Table of Contents
December 4, 2001
Presentation and Discussion: Community
Health Centers: Needs and Strategy
Public Comment
Presentation and Discussion: State
of Tennessee Screening Process for Past Exposure
Public Comment
Unfinished Business: Update on Subcommittee Nominations and
Update on ORRHES Website
New Business/Issues/Concerns: Work Group
Recommendations and Future Meeting Dates
Public Comment
Identification of Action Item Assignments/Closing Comments
Evaluation Consensus - Building Process
Day 2: Opening Comments
At 8:19 AM on Tuesday, December 4, 2001, Dr. Davidson
welcomed the group to the second day of the Oak Ridge Reservation
Health Effects Subcommittee meeting. The Subcommittee did
a "roll call," and there was a quorum present.
Presentation
and Discussion:
Community Health Centers: Needs and Strategy
Dr. Robert Jackson
Associate Director for Primary Care
Southeastern Regional Field Office
Health Resources Services Administration (HRSA)
Dr. Jackson addressed the group on the topic of Community
Health Centers, explaining that HRSA is the arm of HHS
that is concerned with personal care, access to care, and
disparities between and among population groups. The agency
provides leadership for ambulatory care, primary care,
and other special healthcare needs around the country.
HRSA is leading the Health Centers Presidential Initiative
and covers all 50 states and the territories.
For the first time in a long time, significant new resources
are being devoted to community health centers and related
organizations. There is not yet a budget for the fiscal
year. Given the times, reductions in the number of new
clinics and in the amount of money available are possible.
To date, about 10.5 million people receive care from HRSA's
various enterprises. There are well over 3000 access points.
Instead of general primary care, some clinics have begun
to address management of specific issues, such as diabetes,
high blood pressure, and trying to improve pregnancy outcomes.
The National Health Services Corps is the clinical work
force of HRSA. They offer scholarships and professional
training through a popular program called loan repayment.
Through prior agreement, clinicians work in under-served
areas and in addition to compensation, receive a certain
amount of dollars to retire their education-related loans.
HRSA is also responsible for Title V of the Social Security
Act, which makes dollars available to states to improve
pregnancy and the general health status of infants and
toddlers. HRSA also operates the Ryan White Comprehensive
AIDS Resources Emergency (CARE) Act.
The southeast is one of the fastest-growing areas in the
discovery and confirmation of new infections. CDC is the
main organization for developing prevention programs, but
when prevention is no longer possible, HRSA ensures that
service and availability is at a proper level of quality
in the community. A growing program at HRSA is in rural
health, where outreach grants in states and communities
support primary care clinics. Each state has an Office
of Rural Health, and this program will likely continue
to grow due to the difficulty of maintaining healthcare
services in rural areas when the population is so migratory
and more health professionals prefer to live in urbanized
areas. There is no shortage of clinicians. The distribution
of those physicians and other clinicians, however, is an
issue. HRSA's programs provide scholarships for people
entering clinical training and loan repayment for people
who are completing their training. The production of health
professionals and clinicians lies within states as states
take responsibilities through various universities, colleges,
and professional schools. HRSA works with states regarding
how many clinicians are needed, where they need to be,
and what incentives need to be developed to influence how
they locate themselves.
Because of increasing attention to healthcare quality,
the National Data Bank of Practitioners is the authoritative
database of clinicians in the country who have been involved
in malpractice difficulties and credentialing. HRSA is
also responsible for organ procurement, transplantation,
and vaccine injury. The many programs of HRSA work together
to provide supportive services in states. HRSA is working
with ATSDR to assess whether situations at Oak Ridge require
HRSA's particular attention and resources. Understanding
the Oak Ridge situation will require a great deal of discussion
and understanding what HRSA can and cannot do because of
their legislative mandates. Dr. Jackson noted that he had
researched the Oak Ridge situation and did not have a "ready-made
answer" regarding the possibility of HRSA's involvement
there.
Discussion Summary:
- Ms. Kaplan observed HRSA's special initiative areas
include women's programs. Women are disproportionately
affected by Iodine-131 exposures. Also, rural areas are
disproportionately affected by the placement of hazardous
facilities because of their low population density. It
is important to understand that traditional healthcare
services are not working in the Oak Ridge area, where
residents have been saying for some time that they are
not well-treated by their healthcare providers.
- Dr. Jackson said that nothing in HRSA's legislation
speaks to environmentally or occupationally challenged
or damaged individuals. There is a piece under the Department
of Energy that includes a very specific, industry-related,
limited entitlement. He asked about the status of the
needs assessment for the Oak Ridge area. HRSA is concerned
with the number of people in need and their particular
needs, including the clinical and technical expertise
needed. The HRSA programs for women are driven by pregnancy,
not by the woman's overall needs. He could not find legislation
that would authorize ongoing clinical oversight of people
who have been in communities and environments that raise
questions of risk and potential damage. Dr. Davidson
replied that the Health Education Needs Assessment is
being conducted. It encompasses not only Oak Ridge, but
the areas around it. The study is projected to be completed
in May 2002.
- Dr. Jackson said that the number of people in need
makes a great deal of difference. All pieces of legislation
are specific about who has eligibility to receive services,
and over what length of time. There is a Worker Health
Protection Program under the Department of Energy in
several communities, including Oak Ridge, with a specific
list of benefits. He noted that in 1982, HRSA administered
the Black Lung Program at a clinic for coal miners in
Oak Ridge. This program ended in 1986 and there was no
successful effort to retain the program. There is no
law requiring retention of records from 1986, so it was
not possible to say why the clinic closed, but Dr. Jackson
surmised that the reason concerned the declining number
of people who make their living from working in coal
mines.
Mr. Lewis then offered a series of questions
to Dr. Jackson from concerned citizens:
What kinds of health clinics does HRSA usually
establish to meet community needs?
Dr. Jackson answered that HRSA usually provides generalized,
primary care services; that is, a clinic is intended to
meet the needs of anyone who visits it. Their interest
is in the primary healthcare "safety net." In order to
provide clinics to respond to specific needs in Oak Ridge,
those needs must be expressed by a needs assessment. Mr.
Lewis noted that the Subcommittee's efforts have not yet
defined those needs. Dr. Jackson understood, and was therefore
hesitant to provide details about what HRSA can do.
What kind of medical clinics can HRSA establish
to meet the expressed Oak Ridge needs?
Dr. Jackson responded that HRSA is legally authorized
to do general primary care, not specific programs for people
with particular needs such as environmental damage or occupational
medicine. They are, however, open to the possibility. He
said that the only occupational group for which HRSA specifically
provides funding is migrant farm workers.
If HRSA cannot meet the Oak Ridge needs,
what other avenues are open to the community to obtain
the desired clinic or clinical services?
Dr. Jackson said that the Department of Energy's program
is very focused, and does not include families. Traditionally,
the government has been reluctant to take on the obligations
of family members in addressing an issue that is perceived
to be occupationally-related, wherein workers are at risk,
not families.
Could diagnosis, treatment, and research
be facilitated by a cooperative agreement between some
Oak Ridge or Knoxville health entity and existing, appropriate
clinics? Can HRSA mediate such agreements?
Dr. Jackson felt that HRSA's responsibility was to mediate
discussions that might be helpful. He was obliged to be
alert to funding needs. HRSA can help the community make
beneficial alliances, but devoting money requires "jumping
hurdles related to legislation." These pieces of legislation
are very detailed and specific. He believed that they should
address the following question aggressively: Is there a
need for generalized primary care in the Oak Ridge area?
The foundation of most available money is in general primary
care. It is widely perceived that Oak Ridge is not a medically
needy area. Measures will determine whether communities
are eligible or competitive for grant dollars. The Bush
administration has been vocal about its wish to expand
personal health services at the community level, so the
discussions should increase in intensity.
If the needs assessment suggests a need, and a response
is desired by the community, then HRSA can assist in convening
a meeting with the parties that can facilitate the process,
said Dr. Jackson. It is possible to create a clinic that
is a "satellite" of another eastern Tennessee clinic. This
process is less competitive and more flexible than other
programs. The Oak Ridge community needs to meet the medically
under-served designation for HRSA to be able to act.
The general discussion then continued:
- Ms. McNally noted that there is no federal legislation
to investigate and protect communities such as Oak Ridge
and Hanford that have been contaminated by problems from
activities during the Manhattan Project. With more political
activism, this area could become a focus in the future.
She asked whether this movement could come as a result
of the state of Tennessee becoming more active. Dr. Jackson
replied that such a movement would be ideal. In this
era, activity is moving to different levels of the government.
He has been impressed by local community initiatives
and innovations, which are politically viable.
- Ms. Sonnenburg emphasized that their ongoing assessment
is for health education needs, not healthcare needs.
This study was arranged before the Subcommittee formed.
The community of Oak Ridge is well-educated. HRSA works
to assure access to comprehensive, quality healthcare
to all, and a group of people do not have comprehensive,
quality healthcare available to them. She pointed out
that workers are tested via a program in which a van
comes to town for testing. If a the workers are deemed
to need healthcare, then they are sent to out-of-town
hospitals.
- Mr. Pardue recalled that the first step toward a clinic
is to identify a need. Assuming that the Subcommittee
recommends a clinic and HRSA is able to mediate or assist
in that project, he asked whether the Subcommittee could
interact directly with HRSA, or if they had to work through
ATSDR. Dr. Jackson replied that ATSDR, HRSA, and whatever
other agency might be identified to assist would join
in the dialogue. He assured the group that they could
rely on HRSA to be responsive.
- Mr. Hill commented that the Employees Medical Screening
Program in Oak Ridge is not available to all employees.
It is only available through the Pace Union through the
AFL-CIO building. It is not available to the workers
at the ORNL, at Y-12, or to the guards. When workers
are sent to out-of-town hospitals, as Ms. Sonnenburg
had mentioned, that work is diagnostic and treatment
is not provided.
- Mr. Hill recalled learning at an earlier meeting that
Hanford had a medical monitoring program that provided
periodic medical evaluations. Dr. Jackson was not sure
about the clinic situation at Hanford. The phenomenon
of providing a diagnostic exam and then referring to
the primary source of care has been the pattern for years.
There are many people who do not qualify for Medicare
or Medicaid and who also are not insured. Community health
centers and those primary programs assure people that
they get what they need, but it is hard to reach all
of those people.
- Mr. Malmquist reflected on the numbers of people needed
to qualify for a program. In Roane County, they had hoped
for a veterans' clinic, but the Veterans Administration
would not operate a clinic unless there were at least
3500 active cases in the service area. He asked if HRSA
had such a specific number requirement. Dr. Jackson answered
that the programs managed by HRSA assume at least 2500
people. In addition to people who have the issues and
concerns that they had been discussing, they should consider
the number of people in the Oak Ridge area who are likely
to use a clinic because they are uninsured or because
it is more convenient. A clinic's existence does not
guarantee that people will use it. HRSA tries to buy
into communities that have energy and organization to
sustain the clinics.
- Dr. Davidson commented that Oak Ridge is an "oasis" within
the area of interest. The outlying areas do not resemble
Oak Ridge. She wondered about the proximity of a rural
community to a town or city that would be considered
under-served. Dr. Jackson replied that the criterion
for unacceptable availability is 20 miles or 30 minutes
of driving time. The residents of the nearby county are
crucial to whether the area should receive a satellite
clinic of an ongoing enterprise. There is a greater likelihood
of building a patient load quickly in this option. It
would be preferable to have the clinic next to the hospital,
but there are many issues to be resolved. For instance,
is the area inhospitable to the clinic because of the
number of physicians' offices nearby? Also, the closer
the clinic is located to groups of physicians, the more
difficult it is to prove a need for additional resources.
- Mr. Johnson wondered about HRSA's receptiveness to
working in collaboration or partnerships with grassroots
communities, initiatives, and healthcare providers. He
also asked how sustainability and self-sufficiency relate
to attracting a clinic to the Oak Ridge area. Dr. Jackson
said that HRSA has become very interested in partnerships.
They encourage partnership development not just because
of resources, but also because of validity in the community.
He said that on the average, their clinics get approximately
45 percent of their annual revenue from a grant and 55
percent from patient fees, reimbursements, write-offs,
et cetera. Factors such as the number of people who bring
insurance and local support from laboratories and hospitals
also contribute.
- Dr. Creasia asked whether Anderson County, in the Oak
Ridge area, is medically under-served. Dr. Jackson replied
that there is a primary care community health center
grant in this part of state which includes part of Anderson
County as its service area. That group might be one to
consult in the process of seeking a clinic.
- Dr. Akin asked whether HRSA's legislation distinguishes
between clinical services and medical monitoring facilities
or capabilities. Dr. Jackson answered that the HRSA legislation
calls for services. Monitoring is included as a form
of service.
- Dr. Akin clarified that "clinic" typically includes
a broad category of services for many medical needs. "Monitoring" implies
more focused efforts; that is, monitoring for a specific
reason such as exposure or another condition in the community.
Around hazardous waste facilities, "medical monitoring" indicated
a focused service for people who feel that they have
been exposed. Dr. Jackson felt that the terms should
not be distinguished. In offering primary care to populations,
these services blend together. "Monitoring" to him applies
to clinical outliers. They should focus on services,
which include monitoring people with occupational or
environmental history.
- Mr. Washington commented that Oak Ridge has been described
by Margaret Mead as "an island of plenty surrounded by
a sea of poverty." If a clinic must be located in a medically
under-served area, then it probably could not be located
in Oak Ridge. The surrounding communities may represent
a better choice. One of the justifications for a clinic
could be related to blood pressure, which could be related
to occupations in this area such as heavy metals affecting
kidney functions over long periods of time. There are
several dialysis clinics in the area, and so a combination
of these factors might lend to the possibility of a clinic.
Oak Ridge is not so much under-served as residents do
not have confidence that the medical community is aware
of, or well-trained in, occupational illnesses that related
to the diseases associated with facilities in Oak Ridge.
Another possibility is HRSA's responsibility for organ
procurement and transplantation. Their effort should
center on a real needs assessment of a geographical area.
Black lung disease still occurs in the area as well.
- Ms. Kaplan called the group's attention to the efforts
of a local activist. His wife worked at ORNL and passed
away, and he has become involved in issues regarding
a clinic at the facility. Legislation is being introduced
into the state that would force the plants' clinics to
be operated independently. This effort might be a good
partner.
- Mr. Lewis said that some community members have identified
Oak Ridge as a "company town." There is also a feeling
that physicians are "on the take." The perception is
that a clinic would be independent of the current healthcare
provider structure. He wondered if similar situations
have been used as the basis for establishing a HRSA clinic.
Dr. Jackson said that HRSA clinics allow for a certain
autonomy and independence because community-based organizations
are not beholden to public agencies or to private interests.
He offered to provide examples of similar efforts after
some research and clearance.
- Mr. Pardue suspected that a large problem with establishing
a clinic is cost. A clinic for this area would be large
and include a great deal of expensive equipment. He wondered
about an approach that would use the Methodist Medical
Center equipment and facilities so that there would not
be duplication. There are concerns about physicians employed
by Methodist Medical Center, but independently-funded,
public health service doctors could see patients and
perhaps conduct research. The community has good research
facilities, and grants could come from a government agency
or from the Department of Energy at ORNL. Dr. Jackson
felt that an approach that utilizes and perhaps augments
existing resources was logical and rational. The problem
is not with the model, but in its implementation, as
HRSA does not have the legislative authority to purchase
the high-tech equipment that might be involved. HRSA
has experience with using the resources of an existing
facility, but they do not advocate for that approach
because of the many problems with the process. It is
difficult to be independent when working in another group's
facility.
- Dr. Pereira asked whether HRSA requires a specific
format for its needs assessment. Dr. Jackson said that
HRSA has certain needs assessment issues that have to
be addressed and he said that he would provide them to
the Subcommittee.
Public
Comment
- Ms. Cheryl Smith asked about the clinic in the Hanford
area. Dr. Jackson replied that to the best of his knowledge,
that clinic is not a HRSA-funded operation. He would
follow up to make sure.
- Ms. Janice Stokes was concerned that discussion about
a clinic was too focused. She asked the Subcommittee
to consider a wider focus that would not only test for
one or two contaminants in the body. Proper and thorough
testing should be done, as a simple blood test will not
identify all toxins and the "body burden." Many people
will test below "permissible limits." A clinic must be
operated independently and carefully and test properly.
Her mother has tested positive for lead and arsenic at
high levels, but they cannot get treatment for her. Toxicologists
have recommended treatment, but the state is taking the
licenses of the few doctors who will treat for metal
poisoning.
- Ms. Gass mentioned a new test for PCBs in human tissue.
She asked if HRSA has had experience with that test or
with testing for heavy metals or cyanide in humans. Dr.
Jackson was careful about making a generalization, as
HRSA has 3000 clinic sites. He suspected that they had
experience, but planned to investigate the issue. The
question is interesting because of the primary care clinics
that operate around various industrial plants on the
eastern seaboard.
- Ms. Faye Martin observed that there is a high frustration
level because of a lack of action. For several years,
the community has wanted clinics. She suggested that
they form a committee that will raise funds for a clinic.
There are doctors all around that area, sick people,
and buildings: what else do they need?
- Dr. Davidson wondered if such a group in Oak Ridge
and the surrounding areas could partner with HRSA.
- Mr. LF Raby addressed the group about Tennessee Senate
Bill 280. This bill requires the Department of Energy
to operate the medical clinics at ORNL, Y-12, and K-25
with private contracts so that the medical clinics can
be independent. The occupational medicine in Oak Ridge
is nonexistent through DOE. There is no Medical Director
for occupational medicine and they have no oversight
in Oak Ridge. He is in meetings to gather support to
get the bill passed. He offered to provide updates on
the effort and gave his contact information: 865-435-1152.
- Ms. Gass also gave her contact information: 898-4263 linda99@mindspring.com
- Ms. Sonnenburg asked members of the public to comment
on the necessity of an independent clinic and to share
the experiences that have made them support an independent
clinic.
- Mr. Raby said that his wife worked for DOE for 23 years
and had her annual physicals at ORNL. The doctors did
not pay attention to her blood work. Her cell lines decreased
continually for ten years and she was never informed
that she had a problem. He asked the Medical Director
for a meeting, but was refused. The Medical Director
would not discuss his wife's medical records: their primary
interest was to protect the contractor, at that time,
Lockheed Martin. If the clinics are operated independently,
then this situation will not occur. DOE facilities operate
in this manner in other locations, and have since 1965.
There is legislation in Washington requiring them to
do that.
- Ms. Stokes said that in the past month, two physicians
have been called before the State Board of Medical Examiners
because they have addressed the fact that heavy metals
exist in bodies. The Tennessee State Department of Health
is stopping physicians from treating patients with heavy
metal poisoning. These actions are a travesty of justice
and inhumane treatment. In 1993, Ms. Stokes went to a
toxicologist who verified that the toxic level of nickel
in her was moderate, which meant that if she did not
eliminate the nickel from her body, she would eventually
die. Within a year, that physician was no longer practicing
in Tennessee. If the Subcommittee is interested in helping
people, then they must stop any entity that is interfering
with poisoned citizens' access to healthcare.
- Ms. Gass wondered if it would be appropriate to ask
the Tennessee Department of Health liaison for the Subcommittee
could bring information to the process. She had asked
for the liaison roles to be clarified. Ms. Brenda Vowell
offered to assess the situation, contacting people in
charge of licensing at the State Board of Medical Examiners.
She said she was not sure that the rest of the Subcommittee
felt that it was appropriate to address requests for
information directly to the liaison members. Occasionally,
questions should be addressed to the Department of Energy,
and the day before, a DOE representative had responded
at the public microphone. The role of liaisons had never
been properly clarified, but she appreciated that sidebar
conversations had stopped. She hoped that there could
be a process for addressing questions of DOE, particularly
how the members of the Subcommittee and the public could
interact with DOE representatives, one of whom was seated
at a side table with the writer/editor.
- Dr. Davidson noted that Ms. Brenda Brooks of DOE had
volunteered to gather information, which was appreciated.
The liaisons communicate with their agencies about Subcommittee
activities and can respond to specific requests, such
as Dr. Akin's working with EPA's soil sampling work.
The Subcommittee's recommendations go to ATSDR and CDC,
not to other federal or state agencies, but ATSDR acts
for the Subcommittee in requesting and obtaining information.
Dr. Joseph of DOE was present at the meeting as a member
of the public, and could sit anywhere in the room save
at the table with the Subcommittee.
- Ms. Stokes said that she was almost sorry for bringing
up the situation with doctors being called before the
State Board of Medical Examiners. The last issue that
she had brought to the Subcommittee was the Mangano study,
which the Subcommittee "beat ... pretty bad." When the
state intervenes with physicians who are trying to treat
patients, the rationale is that the physicians are not
toxicologists. She had challenged the state to replace
those physicians, if they are not qualified, to replace
them with physicians who are qualified. She hoped that
those physicians would not be embarrassed because of
her comments, as Dr. Mangano was. They are loving humans
are trying to help people and who are being stopped for
political reasons, and she did not want to see them "trashed" in
the Subcommittee. Ms. Stokes said that the issue would
be taken up be some person or some agency at the recommendation
of the Subcommittee. The Subcommittee took on the Mangano
paper as an academic exercise and spent a great deal
of money on the effort. She would not provide the Subcommittee
with the physicians' names because she was concerned
that the Subcommittee would somehow discredit them, which
would be "in poor taste." In the past, she said, the
Subcommittee has accused her of having poor taste, being
incompetent, and not being credible. If the physicians
are "raked over the coals," then she would respond in
the press.
- Dr. Davidson responded that the Subcommittee would
not become involved in discussions of individual physicians
and how they treat their patients. She apologized if
the Subcommittee had caused problems for her or made
statements to her. She could not recall making such statements.
The activities of individual Subcommittee members outside
the Subcommittee setting is not controlled by the Subcommittee.
- Ms. Stokes felt that since the Subcommittee members
are paid by ATSDR, then there was control over them.
Dr. Davidson replied that there was no control over members
outside the meetings. Ms. Stokes responded that the Mangano
report was discussed in Subcommittee meetings and in
sanctioned settings. Any review of any paper will reveal
missing details. They should not take a similar approach
to the issue with the physicians. Instead, they should
take the positive approach of trying to get trained toxicologists
who can helate them and make them better rather than "defending
[their] toxins."
- Mr. Lewis said that if the Subcommittee wants comments
and support from DOE, then DOE ought to be at the table.
That issue should be evaluated. He asked for clarification
on disease and symptom prevalence studies, which are
defined as: "A study designed to measure the occurrence
of self-reported diseases that may, in some instances,
be validated through medical records or physical examinations,
if available, and to determine those adverse health conditions
that may require further investigation because they are
considered to have been reported at an excess rate. This
study design can only be considered as hypothesis generation." They
hear about self-reported diseases and linkages, and people
want to pursue these linkages via clinics. This issue
might relate to a clinic in Oak Ridge.
- Dr. Peipins said that the issues in these studies are
related to study design. The crux of the matter is that
a study that looks at symptoms and diseases must include
how well they are characterized, case definitions, how
they are well measured, and whether they can be equally
measured in exposed and unexposed populations. A valid
study requires identical measuring. A unified case definition
is also required to count the diseases in the same way
and to evaluate relative risk.
- Dr. Jackson said that this question related to the
questions and concerns that he had tried to express.
What real symptoms could be identified and differentiated,
and what would it take to treat them? A needs assessment
may not answer these questions, but the questions must
be implied and acknowledged. In many cases, there is
no experiential answer.
Presentation
and Discussion:
State of Tennessee Screening Process for Past Exposure
Mr. Jack Hanley
CDC/ATSDR
Mr. Hanley recalled the January 18, 2001 meeting in Oak
Ridge, at which Ms. Janice Stokes asked a question about
clinics. At that time, the Deputy Assistant Secretary of
DOE answered the clinic question from DOE's perspective.
One of the key points in the transcript is that there has
to be a strong case for the existence of sick workers in
the community who were not being appropriately compensated.
The needs assessment must be done. The Associate Administrator
of ATSDR responded to the question as well, giving an example
of an ATSDR medical monitoring program in Libby, Montana.
At this site, there was long-term, documented asbestos
exposure with outcomes seen in the community.
There are often questions about why the state and ATSDR
focus on environmental data in their public health assessments.
The PHA process is used to evaluate environmental data,
community concerns, and health outcome data, with a focus
on the environmental data. These data are used to identify
people off-site who have been exposed to a specific contaminant
or contaminants at a level of health concern. When the
contaminant and its pathway are identified and a dose to
the population is estimated, the likely health outcome
can be determined. At that point, they make a recommendation
and create a public health action plan. Follow-up occurs
with many other agencies and may include medical monitoring,
surveillance, health education, and advisories, if the
situation is severe. Follow-up can also include exposure
investigations and health studies. The criteria for these
measures can be addressed as the PHA process is underway.
Mr. Hanley then the presented an overview of the screening
process that ATSDR will use in the health assessment at
Oak Ridge as well as how ATSDR will use the state of Tennessee's
screening to focus their evaluation on the contaminants
of concern. There are two screening processes taking place:
- Past exposure
- Current or recent-past data
Past exposure concentrates on the years 1940 - 1990. The
state of Tennessee conducted two studies in this time.
The contaminants that were deemed potential candidates
for further evaluation would be put through the ATSDR screening
process, which would be explained to the Subcommittee in
a later presentation. Current or recent-past data includes
data from 1990 - 2001, which is mostly electronic. The
DOE information system here will be used and the information
will be put through the ATSDR screening process.
The first study conducted by the state was a feasibility
study. The findings from this study went into the dose
reconstruction study. Other contaminants required further
evaluation and screening, so they were taken through another
screening. The purpose of this work was to help the state
focus its resources on the most important contaminants.
The feasibility study for dose reconstruction included
many tasks, four of which focused on the screening of the
contaminant. Task One was an extensive historical review
of the operations and releases from all three facilities.
Task Two incorporated an inventory of the vast amount of
environmental data and contains abstracts. The state used
this information to identify the operations that did not
have the potential for releasing contaminants off-site.
The study focused on the quantities used, the source, and
how they were used. A qualitative evaluation was made.
For instance, releases of volatile organics were small
and not associated with possible off-site health effects.
There is a great deal of Freon, but it has low toxicity.
Acids and bases dilute quickly, so they were also eliminated
as priorities.
Tasks Three and Four identified contaminants that were
at a high priority for further study. The study included
a quantitative evaluation which estimated, based on source
data, quantities that could have gotten off-site and compared
them within different media, across media, and to each
other. The contaminants were then placed in a ranking order.
The radiological contaminants were compared to each other,
and Iodine was considered to have the highest hazard ranking.
All contaminants then had dose reconstructions, except
for protactinium 233, which had a low relative hazard ranking.
Mr. Hanley shared the list of contaminants, including which
ones were screened out and which were included in the dose
reconstruction. For the highest-priority contaminants,
sources, releases, the transport medium, and the basic
pathway of exposure were identified.
After completing the feasibility study, the state was
able to conduct dose reconstruction studies on iodine,
mercury, PCBs, uranium, and White Oak Creek releases. A
group of contaminants needed further study, so they were
evaluated in another round of screening, including a qualitative
evaluation, a threshold quality approach, and a quantitative,
two-level screening evaluation. This list grew as the program
extended and as certain contaminants became declassified.
The qualitative approach was used in the beginning to
identify contaminants that likely posed an off-site health
hazard. The screening also identified contaminants that
were not likely to get off-site or to be at sufficient
levels to cause a health hazard. The quantities of some
contaminants were still classified, so the state used "reverse
engineering" with the threshold inventory approach. They
estimated the level that would cause a health hazard off-site
and then how much would have to be released from the stacks
to reach that level. Then, they estimated the inventory
required to yield that amount. The result was an estimation
of quantities needed on-site, and the quantities on-site
were not at those levels.
The first level of the quantitative portion began with
quantitatively and conservatively estimating the off-site
individual with the highest exposure, using the maximum
concentrations detected off-site and the upper parameters
in other pathways such as fish consumption and length of
exposure. Using this "worst-case scenario," they identified
contaminants that were below a minimum level of health
concern. Level two used slightly less conservative and
more realistic parameters, but there was still conservatism
built into the screening. Exposures for most people were
overestimated in this phase, but underestimated for any
individual, highest-exposed person. This process eliminated
all but the following eight contaminants:
- Beryllium
- Chromium
- Copper
- Lithium
- Nickel
- Technetium
- Arsenic
- Lead
ATSDR will put those contaminants through their screening
process. The previous work not only identified the contaminants
of highest priority, but also the pathways. 80 to 90 percent
of the exposures came from vegetables and fish. Milk and
beef ingestion were a dominant pathway for one of the contaminants.
Discussion Summary:
- Mr. Lewis asked whether, since vegetables and fish
are the dominant pathways, people who live downstream
are at higher risk. Mr. Hanley replied that the risk
depends on the facility. The state used reference populations
for estimating and identifying contaminants. The models
were conservatives. The technical reviewers for this
study commented on the conversion factors of how much
contaminant is absorbed by the vegetables or the fish.
There are new, updated bio-transfer factors available
from the EPA that should be used in the ATSDR process.
- Mr. Lewis reflected on the "reverse engineering" approach
and the concept of secrecy regarding contaminants. He
understood that there are ways, despite secrecy, to eliminate
items, and the facilities have cooperated with these
efforts. Mr. Hanley agreed, observing that ORHASP has
worked to release as much information as possible to
the public.
- Dr. Creasia asked whether the evaluation of toxicity
considered peak exposures, such as when certain plants
will burn inventory that has "outlived its life." These
peak exposures are more severe than regular exposures.
Mr. Hanley was not sure whether the study had taken peak
exposures into consideration. The study used the maximum
identified concentration of contaminants in the initial
screening. Volatile organics were in small quantities
at the plants, but it was feasible that they were released
at once, resulting in these peak exposures. He offered
to look into the issue.
- Dr. Creasia asked about the conservative estimates
at the beginning of the screening. Later in the process,
the estimates became more liberal or typical. Mr. Hanley
agreed, adding that the study used the same, conservative
bio-transfer factors in the screening, which were over-estimates.
- Mr. Washington felt that the screening process was
wrong. Y-12 is a manufacturing plant. Millions of gallons
of Benzine, Xylene, and Toluene were used there. He noted
that fluoride gas does not remain fluorine for long;
it converts to HF, which penetrates through the skin
to the bone. Mr. Hanley replied that fluorine was added
to the list of issues that ATSDR would investigate.
- Y-12 has been in place for more than 50 years, Mr.
Washington continued, and the area around it is contaminated.
T-Male, a classified product, was not included as a contaminant
of concern, even though its TLV is in the PPB range.
He had made the compound, and workers could not remain
in the room for more than an hour because of its toxicity.
When the bombs are torn down and the material is re-used,
there is another exposure in the community as there are
releases from the stacks. Savannah River has a project
in which there is an uptake of mercury in some plants.
During the transferation process, metal mercury is transpired
onto the leaves of plants. In making metals, too, other
elements are added that are released into the atmosphere.
He encouraged ATSDR to look at the big picture, that
Y-12 uses all of the naturally-occurring elements on
the periodic chart, up to element 92, and all of those
elements are then present in the air. The steam plant
burns coal, he added. Mr. Hanley replied that arsenic
is listed because of the coal facilities at K-25 and
Y-12. Most of the classified contaminants are unique
to making metals. Mr. Washington was not sure that anyone
has a good idea of how many of these elements are used,
and how they are used.
- Mr. Hanley commented that the form and manner of use
of materials was considered as well as quantities to
determine what elements might have an impact off-site.
Mr. Washington added that the compounds can remain in
the atmosphere or make other compounds as they react
with UV light.
- Dr. Akin asked about DOE's approach toward chemicals
that are classified and on which there is no information.
Mr. Hanley understood that the state, contractors, and
members of ORHASP could look at all of the data, classified
and non-classified. By the end of the process, the names
of all materials were declassified, but some of the quantities
are still classified and some contaminants and the building
in which they are used are not connected.
- Dr. Timothy Joseph clarified that this issue emerged
often during the study process. DOE declassified the
names of all compounds and elements in all facilities.
The classification issue arose regarding the building
and the process used. Several members of the ORHASP panel
were Q-cleared to see the quantities and buildings with
any compound.
- Dr. Akin asked whether Oak Ridge citizens found this
point to be an issue. He observed that they had an opportunity
to move this issue off of the table and to clarify the
issue with the Oak Ridge citizenry.
- Mr. Washington said that three compounds were classified
and not included on the list. Dr. Joseph assured him
that there were no classified compounds.
- Dr. Davidson noted that the name of all compounds were
not included on the provided sheet because the sheet
was about the screening process, not about which compounds
were classified and listed. Mr. Hanley confirmed the
observation, using the example of cadmium, which is not
on the list. Sampling may reveal that cadmium was released
and exists in the environment. Based on the volume of
historical data, certain compounds and elements were
screened out.
- Dr. Akin said that the ATSDR process is the same process
that EPA uses for its risk assessment at any Superfund
site, whether federal or private. The Subcommittee needs
to understand the process thoroughly, and he was sorry
that some of the community members were not in attendance
for the presentation, as the process should also be understood
by the community. The process is open for criticism,
should there be any. Site characterization and toxicity
information could be questions, as are exposure pathways
and data gaps, that the Subcommittee and the community
should address at these opportunities so that they can
make progress. Mr. Hanley added that the details of the
process were reviewed in the PHA work group. Outstanding
issues could be addressed there. In the end, the process
leads to focusing on contaminants of the highest priority.
- Dr. Davidson commented that the PHA work group would
continue to look at this issue. They can then bring any
outstanding issues back to the Subcommittee.
- Mr. Manley offered a "facetious" comment, rescinding
his offer of vegetables from his garden, from which he
has been eating for 40 years.
- Mr. Lewis asked EPA to endorse the process that Mr.
Hanley described. He hoped to avoid confusion or argument
between agencies in the future.
- Dr. Akin confirmed that the screening process was included
in guidance documents for both ATSDR and EPA. The sheet
of specific contaminants would not be endorsed by EPA,
but the process used to arrive at them was a common process
used to define chemicals that need to be studied further.
Many chemicals are found in the environment, so the environmental
media must be analyzed to name contaminants that may
lead to health problems. Every aspect of the process
has limitations in knowledge, but science must use a
framework to focus on those chemicals that require immediate
action. The ATSDR PHA process will lead to a list of
chemicals that are still a problem today. EPA will address
the chemicals, as a Superfund site, by making decisions
about remediation that may need to be done about chemicals
that remain and may be causing harm. There are gaps and
questions in the process, and the Subcommittee and community
must focus on those questions and gaps. Mr. Hanley pointed
out that the quantitative analysis portion of the process
used to use an EPA reference dose for comparison and
would use new EPA bio-transfer equations. There are many
standard equations.
- Mr. Lewis reiterated that an endorsement of the process
would help the community.
- Mr. Hanley asked whether EPA uses a qualitative judgement
process in preliminary assessments. Dr. Akin replied
that the science is not well-developed in that area,
so there is often not clear information. For example,
metals can be in different forms, which are related to
their bio-availability. These issues are often not clear.
Issues such as these and such as interactions must be
addressed in a qualitative way, so that the judgement
allows work to move ahead without the ideal, exact science.
- Dr. Davidson asked Dr. Akin to provide the Subcommittee
with EPA's screening process to be compared to the ATSDR
process. Dr. Akin replied that he would.
- Mr. Pardue said that in recent years, the question
of whether all classified materials have been identified
has been raised often in public meetings. It is a continuing
issue in the community, as evidenced by the fact that
not all Subcommittee members were aware that the materials
had been declassified. He encouraged Dr. Joseph to make
a public statement to this effect to eliminate the question.
- Mr. Pardue also commented that public acceptance of
the screening process was key to the success of the PHA.
He noted that their current audience was not representative
of the public, so he suggested that they make an announcement
in the Oak Ridger. Almost everyone in the community reads
the newspaper, particularly the editorial and front pages.
The "guest commentary" is an opportunity for ATSDR to
publish this process and to solicit questions from the
community. If the process is understood and known in
advance, then there is less likely to be negative reaction
after the fact. Dr. Davidson supported the idea, particularly
because not all members of the public have access to
the ATSDR website.
- Ms. Kaplan also encouraged a press release that addresses
the changes that have been made in the Subcommittee's
work. She knew of plans at the newspaper to publish an
article about the Subcommittee's one-year anniversary.
The changes that resulted from Subcommittee and public
input are very important.
- Ms. Kaplan asked whether EPA was in charge of remediation
decisions in the off-site communities as well as at Superfund
sites. Dr. Akin said that EPA responsibilities are separate
at public and federal sites. At private Superfund sites,
the site is a moving definition that includes any area
into which a site contaminant is released. Therefore,
a neighborhood that is contaminated by a Superfund site
becomes part of that site for EPA to assess risk and
conduct clean-up, if needed. At federal sites such as
Oak Ridge, DOE is the lead agency and EPA provides oversight.
- Mr. Hill approved of the idea of a news article and
suggested that all community papers be included in such
an effort, including the Roane County News. The release
should include information about the next Subcommittee
meeting as well.
Motion 6
Mr. Hill moved that the Subcommittee recommend that ATSDR
create an article for local media on the screening process.
It is further recommended that information from DOE, via
Dr. Joseph, be included regarding information about declassified
chemicals for the dose reconstruction. The motion received
a second. After discussion, it was added that information
about Subcommittee accomplishments and changes in Subcommittee
process should also be released.
- Ms. Dalton said that ATSDR would do its best to coordinate
its effort with DOE. The information might need to be
presented in two articles rather than in one.
- Ms. Mosby felt that the articles should be released
as soon as possible.
Dr. Davidson opened the meeting for public
comment. As there were no immediate comments from the public,
discussion among the Subcommittee for Motion 6 continued.
- Mr. Hanley asked whether the Subcommittee preferred
an editorial article or a press release. Dr. Davidson
and Ms. Mosby said that the suggestion was for a "your
views" part of the newspaper, which is longer than a
letter to the editor.
- Dr. Kuhaida asked what newspapers should be included.
Mr. Hanley replied that ATSDR usually contacts the Oak
Ridger, the Clinton Courier, and the Roane
County News. They used to advertise in the Knoxville
News-Sentinel, but now they send that paper press
releases.
- Dr. Murray suggested that the motion include specifics
about which newspapers should be included.
- Ms. Dalton said that the agency typically uses press
releases, not paid advertising. They do buy space in
the Oak Ridger, the Clinton Courier,
and the Roane County News to
announce Subcommittee meetings.
- Dr. Davidson did not think that a paid advertisement
was part of the recommendation.
- Dr. Kuhaida reflected that there are three separate
opportunities: one, sharing information about the screening
process; two, changes in the Subcommittee that came as
a result of input and evaluation of Subcommittee activities,
which shows that the Subcommittee is active and responsive;
and three, the issue of declassified contaminants, a
significant issue in the community. He felt that these
issues should be addressed separately because they are
so important. Dr. Davidson repeated the three issues,
and Ms. Mosby added that they should also include the
Subcommittee accomplishments along with the changes.
Dr. Davidson held the vote to allow for public comment.
- Dr. Peele commented that when he entered the ORHASP
panel in 1994, a number of members of the panel felt
that no report could ever be issued due to classification
and the resultant lack of information. Other panel members
felt that a partial report and a classified report could
be issued. As time passed, policies in changed as there
was a national opening of information. The contractors
learned how to make valid screening estimates based on
the limited amounts of data that were declassified. It
is possible to make correct analyses without using classified
information. The final report stated that none of the
conclusions were hampered by classification of information.
He offered examples of public comments on and criticisms
of the screening process that had been heard over the
years. The first complaints regarded pathways. ORHASP
did not estimate exposures for pathways that did not
exist, such as for a river that people did not use. There
were also doubts expressed about the lack of knowledge
about the quantities of contaminants that were released.
Some people doubted the standard coefficients, which
may change over time. The most significant complaint
regarded the confluence of various contaminants, or the "multiple
exposure problem." There is no coefficient for this phenomenon.
It is not possible to assess the toxicity of all known
compounds, never mind of their combinations. The most
obviously-suspicious cases were exposures to PCBs and
mercury, in which similar symptoms occurred elsewhere
in the country. Dr. Peele felt that interactions in the
body have not been studied and understood, but he also
felt that they were not likely. An analogous situation
is with interactions of medicines.
- Other doubts were expressed about whether the transport
of materials was considered properly. In most cases,
these factors were well-assessed. Another problem was
as a result of poor monitoring where people lived, such
as a lack of measurements of ground water. In some instances,
especially 40 years ago, it was not known that these
compounds were toxic, so it is understandable that these
measurements did not take place. The panel was forced
to create some complicated extrapolations due to this
lack of monitoring data.
Dr. Davidson called for the Subcommittee
to vote on Motion 6, however, discussion continued.
- Ms. Mosby wondered whether a Subcommittee member should
write one of the articles, rather than ATSDR because
of possible questions of credibility.
- Ms. Dalton encouraged the Subcommittee to spread its
own message about its accomplishments. It is important
for the community to hear about Subcommittee activities
from its local members.
- Mr. Pardue felt that the statement on declassified
materials should be made by DOE. While the PHA work group
is contributing to the screening process, ATSDR should
write the article on that subject, which can indicate
that the process has been endorsed by the Subcommittee,
if that is the case. He suggested that the chair of the
Subcommittee should write about the Subcommittee's accomplishments
and changes.
- Ms. Dalton mentioned that ATSDR has provided the Oak
Ridger columnist with the Subcommittee changes.
ATSDR can collaborate with the Communications and Outreach
work group to ensure that all Subcommittee accomplishments
are included.
- Mr. Hanley said that his next step was to put the screening
process into writing for the PHA. He would keep his document
concise and readable, then presenting it to the Subcommittee.
- Ms. Mosby felt that the articles should not be combined,
but released in three separate efforts.
Motion 6
Mr. Hill moved that the Subcommittee recommend that ATSDR
create an article for local media on the screening process.
It is further recommended that information from DOE, via
Dr. Joseph, be included regarding information about declassified
chemicals for the dose reconstruction. The motion received
a second. After continued discussion, it was added that
information about Subcommittee accomplishments and changes
in Subcommittee process should also be released. Dr. Davidson
called for a vote on the motion. The motion carried with
a vote of 13 in favor and none opposed.
Public Comment
Ms. Gass
Member of the Public
Ms. Gass reminded the group that the state of Tennessee
spent $15 million on the dose reconstruction, and she has
reviewed meeting minutes from this time. Some of the same
discussions have been going on throughout the process that
are going on now. She reflected on the pathways that Dr.
Peele had addressed. The biggest difference between Hanford
and Oak Ridge is rainfall, and one of the biggest exposure
pathways at Hanford was irrigation using the Columbia River
and the subsequent uptake into produce. Oak Ridge does
not have that exposure, but rain has a more negative than
a positive effect on exposure in East Tennessee, which
should be remembered when comparing the two locations.
She recalled a lawsuit over medical monitoring in Hanford,
and Hanford had public interest attorneys, which are not
available in Oak Ridge. Another difference, which has been
noted by other committees, is the existence of environmental
organizations at the grassroots level in the West. In contrast,
East Tennessee has never had an appreciable degree of environmental
grassroots organizations. She referred to a draft of time-lines
for the three facilities and asked Mr. Hanley when their
final versions would be available. Mr. Hanley did not have
a specific date, but said that they would be finalized
as he makes progress on the screening and receives input
from the work group.
Ms. Gass noted that the time-lines were all historical
information. Mr. Hanley replied that the work was done
as part of the Task Two feasibility study. Most of the
sampling studies included on the time-lines came from the
feasibility study. Ms. Gass said that the books were difficult
to acquire. Mr. Hanley said that the feasibility study
was on a CD-ROM, which is why the state was not printed
them any longer, which was available in the library.
She observed that the information in the feasibility study
anticipates that more work will be done during the ORHASP
process. In some cases, due to time pressure, activities
were not completed or followed-up. She said that the time-lines
were mostly focused on releases. She wondered if person
within ATSDR other than Mr. Hanley was working on verifying
releases for the PHA. Mr. Hanley said that state studies
were being used to examine historical releases. ATSDR evaluated
the data to assess whether it could be used in the PHA,
and concluded that the data could be used in the PHA.
Ms. Gass asked whether technical reviewers recommended
using the data. Mr. Hanley answered that the reviewers
provided input into the data. The conclusions were that
there were limitations and weaknesses, which is the case
with all studies. The reviewers helped ATSDR to identify
those weaknesses and limitations so that the findings could
be used appropriately. In response to a question from Ms.
Gass, Mr. Hanley added that his responsibility was not
to assess whether all releases are included.
Unfinished
Business: Update on Subcommittee Nominations and Update
on ORRHES Website
Ms. LaFreta Dalton
ATSDR/Designated Federal Official
Ms. Dalton gave the group an update on Subcommittee nominations.
The nomination process can begin and will be followed by
Subcommittee member selection and placement. She has been
working with the ATSDR website to have the Subcommittee
nomination information included on the ATSDR homepage and
available for direct printing. The nomination process will
begin when the ATSDR website committee approves the posting.
Packets will also be mailed to everyone on the mailing
list, and copies will be placed in libraries and other
public buildings, as well as at the Oak Ridge Field Office.
She asked for more suggestions for locations for the information.
A press release will go to local newspapers. ATSDR will
work with the Communications and Outreach Work Group to
advertise the nominations in additional ways. It is critical
that Subcommittee take an active role in announcing the
nominations to the community. She does not have firm dates
for when the process would begin, but the nominations will
be open for at least 30 days and perhaps longer because
of the holidays.
Ms. Dalton also gave an update on the website. The Communications
and Outreach Work Group would present recommendation on
the site map and template. The next step in process is
for the contractor to incorporate links. Content can always
be added to the site. When the links are incorporated,
the pilot-testing will begin. Two pilot tests are planned,
and then ATSDR has to give final approval before the page
is added to the ATSDR site.
Discussion Summary:
- Ms. Sonnenburg asked whether an effort would be made
to replace Subcommittee members who had resigned, such
as a doctor. Ms. Dalton replied that one Subcommittee
place was reserved for a sick worker. For the other three
positions, preference for a self-identified ill resident
and consideration to replacing the doctor was suggested.
- Mr. Lewis commented on Subcommittee balance and representation.
It might not be necessary to be sick or ill to represent
the sick or ill, he noted. ATSDR had kept diversity in
mind in its initial selection of Subcommittee members,
and he hoped that ATSDR would consider filling slots
based on the caliber of individuals that had been on
the Subcommittee in the past. Ms. Dalton replied that
ATSDR always hoped to have Subcommittee members of high
caliber who represent the community at large. It does
depend on who applies, and they also have the option
of re-considering the pool of applicants that applied
for the Subcommittee the first time. They are hoping
to match the talent and expertise that the Subcommittee
lost.
- Ms. Mosby asked about the length of the new members'
terms. Ms. Dalton replied that the new members' term
would expire at the same time as current members, in
2004. If an applicant does not come forward for the sick
worker position, then the position will remain open until
the end of the term.
- Mr. Hill asked for clarification on the term "sick
worker." He assumed that the term was defined as a worker
who believes that he or she has had a health impact from
their employment. Ms. Dalton agreed, adding that the
applicant can be a past or current worker who has an
illness that is believed to be associated with the Reservation.
- Mr. Lewis wondered about the procedure if a current
Subcommittee member self-identified as a sick worker.
He said that there is a difference between a sick person
who acts as a representative for a group of people and
someone independent who fulfills that category. Ms. Dalton
replied that such an issue would have to be discussed
by the Subcommittee, as the Subcommittee stated that
an ill worker representative would be needed. She said
she understood that the consensus was to solicit an ill
worker.
- Mr. Hill noted that all Subcommittee represent themselves
only; therefore, a sick worker would not be representing
all sick workers, but their viewpoints only. Ms. Dalton
agreed.
- Ms. Mosby commented that a drawback associated with
a Subcommittee member self-identifying as a sick worker
would be criticism and the perception that they are trying
to circumvent process.
- Mr. Lewis asked whether an individual who resigned
from the Subcommittee could reapply for membership. Ms.
Dalton replied in the affirmative.
- Dr. Davidson noted that the Subcommittee had been operating
for a year with no members being specified as ill workers
and that the process would not be expedited by such an
identification now.
- Mr. Manley asked what constitutes sickness in a worker.
For instance, welders have a tendency to lose their eyesight.
Would this person be a sick worker? Ms. Dalton replied
that the individual's view of him- or herself is the
deciding factor.
- Mr. Washington clarified that a sick worker is a person
who feels that he or she came into contact with some
contaminants while working in a facility that affected
his or her health. There are some illnesses that have
not yet been characterized, but when a number of people
who worked under the same conditions have the same symptoms
but no disease is named, then each individual is responsible
for deciding his or her status as an ill worker. He added
that people will always represent their own interests,
even if they are members of specific groups.
- Ms. Kaplan commented that welders have trouble with
their eyesight, but they also breathe fumes that may
include contaminants.
New Business/Issues/Concerns:
Work Group Recommendations and Future Meeting Dates
Dr. Davidson began by reviewing the recommended amendments
in the Subcommittee bylaws. Several motions were raised.
Motion 7
It was moved and seconded that the following amendment
be made to the Subcommittee bylaws: "The Work Groups shall
include the Guidelines and Procedures Work Group, the Agenda
Work Group, the Communications and Outreach Work Group,
the Health Needs Assessment Work Group, and the Public
Health Assessment Work Group." The motion passed unanimously.
Motion 8
It was moved and seconded that the following amendment
be made to the Subcommittee bylaws: "A quorum at work group
meetings shall consist of two Subcommittee present in person
at the meeting." The motion passed unanimously.
Motion 9
It was moved and seconded that the following amendment
be made to the Subcommittee bylaws: "Subcommittee members
who are absent in person or by conference phone from three
consecutive work group meetings and who do not provide
advance notification of their absence to the work group
chair shall have their name removed from the roster of
the work group. The member may be reinstated after providing
notification to the work group chair prior to the next
work group meeting of their intention to join the work
group." The motion with a vote of 11 in favor and 2 opposed.
The following discussion resulted as a result of Motion
9:
- Ms. Sonnenburg clarified that Subcommittee members
can inform the chair why he or she is missing the meeting.
Dr. Davidson agreed, saying that there may be legitimate
reasons for missing meetings. Dr. Craig added that the
three missed meetings without informing the chair have
to be consecutive.
- Mr. Johnson commented that it might be difficult to
get in touch with the work group chair, but Subcommittee
members can call the field office to say that he or she
will not be present. Dr. Davidson agreed and said that
a person who would miss a meeting could also inform another
work group member of his or her impending absence.
- Dr. Davidson then turned the discussion to the mission
statement. Ms. Galloway had spoken to other members of
the ad hoc committee and attempted to make adjustments
in the mission, vision, goals, and objectives of the
Subcommittee in accordance with the previous day's discussion.
The committee members were not in agreement about the
goals, but were ready to propose the mission and vision
for ratification. Dr. Davidson suggested that the Subcommittee
vote on the vision and mission statements and that the
ad hoc committee reconvene to work on the goals and objectives.
Motion 10
Ms. Galloway moved that the following vision statement
for the Subcommittee be adopted:
"To promote the health of potentially impacted residents
in the 8-county region surrounding the Oak Ridge Reservation."
She further moved that the following mission statement
for the Subcommittee be adopted:
"To provide ATSDR and CDC with advice regarding public
health studies and activities relating to people who may
have been exposed to radioactive and chemical emissions
from the ORR."
The motion received a second, and discussion ensued.
Discussion related to this motion was as follows:
- Mr. Johnson wanted the 8 counties to be named in the
mission statement. Ms. Galloway said that the ad hoc
group had discussed having a watermark of the map of
the affected area. Mr. Lewis wondered how the counties
could be named, since portions of the counties are included
in the affected area.
- Dr. Davidson supported maintaining general language
in the mission statement. There is also ongoing discussion
about the counties in the area.
- Ms. Mosby said that the vision is the ideal perception
for the Subcommittee. The ideal would be for all residents
in the surrounding area to have good health. She supported
the original wording for the vision and mission.
- Mr. Johnson commented that in Knoxville, there are "9
counties, one vision." The counties should be included.
Ms. Mosby suggested that the specifics be addressed in
the goals.
- Dr. Davidson suggested only voting on the mission statement.
Ms. Mosby felt that the vision and mission pieces should
go together, as the goals and objectives go together.
- Dr. Davidson recalled a suggestion from the previous
day's discussion, which was "to promote the health of
all residents in the community affected by the Oak Ridge
Reservation." There was general approval of this wording.
- Mr. Washington did not support that wording because
the emissions from the facilities affect Kentucky and
other areas, both due to airborne emission and by contaminating
waterways downstream. Dr. Davidson felt that if their
work helped the communities surrounding them, then other
areas will benefit as well.
- Ms. McNally recommended the word "directly" so that
the statement would address residents in the communities
directly affected by the Oak Ridge Reservation. Naming
the specific counties could be problematic in the future
if other effects are found in other places.
- Dr. Akin observed that the discussion seemed to indicate
that the original vision statement was their most appropriate
choice, as each modifier used leads to a semantic debate.
Dr. Davidson called for a straw vote to determine the
wording, and amended Motion 10 to reflect the consensus
of the Subcommittee:
Motion 10 - Amended
The vision statement for the Subcommittee was amended
as follows:
"To promote the health of all residents in the community
surrounding the Oak Ridge Reservation."
The mission statement remained unchanged:
"To provide ATSDR and CDC with advice regarding public
health studies and activities relating to people who may
have been exposed to radioactive and chemical emissions
from the ORR."
The motion carried with a vote of 12 in favor and 2 opposed.
The vision and mission statements were adopted, and the
goals will go back to the ad hoc committee. The committee
will also develop appropriate objectives and present
both at the next meeting.
Mr. Pardue then offered three recommendations from the
PHA work group.
Motion 11
Mr. Pardue moved that the Subcommittee approve a resolution
from the PHA work group recommending that the Mangano paper
not be used as a basis for the Oak Ridge Reservation Public
Health Assessment. The motion received a second and passed
with a vote of 10 in favor and 2 opposed. Discussion ensued.
Discussion of the motion was as follows:
- Mr. Pardue clarified that the Dr. Mangano's written
response to the evaluation included new facts, but did
not question the evaluation or its judgements. The new
information should still be evaluated, but did not have
any impact on the recommendation.
- Dr. Davidson further clarified that the recommendation
only applies to the report that is in the open literature.
Motion 12
Mr. Pardue moved that the Subcommittee approve a letter
to Dr. Koplan, administrator of ATSDR, which addresses
the topic of sampling environmental media in the Oak Ridge
area, requesting that ORRHES have input into the process
and that the process be better developed and explained
to the public. Dr. Davidson added that Dr. Elmer Akin would
be added to the list of people who receive the letter.
The motion received a second and carried with a vote of
13 in favor and 1 opposed.
Motion 13
Mr. Pardue moved that the PHA work group draft a letter
to Dr. Henry Falk, assistant administrator of ATSDR, requesting
provision of administrative support in the Oak Ridge Field
Office to improve efficiency. There was a second. The motion
passed unanimously.
The discussion was as follows:
- Dr. Pereira suggested that the letter go to Dr. Falk
through Bob Williams, for protocol.
- Action Item: Mr. Lewis suggested
that Dr. Lucy Peipins be thanked formally for her efforts
in helping the Subcommittee learn more about epidemiology
and assisting with the evaluation of the Mangano paper.
Motion 14
Mr. Lewis moved that Design Number Three be approved as
the ORRHES homepage and site map. There was a second and
the motion passed unanimously.
Mr. Lewis then introduced the second recommendation from
the Communications and outreach Work Group, which addressed
capturing current and historical concerns into a database.
With this system, there will be a formal list of the
issues that are being addressed. There can then be a
link between those concerns or issues and the resultant
resolutions or findings. The recommendation came to the
work group from a non-Subcommittee member.
Motion 15
Mr. Lewis moved that an ATSDR employee read the Oak Ridge
Health Assessment Steering Panel's meeting minutes and
put concerns into the present format to capture the concerns
for ORHASP. The definition of "format" refers to the comment
sheet being used. This motion was amended following further
discussion.
The following discussion was held regarding Motion 15:
- Dr. Davidson wondered whether all meeting minutes were
expected to be reviewed, and wondered whether the feasibility
of this activity should be assessed, since the volume
of minutes was not specified. Mr. Lewis understood that
there were a number of meeting minutes. He agreed about
assessment of reviewing the minutes, adding that once
the process begins, then the feasibility of gathering
concerns from other sources can be assessed.
- Dr. Pereira suggested that in work group meetings,
when a topic of concern is raised but not fully discussed
as part of the agenda, it should be captured in a condensed, "parking
lot" form. With this approach, there can be no interpretation
issues.
- Mr. Lewis added that there should be a standard operating
procedure to capture these concerns. The work groups
should capture concerns, he agreed. The larger problem
is with historical records. There is a history of issues
in the community. They should be captured and addressed.
- Ms. Mosby recalled the request from the work group
meeting. She had not supported it because she found it
to be a tedious task that was too nebulous. The idea
has merit, though, because the historical concerns need
to be captured. She suggested looking at the feasibility
of the project before making a recommendation about it:
its size, where the records are located, and how it might
be accomplished.
- Dr. Davidson commented that database development can
continue, and noted that concerns in Subcommittee and
work group meetings can be captured on an ongoing basis.
Motion 15 - Amended
Mr. Lewis amended his motion to read, the Subcommittee
recommends that ATSDR move ahead with a database that captures
community concerns and issues which has links to the resolutions
that are associated with them. There was a second, and
the motion passed with a vote of 13 in favor and 1 opposed.
General discussion continued:
- Action Item: The Subcommittee
recommended that ATSDR look at the feasibility of reviewing
ORHASP minutes to capture historical concerns of the
Oak Ridge community.
- Ms. Mosby hoped that this action item would have closure
at the next meeting.
- Mr. Lewis pointed out that the needs assessment would
be another source for these community issues and concerns.
- Action Item: Mr. Lewis had
another recommendation from the Communications and Outreach
Work Group, but he suggested taking it back to the work
group for further refinement and review it, in light
of recent changes.
- Mr. Pardue commented that a FACA group just like the
Subcommittee wrote a letter recommending a clinic to
the Secretary of Energy four years ago. The letter was
developed in a work group with broad representation from
sick workers and residents as well as people who were
not convinced that there were ill people. While he liked
to see the idea of a clinic being strengthened, it would
be remiss not to acknowledge the work of the other group
and its letter, which he believed led to the establishment
of this Subcommittee.
- The Subcommittee turned to a consideration of future
meeting dates. They considered conflicts with other groups
that meet in the area. They also noted the need for planning
and preparation.
Motion 16
It was moved and seconded that the next ORRHES meeting
be held in Oak Ridge on January 11th after a
straw vote was conducted to assess consensus. The motion
passed unanimously.
The Subcommittee then tentatively marked meeting dates
through June, 2002. They can revisit whether the format
is working in the future, and the dates can be adjusted.
- February 11, 2002
- March 26, 2002
- May 6, 2002
- June 18, 2002
There was discussion about when new Subcommittee members
would be selected. The hope was to have them selected by
the March meeting. The approval process is lengthy enough
that it was unlikely that they would be confirmed by then,
pointed out Dr. Murray. They could, however, attend meetings
as non-paid, non-voting members.
Ms. Dalton then introduced the ethics video, The
Ethical Choice: Ethics for Special U.S. Government Employees.
Public
Comment
Ms. Gass
Member of the Public
Ms. Gass showed the group a poster that is a draft of
the time line. There is quite a bit of information on the
poster, and it is an attempt to summarize historical information.
Also, it should be noted which processes are well-defined
and over. For example, the 13-year time period for Iodine-131,
in the late 1940s and early 1950s, coincides with the large "baby
boomer" birth cohort being exposed in early childhood.
That process is clearly defined, and its end is clearly
documented. The poster indicates that some processes are
ongoing, or their end is not clearly defined. They should
have as good an understanding as possible of historical
data and of ongoing processes such as current releases,
current processes, and work that is still ongoing. EPA
is charged with reviewing ongoing and future concerns,
but not historical data .
She observed a great deal of change in the past year.
As recently as a few months ago, the thought of having
a clinic in Oak Ridge was not even discussed. She believed
that it was good for the Subcommittee to discuss a clinic
openly. She is more optimistic and has some hope that things
could be turned. It will take a great deal of effort to
turn the momentum from its original direction. The "unofficial
website" has been the source of formative information for
the process. It has not been open and receptive to people
coming forward with concerns. She recalled the day's discussion,
which had included the point that if a person works in
a place long enough, he or she will experience health-related
problems. Nobody in Oak Ridge has an idea of how many people
have been affected, she said. Some of the health concern
are at a deep level.
Ms. Gass offered an example of a citizen who had told
her about how her husband prematurely died of cancer. They
had both been well-positioned in Union Carbide and her
husband continued working into Martin Marietta. When he
was dying, he did not want questions to be asked about
the connection between exposure and his illness. Ms. Gass
said that she had told this lady to be true to her husband's
memory. If he did not want that connection made, then his
widow had to honor that wish. This example illustrates
that many people will not bring their concerns forward.
In some cases, the people are dead or they or their heirs
have given up. Ms. Gass did have hope, though, because
discussion about a clinic would not have been possible
six months ago, when "the c-word" was taboo. The process
has been opened up and she has the hope that several people
on the committee are open-minded and want to do the right
thing for the community, getting to the truth of the matter.
The question now is what to do at the end of the process,
when the truth comes out. She hoped that they would not
worry about legal implications and suppress information.
She also had hope that people who need help would get help.
Discussion Summary:
- Dr. Davidson thanked Ms. Gass for her comments and
assured her that "the c-word" would re-surface in Subcommittee
and work group discussions.
- Mr. Lewis commented that it was helpful when people
from the community take the time to review documents
and to bring issues to the Subcommittee members' attention,
challenging the Subcommittee. The efficiency of their
overall operation should improve to get more information
to the public in a structured way.
Identification
of Action Item Assignments/Closing Comments
Dr. Kowetha Davidson, Chair
Oak Ridge Reservation Health Effects Subcommittee (ORRHES)
Dr. Davidson led the group in a final discussion. She
reviewed the list of action items for the Subcommittee,
reading them into the record. A complete list of these
items, with the motions posed and voted upon included,
is attached to this summary document. She reminded the
Subcommittee that work group meetings should be scheduled
through the field office.
Discussion Summary:
- Ms. Sonnenburg, the chair of the Agenda Work Group,
suggested that their next meeting be on Thursday, January
3rd, at 4:00 pm.
- Mr. Pardue, chair of the PHA work group, proposed that
the next meeting would be Monday, December 10th,
at the Oak Ridge Field Office at 5:30 pm. Major topics
for the agenda included the upcoming visit from an ATSDR
representative regarding current screening for contaminants.
- Dr. Murray ensured that everyone had received copies
of the draft minutes from the last work group meeting
of November 5th. He offered to send the minutes
to any new work group members and confirmed that his
phone number was 865-220-0295.
- Dr. Davidson reminded Subcommittee members that additional
members are needed for the Communications and Outreach
Work Group and that they should sign up for the Guidelines
and Procedures Work Group, even though that group did
not have a task.
- Dr. Tim Joseph addressed the group. He had first seen
the list of missing interviews and requested documents
the previous day. Thanks to Steve Wylie at Y-12 and good
record-keeping on the part of Senes, he was able to obtain
the interviews, which he provided to the Subcommittee
chair. They were not the interviews that Dr. Joseph had
thought they were; they are interviews that were conducted
in Oak Ridge by Senes during their modeling. The interviews
are public information. He was also able to get an additional
interview.
- Ms. Gass said that she had already asked Senes for
the over 150 interviews, and Senes did not have them.
Dr. Joseph said that he could try to get other interviews.
Dr. Davidson said that copies of the interviews would
be made available to Ms. Gass and that the originals
would be kept in the Oak Ridge Field Office.
- Ms. Mosby suggested that the Needs Assessment Work
Group meet on Monday, December 17th at 6:00
pm. The field office would not be available on that day,
so an alternate location would be chosen and the meeting
would be coordinated through the field office.
- Dr. Joseph noted that work groups needing space to
meet could consider doing so at the guard houses, which
have been renovated and are open for the public's use,
free of charge.
- Mr. Washington reviewed a statement of his from the
September 11th meeting, in which an EPA presentation
resulted in his approval of having an EPA representative
on the Subcommittee. Consequently, he made the following
motion:
Motion 17
Mr. Washington moved that the Subcommittee recommend to
ATSDR that a DOE liaison be included as a member of the
Subcommittee. Mr. Lewis seconded the motion. After discussion,
the motion was withdrawn.
The discussion continued:
- Mr. Hill offered a difference of opinion. The Subcommittee
has to weigh the pros and cons that come with inviting
DOE to participate in the Subcommittee. If there is a
benefit to the community and the Subcommittee, then they
should vote. A large population of the community have
concerns about DOE being on the Subcommittee. There are
even concerns that DOE is funding the Subcommittee, thereby
making it biased. He did not feel that the Subcommittee
is biased, but the perception of the Subcommittee in
the community is crucial. DOE has separated itself from
the Subcommittee, which he felt has been beneficial.
He would support any Subcommittee decision, but did not
feel that the Subcommittee has lost flow of information
without having a DOE representative at the table, especially
given the good information provided by Dr. Joseph.
- Dr. Craig agreed that Dr. Joseph had done an outstanding
job of providing the Subcommittee with information, and
that DOE participation was a matter of perception. For
the Subcommittee to maintain its credibility and have
its results viewed as independent and worthwhile, it
must remain separate from DOE. He did not believe that
it was in the best interests of DOE to participate on
the Subcommittee and urged DOE not to come to the Subcommittee.
Ms. Kaplan agreed and pointed out that no other Subcommittee
includes a DOE representative.
- Ms. Sonnenburg felt that the topic should be discussed
at the next meeting, as it is such an important topic
that was not on the agenda. She hesitated to vote on
the topic without prior notice. She offered a counter-motion:
Motion 17A
Ms. Sonnenburg moved that the topic be moved to the next
meeting. The motion received a second and was amended after
discussion.
Discussion continued:
- Dr. Davidson suggested that if discussion on the topic
is postponed, then an ad hoc group should examine it
and bring a report to the full Subcommittee at the next
meeting. Ms. Mosby felt that if the topic is tabled,
then more information on it should be gathered before
the next meeting. Dr. Davidson noted that the Subcommittee
seemed to feel that the topic needed more time for consideration
and discussion.
- Mr. Washington, as the maker of the first motion, offered
his rationale for having DOE representation on the Subcommittee.
All other entities, such as EPA and TDEC, have liaisons
at the table. He had initially not supported their participation
because of community perception. As much as these entities
are part of efforts in Oak Ridge, then they should be
at the table, and the Subcommittee can hold them accountable
to provide information to help them make decisions. EPA
representation on the table resulted in benefit to the
Subcommittee at the September 11th, when a
high-level official addressed them.
- Mr. Lewis said that if a smaller group meets to consider
this topic, then the proceedings should be documented
so that their logic can be documented and clear action
can be specified. He also noted that this issue should
be resolved before new Subcommittee members are selected.
- Dr. Davidson recommended that the topic should be discussed
fully with time in the agenda at the next Subcommittee
meeting. The full Subcommittee should participate in
discussion on this topic, not just a sub-group. Dr. Creasia
agreed.
- Dr. Craig pointed out that Dr. Joseph can get information
for the Subcommittee, as proven by his acquisition of
the interviews, without the Subcommittee having to suffer
any negative perceptions from the community by having
a DOE representative serve as a liaison on the committee.
Motion 17A - Amended
Ms. Sonnenburg amended Motion 17 to read that the topic
be reviewed by the Communications and Outreach Work Group
and then brought to the full Subcommittee for discussion
at the next meeting. The motion was withdrawn after discussion.
Discussion continued:
- Dr. Davidson strongly recommended that the topic be
brought to the full Subcommittee for discussion in a
specific time on the agenda.
- Ms. Mosby noted that bringing the issue to a work group
would collect input from a wide variety of people. It
would also provide a chance to articulate the pros and
cons of having representation.
- Ms. Sonnenburg withdrew her amended motion, asking
Ms. Mosby to restate it. Mr. Washington withdrew his
original motion and offered a new motion.
Motion 18
Mr. Washington moved that the Communications and Outreach
Work Group study the issues surrounding, and conduct a
full discussion of, bringing a DOE liaison to the Subcommittee.
Time on the next Subcommittee meeting agenda should be
devoted to deliberating the Work Group's information and
to full Subcommittee discussion of the issue. The motion
received a second. The motion failed with a vote of 5 in
favor and 6 opposed.
Discussion continued:
- Ms. Kaplan felt that sending the issue to a work group
would be divisive. The work group is an uncontrolled,
small group environment. There is a great deal of emotion
involved in this issue, and she strongly encouraged that
it be discussed fully in the more formal setting of the
Subcommittee.
- Dr. Davidson requested that the Agenda Work Group put
the issue on the agenda for the next Subcommittee meeting.
- Mr. Pardue wondered whether, since Dr. Joseph was working
to get the documents requested, a letter from the PHA
Work Group requesting the interviews was still necessary.
Dr. Davidson decided that the letter-writing should be
postponed to see what Dr. Joseph could produce.
- Dr. Joseph pointed out that the interviews are a small
component of the list, which contains many other documents
and items that are not DOE-owned. He would do his best
to get as many of the items as possible, but they are
not all his responsibility. Mr. Pardue said that they
would write the letter and then see if it was necessary
to send it.
Evaluation
Consensus-Building Process
Mary Ann Downey
Consensus Building Presentation
Ms. Downey addressed the group regarding their work with
the Consensus Building Process. She said she appreciated
everyone's frustration and encouraged them all to take
care of themselves. She provided them with a handout and
said that Ms. Dalton would send them all a copy of the
evaluation summary. In essence, she said, they "are doing
it right." She would also provide the results of the individual
evaluation of the Subcommittee.
She asked the group whether they felt that they were ready
to begin working in small groups, bringing that information
back to the Subcommittee. According to her evaluation,
the group was at that point. They should work at both levels,
gathering information and opinions in a work group setting
and then bringing that "homework" to the full Subcommittee.
Mr. Lewis advocated for developing a process for evaluating
things. Without these processes, a conclusion might not
be possible on any issue. Ms. Downey agreed, and then addressed
the concept of consensus. She works with troubled youth
in Atlanta on consensus, and she keeps the ideas basic:
- Speak out
- Listen up
- Go for diversity
- Teamwork
- Pull together on a plan
She felt that the Subcommittee had consensus "right." She
asked Dr. Craig to read a story about how geese operate
in a collective and what humans can learn from these facts.
Ms. Downey concluded by sharing motivations that she had
found from walking a marathon. She ended the session by
playing a folk song from coal miners in Kentucky.
With no further business posed, Ms. Dalton
thanked the group for their participation. With that, the
meeting was adjourned.
End of Summary Report
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