Health Needs Assessment Work Group
Meeting Minutes
March 13, 2002
ORRHES Members:
Kowetha Davidson, Bob Eklund, Karen Galloway, James Lewis, Susan Kaplan,
Donna Mosby, Brenda Vowell, TN Department of Health
Public members:
Peggy Adkins, T.L. Dishman (phone), L.F. Raby
ATSDR Staff:
Jack Hanley (phone), Bill Murray
The meeting was called to order at 6:05 p.m.
James Lewis apologized for not having a formal agenda for the meeting.
He said the clinic issue is the primary topic of discussion for the meeting
- whether an environmental clinic can be set up in Oak Ridge, what government
agency would support such a clinic, and, if other communities have such
a clinic, how did the community get it. Further, he said there are two
key topics or agenda items for discussion. The first is the March 11,
2002, email that was sent to Donna Mosby but he did not receive a copy.
The email went from Dr. Robert Jackson, Health Resources and Services
Administration (HRSA), to Kowetha Davidson. There will be an update on
that issue. (Copies were handed out to the attendees.) Dr. Jackson gave
a talk on HRSA activities regarding the clinics the agency sets up and
other activities at the ORRHES meeting on December 4, 2001.
James Lewis said there was a list of five questions raised after his
talk and Dr. Jackson is sending the response to the Oak Ridge Field Office
at Kowetha Davidson’s request. He asked the WG members to review
the email.
Susan Kaplan said that it appears that Dr. Jackson is saying if he is
paid he will answer the questions. She said that Dr. Jackson states “the
HRSA budget is expected to include a small appropriation for support
services for citizens who worked in the uranium mining industry and/or
were involved in the testing of atomic weapons.”
James Lewis thinks this is funding for clinics for these people. There
was discussion about what he meant by this statement in his email. He
said we need to look at Dr. Jackson’s responses to the questions
and determine if they meet our needs.
James Lewis asked about the questions
submitted to Dr. Jackson of HRSA and his response to them. He asked
Jack Hanley to read the questions
sent to Dr. Jackson.
Jack Hanley stated that there were five questions
sent to Dr. Jackson for response (copies were handed out):
- Can HRSA
provide an environmental clinic?
- What criteria does HRSA use for determining
if an area can be designated as a medically underserved area (MUA)?
- What clinics have been established by HRSA because medical
care was not independent of factors or influences in a community?
- Would
he send a copy of the HRSA needs assessment?
- Is the Hanford clinic
a HRSA clinic?
Peggy Adkins asked where
Dr. Jackson is located.
Jack Hanley said he works in HRSA’s regional
office in Atlanta. He continued that Dr. Jackson will be sending the
MUA criteria (#2) and
the needs assessment
(#4).
James Lewis said the questions were pulled together was because the
minutes of the December 2001, were not explicit enough to meet the subcommittee’s
needs. A follow-up was needed to clarify these issues and Kowetha Davidson
sent a letter requesting the information. But there is nothing to look at
until his response is received.
There was discussion about the MUA criteria
and the fact that there could
be exceptions to them and there were legislative remedies also where the
criteria
were not met.
Susan Kaplan brought up the Hanford [Hanford Environmental Health
Foundation (HEHF)] Clinic which is a worker clinic set up independently
of the operating
contractor. Mr. L.F. Raby has been involved with the Hanford clinic. She
expressed concern that there are not enough people in Oak Ridge to justify
a clinic here.
We could team up with Mr. Raby’s effort to get the worker clinic out
of the operating contractor. Mr. Raby has filed legislation to get the contractor
out of the loop in providing medical care to DOE workers. She mentioned that
the Hanford clinic is set up for DOE workers and that she believes it provides
services for the worker’s family.
James Lewis said there will be a
presentation on the DOE medical and exposure surveillance program for former
workers at the next ORRHES meeting (March
26, 2002) for the workers at K-25 and the construction workers..
Kowetha
Davidson stated that the health services for current workers are provided
by the contractor’s medical department. She discussed in
some detail about physical examinations that are done on a routine basis
for workers and
some additional medical exams for all workers, including office workers.
The clinic will also refer you to your personal physician if needed.
Susan
Kaplan said the main issue is who runs the clinic. Is the clinic under
management control?
James Lewis asked about the characteristics of the
HEHF clinic. Is it on site? Who funds the clinic? Who controls it?
Donna
Mosby commented that we need to find out more about the HEHF.
Jack Hanley
asked who funds the HEHF clinic.
Bill Murray said that said that the HEHF
clinic is funded by DOE.
Peggy Adkins said that people are not tested
for heavy metals at DOE clinics and it is not part of a routine check-up.
She continued that
heavy metal
screening should be included to plot the right course.
L.F. Raby said that
there is a problem here in Oak Ridge and elsewhere in the DOE complex.
The doctor works for the contractor and his first obligation
is
to protect the contractor liability wise. The worker is way down the line
in terms of priorities. He talked about his wife’s medical problem.
She was never informed of her hematologic problem until it was too late.
He said
her blood counts were decreasing for eight and she was given no warning.
Kowetha Davidson said that after your tests are done you are supposed to
go back and discuss the results with the doctor. They will inform you of
abnormal
results.
Bob Eklund stated that, in line with what Peggy Adkins said, is that in
addition to clinics for routine medical tests, they ought to trying to
attract researchers
who could look at relationships between exposures and the results of the
medical tests or diseases.
Peggy Adkins said doing better at the clinics now than they did historically.
We are still dealing with problems that people had historically with exposures.
Kowetha Davidson said that the follow-up discussions with the doctor originated
within the last five years.
L.F. Raby met with Leah Dever, manager, DOE Oak Ridge Office, to urge her
to send a directive to the doctors to inform the patient about the results
of
all lab tests and the doctor and the patient have to sign off on that.
He said she did that.
Susan Kaplan is concerned that there are not enough people in Oak Ridge
to justify a clinic then we ought to tie-in with the workers and piggy-back
with the workers.
James Lewis said we have captured the concern about what Peggy Adkins said
about heavy metal exposures. The question about exposures to heavy metals
will be presented to the speakers at the March ORRHES meeting. He reiterated
that
there are two issues:
1. What does the HEHF clinic do and is it a DOE-sponsored effort?
2. What is the difference between medical screening, medical clinics,
and medical monitoring? These terms need to be defined. He referred
to the medical screening that is being done at the Paper, Allied-Industrial,
Chemical and Energy (PACE) workers union hall. They do not do treatment.
What does the clinic do? Is it done by DOE?
Peggy Adkins said they need treatment.
Bob Eklund said the clinic doesn’t have to be in one building. It can
be a concept that is already in place.
James Lewis asked who is responsible for treatment for illnesses? DOE is probably
not responsible for treatment.
Brenda Vowell said these are the 330 clinics that are set up for medically
underserved communities and there are several in the area. HRSA has set them
up in several near-by communities, Wartburg and Jellico, TN and Franklin, KY.
Susan Kaplan said that Dr. Jackson didn’t mention them when he spoke
here.
James Lewis asked again about medically underserved areas.
Brenda Vowell said that they are in medically underserved communities and they
all are primary care centers.
James Lewis said the question is do we know about any clinic anywhere in the
country that can handle non-occupational exposures that can handle that.
Peggy Adkins asked about Veterans’ hospitals and aren’t they government-funded?
So that’s one option. So what if there hasn’t been any in the past.
What if we’re innovative enough to say we’re going to do something
differently. We have a problem that we’re going to take care of in an
innovative way.
Susan Kaplan said that Dr. Jackson said there were action that could be taken
in a legislative manner. It may not be easy but there are alternatives.
Peggy Adkins is going to meet with the Tennessee Congressional delegation on
another issue and she will bring this issue up.
James Lewis said there are two issues to examine:
1. How to set up a clinic under the HRSA criteria but we don’t have that
information now so we can’t pursue it.
2. The medical monitoring being done under the PACE program. He has looked
into that program and has prepared a presentation on it. Part of their program
is a needs assessment and that is what he has focused on. That is the second
item on the agenda.
Donna Mosby asked again about the HEHF. Is that issue still under discussion.
James Lewis replied that Jack Hanley had addressed that issue.
Jack Hanley
said that he would present this issue to the DOE speaker for the medical
surveillance program and have that person clarify how the HEHF clinic
is funded and whether it provides medical services only for the worker or
for the worker’s family also.
T.L. Dishman said if the Hanford clinic
is under the control of the contractor, the families will not trust it.
Jack
Hanley clarified that ATSDR can set up a clinic only when an exposure has
been identified and that a medical screening program will be done only
as it relates to the exposure. At Libby, Montana, ATSDR screened 6000
people for asbestos-related disease since there was an exposure and some
were
referred to their family doctor. At Oak Ridge, the Watts Bar exposure
investigation identified people exposed to PCBs and mercury. The residents
were tested
for these chemicals. The screening is exposure-specific and only done for those people who
were potentially exposed.
Susan Kaplan said the screening is done only
for a finite period of time.
James Lewis brought up the DOE medical and
exposure surveillance program (referred to as DOE Former Workers Program
[FWP]). He said his interpretation
was that
there are two phases in the FWP. The 1st phase is controlled by DOE.
Phase One included six worker groups at four sites (Hanford, Rocky
Flats, Nevada
Test Site and ORR), including the OR gaseous diffusion plant and the
construction workers. The gaseous diffusion workers are covered under
the PACE program.
In response to a question whether Hanford workers
are covered under the FWP, only the construction workers are covered.
Kowetha Davidson described the services that are available to Hanford
workers through HEHF from the brochure that came with the videotape.
The HEHF provides
services to all workers and is not under the FWP.
Jack Hanley said
the HEHF is similar to the medical program available to UT-Battelle workers
at the worksite that Kowetha Davidson had
described earlier.
Kowetha Davidson agreed and said the only difference
is that HEHF is off-site and is strictly for workers and does not relate
to
the community.
Donna Mosby asked Jack Hanley to follow up on HEHF
and have them present to the ORRHES.
Susan Kaplan suggested that the funding
from HRSA could be combined with the funding for the occupational clinic
to support an
environmental clinic
for
the community that is not under the thumb of the production
contractor.
Kowetha Davidson said even in the FWP, the worker is referred
to their family doctor.
James Lewis said the two issues that
continually arise are the process issues and the trust issue. We can never
get
through the process
issues without
bringing in the trust issue. He prefers to look at the
process first and then go back
and examine the trust issue.
Peggy Adkins wants to think
bigger and envisions a Mayo Clinic where people from all over the world
can come for
diagnosis
and treatment
of environmental
toxins by specialists for all over the world.
James Lewis
is not disagreeing but wants to move on to what is going on at PACE.
Bob
Eklund wants to make one additional point. The Tennessee Valley Authority
(TVA) is involved here also. Not only
are there historical
exposures
from their plants but also present exposures whereas
DOE exposures are past
exposures. TVA should pay for part of this clinic
too. Rather than buy (pollution) credits,
they should put emission controls on their plants.
James
Lewis talked about pollution controls being needed worldwide and pollution
being spread worldwide.
But
now he wants to focus
on the needs
assessment
for the FWP and compare the PACE process with the
ATSDR process for the public health assessment
(PHA). The
comparison is
set out in
the Table
below:
Program Comparison |
ATSDR |
PACE |
Congressional mandate |
CERCLA, Superfund |
1993 National Defense Authorization Act |
Responsible agency |
ATSDR |
DOE |
Types of assessments |
Public Health Assessment/ Community Needs Assessment |
Needs Assessment |
Methods |
Public Health Assessment/ Community Needs Assessment
|
Needs Assessment
|
Data Sources |
ChemRisk |
ChemRisk
|
Stakeholders |
Residents (Outside fence) |
Workers
(Inside Fence) |
Conclusions |
?? |
?? |
James Lewis emphasized the similarities between
the two programs. The PACE program needs assessment
included
both an exposure
assessment and a medical
needs assessment. Both programs used ChemRisk
as a data
source. The Phase I was used as a means of
making the recommendations for medical
surveillance
needed. There are logical steps and phases
that you go through.
Then you evaluate
the results to identify the medical tests or
monitoring or education so that you can target
the specific
exposures. The key here is
we should
be
taking
information from HRSA or wherever you can and
looking at it and boiling it down as it relates
to this
and make your
call.
If
we go ahead
and start pursuing
that, I did not say we should not research
how they did it,
but I think these questions we’re lining
up are the types of things we should ask. To
me, the key point is we should wait until
we get
through this effort, look at what
our findings are, define what the area of interest
is depending on what the findings are, and
then pursue it from there. Are there
questions?
This is just
a thumbnail sketch of what I was able to extract
from this.
Susan Kaplan commented that when
all of this is done sequentially, it can take
a long time,
especially
if legislation action
is needed. So
there’s no
reason why we can’t look at what obstacles
there are to a clinic to formulate a strategy
or even decide if we want to tackle
that.
We have to understand
what the obstacles are and how to get around
them. If we wait for epi studies, I mean epi
studies are never going to get done.
James Lewis
said there are no epi studies in this. He thinks
that they did their Phase I
in a year.
They went
through
their Phase
I very quickly
and
they looked at it and made decisions. We’re
working at something that’s
a lot bigger and need a lot more information.
But the point is where we are on this is -
we’re collecting the data. This is his
personal opinion. Can you ask for something
if you don’t have data. If go request
something from somebody, somebody will say
well give me some indication. He thinks you
have to have some supportive information and
data. He feels we need to look
where we are, how does this work, look at what
has gone maybe on at other sites and has anything
triggered anything that is associated with
this. In addition
to this, as he was looking at this - the whole
thing about beryllium, for instance, which
is something he thinks there’s a program
they’ve got in place
that they’re do things on, supposedly
assisting people. He thinks we should look
at all the various programs, some where they
set up clinics and
look at what they’re doing, how they
found that, and then try to determine what
we’d like to do.
Kowetha Davidson said
one of the first things you have to do is lay
out a rationale. If you
don’t have a rationale, then you don’t
know what the obstacles are. You have to have
some vision as to where you’re going.
If you don’t
have this vision of the road you want to go.
You have to identify some concepts. HRSA already
has criteria and you have to look at that.
That will give you
a starting point. If you don’t have a
starting point it will be like a shot in the
dark. If you have something in place you
can modify it but you
need a place to start.
Bob Eklund agrees.
Kowetha Davidson continued saying that right
now you don’t have
that but you have to focus on something, start
with an objective approach and look
at this from an objective point of view.
Bob
Eklund said that even if it ends up being a
legislative matter, the other options must
be elucidated.
For
example, if HRSA can’t
do it, that would have to be known before following
through on other avenues.
Donna Mosby said
the other thing about following this process
would help us determine if we
need to think
outside the
box. We need
to know what
the shape
of our box is before we can get innovative
and get outside the box.
James Lewis said that
our perception of being innovative means that you have found that the
same thing is
going on someplace
else. So
we should
follow
this process and look at all the various
programs that are out there. Determine what logic was
used to get
that program
put
in place. You
need a process
and
logic pattern and figure what’s going
on.
Jack Hanley interjected that he is looking
at all these different options that are out
there
and
quickly summarized
them. With
ATSDR, we focus
on exposure and we respond to that exposure.
HRSA provides clinics; primary care clinics
are their main focus. They may support environmental
clinics but we don’t
know and we’ll have to get the answer
to that. It is based solely on need and they
serve underserved areas. Remember what Paul
Seligman (former
Deputy Assistant Secretary of the DOE Office
of Environment, Safety and Health) said last
January. He clearly stated that if we come
up with information that
they can take to Congress, like they did
for beryllium and berylliosis or the compensation
program. To expand the beryllium program
across the DOE complex,
they got the sources, contaminants, exposure
pathways, the ill workers, and they put that
all together and showed it to Congress and
Congress responded.
So you have to get something concrete they
can take to Congress and ask for. That was
his message. Henry Falk’s (Assistant
Administrator of ATSDR) message at that time
was that if we find exposures, we will work
with everybody
and do everything we can to address those
exposures. That’s
the way I see these different programs.
Susan
Kaplan said not to forget how that NHANES
(National Health and Nutrition Examination
Survey) program
can potentially fit
into that.
The program
could be expanded.
Kowetha Davidson said that
has been an ongoing program for many years.
Jack Hanley added that it is
a research program.
Kowetha Davidson said they are doing medical
tests for a specific purpose and as a
research program
you can’t shift in the
middle of it. They are looking to establish
baseline values nationwide that
can be used to compare for abnormalities.
Susan
Kaplan said that they have to be testing
for the proper things to compare
to. If they’re not testing for
nickel, we won’t have a baseline
comparison to know what’s abnormal.
Kowetha
Davidson said just because NHANES isn’t
testing for nickel doesn’t
mean you can’t get baseline values
for nickel.
Jack Hanley said metals are
mostly of interest for occupational settings
and
the information
is readily
available from
NIOSH.
Brenda Vowell asked Jack Hanley
if he knew if HRSA uses the MAPP (Mobilizing
for Action
through
Planning
and
Partnerships) approach
for their assessment
Jack Hanley doesn’t
know. It will be interesting to see
if they do. When we get the materials
from Dr. Jackson. He said he is sending
the instructions
for health center applicants’ assessment
of need. Brenda Vowell said if they
do, I know all of our health councils
(in the
counties) are preparing
to do the
MAPP approach soon.
They will
start by
evaluating the
past and then using the MAPP process
to
go forward.
Question - what is the MAPP
process?
Brenda Vowell said the MAPP process
is Mobilizing for Action through
Planning and Partnerships.
It is a community-wide
strategic planning
process. And
it will have the support of HRSA.
Jack
Hanley said and each county health...
Brenda Vowell said each county
health council...
Jack Hanley reiterated the health
councils are doing this...
Brenda
Vowell said the councils will first evaluate what they’ve
done and then use MAPP to go forward.
Jack
Hanley said a lot of them have conducted in the past what is called
a needs assessment.
Brenda Vowell said
that’s all been done and now they’re moving
on to the MAPP. They’re in
the process of doing their evaluations
right now.
James Lewis puts the
worker at ground zero. Our exposures
differ
from the
workers’ exposures.
He is very interested in hearing
about the worker programs - what
they have found in a program that
has been in place. He wants to
hear about the results
of the medical surveillance. This
is what they will present at the
ORRHES meeting.
Kowetha Davidson
asked why he mentioned 9/11.
James
Lewis clarified that the similarity is that the people they
are focusing
on are those
exposed
at ground
zero.
Peggy Adkins said there are
a couple of other dimensions that will complicate
matters
but
she hopes they
will be considered. One is
the time frame.
The workers and residents who lived
nearby in the 50s and 60's
had different exposures
than now and will have different
symptoms now. Also, the geography,
the flow
of water, the
underground aquifer, all those
things may have an
effect.
The
two dimensions, geography and time,
will complicate this and shouldn’t
be overlooked. There may be people
who lived in different locations
and the well water was of different
composition.
James Lewis asked if
that was examined in the dose reconstruction.
Jack
Hanley said it wasn’t
but that ATSDR will look at that
difference in pathways. We will
look at ground water.
T.L. Dishman said there was over
half the world’s supply of
mercury at Y-12. So many were exposed
and some have symptoms. Please
try to get it included
along with beryllium for health
tests. People have no faith in
the contractors’ doctors;
they think it’s a stacked
deck. And he is one of those people.
If we can get this outside of the
contractors’ hands, we’ll
already be a step ahead. If you
have a program the people don’t
have much faith in, you don’t
have much hope.
Jack Hanley encouraged
Mr. Dishman to come to the subcommittee
meeting
on March
26.
He described
the program.
James Lewis said all
these programs are referred to as pilot programs.
The results
will dictate
what happens.
The beryllium
program is
not a pilot program.
Bob Eklund
asked if he said all existing programs.
James Lewis replied all of the
DOE FWP were pilot programs but
the beryllium
program is not a pilot.
Jack Hanley
said the beryllium program was initiated and in 1999
it was
expanded to
the other sites.
James Lewis said
the jury is out on the other programs.
Bill Murray described the pilot
program is similar to a clinical
trial, where
a medical
test is
studied to
determine
if it
effective in diagnosing
a given
disease. The example used was breast
cancer. Mammography was not always
recommended as a method of diagnosing
breast cancer
until
the studies
showed it was an
effective method of detecting that
disease.
L.F. Raby said a pilot
is a way of dragging things out for a long
period
of time
until all the patients
die
before you
determine
anything.
James Lewis said that
is what the programs are described as.
L.F. Raby talked about the program
to monitor DOE workers exposed
to hazardous and radioactive
substances.
said
the legislation
for the
DOE FWP was passed
in 1993. Congress
directed DOE to reach an agreement
with the Department of Health and
Human Services
and
get it set up
within 180 days.
He talked
to the
medical director
last week and it hasn’t been
done yet.
James Lewis said he went
to the website and looked it over.
The
answers to
a lot of questions
can
be found here.
L.F. Raby said Congress
gave them 180 days from October 22 or 23
in 1992.
This is
2002 and they’ve not done
it yet.
James Lewis said something
is in place. We need to read the
material
ahead
so we know
what questions
to ask.
Jack Hanley said the legislation
is on that website too.
Discussion
about the 180 day startup time.
Donna Mosby said we have to follow
this process that has been laid
out for us.
Discussion
muddled.
James Lewis said various
components have to come together. One component
is HRSA.
This
is one
component. There
is the needs
assessment component.
At some
point in time, we have to lay them
all out and looked at. Each group
seems to
have a
programmatic step
they go through.
There
are weaknesses
to both;
things that can be challenged.
I think they need
to be looked at by someone with
expertise in the area.
Kowetha Davidson
is confused about what he means about the process
being done
by another
workgroup.
What Work
Groups
are involved.
Someone commented
that each workgroup has a specific role.
James Lewis said all of these workgroups
have overlapping things. He talked
about the linkage
among all the
workgroups. And how
it relates
to the subcommittee
Kowetha Davidson
asked how all this relates to the clinic. She
has trouble
understanding
the
connection.
James Lewis replied
that if you wait until the end, when you get
there
you’ve
got more questions than you know
what to do with. But if you follow
through with the appropriate expertise
to raise the questions as you go
along, when
you get to the end there are only
a few questions with the recommendations.
Bob Eklund remarked in terms of
being prepared, it would be helpful
if
Kowetha Davidson
shared Dr. Jackson’s response
with the whole subcommittee.
Kowetha
Davidson said the information will
be disseminated.
Jack Hanley remarked
that the website shows the whole law and will clarify
the 180
day period.
Donna Mosby said the
issue of the delay in implementation is not
the Work Group’s
issue.
L.F. Raby said people should
understand that DOE is not interested
in the
health if the
workers. In November
2001, a group of
senior managers recommended
that
440.18, the directive for occupational
medicine for all
DOE, be deleted and not replaced.
They said it was contrary and
redundant to contractors’ programs
and programs established by other
agencies.
Peggy Adkins asked what
action had been taken.
L.F. Raby
said none had been taken yet but it was a recommendation
from an Assistant
Secretary to
delete it.
James Lewis said we should
write it up and make sure it is presented
to
the
DOE representative.
Peggy Adkins
brought up a point to make sure she was interpreting
the
meeting
the same
way as the
others.
She has written
it up as a motion,
but will
not submit it as a motion. It seems
that this group has agreed to aggressively
pursue basic
information,
necessary
to create
a diagnostic,
treatment,
research,
and public education center or
clinic related to environmental
toxins,
particularly identified
in
DOE or TVA releases
from 1944 to present.
Is that what we’re
about?
James Lewis said we are aggressively
looking at coming to conclusions.
Susan
Kaplan said we need to establish exposure pathways first.
Bob Eklund emphasized that we need
to look at HRSA’s options.
Donna
Mosby said we must look at all
options.
James Lewis said to look
at the ideal - consider the vision and
mission.
We have
to determine
what’s measurable. First
we have to identify the problem.
Kowetha
Davidson said the HRSA criteria
must be met. Look at the
whole box
first.
Donna Mosby remarked that
we can do fact finding.
There was discussion about getting
the information from Dr.
Jackson or any federal
agency.
James Lewis summarized
the action items:
- ATSDR will follow up on HEHF - operation, funding budget,
etc.
- ask DOE rep about the status of the agreement.
Peggy Adkins said we
need to broaden our scope. Look at the VA, UT hospital (teaching and
research)
James Lewis adjourned the meeting at 8:20 p.m.
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