular level of contamination included in related Environmental Protection Agency (EPA) guidance or enforceale regulation. oth natural processes and human activities. Some industries use enzene to make other chemicals which are used to make plastics, resins, and nylon and synthetic fiers. Benzene is also a natural part of crude oil, gasoline, and cigarette smoke. Breathing enzene can cause drowsiness, dizziness, and unconsciousness; long-term enzene exposure causes effects on the one marrow and can cause anemia and leukemia. The Department of Health and Human Services (HHS) has determined that enzene is a known carcinogen. uid used as a solvent for waxes and resins; in the extraction of rubber; as a refrigerant; in the manufacture of pharmaceuticals and artificial pearls; in the extraction of oils and fats from fish and meat; and in making other organics. EPA has found trans-1,2-DCE to potentially cause central nervous system depression when people are exposed to it at levels aove 100 parts per illion for relatively short periods of time. Trans-1,2- DCE has the potential to cause liver, circulatory, and nervous system damage from long-term exposure at levels aove 100 parts per illion. uid with a mild, sweet, chloroform-like odor. Virtually all of it is used in making adhesives, synthetic fiers, refrigerants, food packaging, and coating resins. EPA has found 1,1-DCE to potentially cause liver damage when people are exposed to it at levels aove 7 parts per illion for relatively short periods of time. In addition, 1,1-DCE has the potential to cause liver and kidney damage as well as toxicity to the developing fetus and cancer from a lifetime exposure at levels aove 7 parts per illion. urns. HHS has determined that methylene chloride can e reasonaly anticipated to e a cancer-causing chemical. uid which occurs naturally in crude oil and in the tolu tree. It is also produced in the process of making gasoline and other fuels from crude oil and making coke from coal. Toluene may affect the nervous system. Low to moderate levels can cause tiredness, confusion, weakness, drunken-type actions, memory loss, nausea, loss of appetite, and hearing and color vision loss. Inhaling high levels of toluene in a short time can result in feelings of light-headedness, dizziness, or sleepiness. It can also cause unconsciousness, and even death. High levels of toluene may affect kidneys. Studies in humans and animals generally indicate that toluene does not cause cancer. stance that does not occur naturally. It can e formed when other sustances such as trichloroethane, TCE, and PCE are roken down. Breathing high levels of vinyl chloride for short periods of time can cause dizziness, sleepiness, and unconsciousness and at extremely high levels can cause death. Breathing vinyl chloride for long periods of time can result in permanent liver damage, immune reactions, nerve damage, and liver cancer. HHS has determined that vinyl chloride is a known carcinogen. Well TT-23 is also referred to as “TT-new well” in Marine Corps documents. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

Summary: In the early 1980s, volatile organic compounds (VOC) were discovered in some of the water systems serving housing areas on Marine Corps Base Camp Lejeune. Exposure to certain VOCs may cause adverse health effects, including cancer. Since 1991, the Department of Health and Human Services' Agency for Toxic Substances and Disease Registry (ATSDR) has been examining whether individuals who were exposed to the contaminated drinking water are likely to have adverse health effects. ATSDR's current study is examining whether individuals who were exposed in utero are more likely to have developed certain childhood cancers or birth defects. GAO was asked to testify on its May 11, 2007 report: Defense Health Care: Activities Related to Past Drinking Water Contamination at Marine Corps Base Camp Lejeune (GAO-07-276). This testimony summarizes findings from the report about (1) efforts to identify and address the past drinking water contamination, (2) the provision of funding and information from the Department of Defense (DOD) to ATSDR, and (3) an assessment of the design of the current ATSDR study. GAO reviewed documents, interviewed officials and former residents, and contracted with the National Academy of Sciences to convene an expert panel to assess the current ATSDR study. Efforts to identify and address the past drinking water contamination at Camp Lejeune began in the 1980s, when Navy water testing at Camp Lejeune detected VOCs in some base water systems. In 1982 and 1983, continued testing identified two VOCs--trichloroethylene (TCE), a metal degreaser, and tetrachloroethylene (PCE), a dry cleaning solvent--in two water systems that served base housing areas, Hadnot Point and Tarawa Terrace. In 1984 and 1985 a Navy environmental program identified VOCs, such as TCE and PCE, in some of the individual wells serving the Hadnot Point and Tarawa Terrace water systems. Ten wells were subsequently removed from service. DOD and North Carolina officials concluded that on- and off-base sources were likely to have caused the contamination. It has not been determined when contamination at Hadnot Point began. ATSDR has estimated that well contamination at Tarawa Terrace from an off-base dry cleaner began as early as 1957. Since ATSDR began its Camp Lejeune-related work in 1991, the agency has not always received requested funding and has experienced delays in receiving information from DOD. However, ATSDR officials said that while funding and access to records were probably slowed down and made more expensive by DOD officials' actions, their actions did not significantly impede ATSDR's Camp Lejeune-related health study efforts. The ATSDR officials also stated that while issues such as limitations in access to DOD data had to be addressed, such situations are normal during the course of a study. Members of the expert panel that the National Academy of Sciences convened for GAO generally agreed that many parameters of ATSDR's current study are appropriate, including the study population, the exposure time frame, and the selected health effects. Regarding the study's proposed completion date of December 2007, the panel experts had mixed opinions: three of the five panel experts who commented said that the projected date appeared reasonable, while two said that the date might be optimistic. DOD, the Environmental Protection Agency, and the Department of Health and Human Services provided technical comments on a draft of the May 11, 2007 report, which GAO incorporated where appropriate. Three members of an ATSDR community assistance panel for Camp Lejeune provided oral comments on issues such as other VOCs that have been detected at Camp Lejeune, and compensation, health benefits, and additional notification for former residents. GAO focused its review on TCE and PCE because they were identified by ATSDR as the chemicals of primary concern. GAO's report notes that other VOCs were detected. GAO incorporated the panel members' comments where appropriate, but some issues were beyond the scope of the report.