ORRHES Meeting Minutes,
March 19-20, 2001
March 20, 2001
The Agency
for Toxic Substances and Disease Registry (ATSDR) and the
Centers for Disease Control and Prevention (CDC) convened
the third meeting of the Oak Ridge Reservation Health Effects
Subcommittee (ORRHES) on March 19-20, 2001. The meeting,
which was held at the Oak Ridge Mall, began at 12:00 p.m.
Members present were:
Alfred A. Brooks, Ph.D.
Robert Craig, Ph.D.
Donald A. Creasia, Ph.D.
Kowetha A. Davidson, Ph.D., Chair
Robert Eklund, M.D.
Edward L. Frome, Ph.D.
Karen H. Galloway
Jeffrey P. Hill
David H. Johnson
Susan A. Kaplan
Ronald H. Lands, M.D.
James F. Lewis
Lowell P. Malmquist, D.V.M.
L.C. Manley
Donna Mims Mosby
William Pardue
Barbara Sonnenburg
Charles A. Washington
Members Therese McNally and Andrew J. Kuhaida were absent.
All the liaisons to the Subcommittee attended:
Elmer Warren Akin, U.S. Environmental Protection Agency
(EPA)Brenda Vowell, R.N.C., Tennessee Department of Health
Chudi Nwangwa, Tennessee Department of Environmental Conservation
(TDEC)
Agency staff present were:
ATSDR: Bert Cooper; La Freta Dalton, Designated Federal
Official and Executive Secretary of the Subcommittee;
Michael Grayson; Jack Hanley; Sandy Isaacs; Karl Markiewicz;
Bill Murray; Theresa NeSmith; Marilyn Palmer; Jerry Pereira.
CDC/National Center for Environmental Health (NCEH):
Arthur Robinson
DOE/Oak Ridge Reservation: Timothy Joseph
EPA: Cheryl Walker-Smith
Others present over the course of the meeting included:
John Bajek?, Site Specific Advisory Committee
Gordon Blacock
J.W. Fouse, PACE
Meg Gwaltney, COSMOS
Ann Henry, Methodist Medical Center
Marie Murray, Recorder
Dwight Napp, SOCM
Grace Paranzino, Hahnemann University
Rebecca Parkin, George Washington University
Robert Peele
Melanie Russo, Eastern Research Group
John Stewart
John Stockwell, DHHS, PHS
Thérèse Van Houton, COSMOS
Opening
Discussion
Mr. Jerry Pereira introduced Ms. La Freta Dalton, the new
Executive Secretary of the Subcommittee. Dr. Brooks moved
to approve the agenda, and was seconded by Mr.
Manley. With all in favor, the motion passed.
Correspondence: Dr. Davidson reported receipt of a letter
from Ms. Janice Stokes, Chair of Save Our Cumberland Mountains,
expressing concern about the Subcommittee and the Health
Assessment process. It was distributed to the Subcommittee
members and is attached to this document (Attachment #1).
Ms. Dalton announced that the nomination for a worker representative
member was completed. The public solicitation for nominations
was to begin on this day, and was distributed (Attachment
#2). Dr. Davidson announced that the action items from the
previous meeting had all been completed. Comments on the
minutes of the last meeting were sent to the recorder and
incorporated. With no objections, Dr. Davidson stated that
she would sign them as approved. There was no objection.
Presentation
on Roberts Rules of Order
Dr. Al Brooks referred to the Agenda Work Group report
and Introduction to Robert's Rules included in the members'
packets. The rationale for using these rules is that they
are recommended by the General Services Administration for
Subcommittee work, and they are a complete set of tested,
flexible rules for efficiently running a meeting. There
are both formal and informal levels of application, from
the most formal "committee of the whole," then a "quasi-committee
of the whole," and then informally. The only real difference
is the rule of how long a person can speak.
The main motions in order of precedence are 1) to make
a main motion (for a specific action) which can be amended;
2) a motion to amend the original motion; 3) a motion to
refer it to committee ("motion to refer/commit," which sends
the whole topic including the amendment to a work group);
4) motion to call the question, which ends debate and requires
a two-thirds vote because it changes the rights of the group;
and 5) motion to adjourn.
Processing a debatable, amendable motion. When a motion
is made (and described, if needed), it is seconded. Suggestions
for minor changes or corrections are made if acceptable
to the mover and are not considered to be debate. When finished,
the Chair states the motion and requests discussion. This
puts the question on the floor and makes it the property
of the assembly; the maker cannot arbitrarily change it.
When the Chair senses that discussion is finished, s/he
asks if the members are ready to vote by voice, show of
hands, or ballot, and the results are announced. Or, the
Chair can ask if there is any exception to the motion (as
done with the minutes on this day. If none is voiced, it
is considered passed. There also is a motion to suspend
the rules; if two-thirds of the members agree, all the rules
are suspended.
Dr. Brooks outlined in order of precedence from lowest
to highest, the motions likely to be used for most of the
business of a small committee as this one: 1) Motion, 2)
postpone indefinitely (if not supported); 3) amendment (the
original motion can be changed once); 4) motion to commit
or refer (the kinds of changes needed and a time table to
report back can be specified); 5) postpone indefinitely
or for a certain time; 6) extend or limit debate (if the
allotted time for discussion expires (this requires a two-thirds
vote because it changes the rights of the assembly); 7)
previous question is in order (closes debate and calls for
a vote); 8) table the motion (if left tabled through the
next meeting, the motion expires); 9) call for the order
of the day (a call to return to the agenda can be done by
one person unless the committee votes it down and decides
to stay off the agenda); 10) order of privilege (a very
high priority, e.g., if a member cannot see or hear well
enough to participate in the discussion); 11) motion to
recess (not debatable, can be done to discuss an amendment
for 5-10 minutes); and 12) motion to adjourn.
Another rule is the point of order, which is not a motion,
but interrupts a discussion to ask the rules or to note
that they are not being followed. Generally, Roberts Rules
should not be abused if the Chair and the Parliamentarian
attend to them. The latter can be hired or appointed by
the Chair.
Committee discussion included:
-
The motion to reconsider was used at last meeting.
That, and the motion to reconsider in place of the minutes
have a high priority, being intended to stop a possible
mistake. If motion to reconsider a motion passes, the
motion and vote cannot be effected until the next day.
When recalled to the floor, it need not be seconded
again; the previous second indicates that discussion
is desired by more than one person. There is no time
limit for reconsideration, which may not necessarily
be done at the same meeting.
-
The rules sometimes can appear to be intimidating or
constraining, particularly in addressing the real-life
process the Subcommittee will address. If more discussion
is needed, substance was favored procedure.
-
The most common mistake of meetings is to have discussion
first, then to make a motion and vote. If a topic is
on the floor for which there is no motion, it is left
to the Chair to decide what the topic is. The rules
are generally agreed to by all and provide a reasoned
process for member participation without limiting the
Chair, who administers them with the Parliamentarian's
help.
-
If there are experts in the audience who could contribute,
any person can request that that member of the audience
be allowed to speak. This issue is actually a question
of bylaws, but the ORRHES Chair has reserved the right
to hear from an attendee who can contribute technical
expertise (as opposed to the opinion expressed in the
public comment period).
-
Ms. Sonnenburg suggested, before voting on any issues
discussed for some time, that the Chair ask if members
of the audience would like to address the issue first,
rather than waiting for the public comment period. Dr.
Davidson agreed, if the comment is technical, but not
if it would detract from the public comment period.
Any member can move to suspend the rules for an audience
comment. The Chair would allow that with no objection;
if none, the person speaks.
-
The main concern expressed about using Roberts Rules
was that they not be used to stifle the process. If
facilitation is needed, it should be arranged. The problem
may not be the length of time for speaking, but helping
to draw out someone who may feel intimidated.
-
There are other rules of order (e.g, Sturges' rules),
which Mr. Washington used in another group, that were
adapted to a two-page summary. No repeated input is
allowed until everyone has spoken. Roberts Rules also
prohibits speaking again until anyone else who wants
to speak and has not yet, does so.
-
Mr. Pereira sensed discomfort by some members with
using Roberts Rules and suggested using whatever the
lowest common denominator is, just to help everyone
stay on task and accomplish their work. Dr. Davidson
agreed, and asked for the members' help to ensure that
nothing hinders the members' opportunity to speak during
the discussion.
Dr. Brooks solicited members as volunteers to conduct a
skit which he had written to illustrate the use of Roberts
Rules, which they did. Dr. Malmquist moved to adopt
Roberts Rules of Order for the ORRHES' procedures
and Dr. Creasia seconded the motion. Dr. Davidson noted
that the bylaws already specify the use of Roberts Rules
unless otherwise indicated, so Dr. Malmquist withdrew
the motion.
Presentation
of the Public Health Assessment, Steps 1 and 3
Mr. Jack Hanley reviewed the purpose of ATSDR's public
health assessment: to identify off-site populations exposed
to hazardous substances at levels of health concern, and
to recommend follow-up public health actions or studies
needed to evaluate and mitigate or prevent health effects.
The process has seven steps: 1) evaluate site information;
2) identify health concerns; 3) determine contaminants of
concern; 4) identify and evaluate exposure pathways; 5)
determine public health implications; 6) determine conclusions
and recommendations, and 7) develop a public health action
plan.
As of this meeting day, ATSDR was beginning Steps 1 and
3. ATSDR has collected data on #2 in community meetings
(which the George Washington University staff will document)
and hopes to gather more through the Subcommittee.
The work done in Step 3 determines the contaminants of
concern (site-specific chemicals and radionuclides that
are further investigated for potential public health effects
in steps 4 and 5). The contaminants used at the facility
are identified, as well as any significant releases. A contaminant
cannot be considered a health hazard until the pathway of
exposure has been analyzed to indicate that they may have
impacted off-site populations. Step 3 determines which contaminants
may have done so, and Step 4 evaluates which exposure pathways
may have been completed. This work will identify each contaminant's
important pathways, across all media, and those contaminants
with the greatest potential to impact off-site populations.
After that, Step 5 will determine the public health implications;
and the Step 6, public health assessment document will communicate
the completed pathways of the overall site and indicate
what should be done to address these exposures. Finally,
Step 7 will develop a public health action plan for subsequent
work.
Steps 1 and 3 of the public health assessment process will
begin by using the 1993 Tennessee dose reconstruction feasibility
study, which was composed of four tasks: 1) describe historical
operations and releases; 2) identify available environmental
data; 3) identify complete exposure pathways; and 4) evaluate
environmental exposure pathways. Mr. Hanley had sent to
the committee members the prior week the documents from
the dose reconstruction. Its Steps 3 and 4 are similar to
ATSDR's public health assessment process.
Task 1. The objectives of the Task 1 feasibility study
described the historical operations that used and released
contaminants; and identified activities that have likely
been associated with significant off-site releases of chemicals
and radionuclides, that were used and released in quantities
sufficient to cause harm even after dilution and dispersion
to the environment. They also looked at any documentation
of offsite releases or presence of contaminants in offsite
environments.
The major categories of activities investigated and reported
on in Task 1 were the historical operations of: 1) X-10,
whose original mission was nuclear reactor development (>15
reactors), the nuclear materials separation process, and
radionuclide production; 2) Y-12, whose original operations
missions were weapons production, lithium separation and
enrichment, zirconium production, disposal, and steam generation;
3) K-25, which was a gaseous diffusion plant that conducted
atomic vapor laser isotope separation, operated a liquid
thermal diffusion plant, the TSCA incinerator, the steam
plant, the recirculating cooling water system, and waste
disposal.
Task 2: The work of Task 2 was to identify available environmental
data; provide an inventory (from the state, EPA, TVA, and
others) of what was collected and analyzed for environmental
data over the years (air, surface and drinking water, soil,
etc.). The Task 2 objectives were to: 1) identify/evaluate
available environmental monitoring and research data; and
2) develop abstracts on ~100 environmental monitoring and
research projects.
A time line was distributed at the last meeting for the
X-10, K-25,and Y-12 activities, demonstrating the materials
by air, water, soil, etc. used and potentially released
over time. For example, X-10's plutonium recovery operations,
before routine treatment and monitoring systems were in
place, released uranium, plutonium, and various fission
products in the first few years. The reactor released uranium,
argon, plutonium, and other fission products over 20 years'
time. The stack also was unfiltered for the first five years,
something the feasibility study recommended examining. The
Thorex process had some short decay runs that produced fallout
in the X-10 facility area. One of the more important processes
was the Radioactive Lanthanum (RaLa) process, which released
iodine and other fission products. More than half of all
that work was done before filtering of the process began.
Y-12 conducted nine different processes, which released
a large quantity of uranium that most likely went offsite.
East Fork Poplar Creek received contaminated liquid effluent
in the first year (1944). The major weapons production operations
were of such magnitude that offsite releases are likely,
primarily of uranium. Also important were the lithium separation/enrichment
operations' release of mercury into the water and air, especially
from 1956-1963. The K-25 gas diffusion processes released
uranium and magnesium 99, and the liquid thermal process
of the mid-1940s was plagued with many mechanical problems
in the early years.
All of these processes were further evaluated in Task 4.
Task 3: Used the information collected in Tasks 1 and 2
to identify important contaminants at the facilities and
important related pathways. Materials mailed the previous
week included a list those contaminants (Table 1). Table
2 listed those not warranting further investigation because
they either were used in small quantities or in processes
not believed to be associated with offsite releases (radionuclides,
lithium, benzene, and chloroform). The other group not warranting
further investigation included contaminants of little or
no toxicological impact, even in large quantities (Freon
and other materials found to be dispersed in the environment,
such as acids and bases like fluorine and fluorine-type
compounds -- irritants associated only with acute exposure).
Table 3 listed the contaminants used in the processes with
high risk of offsite contamination, which were further explored
in Tasks 3 and 4. In the dose reconstruction report, Table
3-5 assigned all the table 3 contaminants to pathways (Attachment
#3).
Task 4: This Task's work evaluated the completed exposure
pathways. Screening analysis was done to: 1) identify important
pathways for each contaminant within each media;
2) and identify, across all media, the ones important
for each contaminant; and 3) identify contaminants with
the greatest potential to impact offsite populations.
In the previously mentioned mailout, Table 4 listed the
screening's identified highest priority contaminants and
sources, recommending media and exposure routes: I-131 from
X-10's RaLa process, conveyed through the milk pathway;
2) Cesium from the X-10 separation process, to White Oak
Creek, the Clinch River, and surface water, to the fish,
soil sediments; vegetables, dairy cows, and milk pathways;
3) mercury from Y-12; and 4) polychlorinated biphenols (PCBs)
from K-25 and Y-12.
The Oak Ridge Health Assessment Steering Panel (ORHASP)
received a detailed dose reconstruction analysis of these
four priority contaminants. They also received additional
screening analyses for other contaminants that were screened
out in Task 4. The first cut of the latter did not produce
any results indicating a potential for further dose reconstruction
work. Additional screening was done due to concerns about
historical accuracy of records (uranium) and because conclusive
screening analysis was not done on uranium, arsenic, beryllium
copper, lithium, other radioactive products. The ORHASP
also recommended a more detailed analysis of asbestos and
plutonium. A report was produced on the re-evaluation of
those contaminants.
The initial list of contaminants of concern for further
evaluation, based on the dose reconstruction study are:
I-131, mercury, cesium-137, PCBs, uranium, fluorine and
various fluorides. ATSDR will look at the latter due to
the large quantities used on site and released. Re-screening
of the other contaminants will be discussed at a future
meeting.
The next steps in the Public Health Assessment process
are to: 1) present and discuss information on contaminants
that received additional screening (a Subcommittee work
group to assist ATSDR could be helpful); and 2) present
and discuss information on contaminants of concern for further
evaluation (overview of available information and their
assessment). In June, work will begin with review of the
state reconstruction of I-131 releases and ATSDR's technical
comments.
Mr. Hanley was thanked for an excellent report. The committee's
discussion with him included the following:
-
Ms. Sonnenburg requested ATSDR's consideration of cumulative
effect from coal burning that was done under the regulatory
limit per ton, but amassed a huge tonnage over time
that has never been totaled. She expected that Mr. Earl
Lemming and Ms. Kaplan would have data that ATSDR could
add to its own for at least a quick analysis. Mr. Hanley
said that this could be discussed with the Subcommittee,
but such cumulative comprehensive assessment is not
typically what ATSDR does, being limited to Superfund
sites. He also agreed to meet with the members to discuss
specific areas of the report. Mr. Lewis said, if effects
from another agency such as TVA are considered, they
should be invited to provide their interpretation of
those releases.
-
Will the Nevada Test Site (NTS) I-131 and I-133 exposures
were be included in the analysis? (Eklund) Mr
Hanley responded that ATSDR will provide an overview
of this topic, as covered in the dose reconstruction
study.
-
Are the Oak Ridge radionuclide releases much higher
or similar to other sources? (Frome) Most of the other
radionuclides were <1% of the iodine; the report
presents a relative risk to I-131. Are the ORR iodine
releases substantially larger than the Nevada Test Site
(NTS)? When the ORHASP document is reviewed, ATSDR can
discuss the effect of those other sources on the area.
Were K-12 and X-10 monitoring data used to determine
the workers' level of exposure on site; were their doses
as high as people offsite might have received? It is
not certain that on-site monitoring was reviewed at
this stage.
-
Will ATSDR examine the potential impact of changing
the initial assumptions used in the calculations of
scrubber efficiencies? (Also, the NTS data are not in
the summary, although they are in the report.) (Kaplan)
Ms. Kaplan agreed to provide ATSDR with two related
white papers she has written. ATSDR will present the
feasibility study's findings and the technical reviewers'
comments, then discuss next steps.
-
Recent studies indicate beryllium is highly toxic in
small quantities; how did it rank in the Task 4 evaluation?
(Johnson) It was included as a carcinogenic chemical,
and so was compared to PCBs, which posed the highest
risk. Beryllium's relative risk was 0.4% of the risk
of PCBs. Beryllium exposure mostly pertained to workers
and involves sensitivity issues. But ATSDR could look
into why that contaminant fell out of the process regarding
offsite exposures. Beryllium's major impact is on lung
capacity, not a cancer issue; PCBs may not be the proper
comparison. (Kaplan/Davidson)
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ATSDR should consider that the gasoline facility was
originally on the ORR, and consider offsite releases
of carbon tet from Y-12 which blew east. (Brooks)
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Did ATSDR review Dr. Kathleen Teeson's list and consider
her concerns? (Sonnenburg). Yes; fluorine was one, which
ATSDR added. Copies of that correspondence will be provided.
-
Who is doing, and at what stage is, the document review?
Are the documents considered acceptable? The ORHASP
membership was similar to this Subcommittee, and they
reviewed everything. ATSDR will check their minutes
to ensure that the questions raised were documented
and addressed.
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How did they/are we looking at the X-10's major processes
that may still delivering an effect? (Hill) There were
cesium releases from the dam in 1985, (Kaplan) and a
flood in 1964 along with regular releases. (Bob Peele).
The dose reconstruction focused on historical exposures.
The radioiodine is long gone, but radioactive products
such as cesium were also released to White Oak Creek.
In the last ten years, a lot of work has been done on
the Clinch River and Watts Barr Reservoir environments,
and ATSDR is involved in that work. Step 3 will combine
the dose reconstruction's historical data with the data
collected in the past 20 years (e.g., state, EPA) and
combine that into one evaluation. The published health
assessment will include both historical and current
exposures offsite.
-
A peer review of the ORHASP studies is needed. They
had informal reviews, and it is not clear that a number
of controversial points were corrected (e.g., higher
and lower levels that suggest some study and evaluation).
The "peer review" done is only a compilation of every
comment received. (Brooks)
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There are levels of peer review. Please ensure that
anything given to the Subcommittee has its peer review
status clear, and please supply a list of any peer reviewed
documents about offsite effects from ORR exposures (e.g.
worker studies published in the literature). (Frome)
The unpublished documents reviewed by the state and
EPA could be supplied, and all the Public Health Assessments
are peer reviewed by a panel of neutral scientists.
Any subsequent health assessments (from protocols on)
will also be peer reviewed. All comments received from
the public are included in the public health assessment
with a response. The technical comments are not included,
but are publically available.
-
Has the porosity of the limestone bedrock below K-25,
Y-12, and X-10 been quantified? (Eklund) Ms. Kaplan
thought she had that data in two papers, one on equity
regarding buried waste. In many cases, DOE does itself
not know what is buried. The sites where most of the
releases are occurring is where the remediation is being
done. Mr. Hanley stated that X-10 waste is moving offsite
in surface water, and DOE is monitoring where it enters
the Clinch River (permits monitored by EPA and TDEC)
ATSDR will look at those data. They will not look at
the burial sites, but if such documents are found, they
will provide them.
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Clarification of "peer review" is needed, which differs
from "peer input" on documents. "Peer review" requires
independence and expertise, and must be responded to
in a publicly available document. (Akin) Mr. Akin added
that little of the latter was done; the Subcommittee
will have to decide what it wants. EPA uses mostly peer
input and comment by peers; but it may not be independent
and does not require formal response.
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How do we capture all these concerns to address them
formally by the experts generating the documents, rather
than piecemeal? (Lewis) Dr. Davidson hoped to establish
a Public Health Assessment Work Group to establish priorities
with ATSDR and report/recommend back to the Subcommittee
on the process.
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The problems of the buried waste include little documentation
on low-level waste, and that the X-10 records on high-level
waste were destroyed on 1984. Some were reconstructed,
but in general that is not an accurate inventory. That
makes more important the good records of the outflows
off the reservation. This is a complex subject that
would take several months to study thoroughly. (Brooks)
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What does "significant" mean? (Washington) Mr. Washington
stated that the ORR scientists, aware of the materials'
toxicity, at some point began recording what was buried,
but not necessarily how much. The surface and ground
water at Oak Ridge interchange. As a manufacturing plant,
Y-12 in the past used many chemicals (benzene, carbon
tet, xylene, toluene, all good solvents and all carcinogenic).
Some bomb components are still produced, even
at a 20-25% production level; and past shifts ran the
plant 24/7, with releases emitted in huge quantities.
There often were no special precautions taken with toxic
materials; and, while the effect of one or two contaminants
may be known, the long-term synergistic effects of multiple
combinations are not. Those must be determined, because
they will skew the data. However, Dr. Brooks disagreed
about the lack of waste disposal standards, based on
his experience as a Y-12 chemist during the war. He
said he had worked in some industries he considered
far more dangerous.
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Is there any time boundary, or where is the disconnect,
for this Subcommittee's function to evaluate the health
effects of the ORR versus that of the public health
assessment? (Akin) ATSDR will develop the public health
assessment with advice from the Subcommittee; it is
not an investigative body that develops its own documents.
The ultimate product of this Subcommittee will be the
public health and community needs assessments. The time
frame includes past and current exposures, and those
in future as much as possible, based on present knowledge
(no new operation could be considered). However, Mr.
Washington noted that the past is germane to the future.
Workers in boots walked through mercury in the Y-12
process using it; and the vapor pressure imbued it into
the walls; on a hot day, you can see it dripping. The
problem is so great that there is an international committee
examining it.
Dr. Craig moved to form a Public Health Assessment
Work Group. All were in favor and none opposed.
The motion passed. Work Group volunteers
were: Johnson, Craig, Brooks, Manley, Washington, Lewis,
and Kaplan.
Public
Comment
Dr. Bob Peele was an ORHASP member, and he offered several
comments. The 1993 screening was a quick process done in
only eight weeks. Because of that time limit, they only
screened for relative (not maximum) risk, to avoid having
to address pathway attenuation. The results were grouped
by radiation and non-radiation, and the most important elements
were chosen (iodine, mercury and PCBs); nothing else measured
approached their levels. The more recent screening (Volume
6) did a still-conservative calculation of the maximum interval
and plausible importance of absolute risk.
The Subcommittee may want to add more contaminants of concern;
and he agreed that all the work should be reviewed. He thought
that I-131 may be the more important ORR release. That was
the biggest analysis, which was reviewed, and the comments
were incorporated by Chem Risk. Everyone wished for better
peer review. It was not done as well as it could have been,
but is still very professional work.
Radiation. The workers' contaminants may sometimes be of
concern to the public. They could inhale the iodine and
residents with backyard cows would be affected through the
milk pathway. That risk was neither understood nor monitored
until the late 1950s. The Hoffman report details how this
can be estimated, as well as adding in the NTS fallout.
The estimates are comparable for sites equidistant to the
ORR, with the ORNL releases more important closer the lab
and the fallout more important further away. The fallout
study results were delineated by county, but the real range
of the fallout remains unknown.
The cesium in the Clinch river was the longest-lasting
isotope, with a 30-year half-life. The report considered
all of them; at certain times different ones were more important
than the others. Regarding the scrubber, only one measurement
was made, but the iodine released was well measured.
Chemicals. The mercury was discharged to protect the workers,
but crossed the hills impelled by big fans and exposed residents.
The biggest problem was from fish exposed in Poplar Creek.
No one measured mercury in the fish, nor in sediment until
1985, which they tried to correlate to DOE plants in other
areas to estimate the fish mercury content. Nearly everyone
who ate those fish had a higher dose than the minimum risk
level.
Dr. Davidson asked if Dr. Peele could participate in the
work group. He declined to be a member, but might attend
from time to time.
Presentation/Discussion
of the Health Needs Assessment
Mr. James Lewis reported the work group's discussion of
the questions raised to George Washington University at
the January meeting: clarifications on how the focus groups
worked, the telephone survey, key informants, and GWU's
overall program. They provided these questions to ATSDR,
who advanced them to GWU. They in turn met with the work
group, which suggested two potential enhancements.
Two of the Principal Investigators, Dr. Rebecca Parkin
of GWU, and Dr. Grace Paranzino, of Hahnemann University,
defined the work group input as invaluable, and presented
a proposal in response. Dr. Parkin reviewed the project's
status: 1) the study proposal is almost done, as is 2) the
document review; 3) two site visits have been done to date,
and additional comments from community received on 4) the
key resource interviews. The work group provided input to
5) the phone survey and 6) the focus groups, which all lead
to 7) the final report.
Steps 4-6 involve interviews of individuals (key informants/phone
survey) and groups (focus groups), which require Institutional
Review Board (IRB) human subjects study review and approval.
GWU granted that; and approvals are pending at Hahnemann
University.
The key informant interviews of groups will include health
officials, health care providers, and community members.
There will be 25-30 members per group and 10-15 minutes
spent per (confidential) interview. The questions will be
open-ended (e.g., asking their experience of health problems).
Then, to help develop a health education program, the project's
purpose, the phone survey component will identify health
issues and information needs and finalize the focus groups
and question guides. The survey will be of the general population.
They will be accessed by random digit dialing to households,
the protocol to obtain a final sample of respondents representative
of the general population. Staff of the GWU Medical Center
for Survey Research will do the survey. About 400 interviews
(again, confidential) are planned, at 10-15 minutes per
interview using closed-ended questions.
The focus groups are to gain knowledge about sub-groups
who have health issues and need health information; to clarify
the health issues; and to identify the information they
need and how they want to receive it. Up to eight groups
are planned, composed of up to 12 people per group with
similar characteristics. The group discussions will be moderated
by project staff and last 1-2 hours; open-ended questions
will be used to allow as much interaction as possible. Confidentiality
is maintained in the final report.
Steps 5 and 6 were the modifications made after the meeting
with the work group. Per Ms. Mosby's suggestion, the term
"key informant" will be changed to "key resource."
Committee discussion with Drs. Parkin and Paranzino included:
-
Why are only adults eligible (age 21)? (Frome) Household
phone answering patterns of previous studies were reviewed
to ensure a good representative sample of the population.
This will be continually adjusted as the survey goes
on; the interviewer will ask for a particular type of
person to be the respondent.
-
What is the opening language? (Frome) That approved
by the IRB identifies the interviewer as from GWU, explains
why they are calling, and gets their informed consent.
They will be asked about broad health issues in general
to capture the breadth of health concerns, what they
would like to know, and how they get their health information
(e.g., the Web, newspaper, etc., to see how to design
the educational program). However, the interview instrument
is not yet set up.
-
Dr. Brooks said the new version of step 5 answers all
his concerns about statistics; which he now withdrew.
-
Be aware; they might expect GWU to do something about
those health issues. In view of such dashed expectations
in the past, they may not want to participate unless
they believe the interviewer credibly needs this information
and/or can help. (Washington) GWU will identify available
health information resources for people to access; and
ATSDR has set aside some funding for the AOEC clinics
to do some follow-up (but what that will be is not yet
known). A risk management tool kit can be applied in
any of the interviews/focus groups. The concerns or
wishes expressed will be documented and passed on to
the Subcommittee and ATSDR.
-
Great concern was expressed that the random digit dial
method described would place most calls in Knox County,
the least impacted, but with most of the phone numbers.
If the criteria are changed, (e.g., to a specific phone
exchange for a portion of a county) GWU could refine
the survey further.
-
How will you balance the representation in the groups,
or reflect the primary focus of the most affected group;
where will the groups be held; and are they open to
the public? (Lewis) The process will be refined as it
proceeds; each part informs the next component. For
example, the phone survey might indicate worry about
one particular health concern in one geographic area,
so all the counties need not be represented. The groups
are not open to public; they have only 12 people to
be able get all the information desired in the time
allotted. The strategy might also rest on who the partners
are (e.g., if asthma is a concern, physicians seeing
asthma patients might suggest participants).
-
Many of the agencies on the GWU advocacy list are underfunded
and cutting services. (Galloway) The resources will
be determined in the data gathering phase, and the focus
groups can use this opportunity to advise what services
are desired. But GWU would avoid telling people specifically
where to go until Phase II, the implementation of the
health plan. Phase I is only to research information
and combine it in such as way as to guide services to
the community.
-
Some physicians will not diagnose contamination-related
illness, or the individual may not make the connection
to self-identify. (Eklund) GWU will focus on providers
already known to see people who may be so affected.
But the community representatives will also be solicited
for such concerns that may not have been presented to
a health care provider. Dr. Parkin expressed her own
personal commitment not to do science that just sits
on the shelf and is not useful. She will do all she
can to ensure something comes of it, and will give that
to the agencies to run with the ball. She also noted
that the health education information is not just for
residents, but could also be useful to health care providers
who need more information about occupational illnesses.
-
Ms. Kaplan asked who decided the community health education
focus, and why? The community wants clinical evaluation,
not education. The perception may be that this is just
another government-funded educational study. The Subcommittee
needs a mission statement to advise what it does; people
want to be helped, and she was unsure this would do
it. Dr. Davidson responded that the ORRHES mission statement
is in its charter. Ms. Dalton stated that ATSDR's Congressional
mandate is to examine site-related contaminants and
any effects on the public. They cannot provide health
care, but they can recommend to other agencies. Ms.
Kaplan asked if there is there some flexibility between
diagnosis and treatment.
Dr. John Stockwell stated that ATSDR's Memoranda of Understanding
(MOU) with other agencies could provide such health care.
For example, the Health Resources and Services Administration
(HRSA) provides environmental medicine/consultation, but
he did not know if those clinics are in the Knoxville area.
He provided a copy of the MOU to Ms. Dalton to share with
the board. She reported that when such issues are raised
at other sites, ATSDR has tried to facilitate a discussion
with HRSA to address them.
Health
Needs Assessment Work Group Report
Mr. Lewis began the Health Needs Assessment Work Group
report by expressing his irritation that the scope of the
survey had suddenly changed with new information. The work
group will now have begin anew. He called for communications
to be improved, specifically stating that the people who
walk out of this room and do not get involved [with the
work group] in the interim, should not come back to complain
and want to change it all later.
The work group had intended to address: 1) identifying
as close to eight focus groups as possible for the Subcommittee
to vote on this day; 2) to identify key informants; 3) to
explain the logic of shifting the phone survey to be done
before the focus groups; and 4) to discuss utilizing either
the Work Group or the Subcommittee in developing a pilot
program to review the questions to be asked.
Dr. Parkin reported GWU's amenability to the latter. While
they cannot be too detailed to avoid hazarding the credibility
of the study, they could interview the Work Group or Subcommittee
as they would interview the residents, with the proviso
that they would not divulge the questions. This could help
in some areas, such as making sure the terminology is correct,
and a pilot test questionnaire could ensure it captures
the information needed.
Ms. Mosby preferred to select most of the 7-11 participants
in this pilot from the Subcommittee, which would provide
a better balance. She also noted that those who participate
in the pilot test would no longer be involved in the survey
(except as key resources). However, further involvement
in either the phone survey or the focus groups was unlikely.
Dr. Brooks moved that the Subcommittee recommend to ATSDR
that the Subcommittee members participate in a pilot test
with George Washington University to determine the appropriateness
of the survey questions. Ms. Sonnenburg seconded the motion.
Ms. Mosby offered friendly amendment that the number involved
be "a minimum of 7 and maximum of 11," to Dr. Brooks' agreement.
Dr. Brooks moved that the Subcommittee recommend
to ATSDR that a minimum of 7 and a maximum of 11 Subcommittee
members participate in a pilot test with George Washington
University to determine the appropriateness of the survey
questions. The vote was 16 in favor and none opposed.
The motion carried.
Dr. Brooks moved that the Needs Assessment Work
Group choose the 7-11 members, the majority wishing to participate
to be selected from the Work Group and the balance from
the Subcommittee. Ms. Sonnenburg again seconded
the motion. A voice vote showed all in favor and none opposed.
The motion passed. The Pilot Test Work
Group volunteers were: Vowell, Sonnenburg, Johnson, Galloway,
Brooks, Creasia, Hill, Malmquist, Kaplan, Lewis, and Mosby.
Dr. Brooks then moved that the Subcommittee accept the
Work Group's recommendation to do the phone survey before
the focus groups, as explained in the modified submission
from GWU (Attachment #4) and the presentation made today.
Dr. Malmquist seconded the motion. In an amendment, Ms.
Mosby moved that the Subcommittee accept the Work
Group's recommendation to identify George Washington University's
Step 4 as the Key Resource Group, Step 5 to be the Phone
Survey, and Step 6 to be the Focus Groups. In a
voice vote, all were in favor and none were opposed. The
vote passed.
Mr. Lewis pointed out that the chart of suggested characteristics
of focus groups had been distributed (Attachment #5), as
had that of the key resource groups/individuals (Attachment
#6). Dr. Paranzino noted that if the population is redefined,
as per the preceding discussion, these focus group suggestions
might change. Mr. Lewis agreed; this should be considered
as a first cut.
Public
Comment
Mr. Pereira hoped that GWU would be able to counter a potential
bias to the process, by gaining the participation of those
most likely to have been exposed but feeling "surveyed to
death." He also stated that nothing is cast in stone that
education must be the point of emphasis. The needs assessment
could be and should be, and the health education component
can follow.
Mr. John Stewart, the PACE union health representative
for 400 active workers and 14,000 past workers, spoke. The
PACE union is doing a medical surveillance survey. He invited
the GWU and ATSDR to attend the meeting hall to find out
what problems need assessing; they see it every day. Just
the previous week, he had helped a worker with six weeks
to live from multiple cancers to finalize his affairs; or
he tries to find physicians to help the workers. He stated
clearly, "Oak Ridge physicians do not, do not, help the
workers;" they go elsewhere for treatment. (He later clarified
that those doctors do not necessarily refuse to treat; but
they are loath to define any problem as occupationally related).
DOE studies have cost $156 million in the last ten years,
and they are going to do another one. They asked the union's
participation in a survey to "help the workers," that produced
a stack of paper 10' tall but not a dime to help the workers.
He felt there to be no need to ask what people think are
health concerns; they can be seen. Many have hearing loss,
the first sense lost by test animals exposed to methyl mercury.
The workers feel like "a bunch of test animals." They only
go to the union now; they are the only ones trying to help.
He stated that what his members need is financial and medical
help. Mr. Hill shared Mr. Stewart's concerns and frustrations
about people with health concerns that he cannot help. But
he was willing to stick with it and asked him to help any
way he can.
Mr. Mike Napp asked several questions:
-
Why were Blount and Merriwell counties not included
in the survey?. Dr. Davidson explained the rationale
for the selection of the seven counties in the Oversight
Committee domain, and Knox County because many workers
live there.
-
How many of the Subcommittee members have health ORR-related
effects? Dr. Davidson objected that the Subcommittee
members were not present to self-identify. None did.
Mr. Napp accepted that, but noted that "we" had nominated
people with offsite contaminants in their bodies who
consider themselves to be ill as a result.
-
ORHASP report identified four contaminants; did EPA
identify others, and will this Subcommittee address
that? Dr. Davidson reported that as having been discussed
earlier, and that the list of contaminants of concern
would be provided to him.
Ms. Linda Lewis acknowledged the importance of discussions
about scope, direction, charter, mission, etc.. but defined
being proactive rather than reactive as more important.
Quoting a song ("don't depend on the train from Washington,
it's a 100 years overdue"), she advised the Subcommittee
not to ask an organization for what it cannot provide. For
example, disseminating information about the R.W. Johnson
Foundation funding to help cancer patients would be more
useful. She urged the Subcommittee to be proactive, find
what takes care of the problems to be addressed, and working
with that. She has immune disorders, and worked at the Oak
Ridge National Laboratory (ORNL) for decades. But her focus
is not whether it caused her illness; her focus is to get
well and to be a victor, not a victim. She provided her
phone number at work (524-8461) and offered her help to
the Subcommittee.
With no further comment, the meeting adjourned at 6:57
p.m.
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