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I am very pleased to provide a written statement regarding the Agency for Toxic Substances and Disease Registry's (ATSDR) programs for Fiscal Year (FY) 2002 appropriations. This is the first opportunity we have had to present ATSDR as a "stand alone" agency. Prior to FY 2001, the appropriations for ATSDR were included in funding to the U.S. Environmental Protection Agency (EPA). Last year this subcommittee recommended a separate account for ATSDR; I assure the members of the Subcommittee that this will not diminish in any way our close working relationship with EPA.

ATSDR is a federal agency created by Congress in 1980 by the Comprehensive Environmental Response, Compensations, and Liability Act (CERCLA), or what is more commonly known as Superfund legislation. As such, ATSDR is the public health agency charged with determining the existence of human exposure to hazardous substances, addressing the nature and extent of health problems at Superfund sites, and advising the EPA and State environmental agencies on clean-up and other actions needed to protect the public's health. To accomplish this mandate, ATSDR received approximately $75 million in FY 2001.

ATSDR works in close collaboration with the EPA, other federal, state, local, and tribal governments; health care providers; and affected communities. The agency has made a difference to all of the partners by evaluating health and environmental information to assist in remedial decision-making, answering the health questions of affected community members, recommending preventive measures to protect public health, and providing diagnosis/treatment information to local health care providers. Providing environmental public health services often is very challenging. ATSDR staff must balance the disciplines of science and effective human interaction at sites and in situations that can be very complex. From new medical issues at sites such as Libby, Montana, to very evident community concerns and broad policy aspects at sites such as Vieques, Puerto Rico; the challenges and solutions are rarely clear-cut.

The volume of ATSDR's work at sites continues to be very heavy and is the major part of our workload. In fiscal year 2000 alone, ATSDR and our partners produced 1,569 health consultations, 108 public health assessments, and 32 exposure investigations. For just those sites evaluated in 2000, ATSDR estimates that more than 4 million people lived in close enough proximity to be concerned about potential exposures. In addition, ATSDR is now being asked to respond to a broader array of sites. As always, ATSDR addresses issues at National Priorities List (NPL) sites listed under Superfund; however, we also find ourselves addressing more and more non-NPL sites. In 1996, a majority of the sites at which we worked were NPL sites; last fiscal year the majority were non-NPL sites, including responses to petitions from citizens.

ATSDR provides environmental public health services to concerned individuals and communities around the country. For example, we address issues:

• in urban areas like Milwaukee and Baltimore where health concerns have arisen in areas of land and building redevelopment;
• involving hazardous wastes at federal facilities such as Andrews Air Force Base in Maryland, the Fernald nuclear facility in Ohio, and Fort Wainwright in Alaska;
• for children and families in Illinois, Michigan, Ohio, and recently in New York, who talk with staff in our Pediatric Environmental Health Specialty Units because they are concerned about exposure to mercury caused by the replacement of outdated gas regulators in their homes;
• on behalf of women who may have decreased bone density or earlier onset of menopause due to their occupational exposure to lead in Idaho;
• and that may have a long-term impact on the public health and health care systems like ATSDR's work in Libby, Montana, and on the response to a possible childhood leukemia cluster in Marion, Ohio.

ATSDR's health consultations, public health assessments and exposure investigations at sites are critical in assisting EPA and state officials with clean-up decisions, addressing community health concerns, and investigating possible increases in disease rates. For example you may have heard about a site we've worked on here in the District.

• Recently, ATSDR provided environmental public health support to the District of Columbia Department of Health (DCDOH) and the U.S. Army Corps of Engineers at the American University/Spring Valley site in Washington, D.C. The American University and Spring Valley community have been built and developed in an area where the U.S. Army had conducted chemical warfare research and testing during World War I. Unexploded ordnance and evidence of past weapons research activities began to surface and varying health complaints also has been found during environmental sampling. ATSDR reviewed environmental sampling to determine potential human health effects, and, in January 2001, conducted an exposure investigation to ensure that children and staff at a university day care center were not adversely affected by arsenic-contaminated soil. Fortunately, analysis of hair samples from children and staff at the day care center found no elevated exposure to arsenic. ATSDR continues to work with DCDOH, the EPA, and the U.S. Army Corps of Engineers to ensure that past activities pose neither a present nor a future public health threat.

ATSDR's work with the District of Columbia Department of Health provides a good example of how important public health considerations can be in evaluating the effects of property redevelopment. Certainly, attention to contaminants and health risks early on can save much anguish and reduce costs in the long term.

Activities in Libby, Montana, provided a very good example of a current site where ATSDR's work is making a difference. The situation in Libby offers a dramatic example of past exposure resulting in serious disease. In 1999, reports from Libby documented cases of non-occupational asbestos-related pulmonary impairment among family members of former vermiculite mine employees as well as others in the community with no connection to the mining operations. They were suffering from three potentially fatal diseases; asbestosis, mesothelioma, and lung cancer related to their asbestos exposure. Finding non-occupational asbestos-related pulmonary disease is extremely unusual and suggests that dangerous levels of asbestos exposure have occurred within the Libby community. Given the latency period for mesothelioma of as much as 40 years, the health care community could be seeing the effects of exposure to vermiculite from Libby for an entire generation.

Beginning in late 1999, ATSDR's activities in Libby have included: epidemiologic investigations, community outreach, close coordination with the EPA regional office on environmental sampling activities, broad ranging communications, education programs for health care providers, and collaboration with area health and social service agencies to provide long-term support systems for concerned local residents.

In 2000 (July through mid-October), ATSDR conducted a medical testing program to assess the public health implications of past human exposure to tremolite asbestos in Libby. We originally anticipated screening about 3,000 people-but over the course of our medical testing program more than 6,100 Libby-area residents and former mine workers volunteered to participate and were screened. They all answered an extensive questionnaire about their possible exposures and received both chest x-rays and pulmonary function tests.

Earlier this year, ATSDR reported a preliminary analysis of the medical testing results from the first 1,078 participants, or 18% of the total number of participants in the medical testing program. These results showed a very high percentage of individuals reporting contact with the contaminated vermiculite, and evidence of health impacts, particularly in the form of thickening and scarring of the outer pleural lining of the lung. Because this is an interim report based upon preliminary data, interpretations of the information need to remain cautious. Although the final percentages, based on data for the whole group, may change there is certainly cause for concern in the preliminary data-particularly in cases where health effects have been found in those with no occupational association with the mine. The final results will be issued this summer.

As a small agency, the workload we have at sites like Libby or American University would be impossible for ATSDR staff alone. To supplement our own staff, ATSDR works in close collaboration with state and local health departments. ATSDR has been funding environmental public health activities in states since 1987. ATSDR currently funds public health activities in 28 states through separate cooperative agreements that provide assistance to conduct public health assessments, health education activities, and epidemiologic studies. In FY 2000, ATSDR made available nearly $10 million to cooperative agreements states; these funds supported approximately 123 environmental health professionals within states.

Following are examples of the collaborative work between state health departments and ATSDR.

• ATSDR is working with the Missouri Department of Health (MDOH) to determine the impact of contamination from the Sentinel Wood Treating site on the surrounding city. This 15-acre facility is contaminated with a number of chemicals (including xylenes, pentachlorophenol, and dioxins) associated with former wood pressure-treating operations that occurred from 1959 to approximately 1978. Additional contamination, mostly volatile organic compounds from another industry located on the eastern boundary of the Sentinel site, joins with surface water and sediment contamination through a drainage ditch that discharges into the creek in the residential area. Contamination from both facilities has been found in surface and ground water, and in the soil. MDOH, the Missouri Department of Natural Resources, ATSDR, and EPA staff are currently evaluating samples taken from the creek, city water supplies, private wells, soil, and stream sediments to determine the extent of contamination and possible health effects for people who are exposed to the contamination. Findings and recommendations are expected to affect children who play in a nearby park and around the creek, people who maintain home gardens, and those traveling the highway alongside the site. Based on early information, residents already are being warned to avoid the stream. A health consultation with specific recommendations will be published in July 2001.
  
  
• In Wisconsin, ATSDR is working with the state Department of Health and Family Services (WDHFS) to assess possible impacts on the environment and health posed by a former manufactured gas plant in Ashland. This is one of the thousands of commercial, municipal, institutional, and industrial gas plants that have operated in the US; there are at least 105 in Wisconsin alone. Manufactured gas plants were used in the US for more than a century (1810-1966) to produce fuel from coal and oil. The Ashland site, including nearby Chequamegon Bay on Lake Superior and surrounding property, is contaminated with polycyclic aromatic hydrocarbons (PAHs) and volatile organic compounds. As a result of WDHFS evaluations, signs have been posted to warn of contaminants in the Bay and nearby park, and drinking water is regularly tested to ensure safety. (A 1999 exposure investigation done by WDHFS found that sport fish caught from affected waters have very low levels of coal-tar related contamination and are safe to eat.) Additionally, former workers at the Ashland waste treatment plant have been interviewed to document their exposure to hazardous substances and health status. Due to the prime location of the site, plans to expand its recreational and commercial uses are inhibited by the contamination. The Ashland site was proposed to the NPL in November 2000; a response from EPA is pending.

The link between exposure and illness

ATSDR's work is not confined to individual sites. We have a clear responsibility to assess the health effects of exposure to toxic substances, to provide the most up-to-date information available on the most hazardous substances, and to educate health care providers and citizens on how best to protect themselves from toxic exposures.

ATSDR's epidemiologic work has gone a long way in furthering our understanding of what health effects may result from toxic exposures. We are proud of our accomplishments in addressing a key mandate - learning more about the association between exposure to toxic substances and adverse health effects and the prevention of illness at Superfund sites. As presented in other Congressional testimonies, ATSDR's health studies have revealed an increased risk of birth defects, certain cancers, respiratory illness, neurologic disease and other health conditions in populations living near hazardous waste sites. ATSDR is currently working on a follow-up study of female former smelter workers in Idaho to determine the association between changes in bone density over time (osteoporosis) and a woman's lead body burden. An original study was conducted in 1994; the current study will provide critical information about potential long-term health impacts of lead exposure. Study results are due by the end of the year (2001).

The toxicological profiles ATSDR produces have become the standard reference for hazardous substances recognized by a broad array of professional organizations, such as the American College of Occupational and Environmental Medicine and the World Health Organization. Toxicological Profiles assemble key information for decision-making. For example, data on mercury was helpful as a reference to assist the U.S. Public Health Service and others in decisions on the safety of childhood vaccines containing mercury preservative; information about DDT was helpful to the State Department in negotiating the Persistent Organic Pesticides (POPs) Treaty. And, most recently, the US Department of Defense requested copies of our new toxicological profile on uranium for use at a recent NATO meeting to discuss of the fate of NATO depleted uranium armaments.

Work that ATSDR, with its partners, has done in the Great Lakes have yielded information that is relevant for people living near and possibly exposed to contamination from fresh water bodies. Through the Great Lakes Human Health Effects Research Program, ATSDR has found:

• vulnerable populations are being exposed to persistent toxic substances in the Great Lakes regions of the US and Canada;
• body burden levels of some persistent toxic substances (including PCBs, dioxins, DDT, and mercury) are two to four times higher in people consuming fish from the Great Lakes than in the general US population;
• the presence of neurodevelopmental deficits in newborns and cognitive deficits in children and adults who have been exposed to hazardous substance found in the Great Lakes; and
• conception rate and the incidence of a live birth are lower in some women who consume sport fish from the Great Lakes.

Among impact on policies and public health activities, findings from the Great Lakes research program were instrumental in implementation of Uniform Great Lakes Sport Fish Advisory issued by all 8 Great Lakes states as well as other states with similar concerns.

The medical community also looks to ATSDR for information on how best to diagnose and treat their patients exposed to toxic substances. In 1989, ATSDR began creating a series of documents called Case Studies in Environmental Medicine to provide a resource for health care professionals. Pediatricians routinely use the Case Study on Lead as the standard for treating childhood lead poisoning. Similarly, our case study entitled "Taking an Exposure History," is a mainstay of ATSDR's health professionals' education activities and is regularly used in medical residency programs and nursing schools across the country.

ATSDR's work spans from the largest communities to the smallest citizens-as evidenced by work in children's health and specifically at the Pediatric Environmental Health Specialty Units (PEHSUs). In 1998, ATSDR joined with the Association of Occupational and Environmental Clinics (AOEC) to develop the PEHSU program. The EPA also supports the PEHSUs. The program is designed to reduce environmental health threats to children; improve access to expertise in pediatric environmental medicine; and strengthen public health prevention capacity. There currently are PEHSUs in each of the 10 EPA regions of the country, in cities such as Washington, D.C., Iowa City (Iowa), Boston, and Atlanta.

The key focus areas of the units are medical education and training, clinical consultation, and clinical specialty referral for children who may have been exposed to hazardous substances in the environment. For example, the PEHSU at Harborview Medical Center in Seattle, one of the first units established, receives about 2,000 calls a month. Callers' concerns cover the gamut of toxic substances exposure, and have included the consumption of well water contaminated with pesticides, elemental mercury exposures, and solvent exposures from painting a child's bedroom. Health care providers specifically trained in both pediatrics and environmental medicine are available on a case-by-case basis to see children and their families, and to provide training and information on toxic substance exposures and childhood environmental health issues. In several cities the PEHSUs are affiliated with poison control centers that are resources for parents whose children have been exposed to toxic substances.

Applied research and surveillance are key to future protection

ATSDR views itself as a service agency and relies heavily on basic research conducted by others. However, because our service areas (health and exposure) still have many uncertainties, we are constantly striving to improve the product and services we offer to communities exposed to toxic substances. ATSDR has developed a small and focused applied research agenda for FY's 2002-2010 to guide research activities and enhance the agency's ability to identify, evaluate, and intervene in toxic exposures and adverse health outcomes. The ATSDR applied research agenda is well positioned to address the agency's mission and mandates, strategic plan, and requirements for the Government Performance and Results Act (GPRA). In addition, ATSDR is working closely with the National Institute for Environmental Health Sciences at the National Institutes of Health, CDC, and other agencies in coordinating research agendas and identifying important areas for collaborative research.

ATSDR will continue to work closely with federal partners and other constituents to maximize a collaborative focus on specific areas of research that are of high importance and of common interest. ATSDR has identified six focus areas for research: exposure assessment, chemical mixtures, susceptible populations, community and (American Indian/Alaska Native) tribal involvement, evaluation and surveillance of health effects, and health promotion and intervention. Research will help answer essential public health questions asked by communities across the country, such as: have I been exposed or harmed?; can the hazardous substances cause adverse health outcomes?; and what can I do to improve my health? For thousands of waste sites and other environmental exposures, these health questions must be addressed.

Surveillance is a critical element in determining the nature and extent of health effects that might be associated with exposure to contaminants in the environment. Since 1990 ATSDR has maintained the active, state-based Hazardous Substance Emergency Events Surveillance (HSEES) system to describe the public health consequences associated with the release of hazardous substances. The system catalogs sickness and death experienced by employees, responders, and the general public that result from hazardous substances emergency events. Currently 16 states participate in HSEES; those states include Alabama, Iowa, Missouri, and Wisconsin. An analysis of five years of data (1993-1997) yielded the following information:

• More than 24,000 emergency events were reported to HSEES; fixed-facility events represented 80% or all reported events, only 20% of all events were transportation related.
• The months of April through August were identified as a "peak" accident period for both transportation-related and fixed facility events. This peak coincides with the agricultural planting season when demand for agricultural chemicals is high.
• There have been more than 9,600 victims of the reported hazardous substances events. A total of 110 deaths were reported (66 in transportation-related events and 44 at fixed facilities).
• Respiratory irritation was the most commonly reported injury for fixed-facility and transportation-related events.

The data gathered provides information on trends in specific events or substances that can be the focus of further investigation and/or safety and training programs. Several states have responded to the findings reported from the HSEES system and have changed programs and policies to reduce injuries or other adverse health outcomes. For example, emergency response instructors have reported that they will update training courses in response to HSEES data about injuries first responders have suffered from illicit methamphetamine drug labs.

Significant progress has been made by ATSDR in developing registries of individuals exposed to specific substances and tracking them over time to assess their health status and provide updated information to those exposed. As noted, such an effort will undoubtedly be important in Libby, Montana. The agency also has begun to look at its responsibilities in the area of disease registries or surveillance (or "health tracking" as referred to by the Pew Commission). We are evaluating an appropriate set of activities in coordination with CDC. ATSDR is now at the point where we can begin addressing the "disease registry" part of our name-and begin assuming a leadership role in the development of systems for tracking environmental disease.

With the additional funds the President's budget recommends for ATSDR's use in FY 2002, we plan to undertake several new activities to initiate disease surveillance around Superfund sites. We plan to look at high-priority environmental diseases to determine their potential association with exposures from Superfund sites. The goals of these activities will eventually lead to:

• development and evaluation of methods to measure and track high-priority diseases with potential links to environmental exposures, including the establishment of operational case definitions, through demonstration projects and pilot programs in selected communities and geographic areas;
• collaboration with existing health surveillance systems to link health databases at the state or local level with other environmental databases and geographic information systems (GIS); and
• an understanding of the basic epidemiology of high-priority diseases (prevalence and distribution within the population) and the identification of potential associations with known environmental exposures.

Time has shown the wisdom of the Superfund legislation. Hundreds of communities are searching for health answers. They are real people with real concerns, particularly about children's health. The public naturally becomes concerned when they see situations such as half of a class of third graders needing to bring asthma inhalers to school, or when persons compare notes about their first diagnosis of multiple sclerosis at a 20 year high school reunion, or when multiple parents within the same neighborhood watch their children suffer from brain tumors and other severe illnesses.

In communities near obvious sources of environmental contamination, people understandably worry that somehow environmental pollution might be playing a role. Our job is to address those concerns-which we do everyday all across the country. Though there is still much to learn and many concerns yet to be addressed, we want to assure the members of this committee that ATSDR will do its best to answer the questions people have whether it is childhood leukemia in Fallon, Nevada, autism in Brick Township, New Jersey, or multiple sclerosis in Wellington, Ohio.

This concludes our testimony. Once again, I thank the Subcommittee for the opportunity to provide written testimony on our budget. ATSDR welcomes any questions subcommittee members might have and will be happy to provide written answers for the record.

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