[Senate Hearing 107-318]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 107-318

                      CHILDHOOD LEUKEMIA CLUSTERS 
                             IN FALLON, NV

=======================================================================

                             FIELD HEARING

                               BEFORE THE

                              COMMITTEE ON
                      ENVIRONMENT AND PUBLIC WORKS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION

                                   ON

 RESPONSES BY THE FEDERAL GOVERNMENT TO ``DISEASE CLUSTERS'' RESULTING 
                  FROM POSSIBLE ENVIRONMENTAL HAZARDS

                               __________

                       APRIL 12, 2001--FALLON, NV


                               __________


  Printed for the use of the Committee on Environment and Public Works


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                            WASHINGTON : 2002
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               COMMITTEE ON ENVIRONMENT AND PUBLIC WORKS

                      one hundred seventh congress
                             first session
                   BOB SMITH, New Hampshire, Chairman
             HARRY REID, Nevada, Ranking Democratic Member
JOHN W. WARNER, Virginia             MAX BAUCUS, Montana
JAMES M. INHOFE, Oklahoma            BOB GRAHAM, Florida
CHRISTOPHER S. BOND, Missouri        JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio            BARBARA BOXER, California
MICHAEL D. CRAPO, Idaho              RON WYDEN, Oregon
LINCOLN CHAFEE, Rhode Island         THOMAS R. CARPER, Delaware
ROBERT F. BENNETT, Utah              HILLARY RODHAM CLINTON, New York
BEN NIGHTHORSE CAMPBELL, Colorado    JON S. CORZINE, New Jersey
                Dave Conover, Republican Staff Director
                Eric Washburn, Democratic Staff Director

                                  (ii)

  

                            C O N T E N T S

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                                                                   Page

                       APRIL 12, 2001--FALLON, NV
                           OPENING STATEMENTS

Clinton, Hon. Hillary Rodham, U.S. Senator from the State of New 
  York...........................................................     8
Ensign, Hon. John, U.S. Senator from the State of Nevada.........     4
Gibbons, Hon. Jim, U.S. Representative from the State of Nevada..     5
Reid, Hon. Harry, U.S. Senator from the State of Nevada..........     1

                               WITNESSES

Beardsley, Tammy, Fallon, NV.....................................    12
de Braga, Marcia, Assemblywoman..................................     9
    Prepared statement...........................................    66
Falk, Henry, assistant administrator, Agency for Toxic Substance 
  and Disease Registry, Atlanta, GA..............................    47
    Prepared statement...........................................   143
Gross, Brenda, Fallon, NV........................................    11
Guinan, Mary, MD., Ph.D., Nevada State Health Officer............    27
    Prepared statement...........................................   160
Guinn, Hon. Kenny, Governor, State of Nevada.....................     5
Hearne, Shelley, executive director, Trust for American's Health.    53
    Prepared statement...........................................   202
McGinness, Hon. Mike, State Senator, Nevada......................     7
Naughton, R.J., Rear Admiral, Fallon Naval Air Station, Fallon, 
  NV; accompanied by Captain D.A. ``Roy'' Rogers, Commander......    30
    Prepared statement...........................................   167
Prescott, Stephen, MD., Huntsman Cancer Institute, University of 
  Utah...........................................................    14
    Prepared statement...........................................   151
Sinks, Thomas, associate director for Science, National Center 
  for Environmental Health, Centers for Disease Control and 
  Prevention, Atlanta, GA........................................    49
    Prepared statement...........................................   196
Tedford, Hon. Ken, Mayor, Fallon, NV.............................    32
    Prepared statement...........................................   171
    Responses to frequently asked questions about Churchill 
      County Leukemia Cases......................................   174
Todd, Randall, State Epidemiologist, Nevada State Health Division    25
    Prepared statement...........................................   166
Trovato, E. Ramona, director, Office of Children's Health 
  Protection, Environmental Protection Agency, Washington, DC....    51
    Prepared statement...........................................   198
Washburn, Gwen, commissioner, Churchill County, NV...............    34
    Prepared statement...........................................   172

                          ADDITIONAL MATERIAL

Letters:
    Bobb, Bonnie Eberhardt.......................................   102
    Churchill Economic Development Authority.....................   191
    Fallon Auto Mall.............................................   191
    Shepherd Miller, Inc.........................................   222
    Shundahai Network............................................   205
Recommendations, Water Sampling Practices, Nevada State Health 
  Lab...........................................................179-189
Reports:
    Bench Scale Test Results for Arsenic in Fallon, NV, Shepherd 
      Miller, Inc................................................   278
    General Accounting Office, Health, Education, and Human 
      Services Division, Washington, DC.........................105-150
    Groundwater Sampling and Analysis of Fallon, NV, and Naval 
      Air Station, Shepherd Miller, Inc.........................321-594
    Leukemia Hearings, Fallon, NV, February 12-14, 2001..........67-102
    Pew Environmental Health Commission..........................   207
    Treatment Technologies for Arsenic in Fallon, NV.............   233
Statements:
    Reid, Mary E., area specialist, Water Resources, University 
      of Nevada, Cooperative Extension...........................   190
    Savitz, David A., Environmental Exposures and Childhood 
      Cancer.....................................................   152
Study, Household Solvent Exposures and Childhood Acute 
  Lymphoblastic Leukemia........................................154-160

 
               CHILDHOOD LEUKEMIA CLUSTERS IN FALLON, NV

                              ----------                              


                        THURSDAY, APRIL 12, 2001

                                       U.S. Senate,
                 Committee on Environment and Public Works,
                                                        Fallon, NV.
    The committee met, pursuant to notice, at 9:00 a.m., at the 
Fallon Convention Center, 100 Campus Way, Fallon, NV, Hon. 
Harry Reid (acting chairman of the committee) presiding.
    Present: Senators Reid, Ensign, and Clinton.
    Also present: Representative Gibbons.

  OPENING STATEMENT OF HON. HARRY REID, U.S. SENATOR FROM THE 
                        STATE OF NEVADA

    Senator Reid. The United States Committee on Environment 
and Public Works is called to order.
    First of all, I'd like to welcome everyone here. This is 
what we call a field hearing. I'm particularly thankful for the 
support that we've gotten from the community in Fallon. It's 
been a lot of work to put this together and the hosts have 
worked very hard to provide this facility for us and to work 
with the staffs of the various Members of Congress who are 
concerned about what's taking place in Fallon. This has been a 
community effort, as I mentioned. All local officials have been 
cooperative, and especially the parents of the children who are 
sick.
    I'm fortunate today to have with me my two colleagues from 
Nevada, Senator Ensign and Representative Gibbons. Senator 
Clinton will be here shortly. Her plane is about to land. When 
she arrives, I'll say a couple things about her. I want 
everyone to know, by virtue of my being the Ranking Member of 
this committee and also under the auspices of Chairman Bob 
Smith of New Hampshire, I have extended an invitation to 
Senator Ensign and Representative Gibbons to act as de facto 
members of this committee today. I'm also pleased, of course, 
to have with us the Governor of the State of Nevada, Kenny 
Guinn, Assemblywoman de Braga, and Senator McGinness, who have 
expressed to me their deep concern about the incidence of 
leukemia in Fallon. I want to extend a special welcome to our 
witnesses, some of whom have traveled great distances to be 
with us here today. We're extremely fortunate to have national 
experts on a range of issues important to the community, 
including children's health, childhood leukemia, cancer 
clusters, and environmentally-related health problems, as well 
as State, local, and U.S. Navy officials, with a wealth of 
expertise and a demonstrated commitment to addressing the 
difficult circumstances surrounding the citizens of Fallon.
    The second goal of this hearing is to examine the Federal 
Government's approach to identifying and responding to so-
called disease clusters, including health problems that may be 
linked to environmental conditions. There's a widespread 
concern among the citizens of this country about our being 
exposed in our day-to-day lives and about what we're exposed to 
and what effect exposures may have on our health and especially 
the health of our children. While a number of Federal agencies 
are doing an excellent job of supporting State and local 
officials in addressing community health concerns, the support 
system often seems uncoordinated, ad hoc, too little, and many 
times too late. So I believe the time has come for the Federal 
Government to craft a coordinated approach for responding to 
the needs of communities for support and guidance in 
identifying and addressing disease clusters and outbreaks.
    Now, here's how we're going to proceed today. After the 
opening statements of my colleagues, we're going to have three 
panels of witnesses. The witnesses on the first panel will make 
remarks of up to 5 minutes, then we'll have questions of the 
panel members from the Members of Congress, and then we'll 
proceed to the second and third panels the same way. Preceding 
these panels, we're going to hear from the Governor of the 
State of Nevada, Kenny Guinn. After the third panel has 
finished with questions, there will have been circulated in the 
audience little cards, and any questions that people have to 
ask Representative Gibbons, Senator Clinton, Senator Ensign, or 
myself, we will be happy to answer those, time permitting. 
Those questions that are in writing that have your address on 
them, if we don't have the opportunity to respond today, we 
will respond to those in writing. The cards are in the lobby, 
and we'll make sure that they're circulated also, for those of 
you who missed them when you came in.
    We must complete this hearing by one o'clock today. There's 
another event scheduled to take place in this room this 
afternoon. Mayor Tedford has worked minor miracles to provide 
us the space, and I have assured him, my staff has assured him, 
that we'll wrap this up in time for him to set up for the next 
event. If anyone wants to submit written testimony, please do 
so. The hearing record will remain open for 1 week. Testimony 
provided by April 19 will be included in the record.
    I think also one of the important things that I want to 
talk about is--and we make mistakes here. My staff gave me my 
pages in reverse order. So I'm now on page 3--I'm on page 2, 
I'm supposed to be on page 3, but it's a minor problem. We're 
going to look at a very complex problem, as I've indicated. I 
have 5 children and soon will have 11 grandchildren, and I can 
think of nothing more heart-breaking than a childhood suffering 
from a serious health condition and nothing more frustrating 
than not knowing the cause of that condition. So, today, we're 
going to examine all of this, and we've got people who will 
help provide some answers. We're facing a very complex problem, 
people should understand, and I'm not going to pretend that 
there's going to be easy answers to the questions, but this 
committee is committed to give the full weight of the Federal 
Government toward answering the many questions that have been 
posed. In this room today we have a unique opportunity to share 
in the experience of working on the goals of Fallon and 
nationally. One of these goals is to find ways in which the 
Federal Government can help join Federal, State, and local, and 
even private sources, to support ongoing investigations in the 
high incidence of childhood leukemia in this community and 
address any other environmentally-related concerns. I want to 
applaud the State of Nevada, Governor Guinn, for the work that 
has been done at this point. I think that other States could 
take a lesson from the work that has been done here, and from 
those of us who work in Washington, we've watched and certainly 
applaud your efforts.
    We're going to now hear from Senator Ensign, Representative 
Gibbons, and then Senator Clinton will probably be here by 
then.
    [The prepared statement of Senator Reid follows:]
  Statement of Hon. Harry Reid, U.S. Senator from the State of Nevada
    I'd like to welcome everyone to this field hearing of the U.S. 
Senate Environment and Public Works Committee.
    I'd particularly like to thank the Fallon community for the hard 
work and support that has gone into hosting this event. And, I'd like 
to recognize in advance the family and community members, and local 
officials, for participating in the hearing: as the people closest to 
the issues to be addressed, your testimony is vital.
    I'm fortunate to be joined by one of my newest colleagues on the 
committee, Senator Hillary Rodham Clinton. In addition to her 
longstanding commitment to children's health and to a clean 
environment, Senator Clinton is facing some of the same challenges 
facing us here, in connection with a cancer cluster in a community in 
her State of New York.
    I have also by virtue of my being the ranking member of this 
committee, and under the auspices of Chairman Bob Smith of New 
Hampshire, invited my colleague John Ensign and Congressman Jim Gibbons 
to act as de facto committee members.
    I'm also pleased to be joined by Governor Guinn, Assemblywoman de 
Braga, and Senator McGinness, who I know share my deep concern about 
the high incidence of childhood leukemia in Fallon.
    And, I want to extend a special welcome to our witnesses, some of 
whom have traveled great distances to be here. We are extremely 
fortunate to have national experts on a range of issues important to 
the community--including children's health, childhood leukemia, cancer 
clusters, and environment-related health problems--as well as State, 
local and United States Navy officials with a wealth of expertise and 
demonstrated commitment to addressing the difficult circumstances 
facing the citizens of Fallon and the surrounding area.
    Today we will examine what I consider to be one of the most 
pressing issues facing this community and our Nation: how we can 
support and enhance the response to environment-related health threats, 
and health outbreaks such as the high incidence of childhood leukemia 
here in the Fallon area. Quality investigations into the factors that 
contribute to these health problems will enable us to better protect 
public health through preventative measures, and through more effective 
response when disease clusters and outbreaks do occur.
    As the father of five children, and grandfather of soon to be 
eleven, I can think of nothing more heartbreaking than a child 
suffering with a serious health condition, and nothing more frustrating 
than not knowing the cause. Yes, we are facing a highly complex 
situation, and I'm not going to pretend that I think there are easy 
answers. But, this committee commits to give the full weight of the 
Federal Government toward answering the many questions herein posed.
    Here in this room today we have a unique opportunity for sharing 
experience and expertise toward our common goals, in Fallon and 
nationally.
    One of those goals is to identify ways in which the Federal 
Government can help to join Federal, State and local resources to 
support ongoing investigations into the high incidence of childhood 
leukemia in this community and address any other environment-related 
health concerns. I applaud the State of Nevada for its tireless work on 
this issue.
    A second goal of this hearing is to examine the Federal 
Government's approach to identifying and responding to so-called 
disease ``clusters''--including health problems that may be linked to 
environmental conditions. There is widespread concern among the 
citizens of this country about what we are exposed to in our day to day 
lives, and what effect exposures may have on our health and the health 
of our children. While a number of Federal agencies are doing an 
excellent job supporting State and local officials in addressing 
community health concerns, the support system often seems 
uncoordinated, ad hoc, and too little too late.
    The time has come for the Federal Government to craft a coordinated 
approach for responding to the needs of communities for support and 
guidance in identifying and addressing disease clusters and outbreaks.
    Here's how we'll proceed. After brief opening statements by my 
colleagues, we have three panels of witnesses. Witnesses on the first 
panel will make remarks of up to 5 minutes each. Then we'll ask some 
questions of the panel. The same for the second and third panels.
    After the third panel has finished with questions, and if time 
allows, we will provide answers to questions raised by people attending 
this hearing. You may submit written questions by filling out one of 
the cards located on the table in the lobby--these cards also will be 
distributed by staff. If we do not have time to get to all of the 
questions, we will send a written response if you include your address 
on the card.
    We will need to complete the hearing by 1 p.m., as another event is 
scheduled to take place in the room this afternoon. I recognize that 
Mayor Tedford has worked minor miracles to provide us this space, and I 
have assured him we'll be sure to wrap up in time for the room to be 
set up for the next event.
    If anyone wants to submit written testimony, I encourage them to do 
so. The hearing record will be open for 1 week--testimony provided by 
April 19 will be included in the record. With that, I welcome my 
colleagues.
    Senator Reid. Senator Ensign?

 OPENING STATEMENT OF HON. JOHN ENSIGN, U.S. SENATOR FROM THE 
                        STATE OF NEVADA

    Senator Ensign. Thank you, Mr. Chairman. I want to 
personally thank you for not only convening this hearing, but 
also for inviting Representative Gibbons and myself to appear 
at the hearing and to participate. This is an incredibly 
emotional issue. I think all of our prayers and sympathies go 
out to the families. I myself have three children. Two of our 
children have had fairly serious medical problems--and the 
nights that you spend in a hospital with your children are very 
painful, probably more painful for parents sometimes than they 
are for the children. So I think all of our sympathies and 
prayers go out to the families.
    It's because of those emotions that we're here to recognize 
work that is being done by everybody concerned. It's important 
because we need to, find causes for these clusters. Most of the 
time we aren't able to find the causes, but that should not 
stop us from pursuing them. What if this happens to be the 
cluster that gives us the breakthrough to stop, clusters in the 
future. That's why maybe some good can come out of this tragedy 
that has befallen this community. This situation illustrates 
the importance of everyone working together--the Federal 
Government, the State government, the local government, private 
entities, and the military--putting their best effort forward 
to be able to try to come up with a cause so that we don't have 
these types of things happening in the future. We all know that 
prevention is the best type of medicine, and if we can discover 
a cause, perhaps we eventually can come up with prevention 
measures in the future.
    So I want to, once again, thank the chairman. Senator Reid 
and I have been working together since I took office in the 
Senate. I just was informed today that I've been a Senator now 
for 100 days as of today, along with my colleague, Senator 
Clinton. As all of you know, Senator Reid and I had kind of a 
rough and tumble election 2 years ago. However, this is the 
type of positive relationship that the people of Nevada can 
look forward to, with the two of us working together, with the 
rest of the congressional delegation, other Senators and our 
Governor and members of the State senate and assembly, working 
together to try to find solutions for Nevada problems. As 
you'll hear later from Senator Clinton, this is not just a 
Nevada problem. This is a national problem, and even a 
worldwide problem.
    So thank you, Senator Reid, for allowing me to be here.

  STATEMENT OF HON. JIM GIBBONS, U.S. REPRESENTATIVE FROM THE 
                        STATE OF NEVADA

    Mr. Gibbons. I want to associate myself with the remarks of 
Senator Reid and Senator Ensign with regard to the importance 
of this issue, the sympathies that we have and share with 
families who are afflicted by this disease. All of us sitting 
here today have children, all of us know and understand the 
importance of their lives and their future and the effect that 
something like this could have, not only on them, but on their 
community as well. The purpose, I believe, of this hearing 
today is for us to gain the information, for us to gain the 
knowledge, if it is possible, to help both the families, the 
children, and this community survive and overcome this terrible 
incidence of leukemia.
    There is so much to be learned, there's so much that we 
don't know. It is very difficult, in my mind, to find the 
answer or to point a finger at this point in time as to the 
culprit of this disease. So we are here today--and certainly it 
can be shown, by the number of people in this room and their 
acute interest in this subject, the high profile that this 
issue has. Hopefully, as Senator Ensign has said, what we will 
receive is information that will help us overcome this issue, 
and will help not only the families and the children afflicted, 
but also the community, so that this community can move on and 
remain one of the great Nevada communities that has already 
been and will be in the future.
    So thank you, Senator Reid, once again for having me here 
today. It's indeed my pleasure to sit on a dais with such 
distinguished members of the U.S. Senate.
    Senator Reid. I've just been advised that Senator Clinton's 
airplane has landed. We'll reserve her statement until she 
arrives.
    Governor Guinn.

    STATEMENT OF HON. KENNY GUINN, GOVERNOR, STATE OF NEVADA

    Governor Guinn. Thank you very much, Chairman Reid, Senator 
Ensign and Congressman Gibbons. It's a pleasure to have you 
here and soon, hopefully to arrive, Senator Clinton.
    We here in Nevada have been working with this problem over 
the past year or so now, and we want to certainly thank all of 
you for having the interest to come here to hear the expert 
testimony that you will receive from Dr. Guinan and our staff. 
They have worked very hard. They have been focused on the 
issues at hand in terms of leukemia and cancer, the problem 
that we have here with the ALL in this community. It is 
certainly a serious concern for all the parents and the 
children who are involved, but it's also a serious concern for 
those who live in Fallon and for those of us who live in the 
State of Nevada. So it's greatly appreciated, the fact that you 
would take the time out of your busy schedule to come here to 
hear this testimony that you will hear today.
    Dr. Guinan and her staff have worked diligently and they 
have been very closely coordinated with the CDC, which has 
given us great guidance and help, and also the expert review 
committee that is set up. So, today, as you see the process 
that they travel through and the great detail that they have 
been working on, I think you will be impressed. By the same 
token, this is not just a Fallon issue or a Nevada issue, I 
truly believe that cancer clusters have been established 
throughout this country over the years. Some have been unknown 
for the last 20-plus years. It is time for those of you who 
have the wherewithal and the ability to coordinate this on a 
national level to do so, and I truly appreciate--and hopefully 
that will be your guidance as you come out of this program here 
today, after hearing the testimony.
    Certainly, it is the unknown that causes the frustration. 
When there is an issue like this--and we know about cancer, but 
if you do not know the agent that is creating the cancer 
cluster, then it becomes an area that is of fear and not 
understanding that unknown. So, today, when you hear these 
issues, if there's anything you can do to help us to promote it 
more on a coordinated basis, which I'm sure you will do, and 
take it throughout this great land of ours in America, then we 
will all be better for having this hearing here today.
    I will leave the rest of the information that you'll get 
from the State of Nevada, certainly from these experts, who 
have worked day and night. Over five full-time staff people 
have been allocated to this, but the real support that we've 
received so far is from the staff of the CDC and also from 
these expert oversight members, who come from some of the very 
best cancer research areas of the universities. So hopefully 
today you will hear a great deal of detail on what the study 
has been doing, and if there's anything you can do to help us 
after that, I'm sure the citizens of Fallon in this great State 
of ours will most appreciate it.
    Senator Reid. Governor Guinn, we appreciate your being here 
today. You and I spoke before the hearing started, and we 
understand you have a legislative session that's in full blow 
at this time and you've got to get back and protect the 
interests of the State, and we want you to do so. We appreciate 
your taking time out for this. There's no busier time than when 
the legislature's in session. So you're excused, and we 
appreciate your being here.
    Governor Guinn. Thank you very much. We will cooperate and 
provide you with all the data and do everything we can to help 
you formulate your plan and your ideas for all Americans. Thank 
you very much.
    Senator Reid. We would now like to hear from Mike 
McGinness, who is the Senator who represents this area. Senator 
McGinness, we also appreciate your being here, with the 
legislature being in session. We would ask you to address the 
committee now and tell us what you feel is appropriate.

    STATEMENT OF HON. MIKE McGINNESS, STATE SENATOR, NEVADA

    Senator McGinness. Senator Reid, thank you very much. I 
appreciate the opportunity to be here. Senator Ensign, 
Congressman Gibbons. As you mentioned, Senator Reid, I too will 
be heading back to Carson City. The judiciary committee has a 
large work session today. Congressman Gibbons and I were 
freshmen in the judiciary committee in the assembly in 1989. We 
do have some deadlines, but I appreciate the opportunity to be 
here today.
    For the record, I'm Nevada State Senator Mike McGinness, 
representing the central Nevada Senatorial district. I 
appreciate the opportunity to provide testimony. Fallon, NV, is 
my birthplace. In fact, about a hundred yards down the road 
here, there was a clinic where I was born. I'm here because of 
the concern for the children and these families that are facing 
such trials. Again, I wish to thank the committee for making 
these children such a priority. Your attention to their illness 
can only contribute to the awareness and assist in the current 
investigation. I would like to thank Governor Guinn. When he 
convened all the parties earlier this year, there was a genuine 
spirit of cooperation to work toward seeking information and 
peace of mind for the children and their families, and I 
encourage a continued collaboration in the investigation.
    I have great confidence in the leadership of this 
community. There's a rich history of strong progressive 
leaders, individuals that have acted responsibly since the 
discovery of this cluster. Many of us have difficulty dealing 
with the negative publicity, since the very reputation of this 
community has been questioned. The community has responded to 
the needs of the families at every available opportunity, and I 
know they'll continue to do so. We want the community, the 
State, and the Nation to know that Fallon, NV, will find the 
cause and cure for this malady today, if possible.
    Particularly pleasing is news that the Centers for Disease 
Control will move the investigation to a new level. The CDC 
will be in Fallon on Tuesday to begin phase two of the 
investigation. As Federal officials, anything you can do to 
expedite their investigation will be appreciated. The community 
can take comfort in the fact that government at all levels is 
acting responsibly. I would hope that the committee finds that 
credit is due to the city of Fallon, Churchill County, the 
State of Nevada, the U.S. Navy, and the Federal agencies for 
their response. Anything that can be done will be done.
    In closing, let me thank you again for coming to Fallon and 
making the care and comfort of these children and their 
families a priority, and I appreciate the opportunity.
    Senator Reid. Senator, good luck on the remaining 60 days 
or so.
    Senator Clinton, you came at a very appropriate time. We've 
just completed hearing from Governor Guinn and the State 
Senator who represents this area, Senator McGinness. We 
indicated that your plane was a little bit late. Let me say to 
everyone here assembled, as Senator Ensign indicated, Senator 
Clinton--this is her hundredth day of being in the U.S. Senate, 
and this is the first time that she has traveled outside the 
State of New York to do business. We all have been involved in 
things in Washington. I personally am very glad that she's on 
our committee, the Environment and Public Works Committee. As 
you've seen reported in the press in recent days, she has done 
a tremendous job on this committee and in the Senate, and we're 
fortunate that she's here in Fallon with us today.
    Senator Clinton, would you give us an opening statement?

OPENING STATEMENT OF HON. HILLARY RODHAM CLINTON, U.S. SENATOR 
                   FROM THE STATE OF NEW YORK

    Senator Clinton. Thank you, and I'm delighted to be here. I 
apologize for being a little bit late. It took longer than I 
thought, but I got to see some beautiful country as I flew 
over. I'm very pleased to have this opportunity to join the 
Congressman and my colleagues, Senator Ensign and Senator Reid, 
for this important hearing. I know that we wish we weren't here 
in a way. We wish we were here for some other reason. I'd love 
to come back to Fallon and get to know more about what goes on 
in this community and have a chance to learn more about what 
our naval base does or what the agricultural interests are, but 
we're here because we have a very sensitive and difficult issue 
to address, and it's one that I care deeply about.
    As Senator Reid might have said, we have cancer clusters 
throughout our country. We certainly have them in New York, and 
I think even some of the witnesses we're going to hear from 
today will speak of some of those. There's a high school in a 
place called Elmira, NY. For reasons we haven't yet been able 
to determine, there are a number of cancers in our children who 
attended that school, and, suprisingly, there's no way yet that 
we can understand the reasons for it. We know it's built on an 
old industrial site. We know that's a community that has had a 
lot of heavy industry, going back to the Civil War. So we're 
looking for answers. We have breast cancer clusters throughout 
New York. Some of the highest rates of breast cancer can be 
found anywhere in our country. This is not something that is 
confined to Nevada or New York, it's something that we face 
around America, and I think that the Congressman and the 
Senators and I are here today to hear from you and to hear from 
experts who have been looking into the issues surrounding the 
leukemia here in Fallon with the hope that we will be able to 
put together some information and recommendations that could 
possibly lead to answers.
    I want to thank my friend, Senator Reid, for holding this 
hearing. It's such a pleasure working with him, serving with 
him. I'm delighted that it's also the hundredth day for Senator 
Ensign, whom I've had the pleasure of getting to know over the 
last months. I've known Senator Reid for a number of years, and 
I see Mrs. Reid here, and there aren't two people who are more 
dedicated and devoted to the people of Nevada than they are, 
and the service that he's given over the years really stands 
alone and what he does every day to make the Senate run, which 
is no easy task, I have learned, is remarkable in and of 
itself. So I want to thank him, not only for his leadership, 
but for his friendship as well.
    We're going to work in a bipartisan way to deal with the 
environmental challenges that face us, the health care 
challenges that we confront. I'm looking forward to hearing 
from the witnesses, because they're really the reason for this 
hearing, and then taking what we learn and going back to 
Washington and, again, working in a bipartisan manner, working 
with members of the House as well as the Senate to try to find 
some answers, and I appreciate all of you giving me the honor 
of being able to attend today.
    Thank you very much.
    Senator Reid. The first panel that we're going to hear from 
today consists of Assemblyperson Marcia de Braga, who has 
devoted weeks and weeks of her life to the problem that faces 
her district, her assembly district; Ms. Brenda Gross, a mother 
of a child with leukemia from Fallon, NV; and Tammy Beardsley, 
a mother of another child with leukemia in Fallon, NV. On this 
same panel, if you would step forward, please, we're going to 
hear from Dr. Stephen Prescott. Dr. Prescott is from the 
Huntsman Cancer Institute at the University of Utah, in Salt 
Lake City. Dr. Prescott is one of the leading experts in the 
world on cancer generally, and we're very fortunate that he's 
traveled to Fallon from Salt Lake to share his expertise with 
us.
    I would remind the witnesses that we all have a lot to say, 
we have a number of questions that--we've reviewed what you're 
going to talk about and the questions we want to ask. So if you 
would do your best to stay within the 5-minute guideline, it 
would be appreciated. You'll see these little lights up here. 
Green means you're in good shape, yellow means you have a 
minute to go, and red means you're out of time. So do the best 
you can. We're not going to call for the sergeant-in-arms to 
throw you out if you go a little bit over, but we do have to 
meet the responsibilities that we have with the mayor in 
getting us out of here by 1 o'clock. We're going to take no 
breaks during the hearing. The court reporter's fingers are--we 
have a reporter that has the best fingers in northern Nevada. 
She said she can take testimony for 4 hours, and we're going to 
test her and see if she can.
    Assemblywoman de Braga, please proceed.

          STATEMENT OF MARCIA de BRAGA, ASSEMBLYWOMAN

    Ms. de Braga. Thank you. It's a great pleasure to welcome 
you to Fallon, and we want to thank you for convening these 
hearings. In the fall of 1999, I read with sadness a story in 
our local newspaper about a fund-raiser for a 5-year-old who 
had ALL, acute lymphocytic leukemia, and then there were a few 
more cases and more sad stories. I called the State health 
division and asked if they thought that four cases of ALL in 3 
months was an unusually high number in a small community like 
ours. I was told it might be just an isolated cluster, but they 
would look into it. In less than a year, eight more cases were 
discovered. The statistical probability of this number of cases 
occurring in an area with our population is 1 in 10 
quintillion. In other words, there is almost zero possibility 
that this cluster happened by chance.
    In mid-February, the Assembly Natural Resources Committee, 
which I chair, held 3 days of legislative hearings. The purpose 
of the hearings was to bring together the experts, the data, 
the research, the knowledge, funds, and other resources in an 
effort to expedite the search for an environmental cause or 
contributing factors. The hearings also served to attract 
considerable media attention and with it a great many offers 
and promises from individuals and agencies and from local and 
State and national officials to work together for a common and 
urgent purpose.
    Others testifying will give you statistics and progress 
reports. What I want to focus on is what I learned through the 
legislative hearings and through listening to the people whose 
lives have been affected by this tragedy. As a result of the 
hearings, we prepared a list of possible causes created from 
our research and the testimony we received. The entire list is 
in your packet, along with the names and agencies of 
individuals that our recommendations have been forwarded to. It 
basically asks those in authority to leave absolutely no stone 
unturned. Our recommendations also include providing 
information to the public and expanding the scope of the 
investigations to cover a longer period of time, other disease 
groupings, the analyzing of water, soil, and air, and the 
testing of blood, bone, tissue, and hair of the children. I'm 
happy to report that yesterday the Assembly Ways and Means 
Committee approved $500,000 to be used specifically for those 
purposes.
    In addition, the committee recommends cleaning up the 
things that our community is concerned about, and doing it now 
and not waiting for science to catch up or to provide positive 
proof. We unanimously agree that the cancer registry and other 
data must be processed in a rapid manner, so that information 
is current and readily available to help the environmental 
officials and the general public.
    This leukemia cluster may only be a part of the whole 
picture. An eminent pediatric oncologist has advised us to 
investigate all marrow diseases and to look for any increases 
in other forms of cancer among children and adults. We know 
that two additional ALL cases were diagnosed in 1992, and in 
1991, a 5-year-old died from myelodysplastic syndrome, a less 
common form of leukemia. We know that earlier this year a 
youngster was diagnosed with aplastic anemia, another marrow 
disease. We know that there may be additional cases that are 
connected to Fallon but were not diagnosed here, and we know 
that there are clusters of other diseases that are also 
suspicious.
    I think it's vitally important that everyone involved be 
proactive and not rely on old data, that we look beyond the 
environmental improvements that are already being done to what 
needs to be done next, and that we approach our problems with 
the hope and optimism that through determination and 
perseverance we can, if not find a definitive answer, at least 
eliminate possible causes and add to our information base.
    Our legislative committee has sponsored a bill that would 
require public and private entities certified to do 
environmental testing to report to the Nevada State Health 
Division or NDEP any findings of specific values that exceed 
the established maximum contaminant levels. Those findings 
would have to be made public if a significant health risk was 
posed. I think it's imperative that we put these protections 
into law and aggressively pursue our search for causes. That 
includes working to eliminate known contaminants. In so doing, 
obviously we improve the general health of all contributors.
    Why do I feel so strongly that we have a responsibility to 
move forward in every way possible? Because this is about 
children, children whose lives have been turned upside down by 
something terrible that's beyond their control. This is about a 
beautiful, smiling little girl whose hair is gone. This is 
about a promising young athlete whose energy now lasts for only 
minutes. This is about a teenager whose HMO won't pay for a 
bone marrow transplant. This is about furthering what is known 
about cancer so that communities might be spared what happened 
here. I applaud your efforts to create a nationwide team to 
deal with these situations, if and when they arise.
    Senator Clinton, I read that you said, ``There is no such 
thing as other people's children.'' You, Senator Reid, Senator 
Ensign and Congressman Gibbons have clearly demonstrated that 
belief by coming to Fallon to hold these hearings. We can't 
thank you enough for your concern and your willingness to help 
our community and communities like this everywhere.
    Thank you.
    Senator Reid. We're going to now hear from Brenda Gross. 
She really has raised the consciousness of the entire community 
to this terrible disease. She's the mother of four children. 
Her testimony was one of the highlights of Assemblywoman de 
Braga's hearings.
    Would you, please, proceed.

             STATEMENT OF BRENDA GROSS, FALLON, NV

    Ms. Gross. Thank you and good morning.
    I would like to thank you for allowing me this time to 
express my thoughts and share with you some of the hardships 
that my son and my family went through. I'm here today speaking 
to you to stress the importance of an aggressive approach on 
this investigation. My son, Dustin Gross, is 5 years old. He 
was diagnosed April 17, 1999. He is doing very well today, and 
I'm very thankful for that. We went through some very hard and 
trying times. As a parent, when your child is very ill like 
that and there is a possibility that you could lose them, it is 
frustrating, because you do not have any--you're the parent, 
you're supposed to take care of everything and you cannot. You 
have to rely on the doctors for this, and thank goodness for 
the doctors.
    One thing that I would like to stress is that when going 
through these things, your child going through many, many blood 
transfusions, surgeries and such things that are needed, and 
the chemotherapy treatments, you often wonder, as you're 
watching this, What did I do? Did I need not feed him 
correctly? Did I allow him to do things incorrectly? Did I--
what, as a parent, did I do wrong? That's why I feel so 
strongly that we need to find the cause, because we do not want 
another child to go through this. I feel very strongly that 
there is a cause. I don't know if it's environmental, I don't 
know what the cause is, but I do feel that there is a cause 
here in our community. It is not by coincidence that 12 
children have a certain type of leukemia.
    I would like to give my thanks and tell my appreciation to 
the State health department. They have been doing a very good 
job on their research. Obviously, I wanted to be more 
aggressive, but I do understand their approach. Some of my 
ideas are maybe perhaps helping with the State health 
department, such as needed funding, needed manpower, expert 
team assistance, CDC assistance, whatever it takes, whatever 
type of testing it takes to protect our children.
    A couple of my concerns--and I have mentioned this to the 
State health department--that I'd like to express to you is, on 
some of the testing--and I want to stress I'm not pinpointing 
any of this as being the cause, but when they do the research 
on the base, the naval base, and look at how they release--
we'll just say the jet fuel, because that's been an issue--and 
how this is monitored and tested and researched, my 
understanding--and I may be incorrect, but my understanding is 
that it is the Department of Defense and the naval base and the 
Government that does this research and tracks and monitors all 
of this. I would like to see an outside company come in. I'm 
not saying that they are doing anything incorrect, but they do 
this, my understanding, on a continuous basis, these tests and 
checking things out. It might become habitual to them, because 
it is their job, and maybe we need an outside firm or company 
to come in there and look things over in a different point of 
view.
    Another thing is, I feel that the research with these 
clusters, we should try to check the other clusters in our 
Nation, see if there's a common link there. I just think a 
national-type--and if we could do a national panel or what 
not--I mean, I don't know how that works, but I think that that 
would definitely benefit the research.
    Also, third, I do not know if our State of Nevada has a 
location or a center for the doctors to send their reports to 
for these cancers. Do we have one--I know that a lot of it goes 
to CDC, but do we have something that is just for the State of 
Nevada for tracking? Because sometimes, to my understanding, 
the CDC gets behind on some of this. Do we have something here 
for our State to track these clusters or cancers?
    Senator Reid. You'll hear from Dr. Prescott. He has some 
information on that.
    Ms. Gross. Great, thank you.
    I would also like to thank our community. This community 
has been wonderful and overwhelming and very supportive, and I 
love living here and I love Fallon. My focal point throughout 
this whole testimony is to continue the aggressive research on 
this, not to let up on it. Even as we continue in our lives and 
this--hopefully we don't have another childhood that gets 
leukemia--and it kind of goes by the wayside, I hope we don't 
let up on it. I want to stress to push this very strong. It 
sounds to me these clusters have been going on for many years, 
and that's too many years.
    Senator Reid. It's very difficult to have a mother of a 
sick child come and testify in front of TV cameras and all the 
people here assembled. We're fortunate that not only have we 
heard from Brenda Gross, but we also are going to hear from 
Tammy Beardsley, who did not want to be here, but she's here.
    Would you, please, proceed.

            STATEMENT OF TAMMY BEARDSLEY, FALLON, NV

    Ms. Beardsley. Thank you, Senator Reid.
    Forgive me if I'm a little nervous. I threw this together 
very quickly, and I probably won't be as well read as Brenda, 
but I'm going to try and speak from my heart. I also was born 
and raised here, and I also love this community very much and 
I'm here just to help.
    I'm here to represent my 5-year-old son, Zach, who was born 
healthy, no list of health problems, no history of health 
problems and, yet, he has cancer. If I'm a bit shaken, he just 
got back from Oakland last night for some procedures and he's 
recovering today. So my husband's not here. So my emotions are 
a little high. Forgive me if I whittle my words.
    I'm not sure what made Zach so sick, and while I don't 
think it has anything to do with the arsenic in the water, I do 
think we need to make better choices when it comes to our 
environment. I drive by and I see cows, hundreds of them, in 
one pen, and when they waste on each other, we give them lots 
of antibiotics to make them healthy. We want them to produce 
fresh meat and eggs and cheese and all the rest of it and, yet, 
their living conditions aren't healthy. I think we need to look 
into that. I think we need to look into how much stuff are we 
gonna throw out, how much stuff are we gonna buy, how much 
money do we all need, how many new homes do we need to build? 
We really need to talk about this. I'm talking from my heart 
now to my fellow human beings. If we don't stop buying more 
than we need, if we don't stop eating more than we need to eat, 
if we don't stop throwing out food, if we don't stop wasting so 
much of our planet, we're going to start seeing more and more 
sick children.
    I come from a very healthy family. I'm in the fitness 
business, I'm in the nutrition business. My children have lived 
healthy lives, and now we're fighting cancer. I don't know how 
I got in this mess, and, of course, I want out of it, but I 
think we need to take a look at the way we're treating our 
home--not our home, but our planet, because I think we're going 
to create more disease and I think we're going to create more 
sick children. I think we need to take a look at the way we 
treat animals, the way we treat our home, the way we treat each 
other, and maybe we can stop creating sick children.
    Senator Reid. Thank you very much.
    We now have the opportunity to hear from Dr. Stephen 
Prescott, who's the executive director of--who is accompanied 
by Dr. Joseph Simone, the senior clinical director of the 
Huntsman Cancer Institute in Salt Lake City, part of the 
University of Utah.
    This cancer clinic, Dr. Prescott, I hope you'll tell us a 
little bit more about it, but we in Nevada are so fortunate 
through the good offices of the University of Utah, especially 
the generosity of one man, John Huntsman, who has given about a 
quarter of a billion dollars of his own money to establish this 
institute, and the reason it's so important to the State of 
Nevada is that much of the work that is done there takes into 
consideration what goes on in northern Nevada.
    So, Dr. Prescott, first of all, I would like you to outline 
your academic background, so the people here in Nevada have 
some knowledge of who you are and how you came to your job, and 
then tell us a little bit about the Huntsman Cancer Institute 
and specifically tell us something about this disease.

STATEMENT OF STEPHEN PRESCOTT, M.D., HUNTSMAN CANCER INSTITUTE, 
                       UNIVERSITY OF UTAH

    Dr. Prescott. I will do so, Senator Reid. Thank you for 
having me here and thanks to all the members of the panel. I 
share Senator Clinton's views. It's very hard to say that I'm 
pleased to be here, because it's such a sad situation that 
brings us here.
    Speaking of my own background, I'm an immigrant to the 
Great Basin region. I'm originally from Texas. I've been on the 
University of Utah faculty since 1982, and for the 10 years 
before I joined Huntsman Cancer Institute, I was a co-director 
of the Eccles Institute of Human Genetics, where we focused on 
trying to find the genetic basis for diseases. We were one of 
the original centers in the human genome project. We developed 
much of the technology behind it and its application to human 
disease. I then became the director of research at Huntsman 
Cancer Institute and then, about 2 years ago, the executive 
director.
    Senator Reid. You are a medical doctor?
    Dr. Prescott. I am. I have a medical degree from Baylor 
College of Medicine, which is in Texas.
    Senator Reid, this year, about 2,400 children in the United 
States will be diagnosed with acute lymphoblastic leukemia, 
which is what's happened to these children here in Fallon. This 
is the most common form of childhood cancer. The good news, if 
there is any to be had, is that the chances for cure for these 
children is really remarkably different today than it was 25 or 
30 years ago. At that time, only about 10 to 20 percent of the 
children survived this disease. Today, somewhere between 75 and 
80 percent will survive. In large part, that was due to the 
efforts of Dr. Joe Simone, our senior clinical director, when 
he directed St. Jude's Children's Medical Center in Memphis, 
TN, where those first dramatic improvements occurred.
    These improvements continue, and we believe that one day 
this will be an entirely curable disorder, but despite this 
success, there are many challenges ahead of us, and that first 
one is, quite obviously, as I've just said, the cure rate isn't 
100 percent, and until it is, we must work toward that goal. 
The second goal is that we have to be able to cure these 
children with fewer side effects. To achieve this, we must 
uncover the causes of childhood leukemia, and in this regard, 
we believe the future to be bright. Although we don't know it 
today, there is great cause for optimism. We just now are 
beginning to understand the events that cause a single cell to 
become cancerous, and these advances can be attributed to many 
types of research, but particularly in the area of genetics.
    I want to pause for a minute, because genetics can mean two 
things. The one easily understandable is, genetic means when 
you inherit a risk from your parent, and I'm not talking about 
that today. What I mean, in this case, is the second type of 
genetics, if you will, in which we acquire damage to our genes 
during our lifetime. All the rest of the genes in the body are 
normal, except those that are in the cancerous cells. We now 
know that ALL happens through this mechanism. The gene that 
regulates the growth of a cell becomes damaged and it begins to 
grow abnormally, out of control. It no longer responds to 
signals from the body that say ``stop growing now.''
    But, as we've heard this morning, the most difficult 
questions that comes up for a physician or for our government 
representatives to answer are when a parent asks--and this 
happens all the time--``Why did my child get leukemia, and was 
there anything I could've done to prevent it?'' It's easiest to 
answer the second question, and the answer to that is, clearly, 
no, there was nothing you could've done to prevent it. The 
answer to why is, unfortunately, we don't know yet.
    When clusters, or these dramatic increases in the number of 
cases in small geographical areas, occur, we always revisit 
this issue of whether a cancer-causing agent from the 
environment or an infection resulted in the increased number of 
cases. It's unfortunate that thus far this approach has not 
identified any causes for acute lymphoblastic leukemia, but we 
would argue it is possible that we're missing some subtle 
relationships, if an environmental or infectious cause is 
present in the community but only affects a certain fraction of 
the population. That is, they may have a particular genetic 
makeup that renders them more susceptible to this infection or 
to a particular environmental agent. The studies today have not 
examined that issue, because they simply didn't have the 
capacity to do so.
    The recent completion of the sequencing of the human genome 
and the technology that it has created has given us an 
unprecedented opportunity to revisit some of these questions, 
both about the cause of cancer, such as ALL, and new ways of 
treatment and prevention. Our specific focus at Huntsman Cancer 
Institute is exactly this--to understand the genetic blueprint 
of cancer, and one of our approaches is to use what are called 
DNA chips. Investigators in our childhood cancer program, led 
by Dr. Bill Carroll, have used this now to define specific 
pathways in different types of leukemia, but particularly in 
ALL. With the understanding of these new pathways, we believe 
we'll invent new ways to treat children more effectively and 
with fewer side effects.
    We also know that certain of these pathways are unique to 
groups of patients who will respond well to current treatments 
and those who will be resistant to treatments or will have 
relapses. We believe it'll be possible to use these genetic 
fingerprints to assign children to the two different groups--
standard therapy will work or they need a different type of 
therapy. In fact, this approach will be implemented nationwide 
within the next few weeks through the Children's Oncology 
Group--again, on protocols led by Dr. Bill Carroll from our 
organization. We believe that this someday will lead to the 
ability to tailor therapy, like a custom-made suit. What will 
be the best treatment, for this particular type of leukemia in 
this particular patient, to optimize the chance of cure and to 
minimize the number of side effects?
    As I said before, we believe the same approach could be 
applied to clusters of ALL or other cancers to try to 
understand why they occur. For example, we would ask, Is there 
a specific genetic pathway, one specific pathway that's damaged 
in all these children in Fallon who have ALL? If this turns out 
to be the case, it would suggest that there is a common cause 
in these children. It wouldn't tell us yet whether it's 
environmental or infectious, but it would say they all followed 
the same pathway to their cancer. To do this, responding ad hoc 
now to Senator Reid's question, one of the things that will be 
essential is a mechanism to rapidly report the cases to a 
centralized body and to collect samples. As you know, your 
expert panel recommended a scheme exactly like this, and I 
believe it to be crucial that there is a prospective way in 
which to identify cases, report them rapidly to a central body, 
and to collect samples under a defined protocol so that we can 
carry out this type of testing to try to find these pathways.
    So in conclusion, although these various projects to define 
these genetic pathways are just underway or, in some cases, not 
yet implemented at all, we've made remarkable progress and we 
believe that by combining sophisticated analysis of DNA changes 
in patients and in tumors--or in this case, the leukemia 
cells--that we will have better diagnosis, more rational forms 
of therapy, and ultimately invent new forms of therapy and 
prevention.
    Thank you.
    Senator Reid. Now the panel will ask questions of the 
witnesses, and we'll have 5 minutes to ask questions before we 
go to the next person, and if we need more questions, we'll do 
more than one round.
    Assemblywoman de Braga, I've heard from a number of people 
here in Nevada who believe that the number of cancers and other 
diseases in this area may have been elevated for years, that 
this isn't something that's new. Do you have any thoughts in 
that regard?
    Ms. de Braga. Thank you, Senator.
    I think that's a real possibility. I spoke to that a little 
bit in my testimony. I personally know of three other cases, 
but we also have somewhat of a transient population. So there 
is a good chance that there are cases that were diagnosed 
elsewhere but that have their basis here. I heard from a lady 
who lives in San Diego, and I spoke about that in my testimony 
as well. She's not included in this present cluster. However, I 
think we need to expand that, because I think that there are 
more cases and more marrow diseases.
    Senator Reid. Is this San Diego woman sick?
    Ms. de Braga. No. She had a baby in San Diego. They moved 
to the base in Fallon when the child was a month old, lived 
here for over 3 years, and moved to Japan when the baby was 4. 
He died when he was five. She said--and I didn't know whether 
to laugh or cry--she said, ``You know, when my son died, I 
thought God wanted him and that was why he died.'' And she 
said, ``After reading this, the environmental possibilities, 
I'm not so sure.'' And what she wanted to tell me about was 
mosquito spraying when she lived here, the fogging that was 
done, and she thought, after reading a lot of this, that that 
was a real possibility. There's a lot of stories out there 
that----
    Senator Reid. That's interesting, Marcia. There was a 
lawyer in Las Vegas, a young man doing very well. He spent most 
of his time--I just thought of this as you mentioned this. He 
was a Mormon missionary in New Zealand, and he and his 
companion were walking, and there was heavy spraying taking 
place and they were sprayed, and his family felt that's why he 
died at such an early age. I don't know if it has anything to 
do with that or not, and maybe Dr. Prescott can tell us.
    Also, would you give me your thoughts about--you've spent 
as much time as anyone else on this issue, and I'd like your 
thoughts as to what aspects a cluster investigation would most 
benefit from the involvement of the Federal Government. Do you 
have any ideas?
    Ms. de Braga. I'm sorry, what aspects of the----
    Senator Reid. What do you think the Federal Government can 
do, in your layman's opinion, to help with this investigation?
    Ms. de Braga. A lot, because I think there are a lot of 
resources through the Federal Government that aren't available 
to us in the State of Nevada, and I think that was just 
demonstrated here this morning, that there are a lot of 
resources. I think that when you're limited in the amount of 
data, research, and experts that you have available to you, it 
narrows the scope of your investigation, and I think that's 
where the Federal Government can play a huge part. I'm not just 
talking about any dollars that are available, I'm talking about 
the new knowledge that's out there, that's going to speed this 
up and help us to find a cause.
    Senator Reid. Marcia, one of the other problems that I 
face, Senator Ensign and all of us up here face, is the 
delicate line we walk between what Brenda Gross wants and the 
fear that is around in the community generally. Does what we're 
doing here have an adverse impact upon the community? As you 
know, Senator, the work that you've done in this regard, it's a 
real delicate line that we walk. What is your comments? Has 
what has taken place regarding this investigation been damaging 
to Fallon?
    Ms. de Braga. I've heard a lot of people say that, yes, it 
has, that we don't want this attention, that focusing on--and I 
think somebody mentioned it this morning--the negative aspects 
hurt real estate sales, those types of things. Of course, we 
don't want our community to have a bad image, but I don't 
believe that's--I would rather live in a place that cared more 
about its children than it does its image and that it's being 
proactive, fixing the things, whether they are the direct cause 
or not, so that they're doing everything that can be done to 
protect children. So the economy slumps a little. I don't 
personally believe that's the case. I think the attention 
that's focused here is absolutely phenomenal. We can go along 
pretty complacent and say, ``Oh, my gosh, this is sad'', but 
unless we make a real aggressive effort like is being done 
here, like Brenda commented on, we don't draw the attention and 
we don't get the forces moving to solve the problem. So I think 
maybe we have to give up a little, but I'm not sure that's 
true. I think this is the kind of image we want, that this is a 
community that cares more about its kids.
    Senator Reid. I'm confident, in the long run, that we'll be 
here.
    I'm going to hear now from Senator John Ensign. What those 
of us in Nevada tend to forget is that this is Dr. John Ensign. 
Before coming to Congress, John Ensign was a veterinarian, and 
as we all know, the training of a veterinarian is very 
comparable to the training for a medical doctor, and he's been 
a big help in helping me understand some of the scientific 
problems we face here.
    Senator Ensign.
    Senator Ensign. Thank you, Mr. Chairman.
    First, I want to say to both of you, obviously, our 
sympathies go out to you and we'll pray for your children. As 
bad as what you're going through, at least it's not 20 years 
ago. Our treatments today are much more successful. We have 
people like Dr. Prescott out there doing the research. So 20 
years from now, it'll even be better. But, once again, it is 
important that we focus on the preventive aspects so children 
don't end up with this and we don't have them go through some 
of the treatments. Even though we're happy those treatments are 
there, they're still brutal for children to go through.
    I want to also thank you, Assemblywoman de Braga, for the 
work that you've done on this. You've been a leader on this 
issue. I think your efforts should be applauded. I want to ask 
some questions of Dr. Prescott. One of them has been puzzling 
to me, because I hear reported often, in most of the reports I 
hear, ``lymphocytic leukemia'' and ``acute lymphocytic'' are 
mentioned yet, you mentioned ``lymphoblastic.'' All the reports 
I thought used the term ``lymphocytic.'' Can you address that?
    Dr. Prescott. They are pretty much the same thing. It's 
just a distinction based on the way that these white blood 
cells called lymphocytes look, and the children, in its acute 
form, usually have a less developed form of those cells. It can 
be either called lymphoblastic or lymphocytic. Adults typically 
have a much more mature--they may have a similar type of 
leukemia, but they have more mature white blood cells.
    Senator Ensign. Are you aware of other clusters or how many 
clusters are discovered throughout the world, let's say in the 
last 30 years, and how extensively they have been studied?
    Dr. Prescott. I think there'll be other experts much more 
knowledgeable than I am about this, as that particular area--
the epidemiology of clusters--is not my expertise. I can't 
answer that. Very many is the answer, but I can't tell you 
precisely. I can say that, unfortunately, as I believe you 
alluded to earlier, none of them have yielded a specific cause, 
the investigations of it.
    Senator Ensign. Have we ever come up with a cause for any 
of the leukemias?
    Dr. Prescott. Yes. In some of the adult forms of 
myeloplastic leukemias, there's certainly a much stronger 
correlation with some types of bone marrow toxins in those 
cases, but it appears to be not the case, at least thus far, 
with ALL.
    Senator Ensign. When you were talking about the genetic 
pathway, who would be in charge of investigating this genetic 
pathway, and who would be responsible for coming up with the 
protocol for making sure that this is consistent? Where can we 
come up with some information?
    Dr. Prescott. Excellent question. At a national level, it's 
being done by the Children's Oncology Group. This is an 
organization that includes all of the major cancer centers in 
the United States, and most children with cancer, including 
leukemia, are treated in major centers. That's because--
although that 2,400 is a large number if it's your child, 
that's a relatively small number compared to, say, breast 
cancer in the United States--the expertise to care for those 
children typically resides in large urban centers, and so most 
children get referred there quite promptly. I was thinking just 
earlier, with respect to Nevada, this creates something of a 
problem geographically. If patients live in the northeastern 
part of the State, they would come to us, without a doubt. In 
the western regions of the State, I suspect they'd go to 
Oakland or UC Davis or maybe to Stanford. If they live in Las 
Vegas, they would go probably to Los Angeles.
    So from the point of view of the State trying to understand 
the incidence rates of a cancer like this and the approach, it 
would be quite fragmented. I think there's a risk that you 
could miss something, because the children are referred in 
different directions, and we would argue for some rapid 
reporting mechanism of Nevada residents, even if they're 
getting their treatment outside of the State.
    Senator Ensign. Right, but the question would be, first of 
all, do we have--we're trying to find out what's the best way 
for us to, maybe, direct the Federal Government. What's your 
recommendation as far as investigating these children and their 
genetic pathway to the potential causes?
    Dr. Prescott. I'd like to second the recommendation of the 
expert panel, and that is to establish a registry of these 
children and a mechanism here, since we know there's a cluster 
going on now. I would argue that a really important component 
of that is rapid acquisition of a blood sample that could be 
used for various studies--of course, with the consent of the 
families and the child, but if they consent to that, it could 
be rapidly put into the system. They exist in the Children's 
Oncology Group now. So that could be taken advantage of 
immediately.
    Senator Ensign. Have those blood samples been taken from 
the children? In the acute form, do these genetic pathways 
change? Do we even know when they're in the acute form of the 
disease, versus farther down, maybe they're in remission? Would 
we still be able to identify their genetic pathway if they're 
farther down? Do we have these samples ahead of time, already 
drawn?
    Dr. Prescott. I can't answer that, because I wasn't 
involved in the initial investigation, but I'm sure that Dr. 
Guinan or someone can. But the answer to the second part of 
your question is that, in the cases where children have already 
responded well to treatment, then we would not be able to do 
the type of test that I just described.
    Senator Reid. Senator Clinton.
    Senator Clinton. Thank you, Senator Reid, and I want to 
thank the panel. I particularly want to thank both Brenda and 
Tammy for being here today. I know this is not an easy kind of 
experience for you, and I join John in wishing your sons well 
and all the other children.
    I'm particularly impressed by what Assemblywoman de Braga 
has done and I am grateful that she took this issue on, and the 
kind of leadership that she's shown at the local and State 
level to leave no stone unturned is exactly the kind of 
leadership we need across the country. You responded to Senator 
Reid's question about the kind of help that might be useful in 
responding to the cluster that has been identified here. Have 
you given some thought and does the assembly, with the approval 
of the $500,000 for investigations and bringing the cancer 
registry up to the current, have specific suggestions about 
what we at the Federal level could do to assist you in 
expediting what you're attempting to bring about with response 
to the cluster?
    Ms. de Braga. Yes. Thank you, Senator.
    Again, both in terms of making available to our State or 
helping our State assemble the resources that are not 
available--readily available in our State, I think the Federal 
Government--because, obviously, there has been a lot of 
research already been done. This isn't the first cluster. One 
of the things that's unique about this cluster is it happened 
in such a very short period of time. So there may be something 
new to learn here, but I think it will take more funding, 
because our staff is limited, and it will then take some 
specific work on the part of either the present expert panel 
that's been formed or one like it, so that we can avail 
ourselves of the experts that are out there and the research 
that's already been done. Senator Reid, I think, said in a news 
article that we don't want to reinvent the wheel. So if we can 
start at a point that is past what's already known and rely 
on--and this is going to take a tremendous amount of help from 
the Federal agencies--then I think we can speed up this 
process. I think that's very important. We don't want what 
might be a readily findable cause to disappear because too much 
time has gone by.
    I also think that we need some means of having a central 
repository for information, that it can be somehow up-to-date. 
That's critical, I think. I asked some health division people, 
if we hadn't brought this to their attention, how soon would 
they have found it on their own through the normal channels, 
and they said it would be at least 2 years. In 2 years' time, 
if there's a readily findable cause, more children will become 
sick.
    Senator Clinton. I think that--and I hope that the Fallon 
community will see this in the years to come--because if we are 
able to do what every one of the panelists recommended, then 
Fallon will have made a great contribution to preventing a 
disease in the future, because, clearly, we are now at a point, 
as I understand Dr. Prescott's testimony, where technologically 
we can really seriously engage in the kind of discovery that 
was beyond our means just a few years ago. The human genome 
project, the advance in information technology, the ability to 
correlate associations that we may find of interest but don't 
know whether they're causal, such as pesticide spraying or 
arsenic in the water, all of these things, we can now track 
much better than we ever could. So I think that, in a very 
important way, advances in determining how to prevent cancer 
could really be attributed to the extraordinary response in 
this community, and for that, I think the entire country and 
maybe even the world eventually will be grateful to Fallon, and 
I hope the people of Fallon will understand how important this 
is.
    Senator Reid. Brenda, it's my understanding you've been 
receiving phone calls--you and other parents who have sick 
children have been receiving calls from around the country from 
other parents who have sick children. Is that true?
    Ms. Gross. Yes, it is. I've gotten E-mails, phone calls, 
and letters with lots of information that's been very 
interesting.
     Senator Reid. Other parents have received the same types 
of communications; is that right, Tammy?
    Ms. Beardsley. Yes, lots.
    Senator Reid. This is more than one or two E-mails or phone 
calls; is that right?
    Ms. Gross. Yes.
    Senator Reid. If you added them up, the 12 families who 
have sick children, it would be dozens and dozens of people who 
have made contact with you?
    Ms. Gross. I'm not sure on the other families, but, myself, 
I have received dozens, several dozens.
    Senator Reid. Tammy, you've also received----
    Ms. Beardsley. I have received dozens.
    Senator Reid. I think that's important, based on what 
Senator Clinton has said. I think we have to have a better 
method, as Dr. Prescott indicated, of rapidly identifying these 
clusters, and when we find something that appears to be a 
cluster, I think we have to have some way of responding as 
quickly as we can, and we don't have that right now.
    Dr. Prescott, in your experience, is it common for 
childhood leukemia to occur in clusters?
    Dr. Prescott. No, it's not. Most of them do not occur in 
that manner.
    Senator Reid. So this is an unusual situation, from your 
experience?
    Dr. Prescott. Absolutely.
    Senator Reid. You've indicated that in the past, when we've 
had these clusters, that we've been unable to find a cause. 
Now, you've read all the material that we've sent you regarding 
this and you understand we have arsenic in the water and you 
understand, here, we have a large agricultural community and 
whatever goes with that agricultural community, and we have a 
very large and important military installation here. Some 
people say there's a--some studies talk about a virus that can 
be communicated. Do you think that it is possible that there 
could be a combination of things that I've outlined and other 
elements that are available that could lead to environmentally 
causing this condition?
    Dr. Prescott. Yes. I think it's less likely that it's a 
combination of things, but I want to apply an important caveat. 
I'd like to know the answer to the question I posed. It may be 
unknowable in this case, but I'd like to know the answer to 
that. Do all these children have a common pathway to their 
cancer? If so, I would be virtually certain that there's 
something from the environment. Now, speaking from genetic 
terms--I would even include a virus in the environment or 
anything outside--I would surmise that it's more likely that 
it's one thing that affected all of them than a combination of 
20 percent this, 40 percent that, but I'm just speculating. I 
don't know the answer to that, but I believe that to be much 
more likely or more probable. But you're right, in these cases, 
we know that many things--we know that viruses can cause 
cancers. We have many examples of that. We know that some 
environmental toxins can cause cancers. It's just the specific 
case of ALL where we've never been able to make a connection 
between those. Part of it comes back to this issue that I 
mentioned before--and I'm reluctant to say this in front of 
people who recently suffer with this, but it's a relatively 
uncommon disorder. We only have 2,400. It sounds like a huge 
number, but it's a very small number compared to the other 
types of cancers we study. So we're often in this position of 
sort of scrambling after the fact trying to go back and say, 
``Gee, I wish I had a blood sample from a month ago, I wish I 
could test this or test that.'' There just aren't big enough 
numbers of cases and samples of blood or samples from the 
environment to make really robust associations so that we can 
really get to those root causes.
    Senator Reid. Dr. Prescott, having grown up in an era 
where--even though I lived in a very small rural community in 
Nevada, as a little boy, I was scared to death I was going to 
get polio. No one knew what caused it, but we knew that the 
disease was devastating and children like me all over America 
worried about this terrible disease. People in Fallon--even 
though this is certainly nothing comparable to polio, people 
here worry, Is this something I can catch, is this something 
that can be communicated from one person to another? What are 
your thoughts in that regard for the people of this community?
    Dr. Prescott. I grew up not being able to swim in the 
summertime as well, Senator Reid, because of the fear of polio, 
and I remember those days very strongly with some of my 
classmates who were afflicted with it. This is obviously a 
crucially important question from a public policy point of 
view, public health point of view, to try to reassure families 
where we can, and we need to do so in an honest and legitimate 
way. I certainly couldn't say to the people here that if there 
were a virus that did this, that we could be absolutely 
confident it's not still here somewhere. What I can say is that 
that's highly unlikely. First of all, there's never been such a 
virus described. We don't know if that's what the cause is or 
not, and we know historically, from these many clusters that 
have been described around the world, that they tend to be 
self-limited. So it would be really quite unprecedented.
    I know that's an incomplete answer, but I think that one 
can be relatively optimistic that it won't continue, but we 
can't--since we don't know the root cause, we can't say for 
certain. Polio was different. Once we knew the type of virus 
and once a vaccine prevention was available, then we could 
approach that with a lot more confidence.
    Senator Reid. Senator Ensign.
    Marcia, I join with the rest of the Senators up here on the 
issue of giving you great credit for your effort and your 
leadership in this regard, as I'm sure the community does as 
well and the families of those affected children. To the 
mothers that are sitting here, Brenda and Tammy, your 
contribution to this hearing is greater than you imagine. It's 
greater than--the fact that you sat there and told us about the 
trying hardship of your children. It's greater because we now 
have a greater empathy for this issue and a greater commitment 
to work on solving this problem. I have no questions of you. I 
just want to thank you for your effort, your courage and 
willingness to share with us your stories on this, and you do 
have our sympathies.
    Dr. Prescott, I really appreciate your insight, because as 
you testified, it was as if a light bulb had gone on that we 
had for so long been looking externally for causes.
    Dr. Prescott. Absolutely. Adult leukemias also often have 
these translocations that I've described in my written remarks, 
which is where one piece of DNA from one chromosome gets 
switched over to another chromosome, and if that happens in 
just the right place to where the switch was made--there's a 
gene that controls the growth of cells--now we have a bad 
situation, where they begin to grow abnormally, and that 
absolutely happens in all types of cancer.
    Representative Gibbon. Dr. Prescott, what can you tell us 
about clusters of adult leukemia?
    Dr. Prescott. There have been clusters of adult leukemia. 
It's not necessarily the case that you would assume there 
should be adults in Fallon with leukemia, because these 
diseases are so different. Adult types of leukemia are so 
different from childhood leukemia, and it would depend on what 
that external signal was. If it were something from the 
environment or an infection, it's perfectly plausible that it 
would affect only childhood leukemia or it would lead to an 
increase of breast cancer. We talk about cancer as one thing, 
but it's really at least a hundred things. It's probably on the 
order of several hundred things, if we get down to the absolute 
root causes of it. So it's not improbable at all that we would 
see childhood leukemia without adult leukemia. Just as in this 
cluster it's only ALL and not other types of childhood 
leukemia.
    Representative Gibbon. Although our research and science 
into the trigger mechanisms lead us to look at the genetic 
sources that may be found, what other considerations should be 
raised, at this point? Are we focusing our effort too broadly? 
Should we be narrowing that effort? What is your opinion?
    Dr. Prescott. It's a question I like to be asked, as the 
former director of research of the Huntsman Cancer Institute. 
First, I'd say that Congress has been very generous to the NIH 
budget, funding basic research. There's always more that can be 
done, and I think the one place that we don't have an effective 
strategy in place is to apply some of what we've learned from 
the genome project broadly to clinical problems, I mean, really 
specifically. One thing that's often overlooked in that process 
is the clinical aspect of it, finding those patients quickly 
and obtaining proper samples, with appropriate informed consent 
and confidentiality, because we tend to focus on the very 
attractive high technology, because it's amazing what we can do 
with sequencing today. That's actually the part now that's 
simple to do, to be honest. It's simple to sequence the DNA.
    The hard part is organizing a system so that you identify 
childhood leukemia cases rapidly, that you get those samples in 
the appropriate way, that you collect information about the 
treatment they had and the outcomes they had, and you can 
correlate that with the DNA sequences. That's the way that 
we're really going to unravel the basis of many types of human 
disease and get into an area that's sometimes called 
individualized treatment, which is what I was speaking about. 
We know that perhaps this type of leukemia might have six 
subsets and that one type of treatment will be better for one 
subset than the other, one type of treatment will cause more 
implications than the other, but if we can clearly get down to 
very precise typing, we'll do much better for the patient with 
respect to curing the disease. This is true of all types of 
cancer.
    It's a long-winded answer. I apologize. To get back to you, 
I would say that in a strategic sense, we don't yet have a 
global approach to how to do that, and I would argue that 
that's the next great leap forward, applying those DNA studies 
to understand human disease and leukemias in children.
    Senator Reid. Senator Clinton.
    Senator Clinton. I just wanted to add on to what the 
Congressman was saying, because I think what Dr. Prescott just 
said is so critically important. Would it be fair to say, Dr. 
Prescott, that it would not only assist us in better curing 
cancers by understanding more about the individual disease, but 
also in preventing it. The more information globally that we 
can collect and that we then use both for cure and treatment, 
we also--if we have the appropriate plan to do this--will be 
able to begin to, perhaps, find answers to some of these 
questions that, right now, we can't answer.
    Dr. Prescott. Absolutely. In the ultimate realization of 
this, of applying this information about DNA sequences and our 
genes and how we're predisposed to the likelihood of disease, 
the distinction between treatment and prevention goes away. If 
you could diagnose early--prevention is the treatment, and it 
absolutely is the great promise of this technology.
    Senator Clinton. One of the things that certainly strikes 
me, just as a layperson, without any of the expertise that Dr. 
Prescott obviously has, is that if we survey the way we're 
living--and this goes back to something that Tammy said, which 
I don't want to lose in the discussion. We are living very 
differently than our grandparents lived. Whether we live in 
Nevada or Arkansas or New York or wherever we're living, we're 
living differently, and in the course of that different living, 
we've had so many blessings that we're grateful for, but I 
think it is appropriate for us to take stock of what are some 
of the unintended consequences of the ways in which we are 
living, so that we don't overreact, but we also don't ignore 
changes that could be made that could keep us healthier longer. 
This is something that may not directly fall in the realm of 
science today, but without adequate research being directed 
toward determining--What are the environmental contaminants 
that we expose ourselves and our children to on a regular 
basis? What is the cumulative effect of those contaminants over 
time? What is the distribution of viruses? What's the 
assessment of exposure to things that we didn't really have in 
our homes or that we didn't understand the impact of?
    I know that there are people who will say, ``Well, but 
we've lived this way for a long time and we don't suffer any 
ill effects.'' I'm often reminded of meeting the 95-year-old 
smoker who says, you know, ``I've smoked all my life. It didn't 
hurt me a bit.'' Well, that's a unique case, because we know 
it's hurt a lot of other people. Our genetic makeup may have 
protected us over time against some of those assaults, but the 
accumulation of the assaults may break down or find that 
genetic pathway.
    So I think that, you know, we do have to ask ourselves 
these hard questions. That's one of the reasons why 
environmental health is, to me, the real frontier of where we 
go now in medicine, because we've made so many advances. Now 
let's take a step back and figure out how do we prevent these 
things, not just enough that we can cure with extraordinary 
medical research childhood leukemias that are way beyond 
whatever was dreamed 25 years ago, but how do we change some of 
the environmental impacts or better understand the virus 
transmissions and the exposure assessments, so that we can 
prevent it, we can relegate it to the dustbin of history. I 
think what Dr. Prescott said, I hope, will inform the Congress. 
I'd like to thank this panel very much. It's been most 
illuminating, and I'm sure that the information we're going to 
take back to Washington as a result of this panel, alone, will 
have made our trip worthwhile. Thanks very much.
    Senator Reid. We're now going to hear from Dr. Mary Guinan, 
the Nevada State Health Officer. She has worked for the Centers 
for Disease Control and Prevention over 20 years and now leads 
our State's response to the Fallon leukemia cluster. She has 
extensive expertise and her relationships within the national 
public health community has given the State a unique access to 
assistance in conducting this cluster investigation. We're also 
going to hear from Dr. Randall Todd, Nevada State 
epidemiologist. Dr. Todd is an associate of Dr. Guinan and is 
responsible for the technical elements of the State's efforts. 
He's primarily responsible for developing many of the programs 
within the State. We're also pleased to have with us Rear 
Admiral R.J. Naughton, who's accompanied by Captain D.A. 
``Roy'' Rogers, commander of the Fallon Naval Air Station. We 
also are going to hear from the mayor of the city of Fallon, 
Ken Tedford, who has worked with us so well and so hard in 
arranging for this hearing, and Ms. Gwen Washburn, who's the 
commissioner with the Churchill County Commissioners.
    We're first going to hear from Dr. Guinan.
    Dr. Guinan. Senator Reid, I'm going to ask Dr. Todd to 
first give us a presentation of his findings. Dr. Todd has been 
the lead scientist in the investigation of this cancer cluster, 
the first phase of the study, and he will present those 
findings.

 STATEMENT OF RANDALL TODD, STATE EPIDEMIOLOGIST, NEVADA STATE 
                        HEALTH DIVISION

    Dr. Todd. Thank you. Good morning, Mr. Chairman and members 
of the committee. For the record, my name is Dr. Randall Todd. 
I am the State epidemiologist and work with the Nevada State 
Health Division. I'd like to briefly describe the Health 
Division's investigation into the cluster of childhood leukemia 
in Churchill County and discuss the role of Nevada's Central 
Cancer Registry assisting us with that investigation.
    The initial phase of our investigation consisted of 
confirming the diagnosis of each reported case and conducting 
an interview with each case family to identify any potentially 
common characteristics or environmental exposures that might 
point to a preventable cause. I should mention that we're 
indebted to the Centers for Disease Control as well as the 
Massachusetts Department of Public Health for their assistance 
in providing us with model interview instruments.
    The case family interviews were conducted face to face with 
each family. This involved a detailed review of the family's 
residential history, from the date of diagnosis back to a point 
in time 2 years prior to conception of the ill child. For each 
residence, we inquired as to the source of water, in-home 
treatment of water, and uses of water. We also inquired about 
known exposures to chemicals from agricultural or home use of 
herbicides and pesticides, as well as indoor uses of chemicals 
and solvents. For each parent, we inquired about occupation and 
occupation-related exposure to chemicals, dust, or radiation. 
We conducted a detailed review of the child's medical history 
and the mother's pregnancy and breast-feeding histories. 
Finally, we asked case families about any hobbies, sports 
activities, or typical travel destinations that might have 
brought them into contact with chemicals, fumes, or radiation.
    From this interview process we learned that half of the 
case families had spent 2 years or more in the Fallon area. The 
others had resided in the area for shorter periods of time. 
These 12 case families had resided in a total of 88 different 
homes over their respective time periods of interest. Of these 
88 homes, 22 were located within Churchill County, and of these 
22 local residences, half were served by public water systems, 
while the others obtained their water from domestic wells.
    Our initial analysis of the occupational, medical, 
environmental, and other historical information provided by the 
case families has not suggested any particular common 
denominator that would link these cases together. We recognize, 
however, that some of our data is subject to recall limitations 
on the part of the families. Specifically, they may not have 
known of an environmental exposure that did, in fact, exist or 
they may have forgotten about it. For this reason, we are 
currently taking steps to obtain additional data through 
objective environmental sampling. This constitutes a second 
phase of the investigation.
    We're now in the process of obtaining water samples from 
these current and former case residences in Churchill County 
that are served by domestic wells. These samples are being 
subjected to the analyses that are routinely done for public 
water systems. In other words, any test required by the safe 
drinking water act for public water systems is also being 
conducted on the water samples obtained from the wells of 
residences where case families have lived. The results of these 
analyses are pending at this time.
    We've also invited the Centers for Disease Control and 
Prevention, as well as the Agency for Toxic Substances and 
Disease Registry, to assist us in identifying and analyzing 
completed pathways for other sources of environmental 
contamination. This would include industrial, agricultural, 
military, or other sources.
    On a parallel tract with these environmental studies, we 
are also collecting data on the overall population dynamics of 
Churchill County. This includes looking at size of various age 
cohorts over the last 10 years, school enrollment information, 
and military populations. This analysis will help us determine 
if Churchill County matches the profile of other communities 
around the world where population mixing has been suggested as 
a possible explanation for increased rates of childhood 
leukemia.
    In closing, I would like to make some brief comments as to 
the importance of cancer registries in the conduct of cancer 
cluster investigations. Nevada has maintained a population-
based cancer registry since 1979. This activity has been 
funded, in part, through a grant from the Centers for Disease 
Control and Prevention since 1995.
    I should mention that all disease reporting systems, 
including cancer registries, do experience a lag in time 
between the diagnosis of a case and the reporting of that case. 
With a disease such as cancer, the patient record may not be 
complete enough to warrant abstracting information until about 
6 months from the date of diagnosis. Additional delays in 
obtaining information beyond this 6-month time period relate to 
workload and staffing. In more rural parts of Nevada, this 
situation is made even more difficult due to the distances 
involved and the relatively low number of acute hospital beds 
in each facility, making it costly and time-consuming to 
collect rural data. For these reasons, if a cancer cluster is 
identified through a cancer registry, it's likely to have been 
going on for some time.
    The increased incidence of childhood leukemia in Churchill 
County was not identified through analysis of cancer registry 
data. The local hospital, physicians, and community leaders 
noted the cases and perceived the numbers to be unusually high. 
Nevertheless, Nevada's cancer registry has been invaluable in 
helping to place the observed number of childhood leukemia 
cases in historical and geographic context. Only through this 
analysis of cancer registry data have we been able to calculate 
the usual rate of childhood leukemia and determine that the 
local cases do, in fact, represent a significant excess over 
the expected.
    I'd be happy to entertain any questions the committee might 
have.
    Senator Reid. Dr. Guinan.
    Dr. Guinan. Yes, thank you.

     STATEMENT OF MARY GUINAN, NEVADA STATE HEALTH OFFICER

    I'm Mary Guinan, State Health Officer. I've been asked to 
speak today on the status of the continuing investigation and 
also Federal roles in the investigation of cancer clusters.
    On February 15, after Dr. Todd had finished the first phase 
of the investigation and after the analysis showed no 
particular environmental or infectious agent that we thought 
was common among the cases and would be a likely causative 
agent, we asked a panel--we invited an expert panel consisting 
of experts from the Centers for Disease Control, the National 
Cancer Institute, the University of Minnesota School of Public 
Health, the University of California at Berkeley School of 
Public Health, and others, several from Nevada, University of 
Nevada School of Medicine, and we asked them to review all of 
the data and to help us plan the next steps of the 
investigation. That occurred on February 15.
    The committee made six recommendations. The first was to 
expand case-finding efforts by seeing if you have all of the 
cases, are there other cases, and we're doing that. We're 
working with the Navy to see if there are any Navy families who 
have been through Fallon and whose children may have developed 
leukemia, and that search is ongoing, and Admiral Naughton will 
speak to that.
    We also want to expand our case search with the Children's 
Oncology Group. Children's Oncology Group is a group of 
treatment centers around the country. As you know, cancer in 
children is rare, and we're very grateful it's rare, and so in 
order to get appropriate treatment protocols, the treatments 
are concentrated in groups around the country--California, 
Utah. We do not have one in Nevada. So the children with 
leukemia--over 90 percent of the children with leukemia in this 
country are treated at these children's oncology centers, and 
they have a data base. So what we want to do next--and we're 
waiting for the funds to do this--is working with--especially 
the California oncology groups--working with them to search 
their directories to see if we have Nevada patients who were 
diagnosed in those centers. We have no pediatric oncologist in 
Northern Nevada. So that all of the cases would be referred 
out. Most of the cases from Fallon are referred to California, 
and there is a pediatric oncologist that comes from California 
to Reno on a regular basis and continues their treatment, but 
the diagnosis is done in these oncology centers. So we will be 
expanding that.
    The second recommendation was to categorize the ALL cases 
by clinically relevant biomarkers, and Dr. Prescott has 
mentioned some of those. What happens is, we need to really 
look at the leukemia tissue in order to do those studies, to 
look at the diseased tissue. So what we have to do now is to--
many of the protocols of these oncology centers require saving 
tissue specimens. So we are going to be in the process of 
identifying each of the centers where the child was--where the 
bone marrow biopsy was done and what kinds of testing were done 
at that center. There are a number of tests that can be done.
    The first broad test that's done is to identify two types 
of lymphocytes. Which cancer is it? Is it B lymphocyte or is it 
T lymphocyte? B lymphocyte cancer, or lymphoblastic leukemia, 
is much more common than the T cancer, and our cases reflect 
that. We have nine B-cell and we have three T-cell cancers. But 
there are subdivisions of that. In other words, each of the B 
cancers have subdivisions and very distinct analysis, which I 
think we need to move forward on, to see if those genetic 
breaks, those chromosome breaks are similar. Because if they're 
similar, then they're more likely to be linked to the same 
source, and that is a critical issue, that if we had known in 
advance and collected, we would know of specimens. We do not 
know whether we have those specimens available at the present 
time.
    No. 3 was to identify potential excess environmental 
exposures unique to the community. Dr. Todd has told you that 
we're in the process of that. Next week, members of the Centers 
for Disease Control and the Agency for Toxic Substance and 
Disease Registry will be here looking at all of the 
environmental testing that has been recommended, seeing how we 
can approach that and who's going to do it and how we're going 
to do it, and also to do a pathways analysis to say, ``If there 
are environmental chemicals that are toxic in the community, by 
what pathway do they get to people?'' That's extremely 
important for us to analyze.
    The next recommendation was to collect and bank biological 
samples for future study, and we are waiting funds for that. We 
need to identify a repository for specimens. We would like to 
collect specimens from the families, as well as the cases. The 
technology is rapidly advancing, as Dr. Prescott said. So maybe 
in 2 months we might be able to have a test that would tell us 
something about causation. It's extremely important for us to 
save those specimens, and we don't have a national sort of 
comprehensive group looking at that, saying this is what we 
have to do for every cancer cluster.
    The fifth recommendation was determine time course and 
characteristics of population movement into the Fallon area, 
and that's to address this population mixing theory, which 
was--it is just a theory, which came out of Britain after an 
investigation of a number of clusters, and that is that a rural 
population has an influx of people and, for some reason, 
there's an increase in leukemia or cancer in that community, 
and the reasons for it are very complex. In Fallon, that 
particular scenario may exist. In other words, that we have a 
small town relatively isolated and then the in-migration of 
various groups, either through the military or others, that 
come and go. So this is a possibility to test evidence for this 
population mixing theory, which go well beyond what the State 
of Nevada would do, but something that the National Cancer 
Institute should be doing, identifying and--there is no 
mechanism for the National Cancer Institute to give us funds 
for research. Their budgets are to study months and years in 
advance. So it's really important for there to be a 
comprehensive plan, as we suggested, for a study to advance the 
causation theory.
    The last recommendation was to maintain the expert panel, 
which they have.
    Now, about the lessons learned--all of the panelists serve 
without--we do not pay for them, they volunteer. They're 
wonderful experts, and we have been really blessed to have 
their interest, and they are volunteering to be here and help 
us, and they have done a tremendous job. One of the lessons 
that we have learned with regard to Federal agency roles in the 
investigation of cancer clusters, although hundreds of cancer 
clusters have been recognized and investigated during the past 
30 years by State and local health departments and Federal 
agencies, little information is available on appropriate 
scientific methods of study, especially with regard to 
determining the causative factors or associated risk factors. 
Well over 90 percent of these investigations have found no 
associated suspect causative agent, and no Federal agency wants 
to expend scarce resources for the investigation of cancer 
clusters that are likely to show nothing. It's an investigation 
which you know that 90 percent of the time you will not find 
anything. So there is a reluctance to invest resources in 
something that has such a low probability of an outcome of 
interest.
    Senator Reid. Ms. Guinan, I think we're going to ask you 
some questions and you'll be able to expand on the rest of your 
statement. I'm going to make your entire statement a part of 
this record. You've answered one of the questions the panel 
already asked directly. We asked Assemblywoman de Braga about 
what the Federal Government can do, and you've told us very 
specifically. I would also just comment that 90 percent is 
great, but if you're part of the 10 percent, you want to make 
sure that's investigated also.
    We're going to turn now to Admiral Naughton. I would say, 
before you begin your testimony, to explain to Senator Clinton 
and some of the audience who may not know, which I'm sure there 
are very few--Senator Clinton, in Nevada, we have two very 
large military installations, of which we're very proud. In the 
southern part of the State, we have an air force base, Nellis 
Air Force Base. It is the largest fighter training facility the 
air force has in the world, and I'm told by everyone, most 
important, if you want to have a Ph.D., so to speak, in the air 
force and be a pilot, you have to go through Nellis. The same 
applies if you're a Navy pilot. We have here in Fallon the 
Fallon Naval Air Training Center, which is something we're very 
proud of. Top Gun is here. It's something that has been great 
for our State, but also certainly for our Nation.
    We recognize how important it is to the State of Nevada, 
but we're going to have some tough questions to ask when we get 
to the part of this hearing when we ask questions. Admiral 
Naughton and Captain Rogers has been through a lot of things in 
their careers, and they understand we're only trying to get to 
the bottom of things. We're going to ask questions about when 
you weren't even at the base. So my point is, the directness of 
the questions has no bearing on how important we feel your work 
is here.
    Admiral Naughton.

 STATEMENT OF ADMIRAL R.J. NAUGHTON, FALLON NAVAL AIR STATION, 
    FALLON, NV; ACCOMPANIED BY CAPTAIN D.A. ``ROY'' ROGERS, 
                           COMMANDER

    Admiral Naughton. Yes, sir.
    Senator Reid, Senator Clinton, Senator Ensign, and 
Representative Gibbons, my name is Richard Naughton. I'm the 
commander of the Naval Strike and Air Warfare Center, which is 
located at NAS Fallon, NV. Here with me this morning is Captain 
David Rogers, who's the base commander. We do welcome this 
opportunity to testify before the Environment and Public Works 
Committee on the military activity that takes place in Fallon, 
in particular, how it may pertain to Churchill County's recent 
childhood leukemia cluster. I'll talk a little bit about the 
background that the Senator talked about, about the mission and 
operations at Fallon, followed by some remarks that I know are 
of special interest to the committee, and we look forward to 
your questions afterwards. Let me assure the committee and the 
local community members that the U.S. Navy is committed to 
public health and to assisting this investigation in every way 
possible.
    One of the cases in question is the child of a military 
family member who was formerly stationed at Fallon. Our base 
population is about 7,200 personnel, which includes all the 
military and civilians and their families, and of that 7,200, 
three quarters live in the local community. So we're very 
involved in the local community and we want to be sure that 
we're part of this solution. The Navy's Bureau of Medicine has 
just completed extensive screening of naval medical cases, 
which might be related to the Fallon cluster. They reviewed 
over 12 million records looking for cases of ALL from 1997 to 
the present, and just the one Navy case that I've already 
identified was the only one that we came up with.
    The Navy is also committed to exploring the expert panel's 
population theory--population mixing theory, and we have shared 
data on the transient activity of NAS Fallon with the State. 
This military data is one of the three transient data 
collection efforts recommended by the expert panel.
    As many of you may know, NAS Fallon began operation in 1942 
as an Army Air Corps base. The focus at that time, until about 
1984, was unit level air-to-ground combat training. When the 
Navy established the Naval Strike Warfare Center in 1984, we 
began 
focusing on entire air wing training of about 1500 people and 
70 aircraft in an integrated fashion. The mid-eighties also saw 
the development of the Fallon Range Complex, an instrumented 
military operating area flown over 6.5 million acres east of 
Fallon. The majority of the land we fly over is unpopulated and 
managed by the Bureau of Land Management. The Navy actually 
only controls 204,000 acres. The third major change in the mid-
eighties was the out-sourcing of many of the functions on the 
base. As a result, 55 percent of our current base population is 
civilian contractors.
    In 1996, with the closing of NAS Miramar and the Base 
Realignment and Closure Act, all graduate level aviation flight 
training moved to Fallon, with the arrival of Top Gun and Top 
Dome from southern California and the establishment of a senior 
two-star officer on the base as the commander of Naval Strike 
and Air Warfare Center. As NSAWC, or Naval Strike and Air 
Warfare Center, I report directly to the chief of naval 
operations and provide oversight of the training of 
approximately 55,000 personnel a year here at Fallon and at our 
weapon centers and weapon schools at other fleet concentration 
areas throughout the United States. Over the past 5 years, 
flight operations have really only increased about 4 to 5 
percent at NAS Fallon, with an average of about 40,000 flights 
per year. There has been an investment in Fallon infrastructure 
at NAS Fallon since 1984 of over $300 million.
    I would like to discuss the specifics of our operations out 
there, as they may affect this investigation. First, the 
consolidation of all our training here in 1996 did not 
appreciably change the way we conduct operations. As a matter 
of fact, our two biggest years of operations at NAS Fallon were 
in 1990 and 1991, preparing for Operation Desert Storm and 
Desert Shield. From an environmental perspective, the flight 
training that NSAWC conducts has changed very little in the 
past few years.
    Second, NAS Fallon's environmental, safety, operations, and 
weapons departments are responsible for the administration of 
all our environmentally-sensitive material. For anything we 
use, there is a safety handling program and a way of disposing 
it properly, where applicable. We follow the guidelines 
established by Federal, State, Department of Defense, and U.S. 
Navy agencies and are probably more heavily regulated than 
anyone in the private sector. Programs such as our fuel 
handling, air emissions, hazardous material disposal, 
electromagnetic radiation effects, and installation restoration 
are all inspected on a regular basis. We have received high 
marks for compliance, and we've shared data on each of these 
with the State Health Division and the expert panel. Next week, 
when the Agency for Toxic Substance and Disease Registry 
visits, we will share our data with them also.
    Third is NAS Fallon's drinking water supply for the 3,000 
personnel who work on the base and the up to 2,000 transients 
that we have there at any one time. It is separate from the 
city of Fallon's, but it taps into the same Basalt Aquifer, and 
the water chemistry is essentially identical. The base tests 
our water supply routinely and monitors for contamination of 
the 8,000 acres of the air station property through the use of 
218 environmental monitoring wells. No DoD activity-related 
contaminants have ever been detected in the Basalt Aquifer or 
leaving the base property. While the State and select panel 
investigations have not established a link between Fallon water 
arsenic levels with the leukemia cluster, these are a matter of 
concern to our people and to the U.S. Navy, and we're working 
very aggressively with the city to build a DoD/city of Fallon 
water treatment facility.
    My detailed written statement previously submitted contains 
lots of information about NAS Fallon and it may be relevant to 
this investigation, and it also lists points of contact. I 
thank you for your attention.
     Senator Reid. We would also order that that be made part 
of the record.
    We're going to now hear from the mayor of the city of 
Fallon.
    Mayor Tedford.

        STATEMENT OF HON. KEN TEDFORD, MAYOR, FALLON, NV

    Mayor Tedford. Thank you.
    Recognizing that my time is brief today, let me begin by 
saying that the city of Fallon sincerely appreciates the 
efforts of the Senators and the Congressman and your staffs, 
just as we appreciate the help that we've received from the 
Governor's office and also from the State Health Division.
    These are trying times for our community, and while we've 
pulled together in the only way we know how, it is comforting 
to know that others want to help. I'm not going to spend any 
time discussing the cluster's cause or possible links between 
the children. I believe the State Division of Health and others 
will do that. The city has cooperated in every way we know. 
First, as the steward of the municipal water system and, later, 
as we began to assess other city-owned facilities. Thus far, 
nothing has been found. We recognize that the health division's 
expert panel believes that an environmental link may not be 
found, due to the fact that the ALL found in this cluster 
generally is not typically caused by environmental triggers. 
Nonetheless, we will continue to cooperate in that search in 
any way we can.
    Our efforts, indeed, have been focused on the children, the 
affected families, and public education. The city council and I 
have formed a group called Fallon Families First, which is 
comprised of local community leaders and social service 
providers to coordinate these efforts. I asked my wife, 
Jennifer, to chair that committee, and they're doing yeomen's 
work. Please realize that our city does not have a social 
service infrastructure. We're too small. So we've had to reach 
out to groups like the FRIENDS Family Resource Center, the 
local hospital, mental health professionals, the clergy, the 
school district, the county, and others. Fund-raising is 
handled through the Mayor's Youth Fund. You can see the white 
ribbons worn by guests here today. This was a suggestion by a 
mom of one of the patients. It's the latest step in our effort, 
and we plan to continue raising funds as long as there are 
needs.
     Fallon Families First recently held its first public 
meeting, a panel discussion focused on the disease itself. 
Local physicians, a mother of a stricken child, a mental health 
professional--these people, who people know and trust in our 
community, helped answer questions that are weighing heavy on 
the minds of those attending. Efforts like this will continue, 
as they are needed. A series of informational mailings is also 
being coordinated with the county and the local telephone 
company. This week, the city launched its first website. Part 
of this effort has been driven by not only the need to 
communicate about the leukemia cluster, but part of our desire 
was also to be generally more accessible.
    So what remains to be done? I can tell you without 
hesitation that the most frustrating part of this process for 
me has been the lack of information. People want answers and I 
don't have them. The investigation's ongoing, but it's bound to 
take a long time. Where do people go for answers? I believe, in 
cluster situations like this, a clear sense of communication 
needs to be established early in the process. Perhaps if the 
State health officer declared a cluster to be in existence, 
that could trigger a Federal, State, and local partnership. The 
mayor's office seems to be the place where people automatically 
go, but in small towns like ours, we don't always have the 
information people want. I have assembled my own team of local 
citizens and other experts who can help the city, but in other 
towns, the mayor might not be so fortunate. I think a standard 
support team should be made available to towns like ours.
    Finally, I would be remiss if I didn't speak briefly about 
the arsenic in our water. I know the Senators are aware of this 
situation, just as I know the experts will testify that 
arsenic's probably not linked to this leukemia cluster, but the 
two things have become linked in the media and in earlier 
meetings. So I feel I, at least, owe you an update of where we 
are today. Fallon's municipal water supply contains arsenic 
levels of a hundred parts per billion. The USEPA has ordered us 
to remove the arsenic, which is naturally occurring here in 
Fallon. As you are well aware, the EPA standard has long been 
under review. It was 50 parts per billion. It was temporarily 
lowered to 10. Now it's back to 50. We have no idea where it 
will finally be set. But for the city of Fallon, it doesn't 
matter anymore. We are proceeding to treat and we will get 
there.
    The city of Fallon, through its environmental engineering 
firm, Shepherd Miller, has begun pilot testing of the 
technology we will use to remove this arsenic. It appears that 
a filtration process called enhanced coagulation is working 
best. We will finish the pilot testing by the end of May, then 
we will design and site a treatment facility. Our goal is to 
have construction finished in time to comply with the EPA 
order, which gives Fallon until September 2003. This date is 
significantly earlier than any other public water system in 
America, and it's still not clear how much arsenic we will have 
to remove. Nonetheless, we are proceeding, and we are doing so 
without regard to cost or where the money will come from. We 
also have been in consultation with the U.S. Navy and their 
officials about a joint treatment plant.
    My suggestion to this body today is that you make Fallon a 
test case. The issue of the EPA standard revolves around the 
best available science and the fact that there is no off-the-
shelf technology to remove arsenic on our level at our 
municipal scale. Things like household reverse osmosis systems 
won't work on a system as large as ours. We believe that since 
Fallon is required to remove its arsenic more quickly than 
other municipalities, there may be benefits to those who follow 
from learning what we have. Perhaps the Federal Government 
could pay for the cost of our treatment facility in exchange 
for the availability of science and treatment methods resulting 
here that could be utilized by all those who follow. We're 
dedicated to treating the city water. Others will have to 
address the many private county wells that have high arsenic 
levels, and all of us will have to address public education 
issues and outside media attention that now surround the 
arsenic. But with your help, we can put this chapter in our 
history behind us and focus all of our energies on this 
leukemia cluster, the children and their families.
    We must maintain our focus on these families. As I've said 
earlier, this is a lonely time for our town. Many people want 
to speculate, many others are well-intentioned in their 
scrutiny, others are just curious, but when the camera lights 
are off and the media attention fades, our families and our 
town will be left to care for these children and assess the 
long-term impacts of this cluster on our community. Your 
presence here today is a chance to change that. I hope you will 
be able to stick with us, and I thank you very much for taking 
the time to be with us today.
    Senator Reid. Thank you very much.
    Commissioner Washburn.

 STATEMENT OF GWEN WASHBURN, COMMISSIONER, CHURCHILL COUNTY, NV

    Ms. Washburn. Good morning, Senators, Representative 
Gibbons.
    I'm Gwen Washburn, the chairman of the Churchill County 
Commission, and I want to tell you that we've not had the phone 
calls, I'm sure, that the mayor has, but we've been working 
closely with him. I do want to tell you that the county 
administration is, first and foremost, concerned about the 
health and well-being of its citizens, and I'm happy to have 
the opportunity this morning to address the leukemia cluster 
that's been identified in this community and also to discuss 
ways to investigate or mitigate the issue. I'll tell you a 
little bit about Churchill County and what the county 
commission is doing. You have several pages of written material 
in your packet, and I'll attempt to summarize those at this 
time.
    Churchill County has sustained a steady growth of about 3 
percent over the years and now is home to about 26,000 people. 
This population is expected to double in the next 15 years. 
We're a progressive small community, boasting modern schools, a 
community college, an art center, and the most modern hospital 
in western Nevada. We have a mix of long-time agricultural-
oriented families, military personnel, young working families, 
and retired people. Many people are born here and grow old here 
with nothing more than average health problems. So, our 
community is alarmed and feels helpless in the face of a 
childhood leukemia epidemic.
    This community has reacted to this crisis in a quick and 
calm manner, working cooperatively together with all agencies 
in an attempt to find an answer or a common link between the 
cases. The county commission is very concerned about the health 
and welfare of not only our 26,000 residents, but those that 
visit us each year as military personnel or tourists. 
Certainly, none of us are experts in the health field, nor are 
we research scientists. So we have no choice but to leave those 
investigations to those experts, but what we can do and have 
done and will continue to do is to support all scientific and 
responsible efforts to find the answer. So far, we've actively 
participated in all efforts of all the agencies in the 
investigations and in the efforts to educate the residents and 
to ease the burden of the affected families. We've assisted in 
reactivation of the University of Nevada's Nevada GOLD Program, 
which is Guard Our Local Drinking water, and we've also 
tightened some of our own business permit ordinances for 
business and industry.
    We are anxious to locate and take reasonable and 
responsible corrective action for any environmental cause that 
may be found to contribute to the incidence of leukemia or any 
other health risk in our community. A thorough and scientific 
study of all the possibilities will take many years and 
millions of dollars. The medical experts have already expended 
many resources examining the patients and their families. The 
community and individuals have all lent their support. The 
State of Nevada is considering committing money. So now I will 
ask you, on a Federal level, to commit Federal resources, and 
there are many, but I'm going to list ones that I think at this 
point are most important. No. 1 is to provide a funding 
mechanism to assure proper medical care for the victims; No. 2 
is to assure thorough scientific research through Federal 
grants; No. 3, grants to the University of Nevada-Reno and 
Churchill Community Hospital to assure continued public 
education on health and nutrition; and No. 4, to assist 
individual well owners with testing and treatment of water. 
Best guess, this community has 4,500 domestic wells that our 
citizens are relying on.
    The written comments that you have before you will expand 
on these thoughts and cover several others. So for the sake of 
time, I won't go into all those comments, but I hope you'll 
take the time to read and consider those, and I'll be happy to 
clarify and expand upon any of those at your convenience.
    On behalf of the Churchill County commissioners, I want to 
thank you for taking your time to listen to our concerns and 
our ideas. We sincerely hope that you'll be able to assist our 
community in some way to ease the suffering of the leukemia 
victims and their families and to help us find the ways and 
means to lessen or, better yet, prevent more occurrences of 
this and other cancers.
    Senator Reid. Thank you very much. Your full statement will 
be made a part of the record.
    Before moving to questions of this panel, I would like to 
say to those people who filled out the forms for asking 
questions of the panel, if you'd be kind enough to pass these 
cards to the center aisle, they'll be collected, so they can be 
given to us following the third panel.
    Dr. Guinan, we've heard testimony about the possibility of 
this being a virus. Now, there's no danger of this being 
transmitted--if a child has leukemia that, by chance, is caused 
by a virus, there's no danger of that child transmitting the 
virus to his friends, is there?
    Dr. Guinan. No, there is not, there is no danger. Leukemia 
is not contagious.
    Senator Reid. That's so important, that people here 
understand that.
    Admiral one of the things I wanted to talk to you about, in 
the written testimony that you've given and other people from 
the Naval Air Station have given, you've indicated that in the 
last 5 years there's only been 40 gallons of fuel spilled, or 
words to that effect. I just want to make sure that the 
record's clear, because I can remember spending a lot of time 
out there 10 years ago relating to a spill of fuel. There was 
some dispute as to how much had been spilled, from a thousand 
gallons to 30 thousand gallons. We really never got to the 
bottom of how much that was. Also, during that same period of 
time, people came forward and indicated that there was fuel 
contaminated soil that was burned for 5 or 6 days in a row at 
the base. This spill and the other information is not part of 
this record, it's simply not there, and much information has 
been gathered up to this point.
    I would like to have the Navy supply whatever information 
you have to Dr. Guinan regarding these prior incidents. It's my 
understanding, and I've read very clearly the testimony given 
in the past, that this information has not been forthcoming in 
this investigation. I'll also say, Admiral, that I don't know 
if burning soil for 5 or 6 days would have any bearing. I 
simply don't know. I don't know if the fuel spill would have 
any bearing on the work that's being conducted here, but I 
think it should be part of the information gathering, so that 
Dr. Guinan and others will have this at their fingertips.
    Admiral Naughton. Yes, sir, we'll provide that, the data of 
the 1988-89 spills. There was lots of discussion on how much 
was or wasn't spilled, where it went, and I know there was much 
confusion. That's one of the reasons that we have these 218 
environmental monitoring wells there right now, to be sure that 
there's nothing--there's no pathway off the base. We will 
provide that data.
    The burning of fuel for 5 or 6 days, I think, perhaps is 
local legend, sir, but we will find out in much more detail. We 
can't find anybody that has any firsthand knowledge of that, 
but we will provide all that data. Again, as I say, our 
strategy is, we want--public health is our primary concern. We 
want to be part of the solution, and we will cooperate fully 
and provide all data humanly possible.
    Senator Reid. I appreciate that very much.
    It's my understanding, Admiral, that the Navy has, during 
the past 4 or 5 years, used a different kind of fuel for the 
jet airplanes. Is that true?
    Admiral Naughton. Yes, sir. We've moved from JP5 to JP8.
    Senator Reid. Can you tell me why you did that and what the 
difference in fuels is?
    Admiral Naughton. Well, JP5 has--it's actually an economic 
issue--JP5 has a higher flash point and must be used on the 
ships. JP8 is the airforce-based fuel. It's almost all 
kerosene, with some additives. The only difference between JP8 
and the jet fuel that's used in commercial airliners is that we 
have an anti-icing ingredient that's added to it. So it's 
essentially identical to what is burned in every airport around 
the world, including Reno-Tahoe.
    Senator Reid. Is it classified information, Admiral, as to 
how much fuel is used at this base over a year?
    Admiral Naughton. No, sir. We use about 40 million gallons, 
about 50 percent of what they use at Reno.
    Senator Reid. At the airport in Reno.
    Admiral Naughton. Reno-Tahoe, yes, sir.
    Senator Reid. The other question about the monitoring of 
the wells--and Dr. Todd, Dr. Guinan, you can chime in here if 
you feel it's appropriate. One of the concerns I have about the 
monitoring of the wells is that I've been told that there's 
really two areas of water that we need to look at here. The 
first is the deep water, and that's what's being monitored----
    Admiral Naughton. No, we're monitoring the shallow water. 
The deep water in the Basalt Aquifer is where we get our 
drinking water, but we monitor the shallow water wells.
    Senator Reid. It's the shallow, at least in my opinion, 
that we have to be concerned about----
    Admiral Naughton. Yes, sir.
    Senator Reid [continuing]. Because that water moves around.
    Admiral Naughton. That's the pathway that we're looking 
for, and we have not seen one--in the monitoring work between 
the Nevada Department of Environmental Protection, they are 
part and parcel of what we do there.
    Senator Reid. The water that you talked about, you have 218 
wells that the Navy monitors, itself, as to where the water 
goes; is that right?
    Admiral Naughton. Yes, sir. If there's any contamination, 
we do test the deep water well routinely, just like the city 
does.
    Senator Reid. Senator Ensign.
    Senator Ensign. Admiral, when they were talking about the 
mixing, I just thought about something. In your investigation, 
when you're looking at mixing of populations, we've heard about 
the possibility that maybe a virus is one of the environmental 
causes. During this period of time, when maybe some of the 
exposures of these children to some people in the community 
occurred, was there a certain part of the world that some of 
our service personnel came from? Have they looked at trying to 
isolate that? We know that there are very rare diseases in 
different parts of the world that Americans are never exposed 
to, and you can become a carrier without even knowing you were 
already exposed. We should look at all possibilities.
    Admiral Naughton. I'm afraid that it'd almost be an 
infinite set. You know, you talk about 50,000 people coming 
through here each year. We have been everywhere. Of my own 
personal experience, I've been on almost every continent. The 
people that come through here, it would almost be impossible to 
track where they each have been. I'm not saying that we can't 
look at it, but we can do some analysis with CDC and the naval 
environmental health agency. We'll try and take that on, sir, 
but I'm a little nervous that it probably would be such a huge 
set of where they came from and what they did, and individually 
tracking each individual is not something that we do because of 
that, but we'll certainly look at it.
    Senator Ensign. Dr. Guinan.
    Dr. Guinan. Yes. I'd just like to say that the theory on 
population mixing is one that suggests, perhaps, a viral cause, 
but it's not a new virus or an exotic virus. The theory is that 
it's a common virus and a mild virus that, for whatever reason, 
there's been an abnormal immune response to and that follows a 
community of relative isolation that has been exposed to the 
virus before and maybe are a little older and have a different 
response to the same virus. That's why it's so difficult to 
find, we think, because it's a common virus, but an abnormal 
response to the virus.
    Senator Ensign. Has that community mixing theory, then, 
been mainly of cancers in older people and not in younger 
people?
    Dr. Guinan. No, it's younger people.
    Senator Ensign. It is.
    Dr. Guinan. In England, there is a cancer cluster in an 
area that's been ongoing for years, and they have put millions 
and millions of dollars into investigation of causes, and 
nothing has turned up. I think one of those things--out of that 
observational analysis came the population mixing theory, and 
as I say, it's just observational and a theory, but the expert 
panel felt that we could provide evidence to support or refute 
the theory with the cluster in Fallon, for a number of reasons. 
No. 1, the timeframe between the cases was so short, that we 
are a rural population with an influx of migration, and also 
that, if we could look at tissue and demonstrate there was some 
similarity, the more likely we could possibly say a virus is 
more likely.
    Senator Ensign. You were talking earlier about the B cells 
versus the T cells and that even the subtypes of the B cells 
being different in some of these cases. Does that not suggest 
different genetic pathways, or could they all be the same 
genetic pathway, and in the end, they branch off?
    Dr. Guinan. Well, I believe that for the B cells--if we 
thought they were linked and if they were all the same, we 
would be much firmer in our belief that they're linked. Since 
we really don't know what the cause is, we really don't know, 
but I think the lines of evidence suggest that T-cell may be a 
different type of etiology than B-cell, but the evidence is 
still relatively sparse, and as I say, there really is no known 
cause. So if we could come to, at least, some understanding of 
the pathway, we would be more likely to pinpoint a cause, 
whether it's environmental or infectious.
    Senator Ensign. I want you to make one comment. It really 
has nothing to do with the particular case today, but it raises 
a question that we're dealing with in Congress where we're 
talking about all this epidemiology. When you're dealing with 
that whole issue, privacy is a big concern. We're hearing about 
reporting and trying to make sure--especially for cluster 
cases--to have rapid reporting. How do you relate that to the 
concerns for privacy and how do you protect people's privacy? 
We have to make policy concerning privacy, but at the same time 
be able to share information to be able to solve some of these 
cases in the future.
    Dr. Guinan. That's a very important question, and I think 
that it's raised each time we ask that a disease be reported. 
As you know, the State has primacy in matters of health, and 
it's the State who decides--the State legislature--what 
diseases are reported, in what form. With cancer, there are 
many people who do not want to be reported, because they want 
privacy. All of the information that's reported on individuals 
to health departments is strictly confidential. Nothing about 
personal identifiers comes out of the health department. 
However, in small communities like this, people know who the 
people are and they're identified for fund-raising in the 
newspapers, but no personal identifiers are ever revealed, and 
that is one of the things that we have to do, and as a health 
officer, I have to maintain that confidentiality.
    We have HIV reporting by name, we have all sexually 
transmitted diseases, we have cases of leprosy, tuberculosis, 
all of those are reported to us, so we can do the appropriate 
public health work that needs to be done around these diseases, 
and they're all done and we haven't had a break of 
confidentiality. In other words, we maintain it, we take it 
very seriously. We have to deal with it now electronically, 
since records are being transmitted electronically, and 
understanding how you can guard the privacy and confidentiality 
of records that are being transported over the Internet, there 
are large Federal looks at that, on how to protect the 
confidentiality of data.
    Senator Ensign. Well, Dr. Guinan, we look forward to 
continuing to work with you on this type of issue. I know it is 
a big concern for a lot of people--to make sure they have their 
privacy, but at the same time, to recognize there are public 
health concerns.
    Senator Reid. Senator Clinton.
    Senator Clinton. Dr. Guinan--I don't know if I should say 
this here in Nevada, but I understand you're actually a native 
New Yorker.
    Dr. Guinan. Yes. Could you tell by my accent?
    Senator Clinton. Well, I also know that you've worked, in a 
very distinguished career, with the CDC and with Dr. Phil 
Landrigin--who's at Mount Sinai Hospital in New York--who is 
very concerned about many of these issues that we're speaking 
about today. Your written testimony is extremely enlightening 
and informative, and I want to, through you, thank the expert 
panel that served with you for putting in their time to come up 
with the recommendations that they've put forth.
    Dr. Guinan, as someone who has been on the forefront of 
public health as you have and, I know, played a major role back 
in the early 1980's in identifying HIV, AIDS, and recognizing 
it as a new disease, what would be your priorities for us to 
take back to Washington? Because one of the things that I'm 
concerned about is that we really come out of this hearing with 
some real priorities that all of us can take back to our 
colleagues and tell them that this is a pathway for us to 
follow in trying to get a handle on some of these issues, 
because I think there are going to be more of them. Maybe it's 
going to be better identification, better reporting, whatever 
the explanation. I think we're going to have more and more of 
these kinds of environmental health issues raised, clusters, 
and other kinds of incidences.
    What would you ask us to do and how would you rank the 
priorities as to how we could respond to Fallon, but more 
generally to these issues?
     Dr. Guinan. Well, I have suggestions on two fronts. One is 
on cancer cluster investigations. It seems to me that there is 
no repository of information on this. There should be. We don't 
know whether the clusters are increasing, decreasing, staying 
the same, and we really don't know what the results of most of 
the investigations of these clusters are, because there's no 
mode of reporting, in other words, there's no reporting on 
them. Sometimes they get published, maybe years after; in the 
Woburn, MA case, for example, from the identification on the 
cluster of leukemia to the final report was 18 years. In the 
meantime, we cannot benefit from the ongoing information they 
have gathered and advance the science. There may be 10 leukemia 
clusters being investigated right now, but we don't know about 
them, and I think it's extremely important to know that. In 
other words, if there are similar clusters ongoing, are they 
related, is there some relationship?
    So the epidemiology of clusters should be done, not with 
the idea that some Federal agency has to investigate each one 
of them, but that there is some repository of information that 
the States and local health departments can go to and know and 
be able to contact those other people and find out what they're 
doing and not have to reinvent the wheel, as Senator Reid has 
said, that we can start from the most recent scientific 
evidence and move forward, and we need resources and we need to 
be able to identify those clusters that have the most potential 
for advancing the science of causation--what are the 
characteristics--and then some money to be able to put the 
resources into those that are most promising.
    With regard to environmental substances that are toxic, 
there is no standard surveillance system for environmental 
agents, and it seems to me that there should be. We're always 
being asked about environmental agents, have we collected 
information on air quality, water quality, food quality, who 
collects it, how do they collect it, and no agency or group of 
agencies have come together and said these are the basic units 
of environmental surveillance that every health department 
should have. We should have air, water, and these are the 
things that we should have. Many States have particular 
environmental health concerns, like Nevada, about radiation, 
that we should have our own system also, besides the core, and 
there is not this kind of thinking. There is the communicable 
diseases. We know that there are communicable diseases and 
everybody agrees that these are the diseases that we should 
report, but there's no agreement on environmental. So I think 
it's extremely important that some thought process go into it 
and then some funding of infrastructure for the States to be 
able to develop those systems.
    Senator Clinton. Thank you very much. That's very helpful.
    Admiral thank you for your being here and for your service. 
This reminds me, back in my prior life, in the White House 
years, I was asked to head up an investigation into the Gulf 
War Syndrome, because we had so many service men and women 
returning from the gulf with unexplained illnesses, and I met 
with a lot of those veterans, I met with a lot of the people 
treating them, and we've made a little bit of progress in 
trying to determine why apparently very healthy young people 
after their service--which really was of limited duration, 
thank goodness, because the operation was so successful so 
quickly--returned home with terrible rheumatic and other kinds 
of diseases. So this is not only something that concerns 
cancer, we have other concerns, and oftentimes our people in 
the military are on the front lines of a lot of these 
inexplicable diseases and conditions, and I appreciate that 
very much.
    One of the things I was curious about, though--it relates 
to Dr. Guinan's point--is that just yesterday the EPA released 
its new toxic release inventory data. We're trying to get a 
better handle on what we do release into the air and what kind 
of emissions and other contaminants might be available in the 
environment. I was wondering, does the Navy and the other 
services report releases to DoD and EPA or just to DoD? Do you 
know that, Admiral?
    Admiral Naughton. There's a lot of things we report. We 
report the release of radio-nucleotides from our nuclear power 
ships to DoE and DoD, and we report our release of chemicals 
through DoD, and I, quite frankly, don't know for sure if we 
report to EPA. I would be surprised--if it's not, it goes 
through DoD, because, as you know, we're a pyramid structure 
and we all work for somebody. It would go through DoD, would be 
my guess on that, Senator.
    You talked about the Gulf War. I'm very familiar with it. I 
commanded a ship that was in Kuwait City. One of the very first 
cases of Gulf War disease was an MS-2 that was on my ship. I 
don't know why. I spent all day on the bridge and I didn't get 
sick. He spent all day inside and he did. So I don't know. But 
we do report all of our emissions and it is collected and it is 
reported to DoD, and we work through the Navy, through the 
Department of Navy health organization on everything we do.
    Senator Clinton. Thank you.
    Senator Reid. Congressman Gibbons.
    Mr. Gibbons. Thank you, Senator.
    Admiral I want to applaud you and Captain Rogers as well 
for your contribution, not only to this Nation in terms of 
making sure we are secure in our Nation's people and our 
interests abroad, but also your contribution to this community. 
The Fallon Naval Air Station, I think, has been one of the 
premiere institutions that this community has oftentimes relied 
upon for technology, for assistance, for help in times of 
emergencies or whatever, and I do want to applaud you for your 
effort to share the information with the Naval medical studies 
that you're undergoing in this regard. I think that shows that 
you're leading the way and that you're willing to be a working 
partner in the solution to this. As somebody who has also 
shared the technology of training in some of your facilities, I 
also want to thank you for being there when we needed you. It's 
always been very important.
    I really don't have any questions for the Navy, other than 
the fact that I did want to say that my understanding is that 
JP4, JP5, JP8, all very similar, maybe except for, as you say, 
the flash point temperature at which they ignite changed, 
primarily due to safety. Jet Fuel A, without the de-icing 
additive in it, is essentially the same as JP8.
    Senator Reid. Jim, I think you're just showing off now.
    Mr. Gibbons. I couldn't keep up with you guys in the 
medical field. So I thought I'd tell you where I do have some 
knowledge.
    But, anyway, when you talk about fuel burned and the effect 
of having a military aviation operation and comparing it to 
Reno-Tahoe International, Reno-Tahoe does burn JP8, with the 
fact they've got National Guard airplanes there that burn that. 
So I think there's, you know, an interest there, but one which, 
I think, will fail in comparison to say that it is the effect 
of the operation of the airplanes that is a causal factor in 
that, unless we start seeing clusters in Nevada in other 
locations, whether it's McCarran, Reno, Fallon, due to the 
combustion of this fuel.
    That would be a question I would ask Dr. Todd. Have you 
seen other clusters in Nevada like this that you've seen in 
Fallon?
    Dr. Todd. No, we have no other clusters at this time of 
childhood leukemia. In fact, when I look at 1999 data 
statewide, I find only 15 cases of childhood leukemia reported 
throughout the State. If I go back over a 5-year period, I find 
only 53 cases reported statewide. So, clearly, that's well over 
half million 0- to 19-year-olds in my denominator coming to 
Fallon, with less than a thousand 0- to 19-year-olds in the 
county population. Having eight cases diagnosed in only 1 year 
is clearly significant. We've not seen that elsewhere 
throughout the State.
    Mr. Gibbons. Let me turn to the mayor and the county 
commissioner and thank them for their appearance here as well.
    Mayor, I know that oftentimes we have read in the newspaper 
that the city of Fallon is dragging its feet with regard to 
dealing with arsenic removal, but I know you, I know the work 
that this community has done, and just for the record, would 
you help us by describing what the city has done in any effort 
with regard to moving forward on the arsenic removal?
    Mayor Tedford. Well, as you know, the arsenic issue goes 
back to--I was a sophomore in high school in 1969, and the 
discussion that began then--I certainly didn't start it, but I 
will be the one that ends it in 2003, that discussion. I think 
I could go back to the compliance agreement with the State that 
we signed in 1990 that we would meet the permanent standard 
when it was set. There's a lot of history, I think, that 
doesn't really need to be gone through today, but it should 
suffice to say, when we heard around 1997 that this standard 
was finally going to be set, after 10 years of waiting, we 
formed an arsenic team with the city. They went to various 
venues around the country, to EPA-sponsored meetings on what 
the standard might be and what the technology was. We had been 
told that there was off-the-shelf technology that we could use, 
and after those meetings in a variety of places, we found out 
there was no off-the-shelf technology that could be used in a 
city of our size.
    In 1999, we got a violation order from EPA, and in 2000, we 
hired Shepherd Miller of Fort Collins, CO, as our consultants, 
and they began the chemical testing of the water. They have 
gone through bench testing, they're at pilot testing now, as 
well as looking for site selection at the same time, as well as 
design. I think we're well on our way to being able to reach 
the mandate that we've been given of September 2003. We've 
expended an inordinate amount of money for a little town. Just 
probably in the last year and a half, we've spent about 
$400,000 with arsenic and its study and its treatment, as well 
as expanding their work to include what's in our water that 
could cause ALL, of which they have not found anything.
    So a lot has been done, but it's not an issue to us 
anymore. Actually in 1990, it wasn't an issue to us, because 
the city signed an agreement that we would do this. 
Politically, that might be a hard decision, because there are 
lots of people in this community who would prefer that we not 
do that, who feel that they're not being harmed by a hundred 
parts per billion of pentavalent arsenic, but that's not the 
decision we have to make. Our decision is to lower the arsenic 
by September 2003, and that's what the city council said to do 
and that's what we said to do, and we're going to do it. We're 
just looking at you all to help us fund that, so we can do it.
    There are some issues with an interim standard, because we 
tried to seek out several funding sources, and with your help 
and Senator Reid's, we've been able to get about $950,000 for 
help with design and siting. We are trying to site that on 
property we own, to save that money. We've been able to get, 
through AB198, about $707,000. We have accrued about a million 
dollars since 1990 to set aside for arsenic. But the bigger 
problem is not just the building of the plant, but also the--
what some people lose sight of is, we spread those dollars over 
2,800 hookups in the city of Fallon. This new standard of 10--
that's our goal to hit--really affects population sizes of 
10,000 or less, as the Senator well knows from the recent 
legislation of Senator Ensign, where there is probably limited 
funds to do these sorts of thing. So this is an area where we--
even though out in Fallon, we like to be self-sufficient, we're 
probably not going to be able to do that.
    Senator Reid. Mayor, there's no question that's the reason 
that Senator Ensign and I introduced the legislation 3 weeks 
ago. There are a lot of Fallons around the country. I agree 
with you. The standard has been set, and no matter what 
standard we set, Fallon has a problem. So we have to get rid of 
that. You were a sophomore in high school, I was a freshman in 
the legislature when this problem came up in the 1969 session, 
and we need to do something about it. If there is a thing that 
will hurt Fallon and the surrounding areas, it's this arsenic 
in the water, as far as growth. We've got to take care of that. 
Whether it has any impact upon this cancer cluster at this 
stage--we don't think so, but we certainly don't know--but 
regardless of that, we're going to take care of the problem, 
because, I repeat, there are a lot of Fallons around the 
country, and we need to provide money to allow this water 
system to be constructed. We're fortunate here in Fallon 
because we have this great military installation here, and 
there is simply no reason for the Navy to build a plant and 
Fallon to build a plant, we're going to do one together.
    Mayor Tedford. We're fully supportive of that.
    Senator Reid. We hope sometime later this year to be able 
to have more than just ``the check's in the mail.''
    Mayor Tedford. I think you're absolutely right. I think the 
cluster's heightened this and I think we've firmed our resolve 
that we need to do this.
    Senator Reid. We realize that Fallon is only a small part 
of Churchill County, and we're going to have to make sure that 
we provide some relief for the rest of the county, and that's 
something we'll talk about later. It may not be done here. 
We're not going to have a third treatment plant either. So 
we're going to try to do something to remedy this problem for 
the whole county.
    One final question I have for you, Dr. Guinan. I don't want 
to ask any questions about epidemiology. I understand over 50 
percent of Nevada Health Division's budget comes from the 
Federal Government. While the health division's total annual 
budget increased in recent years, do you have sufficient 
resources to devote to the cancer investigation and address all 
the activities for which the division is responsible? In 
effect, what I'm saying is, this must be a tremendous burden on 
your budget. Is that a fair statement?
    Dr. Guinan. Yes, it is a fair statement, Senator. The 
Governor has given us carte blanche and said we will provide 
resources to keep this a priority, but Dr. Todd has been taken 
away from all his other epidemiologic duties and spends his 
full time on the investigation, and he has an assistant who 
also spends full-time on this, and that takes away from all of 
our other--and I spend a great deal of my time also on it. We 
have a very small health department and we're a small State. 
This investigation takes a great deal of resources, and I can 
only say, we couldn't have done it without the Centers for 
Disease Control, who have been here since we knew about it, 
helping us with the steps and finding out, getting the 
resources that we need.
    Senator Reid. It is a factor in your general budget. About 
50 percent of it comes from the Federal Government, in some 
form or fashion; is that true?
    Dr. Guinan. I believe it's 85 percent.
    Senator Clinton. Senator, could I just add one final 
thought to what the mayor was saying? Because I really 
appreciate what you said and the resolve that you've shown for 
resolving this problem, and certainly both Senators Reid and 
Ensign are going to stand behind you and try to figure out a 
way to get some resources to you. But I just want to reiterate 
what Senator Reid said, because our infrastructure needs for 
clean drinking water around our country and for waste water 
treatment are woefully underfunded, and part of the challenge 
we face is providing help through Federal resources to 
communities, such as you have here, so that you don't have to 
go it alone.
    It is a very big issue that is really on the horizon. It's 
one of those issues that is not on the front pages of the 
newspaper, but if we stop and look at what we need over the 
next 25 to 50 years to make sure our drinking water is safe, to 
deal with problems like arsenic, to set a standard and stick 
with it, so that you can plan and know what you're supposed to 
be doing, and to deal with, in more populated areas, like the 
many that I represent, the waste water runoff that takes 
pesticides and all other kinds of contaminants, as well as 
sewage, into lakes and rivers and--I was, yesterday, on the 
Long Island Sound--because beaches that people used to swim in 
just 10 years ago are now closed permanently because of 
pollution, because we don't have enough treatment for the 
sewage that is flowing in.
    So I think that what you said in your original statement, 
Mayor, about Fallon being seen as maybe a model or a pilot 
project is something that we ought to take seriously, and we 
ought to find some other pilot projects around the country to 
deal with these infrastructure needs. At the Federal budgetary 
level, these are not issues that either individuals or 
communities can handle on their own. They really do take all of 
us to try to pull together to deal with problems that we know 
we have. So I really want to thank you for your testimony and 
for your response to the questions that have been asked today.
    Senator Reid. Senator Ensign.
    Senator Ensign. I want to discuss something about possible 
areas of funding and getting more resources. I know we have 
heard once or twice about the way that the water system of 
Fallon water is a bit of an issue out here. We know that we 
have a Superfund site upriver on the Carson River, between the 
Truckee River and the Carson River since the beginning part of 
the twentieth century. At least, we have those two rivers 
coming together and dumping into Lahontan Reservoir. That was 
fairly standard practice, I guess, kind of a ``flushing'' type 
of, situation. We don't want to go into all the details of 
what's happened in the last few years, but there has been a 
change, in the way that the rivers flow. The question is: Is 
there a change in the content of those rivers where they come 
together? Can we maybe go after some of the Superfund money to 
possibly investigate the possibility? Is that a place where we 
could look for funding to investigate what's going on?
    Dr. Guinan. Well, luckily, Senator Ensign, you have the 
head of that agency who does the Superfund investigation, Dr. 
Henry Falk from the Agency for Toxic Substance and Disease 
Registry, on the next panel.
    Senator Ensign. I guess we will ask that question to him.
    Senator Reid. Congressman Gibbons.
    Mr. Gibbons. Just one final brief comment here to the mayor 
and the county commissioner. We're all aware that you have the 
welfare of this community, the welfare of this county as your 
No. 1 priority. The No. 1 priority would be the health and 
safety of its individuals. The second priority, of course, 
would be the economic welfare of this community. There've been 
reports and people have called and said there's been an 
economic impact, because of the adverse publicity that this 
issue has given. We've heard testimony today, even 
Assemblywoman de Braga has indicated, that the No. 1 issue 
should be the welfare of these children. We all agree with 
that, but since there are reports of that, since you've 
probably heard the same statements, what can the community do, 
in your opinions, both from the county and the city 
perspective, with regard to dealing with the economic issues 
that are addressed here?
    Mayor Tedford. Well, you know, Congressman, I believe there 
is an impact. There's no question. It just has not been, in the 
City's view, the foremost issue right now. As you say, it has 
been the families, but it is an issue that we know we need to 
get to. I hear from people--like Mrs. de Braga said--realtors 
that housing sales are down, contractors aren't building 
houses. So you hear those concerns, and I think it is something 
that we, as a city, are trying to develop now. We're trying to 
gather information and knowledge and data from other places 
that went through these things, like what we're going through. 
We've even preliminarily planned to make site visits to some of 
those places to ask, ``How did you handle your economy after 
you, hopefully, were done worrying about your families?''
    So I really don't have a hard answer as to what I think we 
can do. I think we're probably going to need some sort of 
economic development money to spur--if there is a lag here--to 
spur growth back to where it was. But, in all honesty--and the 
press have asked me that question many times--it is not an 
issue I've spent a lot of time on, but that I plan on doing 
very soon, because that's a critical issue. It's no different 
than the families. I have four children under 10. So they're 
all in Dr. Todd's factor of 0 to 19. I have to be worried about 
every family.
    Well, the same is true of business, and my responsibility 
is to every business in this community. So that, indeed, is a 
great responsibility that is going to take a lot of thought. I 
think one thing that--if I was thinking of moving a company or 
moving my family to a community, I would want to know, first 
and foremost, this community had a problem, it addressed it, it 
didn't deny it was there, and it helped those families that 
were suffering, and, to me, that would go a long way as far as 
easing some of the economic damage that's maybe being done. 
Commissioner Washburn may have a different take on that than I 
do, but I am hearing those same comments that I'm sure you're 
hearing too.
    Senator Reid. Commissioner Washburn, do you have anything 
to add?
    Ms. Washburn. Yes. I agree that there definitely is an 
economic impact that has come with the notoriety that this 
issue has brought to the community. One thing that I think 
you'll find in my written portion here is that I've asked that 
there should be some Federal funding to underwrite some low-
interest, maybe some longer term loans for the businesses that 
are being proven to be hurt by this. That is one possibility. 
We are attempting to help ourselves as much as we can. The 
Churchill Economic Development Authority is working very hard, 
and I've attended many meetings on this, on what we are calling 
a visioning program at this point, but we're exploring ways to 
put the community in a more positive light for people that are 
looking to put their businesses and small industries in this 
area, ways that we can attract those people and overcome this 
problem and make it a positive place for them to be. We are 
working with that. The other thing that comes to mind is just 
basic cooperation between the city, the county, neighboring 
counties, legislators on all levels. We just need that 
cooperation, and if we can all talk to each other, I think we 
can get through this and our business and industry can come 
back the way it was.
    Senator Reid. Thank you both very much. The whole panel has 
been outstanding. We appreciate your being as candid and 
forthright and informed as you are.
    Senator Reid. We're now going to hear from Panel III, Dr. 
Henry Falk, who is the assistant administrator for the Agency 
for Toxic Substances and Disease Registry. We're going to hear 
from Dr. Thomas Sinks, who's the associate director for the 
National Center for Environmental Health, Centers for Disease 
Control and Prevention. We're going to hear from Ms. Ramona 
Trovato, who's the director for the Office of Children's Health 
Protection, U.S. Environmental Protection Agency. Finally, 
we're going to hear from Shelley Hearne, who's the executive 
director of the Trust for America's Health.
    Dr. Falk heads the Agency, as I've indicated, for Toxic 
Substances and Disease Registry, serves under the director of 
the Centers for Disease Control. This was established in 1980 
under the Superfund law for the purpose of studying and 
tracking the health effects of exposures to hazardous 
substances at Superfund sites and other hazardous waste sites 
and recommending interventions for public health.
    Dr. Falk.

 STATEMENT OF HENRY FALK, ASSISTANT ADMINISTRATOR, AGENCY FOR 
       TOXIC SUBSTANCE AND DISEASE REGISTRY, ATLANTA, GA

    Dr. Falk. Thank you very much, Senator Reid. Good morning 
to you, Senator Reid, and members of the committee. My name is 
Henry Falk, and I'm the assistant administrator for the Agency 
for Toxic Substances and Disease Registry, or ATSDR, as we've 
shortened it. Dr. Aubrey Miller, unfortunately, was detained by 
a snowstorm coming out of Denver and apparently will not be 
able to make it here this morning. I have spoken to him in 
advance of this session.
    Thank you for inviting us to speak this morning. We share 
your concerns about the health and well-being of children and 
families in Fallon and across the country. Certainly, the 
testimony this morning was very moving, and it must serve as a 
spur to all of us in government to do our very best. We also 
share your desire to adequately address the concerns expressed 
about illness and disease that might be associated with the 
environment.
    As you noted, our agency was created by the Superfund 
legislation. As such, we are an agency charged with determining 
the nature and extent of health problems at Superfund sites, 
including Federal Superfund sites, and advising the USEPA and 
State health and environmental agencies on needed clean-up and 
other actions to protect the public's health. ATSDR, of course, 
works very closely with the EPA through our Superfund 
responsibilities. We also work very closely with our DHHS 
sister agency, the Centers for Disease Control and Prevention, 
and, jointly, we will work with the Nevada Health Division to 
assist in investigating the cancer cluster in Fallon. For our 
part, ATSDR will assist in the investigation by reviewing all 
relevant environmental data for toxic substances and assessing 
whether people have been exposed to any of these contaminants 
at levels of concern.
    Unfortunately, the cancer cluster in Fallon is not a unique 
situation. Increasingly, we at ATSDR are being asked by State 
and local health departments to help respond to compelling 
community concerns about apparent outbreaks of serious, 
noninfectious diseases with unknown cause. We work closely and 
collaborate with State health departments and have been funding 
environmental public health activities in States since 1987. We 
currently fund programs in 28 States to assist in carrying out 
Superfund responsibilities, including cancer cluster 
investigations and activities related to concerns about 
hazardous waste and exposure to toxic substances.
    The site work we do directly or through our State partners 
has changed somewhat over time. Our original mandate under 
Superfund called for public health assessments at all National 
Priorities List sites, and these constituted the great majority 
of our workload. While we still are heavily engaged at NPL 
sites, increasingly our site work now is also occurring at 
immediate removal sites, active waste sites, occasionally 
Brownfield sites, and, like Fallon, sites where communities, 
States, or congressional officials have asked or petitioned the 
ATSDR to participate in the investigation.
    I know you are familiar with some of our activities through 
our work in Libby, MT, and Elko, NV, where individuals were 
exposed to tremolite asbestos through vermiculite mining and 
its effects, and I don't want to review all of that, but we 
were very actively involved in the medical screening of over 
6,000 people and providing information back to them. In 
followup to remarks that were made on the last panel, we have 
been working--particularly in the Libby area, but also 
elsewhere--with local, State, and Federal health care providers 
to address health care concerns that arise, specifically to 
help local residents obtain medical care. We've worked closely 
with the Department of Health and Human Services' regional 
health administrator and other DHHS agencies, such as HRSA, to 
ensure appropriate treatment is available.
    Such partnerships are critical to providing needed health 
services in such areas as Libby, Elko, and now Fallon. 
Partnerships are also critical to fully assessing the true 
existence and potential cause of disease clusters. ATSDR and 
CDC, in this respect, are reviewing and responding to the Pew 
Environmental Health Commission Report. The report recommends 
strengthening Federal, State, and local public health capacity 
to tackle environmental health problems and establishing a 
nationwide health tracking network for chronic diseases and 
related environmental hazards. We have made significant 
progress at ATSDR in developing registries of individuals 
exposed to specific substances, and we will work on the issues 
raised by the Pew Commission as well.
    In keeping with the Superfund mandate to establish and 
maintain a national registry of serious diseases and illnesses, 
we at ATSDR see ourselves as having a direct responsibility 
under CERCLA to participate with CDC and others in developing 
disease surveillance or tracking systems, particularly for 
diseases with known or potential relationships to hazardous 
waste and toxic substances. Because of our close working 
relationship with EPA, we are particularly interested in the 
ability to link health data sets with environmental data sets.
    We recognize that more could be done. 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 children suffering from cancer or other health 
problems. We at ATSDR are committed to doing what we can to 
address these very real concerns. We work every day at sites 
around the country to address the concerns of communities 
affected by toxic exposures. We work with our colleagues at CDC 
to address the issue of health and disease tracking, and we 
continue to strengthen our ongoing partnerships with Federal, 
State, and local agencies.
    On a personal note, just briefly, I started my professional 
career at CDC as a pediatrician in 1972. My first investigation 
in 1972 was of a leukemia cluster in Elmwood, WI. I did several 
such investigations over the next 18 months, none of which 
revealed an obvious cause for the clusters. However, my fourth 
or fifth such investigation was of four cases of liver cancer 
in a factory, which turned out to be the first reported cases 
of vinyl chloride-induced liver angiosarcoma in polyvinyl 
chloride polymerization workers. This subsequently led to much 
improved and safer working conditions for the entire industry 
worldwide. I have seen personally how agonizing and frustrating 
this work can be, but I also feel that if we are in the mode of 
carefully scrutinizing health data, then we will be positioned 
correctly to detect new problems as they arise.
    This concludes my testimony. Thank you very much.
    Senator Reid. Doctor, I'm sure it's a comfort to the 
parents of the children who are sick here to recognize someone 
as well qualified as you doing the work that you're doing. So 
I'm glad that you're here.
    We're going to now hear from Dr. Thomas Sinks. Dr. Sinks is 
a member of the State Health Division Expert Panel. He's 
already been of great service to the State health division. He 
represents other Federal agencies besides ATSDR. He's most 
active in assisting cancer cluster investigations and 
addressing environmentally-related community health concerns 
with the Centers for Disease Control and Prevention.
    Dr. Sinks.

  STATEMENT OF THOMAS SINKS, ASSOCIATE DIRECTOR FOR SCIENCE, 
 NATIONAL CENTER FOR ENVIRONMENTAL HEALTH, CENTERS FOR DISEASE 
              CONTROL AND PREVENTION, ATLANTA, GA

    Dr. Sinks. Good morning, Senator Reid, and other members of 
the committee. I would like to say that I'm delighted to speak 
before you on this issue. This is an issue which is very 
important to many people, as can be seen by the media's 
attention and all the people here from the community.
    I want to begin by assuring the people of Fallon and the 
parents whose children have been diagnosed with cancer that we 
at CDC are committed to the health and well-being of children. 
We are encouraged by the wonderful improvements in the clinical 
treatment of childhood cancers. Still, as has been said before, 
we need to identify the preventable causes of these diseases. 
Let me assure you, chance has never caused one case of cancer.
    CDC has been providing technical assistance to Nevada since 
July 2000, and we will continue to do so, as you heard this 
morning. I won't go into the details of that. It's in my 
testimony. Perhaps someday we'll know how to prevent ALL, just 
like we know today that folic acid prevents neural tube 
defects. Whether or not we identify the cause of ALL, we need 
to assure the families of Fallon about the safety of their 
community.
    I'd like to say a few words about cancer clusters in 
general. Public health agencies are challenged by the large 
number of public inquiries. Thousands of perceived cancer 
clusters have been reported. More than 2000 published newspaper 
articles from January 1990 to January 2000 contained the words 
``cancer cluster.'' A survey of 41 State health departments 
found that they registered about 1900 cancer inquiries in 1996 
alone. Public health officials are expected to identify and 
remove the cause of each cancer cluster. Yet, only 10 percent 
to 15 percent of cancer clusters investigated actually find an 
excess of cancer cases. Of these, only a handful have led to 
discoveries of preventable causes of cancer.
    Cancer clusters do provide an opportunity for cancer 
prevention and control. Cancer education and screening programs 
are important tools and can be used effectively in some cancer 
cluster circumstances. Occasionally, scientific investigations 
of clusters do lead to cancer prevention discoveries. I want to 
point out that most of these have come from the observations of 
clinicians working with patients. Another opportunity to 
protect human health occurs when a cluster coexists with a 
hazardous level of an environmental contaminant. In such 
circumstances, removal of the health hazard is prudent, whether 
or not it's related to the cluster. Cancer cluster activities 
in the CDC have included field investigations, a conference on 
clustering of health events, and technical assistance to health 
departments.
    In 1991, CDC published a set of standard investigation 
procedures for investigating chronic disease clusters, and that 
has been distributed to all States and is available on the CDC 
website. CDC also funds State-based cancer registries, which 
is, in my mind, the essential tool for evaluating inquiries 
about too much disease. The Nevada Cancer Registry has received 
more than $1.4 million from CDC from 1994 through 2000. CDC 
also conducts exposure assessments and epidemiologic studies 
that evaluate how people are exposed to hazards and identify 
preventable causes of cancer.
    I want to emphasize that State health departments are on 
the front line of cancer cluster evaluations, and being 
responsive to the public is the single most important element 
to this. Three additional ingredients to enhancing responses 
include infrastructure, scientific credibility, and 
coordination between agencies. Essential infrastructure 
elements are timely chronic and childhood disease registration 
and linking health and environmental data bases, 
recommendations supported by the Pew Environmental Health 
Commission. One significant advance is taking place with the 
creation of a national children's cancer registry through the 
Children's Oncology Group and funded by the National Cancer 
Institute. It will register all children with cancer at the 
time of diagnosis and collect specimens at that time.
    Last month, CDC released the first national report on human 
exposure to environmental chemicals, providing baseline 
concentrations of chemicals in the blood and the urine of 
people in the United States. We plan to use this technology to 
assist the investigation in Fallon.
    Scientific credibility requires staff at the State level 
having expertise not only in cancer, but also in epidemiology, 
statistics, toxicology, and other matters. Independent review 
by expert panels ensures the credibility of cluster 
investigations. Scientific credibility and direction could be 
further enhanced by directing priorities for future cancer 
cluster investigations based upon hypotheses for why cancers 
might cluster. A working group to establish such priorities is 
sorely needed. The successful collaboration in Fallon has not 
only included State health and environmental agencies, the CDC, 
ATSDR, NCI, the Fallon Naval Air Station, and researchers from 
the University of Berkeley and Minnesota, but also the 
willingness and interest of the people of Fallon and their 
appointed officials.
    Thank you, Mr. Chairman and members of the committee, for 
the opportunity to testify before you today, and I'll be happy 
to answer any questions you might have.
    Senator Reid. Thank you, Doctor.
    We're now going to hear from the director of the Office of 
Children's Health Protection, Environmental Protection Agency. 
Ms. Ramona Trovato is the director and one of the office's most 
experienced health officials. She will focus principally on 
EPA's activities relating to the effects of environmental 
pollution on children, including coordination with the Centers 
for Disease Control, the National Institute of Health, and the 
National Institute for Environmental Health Sciences.
    Ms. Trovato.

STATEMENT OF E. RAMONA TROVATO, DIRECTOR, OFFICE OF CHILDREN'S 
HEALTH PROTECTION, ENVIRONMENTAL PROTECTION AGENCY, WASHINGTON, 
                               DC

    Ms. Trovato. Good morning, and thank you.
    I am Ramona Trovato, and I'm the director of the Office of 
Children's Health Protection at the USEPA. I'd like to start by 
saying it's very distressing to me that 12 children in this 
community are suffering with leukemia, and my prayers certainly 
go out to them and to their families.
    EPA's mission is to protect human health and safeguard the 
environment. We do this by controlling the amount of 
contaminants that go into the air we breath, the water we 
drink, and the food we eat. We can only do this in partnership 
with the States. We partner with them on both public health 
protection and environmental protection, and about half of our 
budget is sent directly to the States for their efforts to 
protect human health and the environment. This partnership is 
absolutely necessary, we believe, to address human health 
issues that are related to environmental factors, and it has to 
be a partnership at local, State, and Federal levels.
    Today, I'd like to discuss the governmental efforts to 
protect children from environmental risks, I'll then give an 
example of how we responded in the past to a community problem, 
and, finally, I'd like to close by offering some thoughts about 
how we can work together to help in Fallon.
    Over the last 4 years, Federal agencies have joined 
together to focus on three specific childhood illnesses that 
have environmental links. These are asthma, developmental 
disorders, and childhood cancer. Asthma affects about 5 million 
children and is the leading cause of hospitalization of 
children in the United States. Developmental disorders are the 
leading cause of lifelong disability, and childhood cancer is 
the leading cause of disease-related mortality in children. 
Many of the factors that contribute to asthma, developmental 
disorders, and childhood cancer are unknown. Therefore, the 
Federal Government is focusing on research to better understand 
how these environmental factors contribute to childhood 
disease.
    The EPA and HHS are funding eight centers for the first 
time to investigate the effects of environmental factors on 
children's health.
    The National Cancer Institute is conducting a good deal of 
research into environmental factors that influence childhood 
cancer and is developing a national registry of children with 
cancer.
    Congress authorized the Child Health Act of 2000, requiring 
a longitudinal cohort study, which is a long-term research 
study to examine the impact of environmental pollutants on 
children. As the Framingham study provided us most of what we 
know about heart disease, this study could be the watershed in 
understanding how environmental factors affect children's 
health. Where we have sufficient knowledge to act we have 
developed strategies to address environmental health concerns. 
These strategies are primarily directed to reducing asthma and 
lead poisoning in children in the United States. We're also 
working directly with communities and States to respond to 
their specific child-related health concerns. Currently, 
government agencies work informally together to address cancer 
clusters. State public health departments are the front line, 
and they go out and investigate first. If they want additional 
help, they contact CDC or ATSDR, and finally EPA may be 
contacted if they want an environmental assessment done.
    In 1996, due to public concerns about high rates of 
childhood cancer in Tom's River, NJ, ATSDR and the State of New 
Jersey conducted a study. They found a contaminant in drinking 
water wells from a nearby Superfund site. This contaminant was 
identified by EPA, and we required the company responsible for 
that contaminant to put a carbon treatment system on the wells 
that were contaminated. There is no detectable amount of this 
contaminant in their wells at this time, and we are still 
conducting and overseeing studies to determine if this 
contaminant is a carcinogen and may have contributed to the 
cancer cluster.
    Through the Superfund program, we work closely with ATSDR 
to respond to environmental hazards and associated health 
risks. Communities petition ATSDR for a community health 
assessment and they can request a preliminary assessment 
through EPA of environmental conditions there. If the 
environmental assessment indicates a problem, we can take steps 
to address that problem. EPA also helps communities address 
public health threats in drinking water through the Drinking 
Water State Revolving Loan Fund. This fund provides money to 
States for financing drinking water infrastructure projects. 
The program recognizes and emphasizes the needs of small 
systems, in particular, and those that serve fewer than 10,000 
residents.
    On a national level, I would like to suggest five actions 
to make environmental health protection a priority. The first 
is to formalize the cancer cluster response approach to address 
cancer, as well as other environmental health problems. Second, 
I'd like to see the State and local public health 
infrastructure bolstered to respond to environmental health 
threats. I'd like to see a strengthening of the relationship 
between environment and health departments at all levels of 
government. I strongly support a national tracking system of 
chronic diseases. So we can understand where those diseases are 
occurring and, if possible, look for associations with 
contaminants in the environment. Finally, I think it's 
absolutely necessary to conduct this longitudinal cohort study 
to understand environmental factors that affect children's 
health.
    Finally, I'd like to address how we at EPA can support 
efforts already underway in Fallon. We would like to work 
closely with the city of Fallon, the ATSDR, the CDC, and the 
State of Nevada to conduct environmental assessments. We can 
sample, analyze, model, and cleanup environmental hazards. In 
fact, EPA's Las Vegas laboratory has already offered to conduct 
analyses of chemicals that are not typically found in drinking 
water to help 
understand what else may be here. ATSDR and EPA have also 
established pediatric environmental health specialty units in 
nine locations around the country. These are a first. These 
units provide sources of information for doctors, nurses, and 
parents about 
environmental health threats and how they affect their 
children. In addition, these units will actually see children 
who have been affected. The closest one to Fallon is at the 
University of California at San Francisco.
    Thank you for allowing me to address this committee and the 
community of Fallon. I hope that, together, we can make a 
difference and prevent this in other communities. I'll be happy 
to answer any questions.
    Senator Reid. We will get to some questions in just a 
minute. We're now going to hear from Dr. Shelley Hearne, 
executive director of the Trust for America's Health. Dr. 
Hearne has been involved with the Pew Environmental Health 
Commission. Last year, this commission issued a comprehensive 
report supporting enhanced tracking of chronic diseases in this 
country and the coordinated and enhanced capacity of the 
Federal Government to support cancer cluster investigations and 
to respond to environmentally-related community health 
concerns.
    The most amazing thing I saw in your testimony is that 
you've been doing this for more than 20 years. So I think we 
should notify the Department of Labor for child labor 
violations.

  STATEMENT OF SHELLEY HEARNE, EXECUTIVE DIRECTOR, TRUST FOR 
                        AMERICA'S HEALTH

    Dr. Hearne. I appreciate that comment, thank you. Thank you 
for this opportunity to come to Nevada and have a candid 
conversation about our Nation's ability to respond to clusters.
    I do serve as the executive director of the Trust for 
America's Health, which is a new health advocacy organization 
committed to protecting the health and safety of our 
communities, and we are proud that several members of our 
advisory council are former colleagues of yours--Senator Lowell 
Weicker, Congressman John Porter, and also Congressman Louis 
Stokes. They strictly told me not to use the word epidemiology, 
you'll be happy to know.
    Senator Reid. I'm more happy than you can imagine.
    Dr. Hearne. I did recently serve as the executive director 
of the Pew Environmental Health Commission at the Johns Hopkins 
School of Public Health. It was a blue-ribbon panel charged 
with developing recommendations to improve the Nation's health 
defenses, and I appreciate all of my colleagues here from EPA, 
ATSDR, and CDC for their comments and thoughtful consideration 
of how to incorporate those recommendations in the agencies' 
activities.
    No child or community should suffer like this, and my heart 
certainly goes out to the families of Fallon, but as a young 
health scientist, I am growing actually quite angry watching 
this story repeat itself across the Nation. As Henry Falk 
noted, Fallon is not alone. In 1997, there were almost 1100 
public requests to investigate suspected cancer clusters in 
this Nation. My job as the last panelist, and I guess what 
holds us all before lunch, is to actually deliver some of the 
bad news, that our public health service is actually falling 
short in its duty to watch the health of this Nation, 
particularly when it comes to chronic diseases that may be 
associated with environmental factors.
    We are seeing this all across the country. Back in my home 
State of New Jersey, parents in Brinck Township complained to 
health officials about a feared autism cluster. It took almost 
5 years for the health officials to confirm a cluster of 60 
cases, because no one tracks autism in this country. In Elmira, 
NY, 40 students have been diagnosed with cancer who attend a 
local high school. I can go on and on with stories. Chronic 
diseases account for 7 out of 10 deaths in this Nation, but we 
still have no adequate system in place to detect these 
diseases, nor the ability to effectively respond. Our health 
agencies only coordinate tracking infectious diseases, such as 
polio and typhoid, diseases that a national tracking and 
response system helped to eradicate in the nineteenth century. 
Over a hundred years later, we still have not updated our 
public health system. Our health specialists remain in the dark 
with no resources and unable to find the solutions to today's 
health threats.
    Let me give you a few examples of what's happening here in 
Nevada. Birth defects are the No. 1 cause of infant mortality. 
Yet, Nevada does not have a birth defects registry, nor does 
Nevada track respiratory and neurological diseases, such as 
asthma and Parkinson's. Nevada's cancer registry consistently 
fails to meet national standards. Nevada is the only State that 
charges its hospitals as the only forum of reporting cancer 
cases. It's a perfect formula for poor performance.
    See why I'm last?
    The problem is, Nevada is not unusual. It's actually quite 
close to the norm. To solve this problem, the Pew Commission 
proposed a nationwide health tracking network. Here are a few 
of the basic components: First, we need to build on the 
existing infectious disease data systems that track priority 
chronic diseases and related environmental factors. This would 
include diseases such as childhood cancer, asthma, and multiple 
sclerosis. Next, we need to develop an early warning system 
that would alert communities to health crises, such as lead, 
pesticide, and arsenic poisoning. Third, we need to improve our 
response to identify disease clusters by coordinating health 
officials into rapid response teams to quickly investigate 
these health problems. Each State should have a chronic disease 
investigator. Most States, like Nevada, do not.
    This network is the key to developing prevention 
strategies, which is the most effective way to reduce the $325 
billion a year that we spend on chronic diseases. The estimated 
cost of a network is about 275 million, less than a dollar per 
person and about .01 percent of our expenditures on chronic 
disease. The NIH budget is being doubled. Yet, most of those 
dollars are not going to discover the most basic information 
about why these diseases occur, where they strike, and how to 
prevent future diseases. Ironically, the administration is 
proposing cutting almost a quarter of CDC's chronic disease 
program. Americans care immensely. Nine out of ten registered 
voters support the creation of a nationwide health tracking 
system, and even in today's economic climate, 63 percent feel 
that public health spending is more important than getting your 
money back, it's more important than cutting taxes.
    Most local health departments have faced declining funding, 
inadequate training, and limited laboratory access. In 
addition, they receive minimal guidance from Federal agencies 
on identifying and responding to clusters. CDC and ATSDR must 
be directed to aggressively respond to communities like Fallon 
with modern tracking systems and investigators who can take 
action, and Congress must prioritize the real sources to make 
this happen. Without this kind of commitment, we're going to 
watch asthma, cancer, and other disease clusters grow and there 
will be many more Fallons, and perhaps that's the greatest 
tragedy.
    Thank you.
    Senator Reid. Dr. Hearne, thank you very much.
    Dr. Falk, I'll direct this question to you, but perhaps the 
other panelists could help. One of the things I'm concerned 
about and I've heard from the community is that this disease 
that has stricken these families leaves these families and the 
rest of the community without any real help to work through 
these problems. You know, if there's a suicide in a school, we 
have people trained around the country that come forward and 
help. Is there anything that we have on a national level to 
help communities like Fallon to meet the emotional needs that 
families have, in addition to their physical needs?
    Dr. Falk. We at ATSDR do some of this around Superfund 
sites. We have very active community education programs. We 
work both with members of the community, as well as with 
professionals in the community. We even have programs with 
psychologists in the sense of stress management programs that 
we can do, when indicated. So we try to actually do that, but 
we don't do that beyond the Superfund program.
    Senator Reid. You acknowledge, though, that these families 
have a need in addition to making sure their kids get to a 
physician and take care of their physical needs. I think it's 
something that we have to keep in mind in this very complex 
society, that we have some resource we can call upon for this.
    Dr. Falk. I think there are several aspects to this. 
Probably the most frequent question we see around hazardous 
waste sites is, How will we provide for medical care for those 
who are affected by toxic substances? As you know, as far as we 
are concerned at ATSDR, our mandate relates to advising and 
studying public health issues, but we have no mandate or no 
authorization to provide actual medical care. What we are 
trying to do at the moment is to creatively partner with other 
HHS agencies to see whether existing Federal programs, whether 
regional offices of other Federal agencies can be applied to 
situations such as Fallon and elsewhere. So I think that we 
would like to see existing programs be able to be developed so 
they'll be applicable in situations such as this.
    Senator Reid. Yes, Dr. Sinks, please.
    Dr. Sinks. If I could just add a brief comment. The day 
after I returned to Atlanta from the expert panel meeting, I 
received from Dr. Mary Guinan a request to identify resources 
to help the community deal with the mental health stress that 
they were having in terms of dealing with this extraordinarily 
difficult situation. I think it is a----
    Senator Reid. Were you able to identify any?
    Dr. Sinks. We tried to look at the National Institute of 
Mental Health for resources. We do have a psychologist on our 
staff who deals with refugee health issues in the Third World, 
and Dr. Falk at ATSDR has a staff person who does help with 
Superfund communities on these issues and we linked her into 
the situation. I've not followed up to see where that is. I do 
know that there are some mental health professionals in the 
community working with members of the community.
    Senator Reid. It's obvious from watching the movie ``Erin 
Brockovich,'' which was based upon a true story--I spoke to the 
lawyer who handled that case, and one of the big problems they 
had after they identified there was a problem there is dealing 
with the emotional problems of all the families that had, for 
many, many years, thought that their disease just came out of 
the sky someplace, when in fact it was Chromium 6 that was 
afflicting them. So, anyway, that's a problem we have to 
acknowledge.
    I want to direct a question to you, Dr. Falk, or maybe Dr. 
Sinks. I'm fascinated by the studies that we have as to this 
maybe being a population mixing problem. There's no better 
example of this in Nevada than in Fallon, unless, perhaps, 
Nellis. We have people coming literally from all over the 
world, we have people staying here for short periods of time 
and leaving, and we have population exposures taking place 
here. What we heard earlier is that there simply is no method 
to do the tracking, and I'm wondering if you have a reaction to 
this--in fact, anyone on the panel, other than Dr. Sinks and 
Dr. Falk. Is there any way we could do a better job? I mean--
and we've got the parents over here--we should find out about 
it, it shouldn't be too difficult to do. We should do it, if 
it's possible to do the tracking. Can we do this?
    Dr. Falk. One of the things that I have noted over the 
years is that most clusters are identified by members of the 
community. Occasionally by physicians, but very often the 
people themselves recognize that a problem is occurring. We are 
remiss in the sense that somehow the health care data systems, 
or tracking systems, call it what you will, ought to be 
identifying these kinds of situations proactively and arranging 
to deal with them. I assume that many clusters are not even 
brought to anybody's attention, because there is no system that 
identifies them. So, yes, I think we could do a much more 
organized effort to actually identify the distribution of 
cases, look for clusters or uneven distribution of cases where 
the rates are very high and actually explore those in a more 
systematic way and in a more uniform way.
     Dr. Sinks. Allow me to add to that.
    The Kinley hypothesis you're referring to is 
extraordinarily interesting. I view it as one of those 
hypotheses that we ought to be searching for and targeting for 
research. This theory is very interesting, but, we've not 
really come up with a way to scientifically put it to the 
test--prove it correct or false. Perhaps we might pull together 
experts specifically to work at that hypothesis and come up 
with a plan for testing. The second is that we fund extramural 
research through the National Cancer Institute. I think there 
is a role for extramural research in cancer clusters like this. 
There are wonderful researchers out there in the academic 
community, two of which are on our expert panel.
    Senator Reid. Senator Ensign.
    Senator Ensign. Dr. Sinks, when we talk about clusters, 
statistically, what are we talking about here? What makes 
something statistically significant to become a cluster?
    Dr. Sinks. I'm always troubled by the word cluster. I get a 
number of phone calls from the public, from the media, from 
States, a variety of places--and let me say that I really enjoy 
speaking to those people about their issues. The word 
``cluster'' seems to be something that is defined differently 
from one person to the next. In my mind, in the simplest sense, 
it's the concept that we're observing more cases of some 
disease than we would expect to see, given our baseline 
information, which we hopefully have, and we do have that for 
cancer. For many of the cancers, we do have population----
    Senator Ensign. But that's what I'm saying. Then at what 
level is it statistically significant?
    Dr. Sinks. Well, this is the problem. Statistical 
significance simply implies the likelihood of chance. The 
likelihood of chance is very much influenced by the size of the 
population and the number of cases, and it's not as relevant on 
the likelihood of cause as other things. So I, myself, am not 
so hung up on what the P value is in terms of, is the 
probability one in a thousand or one in ten thousand? I'm more 
concerned about, are there things that make biological sense 
here in terms of a possible agent that people might be exposed 
to?
    Senator Ensign. Well, isn't the reason--if it's possible by 
random chance--what Assemblywoman de Braga talked about, one in 
a quadrillion? I don't know if that's an accurate number, but 
certain parts are statistically impossible when you get to a 
certain level of a number.
    Dr. Sinks. Well, Senator Ensign, I think this is the 
double-edged sword of looking at clusters. On the one hand, if 
we simply go out and try to draw circles around the population 
looking for events, we're going to find them. Whether the 
chance is one in a thousand or the chance is one in ten 
thousand, if we do a thousand searches, we'll find one. We have 
to be a little cautious, when we start drawing circles, that we 
have some fundamental understanding of why we're drawing the 
circle, that there might be something that we're looking for.
    I don't know if I'm answering your question.
    Senator Ensign. Well, not really.
    Maybe, Dr. Falk, you want to take a shot at this. Is this 
random chance? Obviously, I think this one is a fairly extreme 
case. We see such a small population, and the chances of this 
being random, I think, are pretty slim. When we look at other 
clusters as we're forming public policy, and we are not just 
forming public policy for Fallon--when we're developing these 
type of things, looking at other cases in the future, we need 
to know what is significant in the future. We want to know when 
to bring these resources to bear.
    Dr. Falk. I think this is one of the hardest aspects of 
dealing with problems like this. If you think of tens of 
thousands or even hundreds of thousands of cases of cancer 
across the United States, given the distribution that may 
occur, even randomly, there would obviously be many occurrences 
by chance that look like they're unusual but may not be, and 
it's so very hard to know which ones to actually focus on. 
Sometimes, as you pointed out, the statistics are so striking, 
as here, that we say ``Oh, definitely, this is where we should 
focus.'' But I think there's a huge gray area in between 
something that looks like a perfectly normal distribution and a 
situation such as we're discussing this morning, where there 
will be only two or three cases or seemingly unusual 
distributions, certainly ones that would seem so to people who 
are concerned. I think, as Dr. Sinks points out, it will take a 
lot of judgment to know where to focus and where the best 
hypotheses are to pursue these leads.
    Senator Ensign. I would just suggest to you that this seems 
to be a fundamental question that we need to answer as we're 
going forward. Resources are not unlimited. If we are going to 
focus resources in the best possible manner, we are going to 
have to deal with this question. If we're going to have a 
national register or if we're going to have a focus, at what 
point do we ask Federal, State, and local governments to work 
together with private entities? You mentioned in your testimony 
that 90 percent of them turn out not to be clusters. Well, what 
do you mean by that? If you don't know what a cluster is, how 
do you know that it's not a cluster? That seems to be a 
fundamental question we need to have answered. I would 
appreciate us giving some thought, as we go forward, to this, 
and maybe the Pew Center will give this a great deal of thought 
as well.
    Senator Reid. Senator Clinton.
    Senator Clinton. I'm clustered. I thought I was making 
progress understanding all this, but now I feel like I've gone 
10 steps back. I think that may be helpful, because, clearly, 
we have a lot more questions than we do answers, and I think 
it's very important for us to begin to put into place the 
capacity to define the questions clearly and then to begin to 
answer them. From what I understand with this panel, that seems 
to be their recommendations.
    Dr. Hearne, I really appreciate the work that the Pew 
Foundation has done with the report and now following up with 
the Trust for America's Health, and I am very pleased that you 
got specific recommendations, that it's not just an analysis 
that doesn't tell us what you think should be done, and they're 
pretty hard hitting recommendations, I must say. Maybe, Harry, 
the reason that Dr. Hearne is the front woman is because she 
seems so much less hard than the recommendations.
    Dr. Hearne. They're willing to sacrifice their young.
    Senator Clinton. That's right, sacrifice their young for 
this.
    One thing that you said which really caught my attention is 
that the proposed budget from the administration recommends 
severe cuts for the Nation's chronic disease prevention 
programs. Can you elaborate on which programs are slated to 
receive cuts and how those cuts might impact on what we're 
talking about today, which is to put into effect a health 
tracking system nationwide that will assist people at all 
levels of government?
    Dr. Hearne. As you know, the budget from the administration 
was just recently released. So we're still going through those 
numbers, but currently the Center for Chronic Disease and 
Prevention at CDC has been targeted with a 23-percent cut of 
its budget. That is the sentinel spot in this country for work 
on looking at the prevention opportunities of reducing the No. 
1 cause of death in this country. I highlight that because I 
think there has been a very strong bipartisan commitment in 
this country to really move forward and advance our biomedical 
research, and I cannot applaud that effort more as a health 
scientist.
    But I think it's also important--I think Dr. Prescott 
actually noted this earlier on the first panel. We're at a 
stage right now that we need to be starting to apply our 
knowledge into the clinics, into the communities on how to 
actually respond and prevent disease. We can't simply be 
investing on the treatment side. We must stay with that front, 
but we have the opportunity within our grasp for preventing 
disease. I think one of the great examples--Dr. Sinks mentioned 
folic acid and how our knowledge of that very simple vitamin or 
nutritional addition to our diet has been reducing the cause of 
neural tube defects, a key birth defect in this country that 
was actually discovered from a birth defect registry in Texas. 
Texas had a terrible birth defects crisis many years back and 
couldn't answer the community's concerns, because they didn't 
have a tracking system. Texas now has one of the best tracking 
systems in the country for birth defects, and it was able to 
put that information together, that by adding folic acid to the 
diet, we can prevent birth defects. That's where this entire 
concept of nationwide health tracking comes from, that we need 
to have those investments.
    Is there a line item for a nationwide health tracking 
network? No. We hope, though, through leadership--and that was, 
yes, the Pew Commission's recommendations. We made it as simple 
but hard hitting as possible, and thanks to Governor Weicker, 
Lou Stokes, and other thoughtful Members of Congress, they're 
meant to be pragmatic, to deal with the concerns that 
communities have, with the thoughts that the clinicians have, 
the agencies. We heard from the State's own epidemiologist and 
health officers--we need to track.
    Senator Clinton. I hope that out of this hearing, which you 
know certainly is receiving a lot of national attention, not 
just attention here in Nevada, that we'll take another look at 
that, because there has been a very strong push to increase and 
double the NIH budget, but if we don't start applying what we 
have learned to prevention, then we're going to be constantly 
playing catch-up, and I don't think that's in our best 
interest.
    I also believe it's important, as you point out in your 
report, that there are other diseases or conditions that seem 
to be increasing without any real understanding, and you said 
autism. I recently met with a group of experts on autism, and 
it is just astonishing how much autism we now find among our 
children. In fact, it seems to be down to about 1 out of 200 to 
250 children who are being diagnosed with some form of the 
autistic syndrome. We know we have an asthma epidemic in many 
parts of our country. It's the leading cause of admission into 
hospitals, and we haven't yet figured out what it is we're 
doing in our homes and in our communities that is prompting so 
much asthma.
    So I really do hope that the recommendation that Dr. Hearne 
is putting forth is going to be given some serious thought in 
Washington and in the administration, as well as in Congress, 
so that we can start to find out more about a lot.
    I just had one question, perhaps, to Dr. Falk. Under the 
toxic chemicals, the list and the myriad numbers of chemicals 
that are out there that have an impact on our well-being and 
our health, what predictability are we putting into some of our 
effort with regard to these diseases that we're now seeing? 
Where are we with regard to that level of predictability? Do we 
have a high confidence in that predictability, or is it at an 
evolving predictability level?
    Dr. Falk. I think this is very much evolving. We know that 
there are relationships between certain toxic substances and 
disease, lead and lead poisoning and so on, but the great bulk 
of diseases, in terms of chronic diseases, is really of unknown 
etiology. We don't understand what causes most chronic 
diseases. There are some--cigarette smoking, for example, and 
lung cancer--where we have a pretty good understanding, but 
many types of cancer, other types of disease, we don't 
understand really all of the factors that cause those diseases.
    I think one of the important aspects of doing better health 
tracking would be to identify in a better way what are the 
likely environmental inputs to disease, what are the 
environmental factors that may relate to disease. I also think 
that we could do a better job of coordinating the collection of 
environmental data and the collection of health data. We have a 
lot of environmental data bases. The EPA, State health 
departments, and others have health data bases, but we probably 
don't do a sufficient job of actually linking those data bases 
to look for the connections that might help fill in some of the 
blanks. So what Shelley Hearne and the Pew Commission have 
espoused is a better collection of health data, but I think 
part of that also is better linkage to environmental data to 
explore the potential concerns.
    Mr. Gibbons. Ms. Trovato, thank you for being here. It's 
not often that we get the EPA with such a powerful individual. 
I would like to put you on the spot. We do know that the EPA 
does have a provision for their safe drinking water 
infrastructure funding. Could we get a commitment from you for 
this community here?
    Ms. Trovato. We distribute that money to the States, and 
then the States make the decisions, so we would have to begin 
with a converstion with the State of Nevada.
    Thank you, Mr. Chairman.
    Senator Reid. Thank you, Congressman.
    Dr. Falk, I want to thank you and your agency for 
conducting the medical screening of approximately 70 people in 
Elko who had worked in Montana and been exposed to asbestos-
related illnesses. That brought a sense of relief to those 
people, some of whom got bad news, but the vast majority of 
them got good news. So we're going to follow that, but I think 
it's important to recognize that the work that has been done 
there is extremely important and will have a long and lasting 
impact on, I guess, a positive feeling of the people who have 
been pulled out of the blue, so to speak, and told that they 
need to have these tests conducted, and it was one example that 
the Federal Government's here to help.
    Dr. Falk. Thank you.
    Senator Reid. I understand that Nevada's cancer registry is 
currently not certified. What does this mean, Dr. Hearne?
    Dr. Hearne. There is a national program with a long title, 
NAACCR. I think epidemiology might be in there somewhere, so I 
don't want to tackle that one. But it essentially sets a series 
of criteria of expectations with minimal performance for a 
cancer registry, to ensure its timeliness, its accuracy of 
information, and the quality of analysis that is conducted with 
that registry. In the last few years, that organization has 
been announcing which States, which programs actually meet the 
national standards of quality. It had been a very small number 
back in 1995. It's been increasingly going up, partly a 
reflection of the Federal commitment to invest in cancer 
registries.
    Nevada is probably one of the last States right now that 
has failed to meet those national standards. In part, I believe 
recognition--and I don't know the details on Nevada's system, 
but I think it reflects that it has a limited ability to 
collect all of the cancer cases in the State, because 
information is limited by being generated from the hospitals. 
Today, with increasing outpatient care, there may be many cases 
that actually slip the radar screen, so that there would be 
significant under-reporting in this State. In 
addition, lack of resources prevent a timely analysis and 
dissemination of that information, information that is critical 
to the communities, to health workers, and many others involved 
in doing investigative research.
    Senator Reid. How does anyone on the panel recommend that 
Federal and State agencies go about correlating exposure to 
toxins in the environment? It seems to me that we have a lot of 
things in the environment that we know aren't good for us, but 
we don't have any way of correlating where they are and what 
they do.
    Dr. Sinks. I'm going to try to answer that by saying, I 
think we've got a tremendous amount of work before us to truly 
coordinate all of these data bases into something comprehensive 
that can be used, and not only comprehensive but useful, in 
terms of the type of information that exists.
    From our side at the Centers for Disease Control and 
Prevention, we're only beginning to launch into a new era where 
we're collecting national data on levels of contaminants in 
people, body burdens, if you will, of pesticides, of heavy 
metals, of chemical contaminants that exist in people. We 
believe that's one of the best ways to determine what's 
actually getting into people. But we need to link that 
information as well to the type of data that the States collect 
on drinking water, air pollution releases, those things, and we 
need to make those connections.
    Senator Reid. My concern is that there was a period of time 
when the State of Nevada was required to collect information 
dealing with people who gamble. We did certain things and 
collected all the information, which the Federal Government 
just dumped in a warehouse, and no one ever looked at it. It 
was just collected. For what reason, I've never learned. In 
this instance, we not only don't collect information, but when 
we do, it's not correlated.
    Let me close by saying this: I know for the parents of 
these children who are sick, we need some finality. I have 
heard, during the time that we've heard these three panels--I 
think there's an agreement that we could all have that would 
give some consolation to these families. First of all, I think 
there is a consensus among the panelists on the recommendations 
of Dr. Hearne for a national system for tracking environmental 
exposure and chronic diseases. All four of you agree there, do 
you not?
    Do we also have a consensus among this panel on the 
recommendation of Dr. Hearne on the need for a coordinated 
rapid response protocol within the Federal Government, who will 
work in conjunction with State and local health officials to 
address these clusters or other environmentally-related 
illnesses. You would agree with that also. Is that fair?
    [Nod in agreement.]
    Last, do we have a consensus among the panelists on the 
recommendation of Dr. Guinan for a Federal blueprint for State 
investigation of clusters and for environmental monitoring, in 
conjunction with the Federal Government?
    [Nod in agreement.]
    So I think those are three things that are very important.
    Yes?
    Dr. Sinks. Senator, just as a last particular point, I want 
to emphasize as well the partnership of the States. Most of the 
States do have protocols for dealing with these issues, and I 
think that whatever we at the national level do, we need to 
partner with the States and involve them in these discussions 
and make sure that we are doing this together with the States.
    Senator Reid. I think we've learned, in all things--I had a 
hearing earlier this week dealing with the environment, and it 
was clearly established by everybody that no matter how well-
meaning the Federal Government might be, unless the people on 
the ground, locally, are involved in what we're trying to do, 
it won't work. So the same applies here.
    Senator Ensign.
    Senator Ensign. Thank you, Senator Reid.
    I think it's really been an excellent hearing, as far as 
the information coming forward. It's really been terrific.
    I want to address the three questions, because I want to 
try to have an understanding of how to go forward. Senator 
Reid, I'm glad you asked those questions, because that's 
exactly where I wanted to go with my last line of questioning. 
Dr. Guinan had said earlier, and you and Dr. Hearne have talked 
about matters that seem to have somewhat to do with each other. 
How do you structure this, and does money come from someplace 
else? Does a new bureaucracy need to be set up, and which 
agency or which entity is it to be set up in?
    Dr. Hearne. This isn't rocket science. This is what public 
health did with infectious disease back in the 1800's, and 
we've won those battles. What we need to do is have CDC in 
partnership with ATSDR and the State and local health 
departments, modernize the public health system to deal with 
chronic diseases. This effort must build on the existing 
systems. They're antiquated systems and they've been starved 
for a long time. It would take both an infusion of money--and 
I'll answer that second part of your question--but it really is 
about building on what we already have there, with a focus on 
chronic disease and environmental exposures. It really just 
takes the vision, as you've heard, from all of today's 
panelists. We just now have to have the leadership to make it 
happen.
    We're not talking about a lot of money. I think the first 
installment is getting a chronic disease investigator into 
every State. There is already a system of EIS officers that 
could be augmented to get that to happen. The tracking systems 
will take an investment, but we're talking about a fraction of 
money in comparison to many of our other investments on both 
the health and environment side. I ideally would love to see 
the health investments in this country increase, but I know 
that that's more of a challenge, and I'll throw it back to 
Congress in terms of where the money comes. But $275 million--
it's about 200 miles of highway roads--a fraction of one 
environmental investigation into ambient air monitoring 
programs, is what many people call ``dust'' in the budget 
process. With a little creative thinking, that kind of small 
investment could go a long way and really could modernize our 
public health system.
    Senator Ensign. Dr. Falk, you wanted to comment?
    Dr. Falk. I certainly agree. You know, at ATSDR--the 
original CERCLA legislation gave us the name of Agency for 
Toxic Substances and Disease Registry--though I think that for 
too long our agency never really actualized the last part of 
the name, ``Disease Registry.'' So I see that as a direct 
responsibility under our mandate, and certainly not one just 
for us, but one that we would work on with the CDC and others. 
So I think, for ATSDR, we would be very interested, willing, 
and certainly eager to participate in thinking through these 
issues and developing a better system.
    Senator Ensign. I'm glad you said that.
    Two other comments. One is that, in veterinarian medicine, 
we actually focus on prevention. That's what our whole focus 
is--diet, vaccinations, population, medicine. I've often said 
and campaigned on many times that America has a sick care 
system, not a health care system, and we need to change it more 
to a preventive health care system. So I'm glad that--and the 
families, I hope, take some comfort in--really, some good may 
come out of this hearing today. Some profound changes in our 
health-care system could come from this hearing today. I think 
that that's very exciting. But I can't get away without letting 
Dr. Falk answer a question that I asked of the last panel. 
Regarding the issue of the Superfund site up on the Carson 
River, are there funds available that we can possibly get to 
use for this situation down here?
    Dr. Falk. You know, our role is to advise EPA. We don't 
disburse the clean-up funds, but, in our role of advising EPA, 
we will take that question up with them and discuss it.
    Senator Ensign. I appreciate that.
    Dr. Sinks. Let me respond a little bit to the last 
question, not in terms of the Superfund site, but in terms of 
what we're doing with Fallon and the State. Everything 
recommended by the expert panel, that is being asked of CDC and 
ATSDR, we will find the resources in our budget to see that 
it's done. We are not going to ask the State of Nevada to 
provide us resources to help them in that work. I'm not sure 
what additional resources we particularly need, we'll have to 
wait to see the exact protocols. Every time I have asked for 
help from EPA or ATSDR, it has been forthcoming. We will get 
those resources and we will see that they're delivered to this 
issue.
    Senator Reid. Senator Clinton.
    Senator Clinton. Yes.
    Dr. Falk, would you mind submitting for the record what 
ATSDR activities and ongoing studies are currently underway in 
New York, just so that I have that information?
    Dr. Falk. Sure.
    Senator Clinton. I sure appreciate that.
    Maybe we've got the makings of a Reid-Ensign-Clinton public 
health bill that will be, of course, sponsored by Congressman 
Gibbons in the house. I think that, like John, I am really 
pleased at how much information came out, certainly information 
I was not aware of, and some of the interactions among the 
agencies that we can zero in on and try to create more support 
for, as we do upgrade our public health system. One of the real 
issues, I think, for the 21st century for our entire country is 
how we build on the successes of the past, because I'm 
certainly sure that every one of us want to live and continue 
to live in a country where the water is safe to drink and the 
air is safe to breathe and the food is safe to eat, and, yet, I 
think we've fallen behind in dealing with some of the 
challenges that we've now heard very eloquently addressed and 
that we have an obligation to try to come up with solutions 
for.
    I appreciate the consensus among this panel and the 
previous panelists about what needs to be done. I would just 
point to, perhaps, some analogous situations. You know, we now 
have a very good Federal emergency management assistance 
program. We worked on it over the years, and it had to be 
improved. We now not only deal with emergencies when they 
occur, we've put in a lot more on the preventative side, and I 
hope we continue to do that. You know, we help people deal with 
earthquake issues after some terrible earthquakes, and we 
really cut the amount of loss of life and damage from the 
Seattle earthquakes. We have dealt with hurricanes and 
tornadoes and other kinds of natural disasters. Certainly we 
have had a good response to outbreaks of food poisonings, like 
E. coli and the like, and I think we need to look at that 
system. So I believe that we've got some good public, private, 
and State, Federal, and local partnerships to look at as we 
address the concerns that have been raised at this hearing, and 
I anticipate there'll be a lot of work done in order to be able 
to come up with some solutions.
    So I really want to thank all of the panelists for coming 
forward.
    I join with the Senators up here in our compliments for the 
panel and the testimony that they've presented to us today was 
very enlightening. I do believe, as many of you do, that if we 
are going to ever reach parity between treatment and 
prevention, that we are going to have to make some significant 
investments into this system. It is enlightening to hear the 
testimony, but I also am reminded that over the last 20 years, 
the evolution of information technology has made a contribution 
to the macro side, which is where I believe each of you is 
suggesting that we go--to look at the broad picture, as well as 
the narrow choices that we have in making some predictability 
to these diseases that we have affecting us today.
    I just want to thank you again for your presence here 
today.
    Senator Reid. I want to thank everyone for being here 
today. The audience has been considerate and polite and quiet, 
for which we all up here acknowledge and extend our 
appreciation.
    We have here about 20 questions that have been submitted to 
us. As you can see by the time, we're not going to be able to 
answer those orally here today, but, as I indicated, everyone 
here has their name and address, and we will in detail answer 
these questions.
    I want to extend my appreciation to the Environment and 
Public Works staff. They have been working on this hearing for 
several weeks. We've had people here on the ground. These are 
your taxpayer dollars being spent to prepare this hearing. You 
should be very proud of the work that each of these individuals 
have done to allow us to arrive at this point. I want to extend 
my appreciation to the staffs of Senator Ensign, Senator 
Clinton, and Congressman Gibbons for also working to make this 
hearing as good as it has been.
    Let me say to the reason that we're here, the parents and 
the children who are afflicted with this disease: This program 
which has been conducted today has been helpful, and we are 
going to do everything we can to find out if there is some 
cause that we can find that has resulted in the illness of your 
children, but also everyone within the sound of my voice should 
understand that in the future we're going to do a better job 
with these clusters. We're going to have the ability of the 
Federal Government to respond in a way that we haven't 
responded in the past. As it's been indicated, we're not going 
to each time reinvent the wheel. Every time, for example, there 
is an airplane crash in America, we have the National Air 
Traffic Safety Board who responds immediately. They know 
exactly what they're going to do when an accident occurs. We 
also want to be able to respond that quickly and 
scientifically.
    I wish I could express to the panelists how much I 
appreciate your time and expertise. From the first witness to 
the last, it has just been a feast of information. Now we turn 
this over, as we do so many times, to our very responsible 
staffs and they're going to prepare a report based on the 
testimony--every word has been taken--and they're going to 
report to the committee and to the Congress and, hopefully, 
come up with things that are going to be beneficial to our 
country and certainly the community of Fallon.
    This committee stands in adjournment.
    [Whereupon, at 1:00 p.m., the committee was adjourned, to 
reconvene at the call of the chair.]
    [Additional statements submitted for the record follow:]
            Statement of Nevada Assemblyman Marcia de Braga
    Good morning. It's a great pleasure to welcome you to Fallon and we 
want to thank you for convening these hearings.
    In the fall of 1999 I read with sadness a story in our local 
newspaper about a fund raiser for a 5-year old who had ALL (Acute 
Lymphocytic Leukemia). Then there were a few more cases and more sad 
stories.
    I called the State Health Department and asked if they thought that 
four cases of ALL in 3 months was an unusually high number in a small 
community like ours. I was told it might just be an isolated cluster, 
but they would look into it to be sure.
    In less than a year eight more cases were discovered. The 
statistical probability of this number of cases occurring in an area 
with our population is one in ten quintillion. In other words, there is 
almost zero possibility that this cluster happened by chance.
    In mid-February, the Assembly Natural Resources, Agriculture and 
Mining Committee, which I chair, held 3 days of legislative hearings. 
The purpose of the hearings was to bring together the experts, data, 
research, knowledge, funds and other resources in an effort to expedite 
the search for any environmental causes or contributing factors.
    The hearings also served to attract considerable media attention 
and with it a great many offers and promises from individuals and 
agencies as well as from local, State and national officials to work 
together for a common--and urgent--purpose.
    Others testifying will give you statistics and progress reports. 
What I want to focus on is what I learned through the Legislative 
hearings and through listening to the people whose lives have been 
affected by this tragedy.
    As a result of the hearings, we prepared a list of possible causes, 
created from our research and the testimony we received. That entire 
list is in your packet, along with the names of agencies and 
individuals our recommendations have been forwarded to. It basically 
asks those in authority to leave absolutely no stone unturned.
    Our recommendations also include providing information to the 
public and expanding the scope of the investigation to cover:
     A longer period of time;
     Other disease groupings;
     The analyzing of water, soil and air, and
     The testing of the blood, bone, tissue and hair of the 
children.
    I am happy to report that yesterday the Assembly Ways and Means 
Committee approved $500,000 to be used specifically for those purposes.
    In addition, the committee recommends cleaning up the things the 
community is concerned about now and not waiting for science to catch 
up or provide positive proof. We unanimously agreed that the cancer 
registry and other data must be processed in a rapid manner so that 
information is current and readily available to health and 
environmental officials and to the general public.
    This leukemia cluster may be only a part of the whole picture. An 
eminent pediatric oncologist has advised us to investigate all marrow 
diseases and to look for any increases in other forms of cancer among 
children and adults.
    We know that two additional ALL cases were diagnosed in 1992 and, 
in 1991, a 5-year old died from Myelodysplastic Syndrome, a less common 
form of leukemia. We know that earlier this year, a youngster was 
diagnosed with aplastic anemia, another marrow disease. We know there 
may be additional cases that are connected to Fallon but were not 
diagnosed here. And, we know there are clusters of other diseases that 
also are suspicious.
    I think it is vitally important that everyone involved be proactive 
and not rely on old data, that we look beyond the environmental 
improvements that are already being done to what needs to be done next, 
and that we approach our problems with the hope and optimism that, 
through determination and perseverance, we can--if not find a 
definitive answer--at the very least eliminate possible causes and add 
to our information base.
    Our legislative committee has sponsored a bill that would require 
public and private entities, certified to do environmental testing, to 
report to the Nevada Health Division or NDEP any findings of specific 
values that exceed the established Maximum Contaminant Levels. Those 
findings would have to be made public if a significant health risk was 
posed.
    I think it's imperative that we put these protections into law and 
aggressively pursue our search for causes. That includes working to 
eliminate known contaminants. In so doing, obviously we improve the 
general health of our people and we very well may destroy some of the 
ALL contributors.
    Why do I feel so strongly that we have a responsibility to move 
forward in every way possible?
    Because this is about children--children whose lives have been 
turned upside down by something terrible that's beyond their control. 
This is about a beautiful, smiling little girl whose hair is gone. This 
is about a promising young athlete whose energy now only lasts for 
minutes. This is about a teenager whose HMO won't pay for a bone marrow 
transplant.
    This, as you well know, is about furthering what is known about 
cancer so that other communities might be spared what's happened here. 
I applaud your efforts to create a nationwide team to deal with these 
situations if and when they arise.
    Senator Clinton, I read that you said, ``There is no such thing as 
other people's children.'' You, Senator Reid, and Senator Ensign have 
clearly demonstrated that belief by coming to Fallon to hold these 
hearings. We can't thank you enough for your concern and your 
willingness to help our community and communities like this, 
everywhere.
    Thank you for the opportunity to testify. I would be happy to 
answer any questions.
                                 ______
                                 
 Report of the Leukemia Hearings, Fallon Leukemia Cluster, February 12-
    14, 2001, Prepared by Linda, Eissmann, Senior Research Analyst, 
                       Legislative Counsel Bureau

    The Nevada State Assembly's Committee on Natural Resources, 
Agriculture, and Mining, and its Committee on Health and Human 
Services, held a series of hearings related to a cluster of leukemia 
cases in Fallon, Nevada, on February 12, 13, and 14, 2001. They were 
held in the Legislative Building in Carson City. This report provides a 
brief overview of the cluster, testimony provided throughout the 
hearings, and the recommendations adopted.

                               BACKGROUND

Acute Lymphocytic Leukemia
    Childhood Acute Lymphocytic Leukemia (ALL) is a disease in which 
underdeveloped lymphocytes (white blood cells) are found in unusually 
high numbers in a child's blood and bone marrow. Under normal 
conditions, the bone marrow makes cells known as blasts that mature 
into several different types of blood cells, including red blood cells 
that carry oxygen and platelets that help the blood to clot.
    However, in ALL the developing lymphocytes become too numerous and 
fail to mature. They crowd out the normally-occurring red blood cells 
and platelets in the blood and bone marrow. As a result, the bone 
marrow of children with ALL is unable to make sufficient red blood 
cells to carry oxygen, and the child may develop anemia and tire 
easily. In addition, without sufficient platelets, the child may bleed 
or bruise easily.
    Acute Lymphocytic Leukemia is the most common form of leukemia 
found in children, and is the most common kind of childhood cancer 
accounting for 85 percent of childhood acute leukemias. Thanks to 
progress made over the last 50 years in the diagnosis and treatment of 
leukemia, there is now an 80 percent survival rate.

Investigation of the Fallon ALL Cluster
    A cluster of ALL patients all under the age of 19, has been 
identified in Fallon, Nevada. The cluster has been defined by the 
Health Division as ``medically confirmed diagnosis of ALL, in an 
individual age 0 to 19 at the time of diagnosis, having resided in the 
Fallon area prior to diagnosis.'' At the time of the hearings in the 
Nevada State Assembly on February 12, 13, and 14, 2001, the State's 
Health Division was investigating 11 confirmed cases of ALL in the 
Fallon cluster. Of these, one was diagnosed in 1997, two in 1999, and 
eight in 2000. Only a few weeks later, a 12th case was confirmed (2001) 
and added to the cluster.
    The expected rate of ALL cases statewide is calculated to be 2.78 
per 100,000 population per year. With a population of only 7,850 
people, the expected rate of ALL in Fallon would be 0.22 cases 
annually. However, in the Fallon cluster, eight cases were diagnosed in 
a single year (2000), representing a statistically significant event. 
As such, the probability of the Fallon cluster being a random 
occurrence was determined to be highly unlikely.
    The epidemiologic study at the heart of the Health Division's 
investigation involves a detailed questionnaire for each affected 
family, a review of all laboratory and medical reports, environmental 
sampling, and consultation with health and disease experts from around 
the country, in an effort to find a common link between the cases.

                   TESTIMONY AT THE LEUKEMIA HEARINGS

    Testimony at the leukemia hearings was provided by many State and 
Federal agencies; local governments; experts in pediatric oncology, 
childhood leukemia, arsenic research, and cluster investigations; a 
leukemia patient's family; and members of the general public. 
Attachment A contains the agendas and topics covered for each day of 
the hearings.
    For a complete overview of the testimony presented, please refer to 
the minutes of the hearings, found in Attachment B of this report.
    Although specific causes of ALL are not known, medical experts 
testified that several environmental and demographic features (as well 
as predisposing genetic syndromes) have been associated with an 
increased risk for leukemias in children. Risk factors for the disease 
may include (but are not necessarily limited to) ionizing radiation, 
nonionizing radiation, chemical and toxic exposures, viral and 
infectious agents, and parental occupational exposures. Overall, 
childhood ALL has been classified by scientists as a heterogeneous 
group of diseases, with varying immuno-phenotypes. Testimony also 
revealed that most ALL cases have a genetic link.
    Throughout the hearings, the committees heard a great deal of 
testimony about a variety of suspected causal factors for the leukemia 
cluster, including a number of potentially hazardous materials and 
environmental contaminants. The possibility that the leukemia cases are 
the result of a combination of factors was another common theme 
throughout the hearings.
    Due to the high levels of naturally-occurring arsenic known to 
exist in the water supply of Fallon, arsenic was suggested as a 
possible contributor. However, several expert witnesses testified that 
while arsenic has been associated with some cancers (including lung, 
bladder, skin, liver, kidney, and prostate cancers), research has not 
revealed a clear link between arsenic and leukemia.
    In addition to water quality concerns, other factors identified as 
potential contributors to the ALL cluster were agriculture and domestic 
chemical uses, military activities associated with the Naval Air 
Station (NAS) in Fallon, and a variety of environmental contaminants.
    The following is a summary of the concerns and possible health 
risks identified during testimony:

Agriculture and Domestic Chemical Uses
     Agricultural and other pesticides and herbicides used 
throughout the region.
     Possible effects of combined agricultural activities, 
including chemicals and crop burning.
     Overall inability to monitor uses of appropriate domestic 
pesticides and herbicides.
     Need to educate the public about reading label directions 
for domestic chemical applications.
Water Quality Concerns
     Implications of high levels of arsenic in the Churchill 
County area water supply.
     Insufficient water quality testing.
     Inadequate laws to require water well testing.
     Need to educate the public about the necessity of water 
quality testing and possible mitigation activities.
Possible Implications of Military Activities
     Potential contamination/use of hazardous substances at the 
NAS Fallon, including jet fuel ``dumping'' or other emissions.
     Stability of the jet fuel line to NAS Fallon.
     Distribution and migration of chaff during military 
training exercises.
     Microwaves from radar systems.
     Electromagnetic ground waves as a result of the Extremely 
Low Frequency radio transmitting station installed in Churchill County 
by the Navy.

Other Environmental Contamination
     Surface, subsurface, and airborne radiation and other 
contaminants as a result of Project Shoal weapon test conducted 28 
miles southeast of Fallon in 1963.
     Adequacy of industrial emissions monitoring (including 
air, ground, and water contamination).
     Possible implications of ionizing radiation, depleted 
uranium, radon, nitrates, fluoride, MTBE, volatile organic compounds, 
other industrial contaminants, and the possibility of other radio 
nuclides in the Carson and Truckee Rivers.
     Reported PCB contamination at the Fallon Freight Yard.
     Flooding of the Carson and Truckee Rivers in 1997.
    In addition to these potential risks to public health, suggestions 
were also made to improve or expand the Health Division's investigation 
of the Fallon leukemia cluster:
Cluster Investigation Issues
     Expand the scope of the investigation to determine if 
there are other leukemia cases or clusters that should be included in 
the analysis, or any other related marrow diseases that have a bearing 
on the investigation.
     Determine if there has been an increase in adult cancers 
over the last decade.
     Consider any combinations of possible factors and the 
potential involvement of past contaminations.
     Test blood, bone, hair, and tissue samples from afflicted 
children.
     Occurrence of other possible disease clusters in the 
Fallon area.
     Possible implications of medical procedures including x-
rays, ultrasound, and immunizations.
     Potential role of viral and bacterial infections as a 
contributing factor.
     Coordination with and guidance to local veterinarians for 
possible/related animal diseases.

                            RECOMMENDATIONS

    Following the hearings, and upon announcement of the 12th confirmed 
case of childhood ALL, Assemblyman Marcia de Braga (Chairman of the 
Committee on Natural Resources, Agriculture, and Mining) requested an 
emergency appropriation to assist the investigation. Assembly Bill 359 
would make $1 million available to the Health Division for expenses 
relating to:
    1. The testing of victims of leukemia;
    2. The testing of the environment to determine what factors may be 
contributing to this outbreak of leukemia;
    3. The compilation of data from the results of such tests; and
    4. The dissemination of factual information and health advice to 
the residents of Fallon.
    A copy of A.B. 359 is found in Attachment C.
    A subcommittee was also formed to evaluate and finalize a list of 
specific recommendations to enhance the sharing of resources among all 
participants, and to assist the investigation in finding and addressing 
the cause of this leukemia cluster as quickly and thoroughly as 
possible.
    Members of the subcommittee were:
    Assemblyman Marcia de Braga, Chairman, Committee on Natural 
Resources, Agriculture, and Mining (NRAM)
    Assemblywoman Ellen M. Koivisto, Chairman, Committee on Health and 
Human Services (HHS)
    Assemblywoman Sharron E. Angle (HHS)
    Assemblyman John C. Carpenter (NRAM)
    Assemblywoman Sheila Leslie (HHS)
    Assemblyman Harry Mortenson (NRAM)
    Assemblyman P.M. ``Roy'' Neighbors (NRAM)
    The subcommittee met twice, on March 6 and 8, 2001, and adopted a 
formal list of recommendations. Immediately following adoption of this 
list, the recommended Bill Draft Request (BDR) was made (and has 
subsequently been introduced as Assembly Bill 630), and all recommended 
letters were sent to the appropriate recipients.
Recommendations to Assist/Address the Leukemia Investigation
    1. Committee BDR (40-1456, A.B. 630) should specifically include 
the following:

    a. If a public health risk is detected in an area, the overall 
results should be made public; and
    b. Require private or public entities certified to conduct 
environmental testing (including air, ground, and water testing) to 
report the results of these tests to the Health Division when specific 
values exceed the established Maximum Contaminant Levels. The intent is 
to make sure that the Health Division is able to track or detect any 
public health risks by having information about contamination or 
elevated risk levels reported to them.
    2. Letter to the NAS Fallon urging it to:
    a. Fully disclose to Nevada's Health Division all toxic and 
hazardous materials historically or currently kept onsite, and all 
instances of contamination with resulting clean-up measures;
    b. Consider any and all other possible contaminates (including 
those that may have been previously used) as possible contributors, 
beyond those currently included in the investigation;
    c. Evaluate medical histories of families formerly assigned to NAS 
Fallon, insofar as there may be additional leukemia and other cancer 
cases in families who have since been reassigned;
    d. Compare results of the Navy's water testing of the wells on the 
base, with the City's test results and any results of testing from the 
Fallon Paiute-
Shoshone Tribe;
    e. Address/confirm reports that benzene was found in one of the 
Navy's wells, and if true, explain when and what corrective actions 
were taken;
    f. Address/confirm reports of jet fuel used in diesel trucks and as 
weed spray;
    g. Explain why Halon 1211 is listed on the NAS Fallon Section 311 
``Emergency Planning and Community Right to Know Act'' for the 1999 
Reporting Year, including how it has been used, is stored, and what 
``maintenance activities'' involved the use of jet fuel; and
    h. Consider any possibility that the general public might have come 
into contact with any of the materials listed on the Section 311 report 
of reportable materials.
    3. Letter to Nevada's Health Division recommending it:
    a. Expand the scope of the investigation to determine if there are 
other leukemia cases or clusters that should be included in the 
analysis, or any other related marrow diseases that have a bearing on 
the investigation;
    b. Determine if there has been an increase in adult cancers over 
the last decade;
    c. Consider any combinations of possible factors and the potential 
involvement of past contaminations;
    d. Test blood, bone, hair, and tissue samples from affected 
children;
    e. Continue to provide information to the general public and 
coordinate education efforts about possible public health risks;
    f. Continue to solicit input from the public regarding possible 
causes; and
    g. Address/consider the concerns and possible health risks 
identified during testimony (as previously described on pages 3 and 4 
of this report).
    4. Letter to the Health Division encouraging it to act as the lead 
agency to coordinate all educational, research, and investigative 
efforts.
    5. Letter to the Health Division requesting it to proceed with the 
proposal provided by the University of Nevada, Reno, Department of 
Civil Engineering, to perform the Ames test on air, water, and 
``residue'' samples collected in the study area, and to work closely 
with all parties in research sampling efforts with the primary goal 
being to delineate any areas or sources of increased mutagenic 
activity.
    6. Letter to the Health Division requesting it to thoroughly 
examine Nevada's Cancer Registry and the current abstraction process, 
to determine ways in which it could be improved and ways in which the 
lag time might be minimized. Letter will request the Health Division to 
undertake necessary steps to improve the registry and report to the 
Legislature no later than May 1, 2001, what it has learned.
    7. Request the Health Division to provide regular updates to the 
committee(s) about new developments and the progress of its 
investigation and research, including any reports of its expert panel.
    8. Letter to Nevada's Division of Environmental Protection; urging 
it to:
    a. Continue its participation with the Health Division in its 
oversight capacity for environmental contamination (including air, 
ground, and water contamination) in the Fallon area; and
    b. Continue to monitor the progress of Project Shoal and the 
migration of surface, subsurface, and airborne contaminates from the 
initial project site.
    9. Letter to Nevada's Department of Agriculture urging it to assist 
the Health Division in the leukemia investigation, by providing 
agricultural chemical use data and by collecting and analyzing 
additional/necessary environmental samples (including air, ground, and 
water samples) in an effort to help identify any problems resulting 
from the use or combined uses of pesticides and herbicides in the 
Fallon area.
    10. Letter to Kinder-Morgan requesting information about the jet 
fuel pipeline, including:
    a. The frequency of inspection;
    b. Reporting/inspection procedures;
    c. Methods used to detect leakage;
    d. Precautions used to avoid leakage;
    e. History of repairs or upgrades; and
    f. Potential to relocate the line if problems are detected.
    11. Letter to the University of Nevada, Reno, asking it to assist 
with the investigation, collaborate with the Health Division, and 
participate with in-kind contributions to the extent possible.
    12. Letters to the City of Fallon and Churchill County, indicating 
the Legislature has undertaken hearings and held sequent meetings in an 
effort to combine resources and expedite a solution to the leukemia 
investigation. A copy of the recommendations will be enclosed. The 
letters will further indicate that the committees wish to assist the 
City and County in any way possible in their coordination activities 
and educational efforts.
Recommendations to Assist/Address the Potential Public Health Risk of 
        Arsenic
    13. Letter to City of Fallon urging it to:
    a. Take whatever steps are necessary to adhere to the new EPA 
standards for arsenic as soon as possible;
    b. Evaluate opportunities for combining efforts of the City, NAS 
Fallon, and the Fallon Paiute-Shoshone Tribe to reduce the overall cost 
of a common filtration system; and
    c. Compare its water testing results with those of NAS Fallon and 
the Fallon Paiute-Shoshone Tribe.
    14. Letter of support for Senate Concurrent Resolution No. 5 to the 
Senate Committee on Legislative Affairs and Operations.
    15. Investigate the cost of installing ``point of entry'' 
filtration systems at each of Fallon's eight schools.
    (Note: Subsequent to adoption of this recommendation, staff learned 
that the Churchill County School District has determined that ``point 
of use'' systems are more cost effective, including 79 reverse osmosis 
systems at water fountains and kitchen faucets throughout the district. 
These systems are estimated to cost $70,000 to $80,000.)
Other Recommendations
    16. Investigate whether community/public notification is made when 
the Weed-Mosquito Abatement District undertakes its spraying 
activities.
    (Note: Subsequent to adoption of this recommendation, staff learned 
that the Churchill County Weed-Mosquito Abatement District publishes an 
article once per month in the local newspaper, informing residents 
about mosquito and weed problems, general areas targeted, and chemicals 
that will be used. However, representatives of the Abatement District 
indicate that it is difficult to notify the public of the exact time 
and place to be sprayed because of weather variability. Also, most 
spraying takes place at the Carson Lake, 10 to 15 miles south of 
Fallon.)
                               conclusion
    The Committee on Natural Resources, Agriculture, and Mining, and 
the Committee on Health and Human Services, expresses sincere 
appreciation to the many witnesses who testified throughout the 
leukemia hearings for their interest and participation in this unique 
and compelling situation. Special appreciation is also extended to the 
Health Division and members of its expert panel for their dedication 
and the thoroughness of this investigation.
                                 ______
                                 
                              ATTACHMENT A
 Assembly Agenda for the Committee on Natural Resources, Agriculture, 
                               and Mining
Day: Monday
Date: February 12, 2001
Time: 1 p.m.
Room: 1214
               special hearing on fallon leukemia cluster
    Briefing.--Health Division.
    Medical Overview.--Pediatric leukemia specialists; Local physicians 
experienced in leukemia and immunology.
    Environmental Overview.--Nevada Division of Environmental 
Protection; Arsenic, Drinking Water Toxicologist, U.S. EPA.

Day: Tuesday
Date: February 13, 2001
Time: 1 p.m.
Room: 1214
    Environmental Overview.--Jet fuel, NAS Fallon; Agriculture, 
pesticides and crop spraying, Nevada Department of Agriculture, 
Mosquito/Weed Abatement District; Other.
    Impacts to the Community.--City of Fallon; Patient families.
    Public Testimony.

Day: Wednesday
Date: February 14, 2001
Time: 1 p.m.
Room: 1214
    Public testimony.
    Medical and Environmental Overview.--Centers for Disease Control; 
Arsenic research specialist; Oncologist.
    Strategies, coordination, and recommendations of the committee.
                                 ______
                                 
                              ATTACHMENT B

Minutes of the Meeting of the Assembly Committee on Natural Resources, 
   Agriculture, and Mining, Seventy-First Session, February 12, 2001
    The Committee on Natural Resources, Agriculture, and Mining was 
called to order at 1 p.m., on Monday, February 12, 2001. Chairman 
Marcia de Braga presided in room 1214 of the Legislative Building, 
Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest 
List. All exhibits are available and on file at the Research Library of 
the Legislative Counsel Bureau.

    Committee Members Present.--Mrs. Marcia de Braga, Chairman; Mr. Tom 
Collins, Vice Chairman; Mr. Douglas Bache; Mr. David Brown; Mr. John 
Carpenter; Mr. Jerry Claborn; Mr. David Humke; Mr. John J. Lee; Mr. 
John Marvel; Mr. Harry Mortenson; Mr. Roy Neighbors.
    Committee Members Absent.--Ms. Genie Ohrenschall (Excused)
    Guest Legislators Present.--Assemblywoman Sharron Angle, District 
29; Assemblywoman Merle Berman, District 2; Assemblywoman Vivian 
Freeman, District 24; Assemblywoman Dawn Gibbons, District 25; 
Assemblywoman Ellen Koivisto, District 14; Assemblywoman Sheila Leslie, 
District 27; Assemblywoman Mark Manendo, District 18; Assemblywoman 
Kathy McClain District 15; Assemblywoman Bonnie Parnell, District 40; 
Assemblywoman Debbie Smith, District 30; Assemblywoman Sandy Tiffany, 
District 21; Assemblyman Wendell Williams, District 6.
    Staff Members Present.--Linda Eissmann, Committee Policy Analyst; 
Marla McDade Williams, Committee Policy Analyst; June Rigsby, Committee 
Secretary.
    Others Present..--Yvonne Sylva, Administrator, Nevada State Health; 
Division; Dr. Mary Guinan, Nevada State Health Officer, Dr. Randall 
Todd, State Epidemiologist, Nevada State Health Division; Galen Denio, 
Manager, Public Health Engineering, Nevada State Health Division; Dr. 
Ronald Rosen, School of Medicine, University of Nevada, Reno; Dr. 
Carolyn Hastings, Oncologist, Children's' Hospital of Oakland; Dr. Vera 
Byers, Clinical Immunologist; Dr. Al Levin, Immunologist; Allan Biaggi, 
Administrator, Division of Environmental Protection; Paul Liebendorfer, 
Chief, Bureau of Federal Facilities; Dr. Bruce Macler, Regional 
Toxicologist, EPA, San Francisco.

    Chairman de Braga called the Assembly Natural Resources, 
Agriculture, and Mining Committee to order. Roll was called and a 
quorum was judged to be in place. All members were present except for 
Assemblywoman Ohrenschall who was noted as an excused absence.
    Chairman de Braga welcomed as guests the Assembly Committee on 
Health and Human Services. Roll was called, and all members were 
present, except for Assemblyman Tiffany who was noted as an excused 
absence.
    Chairman de Braga opened the meeting with a welcome to both 
committees and an acknowledgement of the research and support that 
contributed to the leukemia hearings. Chairman de Braga stated the 
purpose of the 3-day special hearings was to gather information about 
the recent Acute Lymphocytic Leukemia (ALL) cluster in Fallon and to 
explore possible environmental causes. The hearings had been designed 
to provide a forum for the pooling of research, data, experts, 
community leaders, agencies, government officials, health and 
environmental experts, and all other resources.
    With the discovery of 11 cases of ALL in the Fallon area within a 
short number of years, it had become imperative to address the expected 
concerns of the residents as well as be aware of the welfare of the 
community as a whole. With the extensive media coverage, Chairman de 
Braga explained that publicity had served a positive purpose by 
bringing attention and resources to the community.
    The format for the 3 days was described as a balance of expert 
testimony and public input. Following the testimony of witnesses, 
questions by the two committees were slated. Guests were encouraged to 
sign in and participate, and no questions would be judged as worthless. 
At the conclusion of the 3 days, a panel would assemble recommendations 
based on all of the testimony.
    Chairman de Braga emphasized that, even if the specific cause of 
the cluster was never identified, public concerns would be addressed 
and environmental improvements made on behalf of the entire community.
    Because of the pre-scheduled commitments of the two committees in 
attendance, Chairman de Braga stated that, if at any time, a quorum 
failed to be present, the hearings would continue uninterrupted under 
the status of a subcommittee.
    Chairman de Braga introduced the opening expert testimony from the 
Nevada State Health Division. The committees received two handouts, 
which were as follows:
     A 6-page report entitled State of Nevada Health Division--
Leukemia Cluster Fact Sheet (Exhibit C).
     A portfolio of reports which included leukemia fact 
sheets, a summary of what constituted a cancer cluster, status reports, 
an overview of Health Division actions, and other pertinent background 
information compiled by the Nevada Health Division (Exhibit D).
    Yvonne Sylva, Administrator of the State Health Division, outlined 
their official action since being notified in July 2000 of the high 
number of ALL cases in Fallon. Their role as the first line of response 
was recognized. A complete investigation was initiated, with two 
employees assigned full time, Dr. Mary Guinan, State Health Officer, 
and Dr. Randall Todd, State Epidemiologist. By November 2000, it became 
apparent that additional resources would be required. The calls from 
the news media dictated the hiring of a full time media coordinator as 
well as a bilingual research assistant to Dr. Todd.
    Ms. Sylva summarized the multitude of State and Federal Government 
agencies that were engaged for the fact-finding phase of their 
investigation. These included the Center for Disease Control in 
Atlanta, the National Institute of Cancer, EPA, Department of Energy, 
the Nevada Department of Agriculture and Nevada Environmental 
Protection. In January, an additional employee was assigned to field 
requests from the public and the news media.
    According to Ms. Sylva, the investigation had been designed as a 
partnership with the community of Fallon and was evidenced by a 
community presentation made to Fallon residents in January. A separate 
community forum at the Naval Air Station followed, with attendance 
estimated at 80 residents. A community meeting in early February 
provided additional opportunity for more than 250 citizens to ask 
questions and air their concerns. A community telephone hotline (1-888-
608-4623) was established, with a reported 56 inquiries to date. Ms. 
Sylva welcomed additional recommendations for addressing public 
concerns.
    Scrutiny of the Health Division's investigative work had been 
openly solicited, with requests made to Federal agencies across the 
country. This peer review was designed to be an analytical critique of 
the soundness of their investigative methods as well as their findings 
to date. Recommendations on improvements to their methodology were 
invited.
    In response to Chairman de Braga's question regarding the nature of 
hotline questions, Ms. Sylva replied that citizen concern centered on 
the safety of continuing to live in Fallon, the chances of other 
children developing leukemia, and the safety of drinking the water.
    Assemblywoman Gibbons requested clarification of Fallon population 
figures, the percentage of ethnic minority citizens, history of 
residents who had requested testing of their private wells, and data on 
other cancer cases that were linked to arsenic in well water in the 
Fallon area. Ms. Sylva deferred to the upcoming testimony of Dr. Todd 
and Galen Denio. Chairman de Braga clarified that the population of 
Fallon was estimated at 8,300 within the city limits and 26,000 within 
the county.
    Dr. Mary Guinan, State Health Officer, resumed testimony for the 
Nevada State Health Division. In July 2000 a call had been received 
from Chairman de Braga regarding the alarming number of leukemia cases 
at the Churchill Community Hospital. Following a review of the Nevada 
State Cancer Registry, it became readily apparent that the rate of 
current ALL cases in Fallon did represent a significant increase from 
what would be expected statistically.
    Phase 1 of their investigative work commenced with consultation 
among experts from various schools of medicine and public health 
agencies. All agreed that phase 1 had to be a thorough interview with 
each of the affected families for purposes of determining common 
exposures. Questionnaires from previously conducted epidemiological 
studies were reviewed, which resulted in the development of a 32-page 
questionnaire customized for the Fallon cluster. The time to conduct 
each family interview was estimated at 2-3 hours. The participation by 
affected families, voluntary in nature, was 100 percent. Scientific 
methodology was closely followed in the gathering of the data. 
Interviews of nine families were completed by November. The results 
were analyzed and presented to the families in December by Dr. Todd.
    In response to a question by Assemblywoman McClain regarding the 
place of diagnosis of the nine cases, Dr. Guinan clarified that the 
definitive diagnosis of leukemia was a bone marrow biopsy. This 
specialized test had to be done at the hospital where the treatment 
would occur.
    Assemblywoman McClain requested clarification about the Health 
Division's ability to track cases in other parts of the nation. Dr. 
Guinan reported that the publicity did result in the addition of two 
cases in individuals who were not residents of Fallon at the time of 
diagnosis. Word-of-mouth reports from the citizens of Fallon 
contributed to the identification of the first nine cases.
    Assemblywoman Leslie inquired about whether the Health Division 
investigation included the comparison of physical evidence (e.g., blood 
test results) that might tie these cases together. Dr. Guinan explained 
that questions did focus on discovering common experiences with the 
goal of generating hypotheses that could be tested in the next phase of 
the investigation. Environmental exposures were a principal focus. 
Additionally, each family was invited to speculate about any theory 
they had about cause or commonality with other families.
    In response to Assemblywoman Leslie's request for clarification 
regarding testing of the children and environment, Dr. Guinan explained 
that no testing had been conducted. Phase one was descriptive in 
nature, and additional testing would be premature until possible causal 
agents could be identified. Testing of children (e.g., blood, hair 
analysis) dictated a judicious approach.
    Assemblywoman Angle raised the issue of the number of phases of the 
investigation, any planned efforts to be proactive in uncovering new 
cases of leukemia, and a timeline of when the results of the study 
would be available.
    Dr. Guinan explained that the number of phases of the investigation 
was unknown. There had been hundreds of investigations of clusters, 
with few resulting in identification of cause. The Woburn cluster, one 
of the few with an identified cause, took 18 years. The Health Division 
had planned to proceed step-wise. Assurance of public fears had to be 
the first matter of importance.
    In response to Assemblyman Neighbors, Dr. Guinan clarified that an 
historic review of the health records had been conducted for purposes 
of comparing the current cancer rate with historic rates. The rate for 
Churchill County had been the same as the State average, with no 
increase evidenced prior to this cluster. An essential piece of 
information was described by Dr. Guinan as the population figures for 
children up to the age of 9 years in the Fallon area.
    Assemblyman Neighbors requested clarification on whether Fallon's 
drinking water had been tested for substances besides arsenic. Dr. 
Guinan reported that tests had included radioactive substances and 
pesticide tests, with no evidence of significant levels. Jet fuel tests 
of water had been negative as well. It was further noted that some of 
the leukemia victims were served by the municipal water system while 
others were on private wells.
    In response to Assemblywoman Gibbons, Dr. Guinan outlined the 
expected rate of cancer versus actual rates of cancer in Fallon. Dr. 
Guinan reported that the same rate, 3 per 100,000 cases, would be 
expected throughout the State of Nevada. Multiple comparisons had been 
made with cancer registries across the nation, and the conclusion was 
that we had a definite increase in Fallon.
    Dr. Todd, State Epidemiologist, resumed testimony for the Nevada 
State Health Division. Background information regarding communicable 
disease and cancer reporting practices for Nevada was presented. Dr. 
Todd referred the committees to his portfolio of handouts (Exhibit D). 
Nevada Revised Statutes (NRS) 441 was cited as the guideline for their 
tracking programs for 60 communicable diseases. NRS 457 contained the 
regulations for tracking cancer. Since 1979, all invasive cancer had 
been required to be reported by hospitals, with laboratories and 
physician offices being added to reporting requirements in the late 
1990's. It was noted that outpatient management of cancer had 
interfered with the completeness of data in the cancer registry. This 
had been compounded by an almost 2 year reporting lag in updating the 
data of the cancer registry, a common problem nationwide.
    Dr. Todd elaborated on the three principal uses of the registry 
data, which included research, resource allocation, and program 
evaluation. The value of the registry data was illustrated by its 
application in cluster investigation.
    The unusual number of ALL cases in a small community like Fallon 
within a short timeframe grabbed the attention of the Nevada Health 
Division. Using population figures of Nevada communities, mathematical 
calculations of expected rates and actual rates were scrutinized. 
Regardless of how the data was sliced, the probability of the Fallon 
cluster being a random event was judged to be highly unlikely. For the 
years 1995 to 1999, Churchill County had expected to see only one case 
of childhood cancer. Statistical analyses were alarming and indicated 
high probability of a non-random event.
    The expected rate in Nevada for residents up to age 10 was 
calculated at 2.78 cases of Acute Lymphocytic Leukemia (ALL) for a 
population of 100,000. Churchill County, with eight actual cases, was 
judged to be a statistically significant event given the expected 0.22 
cases for its population of 7,850.
    Dr. Todd elaborated on the epidemiological investigation, 
specifically the 32-page questionnaire. Residential history was 
examined starting with 2 years prior to the birth of each victim. 
Occupational history of both parents, medical history of the index 
child, prenatal history, environmental exposure data, types of pets, 
activities, and hobbies, household products, types of appliances in the 
home, and drinking water sources were all investigated.
    A timeline was displayed which captured residency in the Fallon 
area for all of the affected families. Data was charted on bar graphs 
and then examined for overlapping of residency and other significant 
marker events. The preponderance of overlapping points was identified 
as November 1996 through June 1999. This became the timeframe of 
interest and prompted research questions about coincidental 
environmental events in Churchill County.
    Scrutiny of water analyses received priority attention, especially 
synthetic organic compounds (SOC) and volatile organic compounds (VOC). 
None were detected in the municipal water supply that served 
approximately half of the victim families. Data for private drinking 
water wells was not complete. Mercury, arsenic, gross alpha radiation, 
select components of jet fuel, benzene, and select pesticides and 
herbicides were tested, and all were at or below the allowable limits.
    Occupational history data included specific questions about 
chemical, fume, and radiation exposures on the job. Although some 
incidents of exposure were discovered, this was judged not to be a 
common characteristic across all families. The medical history of each 
index child was reviewed and revealed no common denominator. Maternal 
pregnancy questions included many subjects such as alcohol and food 
consumption, medications consumed, occupational exposures, and breast-
feeding habits. Questions related to family history of cancer revealed 
no pattern.
    The most prominent question fielded by Dr. Todd during his 
investigation had been the possible link between leukemia and arsenic 
in the drinking water. Research did not reveal a preponderance of 
evidence that linked arsenic with leukemia. Arsenic had always been 
present in Fallon, which begged the question of why the recent cluster 
suddenly emerged. The pathway of exposure, as well as the biological 
mechanism through which a suspected agent caused leukemia, were 
described as essential elements of their epidemiological investigation.
    Chairman de Braga requested clarification about the State cancer 
registry, specifically at what point in time the registry would have 
revealed a cluster of cancer. Dr. Todd explained that it would have 
taken several years before he would have been confident to draw 
conclusions about a cluster. The lag time between diagnosis and 
reporting was reported to be common for most cancer registries across 
the nation. Chairman de Braga urged the Nevada Health Division to 
submit recommendations about methods for expediting the cancer 
reporting process.
    Assemblywoman Parnell inquired about substances tested in drinking 
water, specifically hydrocarbons and chemicals similar to those 
detected in Woburn. Dr. Todd explained that trichloroethylenes and 
tetracholorethylenes were among the substances tested.
    Assemblywoman Smith requested clarification on lag time, 
specifically whether it was a lag between the initial reporting of the 
cancer, the completeness, or both. Dr. Todd explained that lag time was 
a multifaceted problem, with the first component of lag described as 
the delay between diagnosis and compilation of the patient's medical 
record. The second component of lag was related to the abstraction of 
the information from the medical records, a problem that was evident 
whether the abstraction was performed by the hospital or by a 
representative of the Nevada Health Division. Dr. Todd estimated the 
abstraction time for each medical record at 40 to 60 minutes. The 
addition of laboratory reporting was anticipated to be a means to 
expedite the process. By way of comparison, the Center for Disease 
Control (CDC) standard was reported to be 90 percent at the 1-year 
mark.
    Assemblywoman Smith resumed questioning with a request for 
clarification of dates of water testing, specifically the inconsistency 
in the testing schedule and the reported 2-year gap. Dr. Todd deferred 
to Galen Denio's upcoming testimony.
    In response to Assemblywoman Smith's question about private well 
testing, Dr. Todd clarified that private well testing had most often 
occurred when the property changed ownership. The mortgage companies, 
not the state, were the requestors of the water test and reportedly did 
not routinely order detection of the more complex chemical substances.
    Assemblywoman Smith inquired about the possibility of school 
commonality. Dr. Todd reported no clustering or connection to any 
school site.
    Assemblywoman Koivisto pursued the issue of the amounts of 
synthetic organic compounds (SOC) and volatile organic compounds (VOC) 
detected in the water. Dr. Todd clarified that water analyses revealed 
zero detection.
    In response to Assemblywoman Leslie's question regarding high 
levels of other diseases in the Fallon area, Dr. Todd explained that 
his review of the cancer registry data through 1999 revealed only the 
childhood ALL cases in Fallon.
    Assemblywoman Gibbons inquired about the probability that the 
Fallon cluster could be a statistical anomaly. Dr. Todd replied that it 
was impossible to State with absolute certainty that it was not a 
fluke. Despite the fact that most cluster investigations failed to 
conclusively identify a causal link, public concerns dictated the need 
to continue the investigation.
    Assemblyman Mortenson shared his personal experience with recent 
water testing and cited a line in his water report which stated that 
radioactive substances were not included in the analysis. In response 
to Assemblyman Mortenson's request for clarification, Dr. Todd added 
that the municipal water data presented were historical in nature and 
not connected to his current investigation.
    Assemblyman Mortenson inquired about possible medical procedures 
and diagnostic x-ray exposure that the leukemia victims may have 
experienced. Dr. Todd clarified that those were precisely the types of 
questions asked of the victims. No pattern of exposure, including 
prenatal ultrasound testing, was revealed. In response to a question of 
statistical probability, Dr. Todd stated that the projected statewide 
probability rate of 0.84 per 100,000 residents had not held up in 
Churchill County. Assemblyman Mortenson next requested if the 
improbability of such events had been calculated, to which Dr. Todd 
replied that it had not been determined.
    Assemblywoman Berman cited an upcoming bill dealing with the 
comprehensive cancer plan in Nevada. She specifically inquired whether 
her bill should be amended to address the need for expeditious 
identification and response to cancer clusters. Dr. Todd replied that 
this would require additional thought and that his written response 
would follow after consultation with his colleagues.
    In response to Assemblyman Bache's question regarding the possible 
connection with the 1997 flood, Dr. Todd explained that the flood had 
been one of the most prominent events identified for the time period of 
interest. Initial investigation had not revealed any evidence of 
contamination of municipal water supplies. Aquifer contamination would 
need further study.
    Assemblyman Brown inquired about the geographic boundaries of the 
investigation. Dr. Todd reported that the cases were distributed 
throughout the city and surrounding area. Chairman de Braga called the 
committees' attention to their information packets and to a copy of the 
published map which pinpointed the 11 cases.
    Galen Denio, Manager of Public Health Engineering, Bureau of Health 
Protection Services resumed testimony for the Nevada State Health 
Division. A handout (Exhibit E), which outlined the procedures for 
protection of public water systems, was distributed. Mr. Denio 
presented an overview of the principal functions of the Bureau, the 
focus of which was ensuring compliance with drinking water regulations.
    In response to earlier questions regarding water testing, Mr. Denio 
clarified that the maximum contaminant levels (MCL) had been set by the 
Environmental Protection Agency (EPA) and adopted by the State of 
Nevada. The contaminant list was described as extensive. In regard to 
private well water, Mr. Denio reported that the bureau did not test 
these drinking water sources. In regard to the non-detects referenced 
by Dr. Todd, current methodology did not allow for detection.
    Chairman de Braga cautioned the committees of the need to maintain 
open minds on the issues, especially given the extensive media coverage 
and speculation about arsenic as a possible cause. Chairman de Braga 
requested clarification about the policy and procedure for alerting the 
public in cases of high level of contaminants in the drinking water. 
She cited the recent case of private well contamination at Soda Lake 
and inquired about the follow-up procedure.
    Mr. Denio explained that, because it was not a public water system, 
the Nevada Health Division had not been advised through formal 
channels. Chairman de Braga emphasized that, although not a public 
water supply covered by law, it was nonetheless a health threat to 
residents in that area. She expressed concerns over the lack of a 
system to alert the residents of the danger.
    Mr. Denio clarified that the Federal mortgage lending agencies had 
required well water testing when the property changed ownership. The 
State did not have the responsibility with regard to private wells. 
Chairman de Braga restated her concern that the quality of the drinking 
water should be disclosed as part of the real estate transactions. This 
breakdown in communication could be addressed in the final report of 
recommendations.
    Dr. Ronald Rosen, School of Medicine, University of Nevada, Reno 
commenced testimony. Two handouts, a pamphlet entitled ``Epidemiology 
of Childhood Leukemia'' and a one-page summary of comments (Exhibit F), 
were distributed. Dr. Rosen reviewed the remarkable progress made 
during the last 50 years in the diagnosis and treatment of leukemia, 
with an estimated 85 percent survival rate. Children had accounted for 
only 1 to 2 percent of all cancers, with Acute Lymphocytic Leukemia 
(ALL) the most common malignancy. The projected ALL rate was described 
as 3 per 100,000. At the point of diagnosis, ALL peaked at 2 to 5 years 
of age. Gender and race had been discovered as significant, with a male 
dominance of ALL and a prevalence in affluent white children.
    Dr. Rosen explained the differences between the various forms of 
leukemia. The childhood ALL had been classified as a heterogeneous 
group of diseases, with varying immuno-phenotypes. He further 
emphasized the point that 80 percent of all ALL revealed a genetic 
link. These actual genetic abnormalities within the cells had the 
promise of enabling scientists to understand how the genetic and 
environmental factors linked together.
    The trend, as described by Dr. Rosen, was one of increasing rates. 
Trends also included striking differences in the international 
statistics of cancer in children. Possible explanations were offered by 
Dr. Rosen and included access to higher quality medical care, a finer 
ability to diagnose cancer, and better cancer reporting systems.
    Dr. Rosen summarized the risk to develop cancer as a complex 
interplay of inherited predisposition, exogenous exposure to agents 
with leukomogenic potential, and chance events. Despite impressive 
advancements in the treatment of ALL, cause had evaded science and, 
when discovered, was predicted to be complex. Dr. Rosen elaborated by 
stating that ALL was a genetic disease, but rarely inherited as a 
genetic syndrome. Of interest was the leukemia rate for children with 
genetically-based Down's Syndrome, where the rate was 20 to 30 times 
greater than the general population.
    Dr. Rosen restated that little was known about epidemiology and 
etiologic patterns in childhood cancers compared to adults. A strong 
causal relationship had been established with prenatal radiation 
exposure, albeit connected to a small percentage of ALL cases. Through 
the decades, documentation from atomic bomb events had been thorough 
and included occupational exposure of workers and their subsequent 
deaths from cancer. The data for ionizing radiation, overall, had been 
conflicting. High dose exposure had been correlated to the high 
incidence of leukemia among survivors of atomic blasts, while age was 
strongly correlated to the type of leukemia.
    Non-ionizing radiation research had been extensive but 
inconclusive. Finding a control, non-exposed population would be almost 
impossible. EMF (electromagnetic fields) research had been largely 
inconclusive and remained controversial. Research on chemical exposures 
to herbicides and pesticides had been associated with certain forms of 
leukemia.
    Dr. Rosen described the unique population of interest, specifically 
young children between the ages of two to five in developed countries. 
Epidemiological evidence supported the view that childhood ALL occurred 
in this age group due to a rare abnormal response brought on by unusual 
timing in combination with individual genetic susceptibility to a 
common infection.
    This indirect evidence had been judged to be very compelling. The 
etiologic role in this infection was described in the context of 
population mixing. On the subject of population mixing and herd 
immunity (e.g., polio virus), Dr. Rosen described an increased risk of 
infection after population mixing and movement. Leukemia clusters 
occurred when herd immunity was deregulated by population mixing.
    In summary, Dr. Rosen highlighted that in the unique population 
with ALL it was a delayed first exposure that had been considered to 
contribute to pathogenesis of several diseases associated with socio-
economic affluence. Decreased breast-feeding practices in affluent 
populations had been suggested as a factor and would need analysis in 
the Fallon group. An abnormal immunologic response was emphasized as a 
probable factor in the development of childhood leukemia.
    Dr. Rosen highlighted the distinction between descriptive and 
analytical statistics that resulted from epidemiological studies of 
leukemia. Interpretation of data had been challenging, with conflicting 
results between studies. A lack of prevalence of pediatric malignancies 
plus confounding circumstances contributed to the chance of bias in 
studies.
    In closing, Dr. Rosen reiterated that the Fallon cases had great 
significance and could contribute to the eventual link of 
environmental-genetic interactions to the pathogenesis of the various 
types and subtypes of childhood leukemia. Prevention would follow as a 
realistic goal.
    Chairman de Braga expressed her appreciation to Dr. Rosen. She 
inquired as to whether the recommendations to which he alluded were in 
the handouts. Dr. Rosen clarified that recommendations were not 
included, however he would be happy to contribute input.
    Dr. Carolyn Hastings, Pediatric Hematologist and Oncologist at the 
Children's Hospital in Oakland, commenced testimony. Dr. Hastings had 
practiced medicine for more than 10 years in northern Nevada and had 
firsthand experience with the Fallon cluster. It was noted that, 
because of the relative rareness of childhood leukemia (i.e., 3,000 
cases per year), pediatric oncologists across the Nation networked for 
purposes of sharing knowledge and experience.
    The pooling of knowledge allowed for expansion of research and 
hypothesis generation. Genetic mutation had been determined to be a 
significant piece of the puzzle. One mutation that had developed in-
utero was thought to be complicated by a second mutation in early 
childhood, probably due to some environmental exposure (e.g., 
infection). Establishment of the type and subtype of leukemia was 
described by Dr. Hastings as essential to scientific comparisons.
    Demographics were highlighted as the second essential component of 
the research. Correlations with age, race, and gender had been 
established. Children under the age of 5 years and Hispanic children 
had been cited as having a higher incidence.
    Assemblywoman Gibbons requested clarification of the role of socio-
economic factors and the possibility of the development of another type 
of cancer. Dr. Hastings explained that it was impossible to determine 
with certainty when the leukemia developed in a child.
    In response to Assemblyman Carpenter's question regarding the 
existence of a diagnostic blood test, Dr. Hastings explained that there 
was no screening test available to predict the disease. The complete 
blood count (CBC) was described as the most common screening tool. 
There would be no predictive quality to the test, only diagnostic 
value. A bone marrow test, described as highly invasive, would alert 
the physician in advance of active symptoms. Acknowledged as the most 
conclusive of all laboratory tests, Dr. Hastings added that bone marrow 
testing would be done only after reasonable suspicion.
    Chairman de Braga requested a comparison between suspected 
environmental causes of lymphoma and leukemia. Dr. Hastings confirmed 
the similarity. She elaborated on the two major hypotheses, genetics 
and environmental exposures. Chairman de Braga expressed her gratitude 
to Dr. Hastings and requested any recommendations.
    Following a break, Chairman de Braga called the meeting to order 
and stated that, because a quorum was not present, the hearings would 
continue as a subcommittee. An introduction of Dr. Vera Byers and Dr. 
Al Levin was made. An outline of their presentation (Exhibit G) was 
distributed.
    Dr. Vera Byers, a physician with a specialty in clinical 
immunology, commenced testimony and described with her experiences with 
the Woburn, Massachusetts cancer cluster case. Woburn was judged to be 
the prototype for cluster investigation. Dr. Al Levin, a physician and 
scientist, interjected with his description of the role he played in 
the Woburn case.
    Dr. Levin stated with certainty that he believed the Fallon case 
would be a very easy case. There had been signature genetic lesions 
evident in these diseases that could be connected to etiologic agents. 
Examination of the siblings, parents and neighbors promised to be 
revealing of any common environmental exposure. Dr. Levin expressed 
confidence at discovering the disease process, the causal agent, and 
perhaps the pathway.
    Dr. Byers resumed testimony with an overview of the Woburn cancer 
cluster. Woburn, a town with a significant industrial presence, saw the 
development of 12 cases between the years 1969 to 1979. The cause was 
determined to be well water contamination by tricholoethylene (TCE) and 
percholoroethylene (PCE).
    One of the outstanding features of the Woburn cluster was that the 
community itself identified the increased number of cases (as did 
Fallon) as well as the suspected source of contamination. The close 
proximity of the affected homes was significant. Since 70 percent of 
all cancers had been known to have a carcinogenic cause (as opposed to 
genetic), water, soil and air sources were tested for chemicals.
    Dr. Byers highlighted the value of testing family members and 
neighbors to uncover similar abnormalities. In Woburn, immune 
abnormalities were evident and correlated strongly with TCE 
contamination. Sources of domestic exposure were scrutinized because it 
was known that, increasingly, industrial chemicals were invading 
households in alarming amounts. The significance was described as being 
directly related to continuous low dose exposures within the contained 
atmosphere in a home.
    Dr. Byers reiterated the need to empower the community of Fallon. 
Historically, it had been the community (e.g., Woburn) that not only 
uncovered the cluster but the source of the environmental 
contamination. The prolonged investigation over almost two decades was 
attributed to the failure of the scientific and medical communities' to 
believe the residents of Woburn.
    Assemblyman Carpenter requested clarification of the map displaying 
the location of cases in Woburn. Not all of the dots were included in 
the Woburn cluster, highlighting the difficulty of cluster 
identification. In terms of the genetic link, a prenatal exposure 
compounded by a secondary environmental insult had been the leading 
theory.
    Dr. Levin interjected with an explanation of the role of genetics 
in the development of all diseases. Disease was described as a function 
of the individual as he responded to an etiologic agent.
    Chairman de Braga asked if the findings in Woburn had been 
conclusive. Dr. Byers replied that the findings were highly conclusive 
and included the confirmation of autoimmune abnormalities among family 
members of the leukemia victims. In response to a question regarding 
the 20-year timeframe, Dr. Byers clarified that once the active 
investigation was instigated and publicized, the answers were apparent 
within 3 years. Woburn demonstrated conclusively that it was in-utero 
exposure and that when the suspect water wells were closed, new cases 
ceased within 10 years (i.e., latency period).
    Chairman de Braga acknowledged the contribution of Dr. Byers and 
Dr. Levin and requested submission of their recommendations for future 
action.
    Assemblywoman Gibbons summarized the factors that were known to be 
correlated with leukemia, for example a virus. She also requested 
clarification on the socio-economic status of the families in Woburn 
and the role that Dr. Byers and Dr. Levin would play in the Fallon 
investigation. Had they been invited to participate? Both responded 
``no'' to the question of invitation.
    Dr. Byers expanded her explanation of viral etiology by stating 
that interaction with a chemical carcinogen was required to trigger the 
cancer. In terms of socioeconomic class, Dr. Levin stated that all of 
the Woburn families had great similarity as well as stability (i.e., 
long term residence in the area).
    In response to Assemblyman Carpenter's question about the known 
causes of up to 70 percent of cancers, Dr. Byers stated that triggers 
such as smoking and tricholorethylene exposure had been well 
established and documented. Assemblyman Carpenter observed that there 
appeared to be more cases of cancer, despite the recent medical 
discoveries. Dr. Byers shared her theory on the movement of industrial 
chemicals into households and the significant increase in exposure. Dr. 
Levin added his observation that pancreatic and brain cancers, once 
rare, had become much more common today. Breast cancer appeared to be 
epidemic.
    Assemblyman Carpenter probed for a theory on the increase in 
cancers. Dr. Levin explained that brain cancer had been tied 
conclusively to maternal cigarette smoking and exposure to certain 
pesticides.
    Assemblywoman McClain requested a comparison between Fallon and 
Woburn, specifically the compact number of years in the Fallon cluster. 
Dr. Levin stated emphatically that the circumstances in Fallon 
suggested an ideal case and great opportunity to learn. Chairman de 
Braga expressed her hope of the continued involvement of Dr. Byers and 
Dr. Levin.
    Testimony resumed with Al Biaggi, Administrator of the Division of 
Environmental Protection. A report entitled ``Environmental Conditions 
Summary of the Fallon, Nevada Area'' (Exhibit H) was distributed to the 
committees. Mr. Biaggi introduced his staff and then presented an 
overview of the agency's principal activities.
    Water quality issues received highest priority with Nevada 
Environmental Protection. Issuance of permits, followed by quarterly 
compliance reports were, reported to be the key elements of their water 
monitoring programs. Periodic inspections had been conducted by the 
agency to further ensure compliance with regulations. Mr. Biaggi 
referred the committees to the handout, which contained summary tables 
of caseload data.
    In terms of Fallon, Mr. Biaggi described the area as not being a 
heavily industrialized area. Fallon had a total of 64 permits, with 14 
connected to industrial storm water and 19 assigned on a temporary 
basis for cleanup of site contaminations. Waste management covered 
solid waste (i.e., landfills), waste generation of hazardous waste, and 
the oversight of facilities using highly hazardous materials. Mr. 
Biaggi added that there were four facilities in Fallon designated as 
hazardous waste facilities, one being a chrome-plating operation and 
the remaining three being geothermal power plant operations. In regard 
to solid waste management, there had been a steady decrease in the 
number of landfills, with only one remaining in the Churchill area.
    Mr. Biaggi outlined the air quality programs which operated in 
concert with the permitting processes described above. For Fallon, only 
two companies at three facilities had been subjected to reporting under 
the EPA TRI--Toxic Release Regulations. Statistics for the two 
companies had been unremarkable.
    Strong inspection and enforcement programs ensured compliance with 
regulations. In Fallon, there were permits issued for six geothermal 
plaints, six mineral processing facilities, eight sand and gravel 
operations, two industrial permits, four surface area disturbance 
permits, and two NAS permits (e.g., boilers and power generators).
    Data for spills and accidents revealed 86 sites in the Fallon area, 
with 76 cases involving petroleum products. Ten cases were reported to 
be still active.
    Mr. Biaggi introduced Paul Liebendorfer, Chief of the Bureau of 
Federal Facilities, who presented an overview of the Fallon Naval Air 
Station activity. Mr. Liebendorfer stated that 26 sites were known at 
the base and under current scrutiny. Principal contaminants included 
fuel oil, paints, solvents, and industrial refuse materials. The upper 
aquifer had been contaminated to a depth of 20 feet, however no 
contaminant had migrated off the base. General ground water flow was 
known to be to the southwest direction and away from the Fallon area.
    Chairman de Braga requested clarification on the testing of soil 
and air in addition to water testing. Mr. Leibendorfer explained that 
all of the contamination had been determined as subsurface, therefore 
no air tests were warranted. Chairman de Braga questioned the follow-up 
procedures for fuel dumping. Mr. Biaggi interjected to explain that 
fuel dumping in the air was considered a distinct activity and not 
related to their responsibility to address soil and ground water 
contamination.
    In reply to Chairman de Braga's question about well contamination 
with JP8 jet fuel, Mr. Biaggi acknowledged a problem with groundwater 
contamination at the site with JP8.
    Assemblywoman Gibbons asked for clarification on the scope of the 
authority and the ability of the State Environmental Protection 
Division to govern environmental events at the Fallon NAS. Mr. Biaggi 
characterized the relationship as a cooperative agreement with the 
Federal Government.
    In response to Assemblyman Carpenter's question regarding detection 
of jet fuel in well water, Mr. Biaggi stated that there had been no 
indication of hydrocarbon contamination. Assemblyman Carpenter next 
asked Mr. Biaggi if other tests had been conducted which might provide 
insight to cancer. Mr. Biaggi reiterated that municipal wells were 
tested frequently and that hydrocarbons had not been detected.
    Chairman de Braga stated that it would be helpful to get a list of 
recommendations which included what could go wrong. Mr. Biaggi 
explained that there had to be an exposure pathway and that the mere 
presence of a chemical contaminant would not be enough to cause harm. 
Water would be suspected as a likely pathway, however there had been no 
proof to date.
    In response to a question about agricultural activities by 
Assemblyman Carpenter, Mr. Biaggi acknowledged the testing of water for 
agricultural contaminants. He referred the committees to the Nevada 
Department of Agriculture.
    Mr. Biaggi reintroduced Mr. Liebendorfer and the topic of the Shoal 
Project, an underground nuclear detonation near Fallon in 1963. Through 
the years, testing and remedial efforts were implemented, and Mr. 
Liebendorfer described the site as contained today. Ground water wells 
had been monitored through the years, with one well revealing traces of 
a radionucleide. Any movement of ground water would be away from the 
Fallon area.
    In response to Chairman de Braga, Mr. Liebendorfer clarified that 
the wells had been tested within the last 6 months. The Department of 
Energy had hired the Desert Research Institute to conduct a full-scale 
study of the groundwater movement at the site of Project Shoal.
    Mr. Biaggi concluded his presentation with mention of Nevada's only 
superfund site, the Carson River. With known high levels of mercury, 
the Carson River had long flowed through the Fallon area, however, 
links between mercury and cancer had not been established.
    Assemblywoman Gibbons requested clarification of the flow of 
groundwater to the east. Mr. Biaggi reiterated that the flow and any 
potential contaminants from the navy base would be away from the Fallon 
community. Mr. Biaggi expressed his appreciation for the opportunity to 
participate and assist in the investigation.
    Chairman de Braga introduced Dr. Bruce Macler, Regional 
Toxicologist, EPA, San Francisco. Dr. Macler shared a handout of his 
presentation (Exhibit 1). Dr. Macler stated that the focus of his 
testimony was arsenic and its possible relation to the Fallon cluster. 
Exposure routes to arsenic were described as varied. Dr. Macler 
emphatically labeled arsenic a poison, regardless of ingestion route. 
Arsenic had been conclusively linked to lung, bladder, skin, liver, 
kidney, and prostate cancers, as well as diabetes and neurological 
complications. Like other cancers, leukemia occurred when damaged genes 
caused cells to reproduce uncontrollably.
    Dr. Macler elaborated on the quantification of disease rates and 
associated arsenic levels. Extrapolation downward from certainty to 
uncertainty was voiced as a concern. Some cancer risks had been 
quantified with confidence; however, information was not abundant on 
the association with childhood leukemia. International studies (e.g., 
Bangladesh) did not reveal an increase in childhood leukemia cases. The 
mechanism of arsenic damage appeared to be related to the repair 
mechanisms of chromosomes. Acute Lymphocytic Leukemia (ALL) had been 
linked to genetic damage in earlier testimony. Dr. Macler speculated 
that arsenic did not initiate the leukemia but rather established a 
toxic background so that the actual causal agent could trigger the 
leukemia. Whatever agent triggered the leukemia was amplified by this 
toxic background, asserted Dr. Macler.
    The question persisted in scientific circles about why Fallon had 
not witnessed increases in other cancers. Over a lifetime, with an 
estimated 10,000 residents in Fallon, 100 people would be expected to 
get cancers of all types from exposure to arsenic.
    Detoxification of arsenic was described as a methylation process in 
the human body and was said to offer some protection to the human. 
Thinking had changed drastically in recent years, and the distinction 
between safe and unsafe forms of arsenic was obliterated. In moving 
from the known to the unknown in calculating risk, regulations 
interfered with risk assessment. Dr. Macler emphasized that toxicology 
and epidemiology and risk assessment were described as different 
processes, but interrelated fields. Risk assessment was depicted as a 
process that had been driven by regulatory needs.
    Dr. Macler emphasized that there was no known threshold for arsenic 
and corresponding adverse effects. It had the status of a nonthreshold 
carcinogen. In summary, Dr. Macler stated that arsenic posed health 
risks and regulatory challenges, however the risks could not be used to 
link arsenic to the childhood leukemia cases. He further stated that 
arsenic had the potential of being a contributing factor.
    Chairman de Braga asked if 10 parts per billion was an unrealistic 
level or excessively low. Dr. Macler replied that he did not agree, and 
added that 10 was feasible and a good place to be. Costs were predicted 
to go down for methods to treat arsenic in drinking water.
    Assemblyman Carpenter referred back to an earlier comment made by 
Dr. Macler and requested that he elaborate on any issues that caused 
him concern during the day's testimony. Dr. Macler explained that the 
nature of childhood leukemia and the associated chromosomal damage 
caused him concern. The immunological steps employed by the body to 
clean up damaged genes and systems needed more research to fully 
understand the relationships, especially in relation to arsenic health 
effects.
    Assemblywoman Gibbons asked for clarification about the data that 
indicated that methlylated arsenic compounds were as toxic as inorganic 
arsenic. Dr. Macler explained that the source of the data would be 
found in the Federal register, in the literature, and on their Web 
site. Dr. Macler reiterated that because arsenic had long been present 
in Fallon, it was likely to be a background amplifier rather than the 
primary cause of the ALL.
    In response to Assemblywoman Gibbons question regarding the role of 
individual genetics and impaired immunity, Dr. Macler agreed that there 
was a possibility of that association. He did not, however, agree that 
it could be a fluke. He cautioned the committee members to remember 
that everyone had been exposed to arsenic in Fallon water, but not 
everyone got sick. Everyone could have been exposed to something else 
in Fallon that might have initiated childhood leukemia. Testimony did 
not indicate compact exposure among these 11 children in Fallon. 
Variability in susceptibility had to be factored into the 
investigation.
    Assemblywoman Koivisto requested clarification about the 
calculation of risk, for adults or for children or for both. Dr. Macler 
stated that the risks were calculated for adults and therefore biased. 
Risks were seldom quantified for childhood cancer.
    Chairman de Braga expressed her appreciation for the testimony. The 
meeting was adjourned at 5:19 p.m.
            Respectfully submitted,
                                               June Rigsby,
                                               Committee Secretary.
                                 ______
                                 
                           February 13, 2001
    The Committee on Natural Resources, Agriculture, and Mining was 
called to order at 1:18 p.m., on Tuesday, February 13, 2001. Chairman 
Marcia de Braga presided in room 1214 of the Legislative Building, 
Carson City, Nevada. As there was no quorum present, Chairwoman de 
Braga convened the meeting as a sub-committee of Natural Resources, 
Agriculture and Mining, and Health and Human Services. Exhibit A is the 
Agenda. Exhibit B is the Guest List. All exhibits are available and on 
file at the Research Library of the Legislative Counsel Bureau.

    Committee Members Present.--Mrs. Marcia de Braga, Chairman; Mr. Tom 
Collins, Vice Chairman; Mr. Douglas Bache; Mr. David Brown; Mr. John 
Carpenter; Mr. Jerry Claborn; Mr. David Humke; Mr. Harry Mortenson; Mr. 
Roy Neighbors.
    Committee Members Absent.--Mr. John J. Lee; Mr. John Marvel; Ms. 
Genie Ohrenschall.
    Guest Legislators Present.--Assemblywoman Sharon Angle, Assembly 
District 29; Assemblywoman Dawn Gibbons, Assembly District 25; 
Assemblywoman Ellen Koivisto, Assembly District 14; Assemblywoman 
Sheila Leslie, Assembly District 27; Assemblywoman Kathy McClain, 
Assembly District 15; Assemblywoman Bonnie Parnell, Assembly District 
40; Assemblywoman Debbie Smith, Assembly District 30.
    Staff Members Present.--Linda Eissmann, Committee Policy Analyst; 
June Rigsby, Committee Secretary.
    Others Present.--Captain D.A. ``Roy'' Rogers, Commanding Officer, 
Naval Air Station Fallon; Charles Moses, Environmental Scientist, 
Nevada Department of Agriculture; Mike Wargo, District Manager, 
Churchill County Mosquito and Weed Abatement District; Ken Tedford, 
Mayor, City of Fallon; Mike Mackedon, City Attorney, Fallon; Dr. Donald 
D. Runnells, Senior Technical Adviser, Shepherd Miller, Inc.; H. Robert 
Meyer, Senior Scientist, Shepherd Miller, Inc.; Bjorn P. Selinder, 
County Manager, Churchill County; Norman Frey, Commissioner, Churchill 
County; Gwen Washburn, County Commissioner; Dr. Bonnie Eberhardt Bob, 
representing the Western Shoshone Nation; Leuren Moret, representing 
Scientists for Indigenous People; Keith Weaver, a long-term resident of 
Fallon.

    This meeting continued the hearings from February 12, 2001, and was 
the second part in a three-part series. Chairwoman de Braga requested 
that committee members and agency representatives write down 
recommendations to be included in the final report to the Congressional 
committee hearings to be held at a future date. A work session was 
planned for February 21 during which no testimony would be taken unless 
an expert was available, but final recommendations for any legislation 
would be made.
    Captain David Rogers, Commanding Officer of Naval Air Station 
(NAS), Fallon, Nevada, opened the hearing by reading a statement 
(Exhibit C) that gave an overview of the history and operations of the 
base since 1942, and issues which pertained to the investigation of the 
leukemia cluster.
    Chairwoman de Braga asked Captain Rogers to explain a little about 
the pipeline that brought fuel to the base, the route it took, who 
owned it and who was responsible for monitoring it.
    Captain Rogers explained that the pipeline was owned and monitored 
by Kinder Morgan Co. of Sparks, Nevada; specifically, it was tank 16. A 
6-inch pipe ran 70 miles along 1-80, then through Churchill County to 
the base. NAS assumed responsibility for the fuel when it was on the 
base. Captain Rogers stated that Kinder Morgan had an extensive 
monitoring program for leakage in the pipeline, which included pressure 
differential testing in the pipe and testing of the soils around the 
pipe. Kinder Morgan had not found any significant problems. 
Additionally, air and water sampling done on the base had not indicated 
any leakage problems.
    Assemblywoman McClain asked if any planes came back to Fallon from 
``Desert Storm'' and if there had been any way contaminants could have 
come back with them. She wondered if the cause of the leukemia problems 
could be airborne and asked if any investigations had been done to see 
if that was a possibility.
    Captain Rogers replied the airplanes that participated in ``Desert 
Storm'' and ``Desert Shield'' action were not based at Fallon. There 
was probably a 1\1/2\- to 2-year time lag before any of those aircraft 
came to Fallon for training. The Navy had not investigated the 
possibility of contamination and submitted that it probably was not 
warranted.
    Assemblywoman Smith inquired if the Navy was doing any follow-up 
with families that had been in Fallon during this time period to 
ascertain if they were included in this study.
    According to Captain Rogers, the Navy medical community was 
investigating whether any families which were no longer based at NAS 
Fallon had cases of acute lymphocytic leukemia (ALL) occur since their 
departure. This investigation would be completed by the beginning of 
March. To date, the study was about 60 percent completed and none had 
been found.
    Assemblywoman Smith asked if the fuel-handling procedures included 
the dumping of jet fuel, or if there had been a particular 
precautionary measure that was covered in the fuel handling.
    In response, Captain Rogers declared, generally fuel handling had 
many aspects: refueling of aircraft, clean-up of fuel spills which 
happened either as the airplanes were refueling or if the fuel 
inadvertently was jettisoned overboard on the ground, and in-the-air 
fuel dumping above 6000 feet of ground level.
    There was an extensive spill containment program; the amount that 
was spilled was handled in various ways based on the size of the spill. 
If on concrete, it was cleaned with absorbent materials that were 
disposed of in accordance with hazardous materials instructions. If the 
spill was on soil, the soil was excavated and burned. The total number 
of spills was insignificant in terms of the amount. Captain Rogers 
offered to provide those figures if they were requested.
    Captain Rogers continued, the only reason to jettison fuel over 
land would be during an emergency when the plane must be reduced to 
landing weight in order to land. The total number of times this had 
occurred was perhaps 3 times in the past 15 years. In all three cases, 
the fuel was jettisoned out to 1he east of the base. As evidenced in 
the monitoring, the contaminants moved 10 the east out of the base 
area.
    Chairwoman de Braga stated that as she read the articles in the 
newspaper, she noted a comment that ``they regularly see dumping'' and 
asked what might have been seen.
    Captain Rogers submitted that probably these were contrails, an 
action between the exhaust product from the airplane and the water 
vapor in the air which created a cloud that could appear like fuel. He 
acknowledged the exhaust from the aircraft smelled like fuel.
    Chairwoman de Braga asked if something had changed in recent years 
regarding the dumping at 6,000 feet rather than the 6,000 meters 
minimum standard of the Federal Government.
    Captain Rogers replied-that the Department of Defense (DOD) 
regulation is 6,000 feet above ground, unless it was a true emergency.
    Chairwoman de Braga, to clarify, stated perhaps it was not a 
requirement but that above 6,000 meters was estimated to be the proper 
range above which fuel dissipated or evaporated before it hit the 
ground.
    Captain Rogers agreed but continued that there had been further 
study. Six thousand feet was the DOD standard until the introduction of 
JP8 jet fuel. JP8 did not disseminate as well as the JP4 and JP5 that 
were previously used by the Navy. The Navy and the Air Force were 
investigating a higher dump altitude. He affirmed that any fuel that 
did not dissipate in the air would do so on the ground within 18 to 20 
hours.
    Assemblywoman Gibbons asked, as 1,800 people lived on base and 
6,400 personnel resided off the base, were the two military children 
diagnosed with ALL living on or off the base? And, was there data to 
compare a base similar to Fallon, and were there any acute lymphocytic 
leukemia cases on those bases?
    Captain Rogers answered the first question by stating he was 
unaware of where the children lived. Regardless, the water came from 
the same aquifer. As for the second question, the Navy had done no 
comparison of ALL rates in Fallon and other military areas. The 
military medical community was ``all over this one'' and if there had 
been another area with this same rate, that would show up in the 
investigations.
    Assemblywoman Gibbons asked how many of the 8,200 are children. 
Captain Rogers offered to get the exact number, but estimated it was 
around a thousand.
    Assemblyman Neighbors said that he had seen much of the aluminum 
foil chaff that was dropped out of the aircraft in the desert and asked 
if everyone was comfortable that it was not a problem.
    Captain Rogers defended that chaff was expended on the range 
considerably east of the town and any chaff migration would tend to 
drift further east with the prevailing wind. He explained that a select 
panel of research scientists from eight universities studied the 
harmful effects of chaff and concluded that there were none Chaff was a 
litter issue, not a health issue. The total amount expended at Fallon 
equated to one quarter of one ounce per acre per year. This was an 
amount that the Navy was willing to use in the name of combat training. 
Captain Rogers further affirmed that the combat training done with 
chaff was essential because it was an end game maneuver that could save 
a pilot's life if a missile was shot at him. Without that three-
dimensional training, people would die in combat.
    Assemblywoman Parnell assumed that NAS Fallon had material safety 
data sheets (MSDS) for toxic wastes and chemicals that they used, and 
asked if the Health Division had seen them.
    Captain Rogers acknowledged the base had that information but was 
unaware if the Health Division had looked at it.
    Ms. Parnell requested to know that the Health Division did have 
that information in their possession. Ms. Parnell pointed out that in 
her packet of information she had a 1999 article from the Las Vegas Sun 
regarding the citation of the U.S. Navy by the U.S. EPA for 
noncompliance and violations of hazardous chemicals that were noted 2 
years prior to 1999. She requested to know the current status of 
compliance.
    Captain Rogers claimed the article, as it appeared in the paper, 
was ``not exactly factual.'' He believed that Mr. Liebendorfer of the 
State Division of Environmental Protection was aware of the situation 
and testified on February 12 that the base was in compliance, and what 
was reported on was a difference of opinion between the State and the 
base regarding the interpretation of the regulation. That had been 
resolved.
    Assemblywoman Leslie questioned whether the live or spent ordinance 
on bombing ranges Bravo 20 and Bravo 16 was swept up and discarded, and 
did this debris have any possible connection to the problem? This range 
scrap was extensive on the four ranges, Captain Rogers admitted. There 
were times during the year when it was swept into large piles until 
portions were removed. Scientists determined that contamination from 
range scrap piled onsite in these dry alkaline lakebeds was not an 
issue. Any migration of contaminants would tend to move eastwards.
    Ms. Leslie asked if this was checked once or regularly every year. 
According to Captain Rogers, the DOD Inspector General prepared a 
report about this and regular testing of the environment was conducted.
    Ms. Leslie's second question regarded the reaction of the families 
of the military. She wished to know if they had asked the Navy for help 
which had not been touched on in this hearing. The Captain replied this 
was an emotional issue. The base had held town meetings. He affirmed 
that the Navy did not feel that Fallon was an unsafe place to live nor 
that this situation warranted moving families out of the area.
    Ms. Leslie asked if the community accepted this or were some asking 
for transfers out of the area. Captain Rogers believed that the 
majority accepted this. Just a couple of people asked informally if 
they could transfer but the Navy would not entertain that until they 
had been convinced there was a problem. The San Diego-based Navy 
Environmental Health Command was intimately involved with the 
investigation and were as concerned as the local civilian community. 
The Navy was doing everything possible to determine a solution. He 
continued that if the DOD felt there was an immediate threat, ``they 
would pull out.''
    Assemblywoman Gibbons questioned whether he knew of any commonality 
between the two cases with military children and the other nine cases 
in the civilian community. The only answer Captain Rogers said he could 
offer was there was nothing that was a common trait. The lifestyles and 
activities were varied.
    Assemblywoman de Braga returned to the pipeline issue asking if the 
Navy could detect small leakages on the base. Captain Rogers guessed 
that would depend on the definition of ``small'' leakages.
    Ms. de Braga restated her question to inquire if the pipeline could 
be leaking in such small amounts that it would not be detected anywhere 
along its route. Captain Rogers acknowledged that a minute amount of 
fuel would be detected in any water source. If fuel leaked from the 
pipeline, he said, the ``very aggressive'' water testing program would 
detect it. Ground testing was also done. The results of the testing 
were reported to him and to State and Federal agencies that oversaw the 
base water quality program. He further explained that Kinder Morgan Co. 
was obligated to inform NAS Fallon if a problem was detected on the 
pipeline anywhere off base. The base received the results of their 
testing but Captain Rogers did not ``know specifically if there's a 
requirement for them to do that or not.'' He would get that information 
for Chairwoman de Braga.
    Ms. de Braga stated that she wanted to be certain that enough 
precautions were in place. She did not feel that there was ``a lot'' of 
ground testing being done, but there was quite a bit of water testing. 
She questioned again what the Navy was proactively doing differently to 
help in this effort; e.g., studies, tests, or other possible 
environmental causes.
    Captain Rogers told the committee that the Navy was more sensitive 
to the environmental issues on base. NAS Fallon, he said, had much 
pride in the environmental programs he outlined previously (Exhibit C). 
He felt the Navy had a good relationship with the State and Federal 
agencies which monitored the activities. Captain Rogers revealed that 
he had a task force on base that assisted with the investigation.
    Ms. de Braga asked if the State had the authority to test on base. 
The DOD and the Navy would give permission if necessary, Captain Rogers 
replied. Assembly-
woman Koivisto asked Captain Rogers about the by-products in contrails 
that people were breathing. He responded that the exhaust of a jet 
airplane was similar to that of a motor vehicle. Contrails were 
essentially water vapor, not a hazardous substance.
    Ms. Koivisto stated that since automobile emissions were controlled 
because of health effects on the population, she found it difficult to 
believe that a jet airplane did not have as much exhaust as 
automobiles. Captain Rogers replied that it had a similar composition 
and offered to get that information for her. He continued that 
obviously there is a larger amount than a car but State and Federal 
regulations controlled their air permits.
    The next speaker, Charles Moses, an Environmental Scientist of the 
Nevada 
Department of Agriculture (NDOA), stated that goals of the 
Environmental Compliance Section (ECS) were to protect health and the 
human environment from the adverse effects of pesticides and to assure 
that pesticides remained available as valuable tools in an integrated 
approach to pest management.
    He stated that pesticides were used and regulated in a number of 
applications, not just associated with agriculture: in ornamental lawns 
and turf, golf fairways, household and domestic dwellings, fur- and 
wool-bearing animals, even pets, wood protection, swimming pools and 
hot tubs, airport landing fields, tennis courts, highway right-of-way, 
mosquito abatement districts, and many more.
    The challenge of regulating pesticides existed, he said, basically 
because of the dual nature of the products. That is, they were a 
tremendous benefit for the production of agricultural products and for 
the protection of human health, but when they were used inappropriately 
or inconsistently with label directions, they had adverse affects.
    Mr. Moses indicated that the State of Nevada had a cooperative 
agreement with the U.S. Environmental Protection Agency (EPA), that the 
State received funding and oversight from the agency to regulate 
pesticide use, manufacturing, sale, distribution and application.
    Mr. Moses continued by giving an overview of the regulatory program 
that enforced the EPA provisions in the state. This defined a pesticide 
as any substance that made a claim of preventing, destroying or 
repelling a pest or a substance or mixture of substances used for plant 
regulators, defoliants and desiccants.
    Since the creation of the EPA in 1972, it has been required that 
all pesticides must be registered. The law was revised in 1996 to 
eliminate the benefit factors on food crops and in areas where children 
would be exposed. All pesticides, new and existing, were required to 
conform to the standards.
    Based on the data submitted for pesticide registration, the EPA 
developed a label that addressed the hazards of using the products. Mr. 
Moses emphasized that what set a pesticide label apart from other 
hazardous chemical labels was that this label was the law. An 
applicator must use this product in accordance with all information 
that was printed on the label. A signal word ``CAUTION'' was used on 
the label for the safest type product to give an indication of how 
acutely toxic the pesticide was. In other words, with a large dose over 
a small period of time, the ``CAUTION'' gave an indication of whether 
the victim would experience health effects. For this type of product, 
he claimed, it would take quite a bit to actually cause health effects. 
However, the signal word would not say how chronically hazardous this 
product was, used over an extended period of time.
    Lastly, Mr. Moses continued, the EPA gave the State the 
responsibility of enforcing the pesticide law and the State had to show 
that it had similar State laws to regulate the sale, manufacturing and 
use of pesticides (Chapters 555 and 586 of the Nevada Revised 
Statutes). Commercial applicators and farmers were trained, tested and 
regulated. The NDOA required all applicators submit reports of 
customers, sites, products and quantities applied. These reports and 
data have been acquired since 1970.
    Mr. Moses said that the NDOA, as part of the agreement with the 
EPA, did inspections on Federal property and had been to the NAS Fallon 
airbase to inspect the pest control activities. In most cases, he 
stated, they found that the Navy contracted with private individuals 
and licensed companies to do the work. According to Mr. Moses, the Navy 
asked the contractors ``to go above and beyond'' what NDOA required, 
and concluded that they had been cooperative with the Nevada 
inspectors.
    Next, Mr. Moses showed a sample of a sales report which showed who 
bought restricted-use products. All of this was public information and 
was available upon request.
    Mr. Moses then shifted gears and explained the ground water 
monitoring program for pesticide residue. In 1988, the EPA found that 
pesticides existed in low levels in a lot of different areas and in 
some cases in public drinking supplies and shallow ground water wells. 
Since then, the EPA has required every State that had a cooperative 
agreement with them to have a regulatory program designed to protect 
ground water from becoming more contaminated or becoming contaminated 
from the applications and use of pesticides.
    For a long time, Mr. Moses admitted, it was thought that pesticides 
could not seep down 150 to 200 feet to water wells. But even with 
proper application, he said, it had been found that pesticides had 
properties that may allow them to leach down into ground water. Mr. 
Moses showed that since the monitoring program was implemented, there 
had been more detections in urban areas than in rural areas in the 
ground water sampling.
    Mr. Moses distributed a fact sheet (Exhibit D) done with the U.S. 
Geological Survey (USGS) that explained the monitoring program. In most 
cases, the wells were constructed by the NDOA to look at the shallowest 
aquifer they could find. If pesticides were to show up in the shallow 
wells, there would be time to implement regulatory measures before the 
pesticides leached to the deeper aquifer.
    In Churchill County last year, Mr. Moses further explained, water 
samples from about 20 wells, many of which were put in by the USGS, but 
some were irrigation wells, were examined for about 40 EPA-registered 
products. The NDOA did not look for products that the EPA canceled due 
to health risks because there would be no regulatory measures that NDOA 
could take to try to keep the pesticide from getting worse because it 
was no longer being used. No contamination was found in Churchill 
County.
    In one other item, Mr. Moses showed that the USGS did some studies 
``in that area'' of ground water and surface water samples and did find 
pesticide residues. The chart he used showed the levels were far below 
what a health advisory would be for these products. Many of the 
products leached into the ground water were a result of right-of-way 
applications. These included Atrazine, Prometon and Simazine. He 
summarized that most of the cases of leached pesticides were not from 
agricultural products but from use around homes, lawns and right-of-
ways. But they were still quite low, far below health advisory levels.
    Lastly, Mr. Moses stated that he had information about studies that 
he had requested the EPA send him. He declared he would be glad to 
submit them to the committee because there had been some links to 
different types of uses where the mothers were working with the 
chemicals when their children developed leukemia.
    Chairwoman de Braga agreed she would very much like to see that 
information because those gaps might lead the committee somewhere in 
this investigation. She felt it helped them to know the extent to which 
the NDOA went to protect people from chemicals. But, she questioned, 
what could go wrong? The bottom line was that there was not complete 
regulation because you could not know if a housewife mixed 409 and a 
non-recommended agent which had fine print on the bottle that nobody 
read. Maybe education would be the key to this. What she and the 
committee wanted to know is not what was being done but rather what was 
missed.
    Mr. Moses agreed that one problem they had was assessing the use of 
pesticides by homeowners. There was data in some of the studies that 
suggested that there were links.
    Mrs. de Braga added that even the people who aerial crop-sprayed, 
who sprayed your house for spiders or whatever, were they taking the 
proper precautions? And what about accidents? The problems might have 
been entirely different from house to house.
    Assemblyman Neighbors asked about the ground water level of the 20 
wells that were tested in the Churchill County. Mr. Moses believed that 
the monitoring wells averaged about 40 feet. Drinking water and 
irrigation wells were much deeper.
    Mr. Neighbors stated that, as he recalled, Nevada law said you may 
put a well and a septic tank on one and a quarter acre. Correct? Mr. 
Moses was uncertain. Mr. Neighbors ask about the percolation rate and 
Mr. Moses replied that he did not know.
    Ms. de Braga suggested that this was not really his area. Mr. 
Neighbors said it would be interesting to know because there were areas 
of Nevada where that had become a problem. Too many nitrates might be 
in the water. Mr. Moses believed that the Health Division had that data 
and it could easily be obtained from them.
    Assemblywoman Gibbons mentioned that the members of the committee 
were given maps of the Fallon area that showed where the children with 
leukemia lived. She asked if there was a map that showed the areas 
where pesticides were used. Could the rainfall or drought years have 
had an effect on this? Mr. Moses answered that he could probably come 
up with a map of the agricultural areas but it would be tougher to do 
the residential usage areas. They did not know what homeowners were 
using nor how much.
    Ms. de Braga inquired about the types of complaints Mr. Moses had 
received about pesticide use. They ranged from human health and 
vegetation damage to possible adverse effects to animals, Mr. Moses 
replied. He got from 10 to 50 of these serious investigations per year. 
At conclusion, Mr. Moses distributed a list of Available Resources for 
the Leukemia Task Force (Exhibit E).
    The next speaker was Michael J. Wargo, District Manager, Churchill 
County Mosquito and Weed Abatement District (MWAD). He distributed a 
letter that outlined the activities of the Mosquito and Weed Abatement 
District (Exhibit F). With this he also distributed material safety 
data sheets for the pesticide used by the District (Exhibit G). Mr. 
Wargo stated that he was a biologist more so than a chemist with a 
degree in entomology, the study of insects.
    Mr. Wargo briefly reviewed the information in the letter that 
addressed the history of the MWAD, the chemicals they used to control 
mosquitoes, and the weed activities. To control the mosquitoes, his 
staff considered the site, the size of the colony, the impact on the 
area and the population of the natural predators at the site. With the 
mosquitoes in an early stage of development, natural agents such as a 
bacteria or mosquito hormones were used for control. In a later stage, 
a light petroleum oil was used in the water to suffocate the pupae. If 
mosquitoes reached the flight stage, they were treated with pyrethrum, 
a compound made from chrysanthemums, or with Dibrom aerially applied 
over a large acreage. These latter two applications were not preferred 
because of the expense and the difficulty of application. Mr. Wargo 
added that most of the mosquito populations were not in Fallon but out 
in the rural surroundings.
    Next Mr. Wargo spoke about the weed control activities that began 
in 1987. The chemicals used were listed on page 3 of his letter 
(Exhibit F). In 1999 and in 2000, Pendulum was used as a preemergent 
along the county roadsides. During the summer, Glyfos and Weedone were 
used. Arsenal was used to create a bare zone that protects a road base 
from emergent weeds that damaged asphalt. Roundup and 2-4-D were used 
as needed to eliminate emerging weeds.
    Mr. Wargo concluded by saying that, from 1998 to 2000, Tall 
Whitetop control along the Carson River required the use of Weedar 64 
and Rodeo. Some isolated patches of Tall Whitetop, Russian Knapweed and 
African Rue were sprayed with Tordon.
    Chairwoman de Braga asked Mr. Wargo if there had been any 
substances used that were now considered unsafe.
    Mr. Wargo replied that he was unaware of any. All the chemicals 
they used, he said, were approved and were used extensively throughout 
the United States by State and county health departments and by other 
mosquito abatement districts.
    Ms. de Braga stated that in the history of the area much was done 
by aerial spraying, but if it were intended to kill insects, how could 
it not be harmful to humans who breathed it?
    In reply, Mr. Wargo referred to Mr. Moses' previous comments that 
the EPA required tests to be done before the chemical was registered. 
The end user had no input into that process.
    Right, Ms. de Braga agreed, then mentioned that the committee was 
back to not knowing what people were breathing in combination with this 
chemical and what deleterious effect this might cause. She asked if Mr. 
Wargo was aware of any use of jet fuel, or something with the same 
components as JP8, for weed killer. She stated she had received a 
report of this possibility in Churchill County. ``No,'' Mr. Wargo 
replied.
    Ken Tedford, Mayor of the city of Fallon, spoke next. He began his 
testimony by stating that Fallon was a tight-knit community, taking 
seriously the good and the bad that happened there. As the 
investigation into the leukemia cases unfolded, more media attention 
was paid to the children. He assured the committee that his focus was 
not on the town's image but rather to put the care and comfort of the 
children first while preserving their privacy. Mayor Tedford's goal was 
to establish a single point of contact in the community, a place were 
the families could go if they had needs that were not met, and a place 
for those who wanted to give their time, money or talent to assist.
    To avoid fear, rumor and lack of information, the city council 
prepared fact sheets and answers to frequently asked questions (Exhibit 
H) and other information for distribution throughout the community 
(Exhibit I). He thanked Governor Guinn, the State Health Division 
Administrator Yvonne Sylva, State Health Officer Dr. Mary Guinan and 
State Epidemiologist Dr. Randall Todd for their efforts. He declared 
that the city would continue to assist in the ongoing investigation.
    Mayor Tedford then began to speak about the city water supply that 
provided services to approximately 2,900 connections from four city 
wells pumping water from the Basalt Aquifer. However, he clarified, not 
all of the affected families were on city water--some used private 
wells and some drank bottled water. He restated the belief that the 
city water supply was not the common link in these cases.
    He acknowledged that arsenic was present in the water of Lahontan 
Valley. Many of the 4000 domestic wells, contained naturally occurring 
arsenic, as did the water in the city and Navy wells. Fallon had known 
of this arsenic for a long time and had struggled to deal with it. But, 
there appeared to be no link between arsenic and leukemia, he held.
    The city contracted with Shepherd Miller Inc. (SMI), an 
environmental and engineering consulting firm, to conduct tests and 
surveys for arsenic removal from the water. The public water system 
would need to comply with the new Federal standards of 10 parts per 
billion by the year 2006.
    Mike Mackedon, Fallon City Attorney, next read from a brief 
memorandum (Exhibit J) that stated that the city had engaged Shepherd 
Miller, Inc. in April, 2000, to provide technical consultation. Within 
the binder (Exhibit K) were some of the water reports ``in history'' 
that the city had provided to the State as part of its regular 
reporting duties, under State or Federal law. Additionally, there were 
numerous studies and analyses conducted by the city in excess of and 
different from those required under any reporting requirement, and some 
in direct response to the pattern of leukemia.
    SMI had been asked to examine past data to determine the quality of 
the data to the extent possible. They were further instructed to survey 
the available or innovative technologies that would remove arsenic from 
drinking water and select a suitable bent-scale test method, to perform 
tests, to review and analyze the results, and evaluate the results; to 
perform pilot-scale testing on the selected treatment technology, 
evaluate those results, and recommend a final arsenic treatment 
technology. The bent-scale tests were completed and pilot-scale testing 
began on November 30, 2000.
    Mr. Mackedon continued that SMI's work was expanded in July of 2000 
when the city learned of the childhood leukemia cases and that the 
pattern might have suggested an environmental cause. The mayor 
instructed Shepherd Miller to: review the available literature and 
research to confirm or not confirm a connection between arsenic and 
childhood leukemia, to review the available literature and research to 
confirm or not confirm a connection between the intake of radon and 
childhood leukemia, to re-review the historical analysis of the water 
chemistry of the city of Fallon, to proceed to develop a list of agents 
known or suspected to cause leukemia, and to perform tests of agents 
not previously analyzed.
    Mr. Mackedon introduced SMI representatives Dr. Don Runnells, 
Senior Technical Adviser, and Dr. H. Robert Meyers, Senior Scientist.
    Don Runnells spoke first, introducing the company, its history and 
himself, a water geochemist and professor at the University of 
Colorado. He reiterated that SMI was hired in April of 2000 to 
characterize the ground water supply and to provide recommendations on 
water treatment technology to address the arsenic issue. From September 
of 2000 through late January 2001, SMI reviewed and compiled data from 
historic groundwater analyses of samples from the city of Fallon water 
wells to determine if any regulated constituents were present in 
concentrations above the Nevada drinking water standards maximum 
contaminant limits (MCL).
    With the exception of an elevated value of lead in 1989 and the 
arsenic in all samples, the water had tested below the primary drinking 
water standards. In the secondary standards, total dissolved solids in 
the water had exceeded the secondary standard of 500 milligrams per 
liter. It also exceeded the standard for PH that is 6.5 to 8.5, having 
been around 9.
    Based on a very recent literature review for potential leukemia 
causing chemicals, Shepherd Miller, Inc. developed a list of chemicals 
and analytes, some of which could potentially cause leukemia, for which 
there had been no previous testing in Fallon. They excluded from the 
list pharmaceuticals, analytes for which there were no analytical 
methods for testing, chemicals used as part of the water treatment 
system, and highly reactive chemicals that had a very short half-life 
and were gone quickly when added to water. Those remaining of possible 
concern included formaldehyde, lead 210, and radium 224. In early 
February of 2001, the city of Fallon wells were sampled for these 
additional chemicals. The results had not yet come in.
    SMI also looked at the composition of fuels such as JP8 jet fuel, 
to determine if historic water analyses might contain components that 
could be related back to hydrocarbon fuels. No historic analyses showed 
a presence of volatile organic chemicals or synthetic organic compounds 
above detection limits. These were expected to be found if a fuel 
supply was, in fact, contaminating the ground water. Dr. Runnells 
remarked that the Fallon water was ``remarkably clean'' with the 
exception of the arsenic. The binder (Exhibit K) summarized the 
findings.
    Assemblywoman Koivisto asked for clarification as to why so much 
emphasis was placed on the water supply when the children who 
contracted the leukemia did not all use the same water source. Dr. 
Runnells affirmed that Ms. Koivisto's observation was correct. SMI was 
brought in originally specifically for the arsenic issue. Subsequently, 
with the community awareness of the leukemia cluster, the mayor and the 
city council directed them to expand the scope of their work to include 
a review of what was known about the relationship between arsenic and 
leukemia and also to identify other chemicals that might be related to 
leukemia. Dr. Runnells avowed that SMI did not believe that the city 
water supply was the problem.
    Assemblywoman Parnell stated that it appeared that most experts 
agreed that the most direct link to childhood leukemia would be that of 
radiation. She asked if it was possible to look for a radiation link in 
the water supply or somewhere else.
    Dr. Runnells affirmed that SMI was looking at the water 
specifically for radionuclides. In the binder (Exhibit K), Table 4 
listed the radionuclides and gave the values they found and the MCL. 
Gross beta could be composed of a number of radionuclides. Therefore, 
SMI also analyzed for lead-210 because it contributed to gross beta and 
had a high risk factor.
    Ms. Parnell asked whether anything on Table 4 alarmed Dr. Runnells, 
especially the gross alpha of Wells 2 and 4. He deferred that answer to 
Dr. Meyer as that was his field of specialty.
    Assemblyman Mortenson asked if the lead-210 was a more energetic 
beta to which Dr. Runnells replied that it was attracted to the surface 
of the bone and therefore had a high risk factor. Mr. Mortenson also 
asked about the short half-life of radium 224 and whether there were 
products in the decay chain that were stable enough to analyze and then 
infer back to the quantity of radium 224.
    Dr. Runnells replied that radium 224 was a decay product of thorium 
that normally was not found in the ground in a natural situation. But 
SMI was analyzing specifically for radium 224 to be certain something 
with a short half-life was not overlooked. The half-life of radium 224 
is about 48 hours.
    Mr. Mortenson asked if lead-210 was not a product in the decay 
chain of radium 224. Dr. Runnells believed that lead-210 came from 
uranium decay chain not the thorium decay chain.
    Assemblyman Claborn requested to know if any studies were conducted 
on small aquatic animals (frogs, fish, even birds). Dr. Runnells 
responded that he did not have that knowledge but that perhaps someone 
from the city or county knew. Mr. Claborn continued that generally when 
something happened [in the environment] it was noticed lower down in 
the chain of life. Dr. Runnells agreed stating he made an excellent 
point.
    Robert Meyer, a Senior Scientist (radiation biologist) with 
Shepherd Miller, Inc. testified next. He summarized the materials in 
the handout (Exhibit K). In late July of 2000, SMI began studies on the 
potential causes of childhood leukemia. They arranged for Dr. Glyn 
Caldwell, an epidemiologist, to participate in the health risk reviews.
    Mr. Meyer reiterated that SMI reached the conclusion that no 
obvious link existed between the Fallon water supply and the leukemia 
cases identified in the area, but the issue was not closed. The 
literature review summaries were provided in the binder (Exhibit K). A 
clear link between arsenic and leukemia was not revealed in the 
literature. As it had always been present in the water supply, arsenic 
did not seem to explain the recent appearance of childhood leukemia. 
One factor could be other sources of radiation, a known cause of 
leukemia.
    There were a number of possible sources of radiation to which 
everyone was exposed. Levels of radiation seen in communities were low 
with respect to the recognized standards for radiation protection. He 
explained there were different types of radiation that could impact a 
human. One would be an external source of radiation, such as cosmic 
radiation, gamma rays and other radiation sources from outer space, and 
from natural deposits of radioactive materials of the sort analyzed in 
the Fallon water supply. These natural deposits were also present, 
typically in low levels, in surface soils and rocks. Exposure from 
these sources included direct exposure and wind-blown exposure.
    Mr. Meyer went on to say that the ``Nevada experience is unique, of 
course, given the presence of the test site and the test that was 
conducted much closer to the city of Fallon.'' He had not studied the 
results of the test nor the weather patterns at the time, but he knew 
there were cases in which the circulation of radioactive materials was 
in other directions.
    There were also other possible sources of radioactivity in the 
environment that could have influenced this situation. It was not 
clear, he acknowledged, how an exposure from the 1950's or 1960's could 
impact a cancer that was rapidly developing. It would be good idea to 
examine the possibility of other sources of radiation in the area.
    Chairwoman de Braga asked if Mr. Meyers and SMI had compared their 
studies with those done at the base vis-a-vis the water system. Mr. 
Meyer replied that they were aware of the findings on the base but had 
not made comparisons.
    Assemblywoman Koivisto asked if the historic levels of arsenic 
remained the same or were there spikes and, were there studies of the 
effects of arsenic on children rather than just adults? Dr. Runnells 
answered that the concentrations of arsenic have been remarkably 
constant. Mr. Meyer stated that he was not aware of toxicological 
models that might extrapolate from adult leukemogenesis to childhood 
leukemogenesis.
    Assemblyman Mortenson related to Mr. Meyer that he recalled reading 
that minor earthquakes could produce fissures. As thorium was all over 
Nevada, he queried, could a minor tremor release a pulse of radon-224 
into the water. Mr. Meyer submitted that radon-222 and radon-220 were 
produced as a natural decay of uranium and thorium. He had read, too, 
that one of the ways to identify the potential for an earthquake 
occurrence would be to measure radon. The release of radon gas then was 
possible. The total exposure over a period of time would be a major 
factor in whether or not cancer might result. He speculated that the 
release of this gas prior to or during an earthquake might be quite 
brief, yet the damage done to a human body normally accrued over a 
period of time. A short low-level exposure would be unlikely to 
increase risk. Risk was proportional to dose.
    Mr. Mortenson apologized that he had meant to say radium-224 to 
which Mr. Meyer stated that he was unaware of particulate materials 
released during moderate earthquakes.
    Mr. Mortenson continued that he had read recently that with 
volatile organic compounds in drinking water, the ``body burden'' was 
via three methods: drinking the water, bathing with it, and through 
inhalation (steam of showers or cooking). Even though someone might 
have consumed bottled water, that was a fraction of the way the body 
absorbed water.
    Mayor Tedford of Fallon again testified the city began looking at 
the water first (Exhibit L) because it was something they had control 
over. The city had also begun looking at their landfills, utilities, 
airport and other lands that they own. He closed by saying that he 
hoped the committee would be vigilant in supporting the executive 
branch that had made this investigation a priority. Funds and staff 
were important to complete the mission. He thanked the committee for 
the opportunity to speak.
    Assemblywoman Leslie thanked the mayor for his testimony and asked 
him to briefly describe the plans for the resource center. She hoped 
that the Fallon Family Resource Center would be included. Mayor Tedford 
said this was to be a clearinghouse for assistance that would allow the 
families to maintain some anonymity. The hospital would assist and the 
Family Resource Center was a good idea.
    Bjorn Selinder, Churchill County Manager, with Gwen Washburn, 
Churchill County Commission Chairman, and Norm Frey, Churchill County 
Commissioner, read the following statement from Commissioner Washburn 
(Exhibit L):

          The Churchill County officials are very concerned about the 
        welfare of the citizens. We want to explore all possible 
        avenues that may attribute to the cause of leukemia but none of 
        us is willing to point to any one cause. We are leaving that to 
        the health experts.
          Ask 10 people on the street and we'll get 10 different 
        opinions as to the cause of the cluster. I will attempt to 
        address what the county is doing about some of the causes.
          In Churchill County, the first thought is always water. We 
        have been very concerned about how the reallocation of 
        irrigation water that historically came into the valley is 
        affecting the quality of the water being pumped from domestic 
        wells, especially since the passage of Public Law 106-18 known 
        as the Negotiated Settlement.
          Churchill County began cooperating with the U.S.G.S. on a 
        ground water monitoring project in 1994. In 1999, the data 
        collection network included water level measurements at 19 
        wells monthly, 39 wells quarterly, and annually at 18 wells. 
        Quality sampling and testing on five wells was done twice 
        during the year, once during the irrigation season and once 
        during the winter. The water was sampled for major ions, 
        arsenic and nutrients. In the year 2000, four more wells were 
        installed in an area slated for development where septic tanks 
        would be used for sewage disposal to provide background data on 
        the effect of development on water quantity and quality. Also 
        in the year 2000, one isotope sample was obtained and analyzed 
        at each of the five water quality wells. There's an attachment 
        that describes some of that activity.
          Realizing the potential for growth and the need to supply the 
        community with a safe and assured water supply in the future, 
        we have for the last several years been in the process of 
        developing a plan for a community-wide water system. The plan 
        is very tentative at this point and the economic feasibility 
        study is not yet complete. We are looking at every possible 
        source to supply this system, including Dixie Valley and the 
        Stillwater Mountain Range. In cooperation with U.S.G.S. and 
        Carson Water Subconservancy District, an injection and recovery 
        experiment storing water for municipal and industrial use from 
        Lahontan Reservoir in the Dead Camel Mountain alluvial fan will 
        begin soon. Every aspect of the proposed water system is in the 
        planning and study stage at this time. For all practical 
        purposes, the water system is many years away. At this point, 
        the cost to install the system, well over $200 million, is 
        prohibitive for a small community. Obviously, funding is the 
        huge hurdle for the county even after the water source is 
        identified and developed.
          In the interim we are faced with the problems here and now. 
        Churchill Economic Development Authority, known as CEDA, is in 
        the process of developing a vision for Fallon and Churchill 
        County. In this process, CEDA has held three public workshops 
        and one meeting of a committee made up of citizens from all 
        business sectors. Water quantity and quality have been 
        identified in every session as the top priority issue.
          There is little that Churchill County can do at this juncture 
        to improve the quantity and the quality of the water but [what] 
        we can do, and are prepared to do, is to educate citizens about 
        how they can help themselves. It has been suggested that we, 
        the county, test the well water. That is not something that we 
        can do. At our best estimate there are over 4,000 domestic 
        wells in the county and it would be not only cost prohibitive 
        and time prohibitive, but there are private property issues 
        involved as well. What we are doing is telling private well 
        owners how they can have their water tested.
          We are actively encouraging the University of Nevada 
        Extension Service to reinstate the Guard Our Local Drinking 
        Water program known as Nevada GOLD. This is a group of 
        volunteers dedicated to educating homeowners about their water 
        supply. It is funded through the agricultural extension budget 
        but has been inactive since the local water specialist became 
        ill more than 3 years ago. At this point it is imperative that 
        the University Extension Service reactivate this water 
        education program. Many people move into the area and purchase 
        their ``dream'' country home and they have no idea that the 
        water comes from their own private well and they have the sole 
        responsibility for that well. We will begin dispensing 
        information about water safety and possible health related 
        issues and testing labs at the local library, extension office, 
        county administrative office, planning office, doctors' 
        offices, and so forth.
          Operations of certain businesses and industries have been 
        blamed. Businesses and industries including agriculture, 
        pesticide operators and dairies that locate in the area must 
        have Churchill County business licenses and meet all the local 
        zoning criteria as well the Nevada Bureau of Health 
        requirements, and have all necessary permits from the Nevada 
        Department of Environmental Protection. We are looking at ways 
        to make the issuance of a business license contingent upon the 
        company showing current permits from the State of Nevada.
          Naval Air Station and jet fuel in particular are suspect. 
        Even though we have a good relationship with the Navy, we have 
        no control over the Federal facility and depend upon the Navy 
        to protect its personnel and its neighbors from any harmful 
        effects of their operation. We must leave investigations of the 
        operations of the Navy in Churchill County to the experts.
          The Churchill County commissioners are as concerned as any 
        one about this leukemia cluster and will work closely with the 
        local hospital to assist the health care professionals in the 
        investigation to best of our ability.
          Now, I would like to comment as an individual. I know that 
        many people are quick to point to the water and water quality 
        in the Lahontan Valley as the culprit in the present leukemia 
        scare. I am not an expert on the water nor in the medical 
        field, so I will not say that water is or is not the cause. I 
        just would like to point out that I began using bottled water 
        service at my home in 1995. This is because I felt that there 
        was a definite deterioration in the quantity, quality and taste 
        of my well water that like most in the valley comes from the 
        shallow aquifer. I subscribed to the water service feeling that 
        it was an inexpensive health insurance. At the time, I was more 
        concerned about water-borne bacteria than heavy metals or 
        minerals. Now, under the changing conditions in the valley, my 
        concern about the quality of my well water encompasses more 
        than just bacteria. At this time I can honestly say that I do 
        not advocate anyone in the valley drinking water from their 
        domestic well unless they have had that well tested recently 
        and that it tested as safe to use.
          The deterioration of our water quantity and quality has been 
        significant since water right buy-out began. The safety of our 
        water supply must remain the top priority of the community.
          Personally and professionally, I thank you members of the 
        Assembly for adding your support to our community at this 
        especially difficult time.

    This concluded the reading of Ms. Washburn's statement (Exhibit M).
    Norman Frey, Churchill County Commissioner, spoke next, and was 
very concerned about the negative press that the investigation was 
generating and stressed that the study must be kept to a scientific and 
professional level. He felt that the general public had not separated 
the presence of arsenic in the water and the leukemia cluster.
    Mr. Frey stated the government must deal with the people's 
perceptions in order to ease their tensions. He claimed the county 
might need assistance from the State to make well testing easier and 
more affordable for some 4,500 well owners. The county might need to 
set up low interest loans to purchase approved types of filtration 
systems for individual homes. He concluded by stressing that Churchill 
County is a very healthy place to live. Thousands had grown up and 
grown old there free of hideous disease.
    Chairwoman de Braga stated that she and the committee would do 
whatever they could to reinstate the Nevada GOLD program at the 
Agricultural Extension Service. She also requested that the 
commissioners would present the committee with recommendations for 
educating the public, especially those in the Soda Lake area, where the 
arsenic rates were very much higher.
    Assemblyman Neighbors requested to know the size of the area that 
contained the 4,500 wells. About 95 percent of the total population of 
Churchill County resided in the Lahontan Valley, which constituted 
Basin 101, the largest groundwater basin in the state.
    Mr. Neighbors inquired, what was the current cost of testing a 
well? The cost appeared to be roughly $15 per item for each item on the 
test, less than $100 per resident. Each property sale required a 
complete test that cost $120.
    In response to Mr. Claborn's question about increased abnormalities 
in animals in the county, Mr. Selinder responded that a veterinarian 
who had practiced in the county for many years had seen none.
    Testimony came next from Dr. Bonnie Eberhardt Bob and Leuren Moret, 
representing Scientists for Indigenous People. Ms. Moret revealed that 
she had worked at the Lawrence Livermore Laboratory in California 
(Exhibit N) and had done research on the Yucca Mountain project 
(Exhibit O) and ran the sampling lab for the superfund project. She 
felt these hearings had been good but that air pathways and sampling of 
the upper dust layer in Fallon had been overlooked. She stated other 
items to investigate included: the incineration of out-dated munitions 
(some depleted uranium) at Honey Lake Depot that had sent a smoke plume 
over Nevada; planes returned to NAS from the Gulf War which might have 
had radioactive metal; the increased toxicity of highly complex and 
mixed compounds such as radionucleides mixed with hydrocarbons; and, 
burns in the fallout areas of Nevada (from the testing of the 1950's) 
which remobilized the radionucleides in the upper dust levels thus 
recontaminating some populations. Constant exposure to low-level 
radiation, she testified, was more dangerous than a flash exposure such 
as was at Hiroshima. She concluded by stating that the water in Fallon 
had not been tested for tritium (radioactive hydrogen), and that the 
city should test surface ditches and drainage for airborne 
radionucleides.
    Dr. Bonnie Eberhardt Bob, a psycho-biologist, answered 
Assemblywoman Gibbons' earlier question saying yes, there was at least 
one Shoshone child who was quite young and has contracted leukemia.
    Dr. Bob related a story of gathering pine nuts with the Shoshone 
last Fall in an area indicated to be ``experimental tree plots'' and in 
which the trees had been dying from the top down. After some research, 
Dr. Bob found that the BLM had planned to bum 870,000 acres of pinion 
trees in Nevada. The chemical that killed the trees, she claimed, was 
probably tebuthiuron, a ground sterilizing agent.
    Another chemical, picloram, also known as Agent White, was one of 
the defoliants used in Vietnam and was now used by the U.S. government 
in the war against drugs in Columbia. Picloram was used to make Tordon 
which when mixed equally with 2-4-D plus 245T (Weedar) was Agent 
Orange. She concluded that, in effect, ``we'' are making Agent Orange 
again, except perhaps with the dioxins removed. Furthermore, in the Ely 
district where there were fires, the fields were sprayed with Garlon, 
which when burned ``mimics estrogens and hormones of women and it ruins 
the reproductive system.''
    Dr. Bob continued her testimony and described the level of picloram 
in Nevada's water and wondered what the reaction was when this chemical 
was mixed with others and used for weed or insect control. She 
expressed her concern for: the burning of parts of Nevada that would 
release radionuclides into the air; tritium that was in the tree 
cellulose and was released into the air from a burning tree; and 
plutonium that would be released into the air when burning occurred. 
Dr. Bob gave the committee a letter she wrote to the Bureau of Land 
Management (Exhibit P).
    Ms. Moret added that the smoke plume from the burning at the Fallon 
Naval Air Station should be investigated as well.
    Dr. Bob ended her testimony by reading a statement from Corbin 
Harney, Shoshone Nation, which emphasized the importance of cleaning 
the earth.
    Keith Weaver, a long term Fallon resident and a member of the de 
Braga family, delivered the final testimony. Mr. Weaver felt that the 
link between arsenic and leukemia should not be eliminated from 
examination at this point, based on a recent article he had read in the 
Journal of Epidemiology. Chairwoman de Braga agreed that the committee 
did not wish to rule out anything at this point.
    The hearing closed at 5:23 p.m. to be resumed February 15 at 1 p.m.
            Respectfully submitted,
                                               June Rigsby,
                                               Committee Secretary.
                                 ______
                                 
                           February 14, 2001
    The Committee on Natural Resources, Agriculture, and Mining was 
called to order at 1 p.m., on Wednesday, February 14, 2001. Chairman 
Marcia de Braga presided in room 1214 of the Legislative Building, 
Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest 
List. All exhibits are available and on file at the Research Library of 
the Legislative Counsel Bureau.

    Committee Members Present.--Mrs. Marcia de Braga, Chairman; Mr. Tom 
Collins, Vice Chairman; Mr. Douglas Bache; Mr. David Brown; Mr. John 
Carpenter; Mr. Jerry Claborn; Mr. David Humke; Mr. John J. Lee; Mr. 
John Marvel; Mr. Harry Mortenson; Mr. Roy Neighbors.
    Committee Members Absent.--Ms. Genie Ohrenschall.
    Guest Legislators Present.--Assemblywoman Sharron Angle, District 
29; Assemblywoman Merle Berman, District 2; Assemblywoman Vivian 
Freeman, District 24; Assemblywoman Dawn Gibbons, District 25; 
Assemblywoman Ellen Koivisto, District 14; Assemblywoman Sheila Leslie, 
District 27; Assemblyman Mark Manendo, District 18; Assemblywoman Kathy 
McClain, District 15; Assemblywoman Bonnie Parnell, District 40; 
Assemblywoman Debbie Smith, District 30; Assemblywoman Sandra Tiffany, 
District 21; Assemblyman Wendell Williams, District 6.
    Staff Members Present.--Linda Eissmann, Committee Policy Analyst; 
Marla McDade Williams, Committee Policy Analyst; June Rigsby, Committee 
Secretary.
    Others Present.--Glen Anderson, Policy Specialist, National 
Conference of State Legislators; Dr. Thomas Sinks, Epidemiologist, 
Center for Disease Control; Dr. Allan Smith, arsenic specialist, 
University of California, Berkeley; Brenda Gross, Fallon parent of a 
leukemia victim; Dr. James Forsythe, Medical Oncologist, Reno; Dr. Gary 
Ridenour, Fallon Physician; Diane Hansen, Fallon citizen; Peter 
Washburn, Attorney, Senator Harry Reid's Office; Jerry Buk, University 
of Nevada, Reno, Cooperative Extension; Juanita Cox, Citizen Lobbyist; 
Robert Sonderfan, Citizen Lobbyist.

    Chairman de Braga called the Assembly Natural Resources, 
Agriculture, and Mining Committee to order. Roll was called, and a 
quorum was judged to be in place. All members were present except for 
Assemblywoman Ohrenschall who was noted as an excused absence. Chairman 
de Braga welcomed as guests the Assembly Committee on Health and Human 
Services. Roll was called, and all members were present.
    Chairman de Braga, in her opening statements, remarked that this 
was the third and final day of hearings on the Fallon leukemia cluster. 
As with the previous 2 days, a balance of expert testimony and public 
input was scheduled.
    Expert testimony commenced with the introduction of Glen Anderson, 
Policy Specialist, National Conference of State Legislators (NCSL). The 
role of the NCSL was described as providing assistance to State 
legislators on environmental health issues. Mr. Anderson distributed 
two handouts that outlined a list of environmental disease registry 
legislation by State (Exhibit C) and NCSL environmental projects 
(Exhibit D).
    Mr. Anderson commenced his testimony with an overview of what was 
known about the link between environmental agents and cancer. 
Scientific investigation of childhood cancer was complicated by the 
relative rarity of cases as well as by the difficulty of estimating 
past exposure levels for young victims after they developed cancer.
    What had been established was that children had less developed 
immune systems and were therefore more susceptible to the effects of 
toxic exposure (e.g., mercury, lead, pesticide). Childhood cancer was 
described as the second leading cause of death in children under age 
14, with leukemia the most common type of cancer.
    Human research on the link between the environment and cancer 
lagged behind animal research. To date, clear causes had evaded 
scientists in cancer cluster investigations. An extensive list of 
variables under investigation included long latency periods between 
exposure and onset of disease, the plethora of potential chemical 
agents, and the tendency of families to change residency often.
    Disease tracking registries were described as offering the greatest 
hope for closing the information gap between exposure data and the 
cancer data. Nationwide, State disease registry information would be 
combined with background data on environmental exposure to promote 
understanding of cancer causes.
    Mr. Anderson reviewed innovations made in other States. Geographic 
mapping was described as a significant enhancement to some State 
registries and promised to aid in more expeditious detection of future 
cancer clusters. Some States had taken a preventative approach through 
the introduction of children's environmental health legislation. 
Because most law had been designed around protection of adult health, 
Maryland and California were cited as two States that enacted specific 
health guidelines for children.
    Federal efforts in the areas of children's health, the environment, 
and disease tracking (e.g. Center for Disease Control) had paralleled 
and supported the States' disease registry efforts. The Food Quality 
and Protection Act of 1996 resulted in the restriction of pesticide use 
that might cause childhood disease.
    The Children's Health Act of 2000 addressed childhood cancer 
through the requirement of the study of environmental and other risk 
factors for diseases such as leukemia. A uniform reporting system to 
track epidemiological data was described as an essential success 
factor.
    Mr. Anderson added that the clean up of identified environmental 
hazards would always be a positive side benefit to all cancer cluster 
investigations, even when a definitive cause for the cluster had never 
been found.
    Chairman de Braga requested recommendations on methods for 
facilitating the sharing of registry data between the States. Mr. 
Anderson explained that there had not been a lot of work done to 
connect cancer cluster data. He was unsure of how a streamlined system 
would be designed. Chairman de Braga posed a question on the prevalence 
of backlog in State registries across the nation. Mr. Anderson 
clarified that all States had registries in place, however it was 
unknown about how vigilant each State was in monitoring their registry 
data. The scrutiny of data by any State, including the integration of 
geographical mapping information, would take a much greater investment 
of time and resources.
    Mr. Anderson reassured Chairman de Braga that his agency did track 
the research on registry efforts in each State. Most States had not 
done a lot to make connections between a cancer cluster and 
environmental exposures. Legislative bills had been introduced, however 
few had been passed. On a positive note, Mr. Anderson added that 
awareness of the need was increasing.
    Chairman de Braga expressed her appreciation to Mr. Anderson for 
his testimony. Before introducing the next expert, Chairman de Braga 
made several announcements to the committees. Senator Harry Reid's 
Office let it be known that a $500,000 Federal fund would be available 
to help enhance the cancer registry data gathering. The second 
announcement was regarding the Nevada GOLD (Guarding Our Local Drinking 
Water) program. Jerry Buck would address a positive breakthrough on the 
future of this program later in the hearings.
    Dr. Thomas Sinks, an Epidemiologist with the Center for Disease 
Control (CDC), distributed a 6-page handout (Exhibit E) that contained 
his testimony on the epidemiology of Acute Lymphocytic Leukemia (ALL) 
and the work of the CDC and their sister agency, the Agency for Toxic 
Substances and Disease Registry (ATSDR). Dr. Sinks commenced testimony 
with his assurance to the residents of Fallon of the CDC's deep concern 
over the leukemia cluster. Although causes had rarely been identified 
in cluster studies, the survival rate for ALL of 80 percent was judged 
to be a significant milestone in the cancer battle.
    Dr. Sinks emphasized that the highest priorities remained the need 
to identify causes and prevent future occurrences. Although described 
as a relatively rare diagnosis in children, the national rate was known 
to be one case of ALL per 6,600 children. This translated to an 
estimated 2,400 new cases of ALL each year in the United States. 
Gender, age, race, and socio-economic status were highlighted as 
significant factors in the profile of a leukemia victim. The peak age 
was reported for children between the age of 2 and 5 years, with boys 
known to be 30 percent more likely to develop ALL. Genetic and 
environmental factors were judged to play a significant, but 
unexplained role, in the development of ALL.
    Dr. Sinks continued with a list of suspected cancer-inducing 
factors, which included ionizing radiation, certain medical conditions 
(e.g., Down's Syndrome), high birth weight, maternal history of fetal 
loss, and birth order. Other inconsistent evidence included parental 
smoking, parental occupation exposure, and postnatal infection. In-
utero exposure to ultrasound examinations had not been associated with 
ALL.
    In terms of cancer prevention and control programs at CDC, support 
of population-based cancer registries and cancer screening efforts were 
described as in place across the country. The compilation of the 
various State registries enabled some longitudinal oversight 
capabilities by the CDC. Federal support in Nevada was further 
illustrated by $1.4 million of funding of the Nevada Cancer Registry 
between 1994 and 2000.
    Dr. Sinks reported that CDC had participated in 108 cancer cluster 
field investigations, convened a national conference on the clustering 
of health events, published recommendations, and provided technical 
assistance to health departments nationwide. He expressed his concern 
over the tremendous amount of time and money required to conduct field 
investigations, with most studies revealing no conclusive findings. 
Positive remedial steps, however, were reported as implemented in most 
cases.
    Chairman de Braga requested clarification of the definition of a 
cluster and the number of years typically involved. Dr. Sinks explained 
that the word cluster, from an epidemiological point, was defined as 
being a greater number of cases than expected statistically. The word 
cluster did not necessarily imply that there would be a unifying cause. 
He further emphasized that statistical tests looked only at 
probabilities of chance occurrence and did not address the likelihood 
of cause. CDC treated each suspected cluster as a unique situation.
    Assemblywoman Berman requested clarification of the term ``panel of 
experts'' on page 6 of the handout (Exhibit E) and why the Federal 
Government was not involved in the testing. Dr. Sinks defended the 
practice of assembling a wide variety of medical, academic, and 
scientific experts for purposes of peer review. In response to the 
issue of Federal involvement, Dr. Sinks explained that the CDC 
responded to numerous requests by the invitation of States facing a 
public health problem. The CDC role was described as being supportive, 
but was not one of assuming ownership of the problem.
    Assemblywoman Leslie expressed her concern that there was no formal 
national tracking system in place for cancer clusters. Dr. Sinks agreed 
that there was need for a national tracking system, but it would 
require higher review and authority. Additionally, it would be a 
difficult process to implement because of the variability of defining 
and identifying clusters. In response to Assemblywoman Leslie's 
question about a cluster being simply one of a high number of cases in 
a specific geographic area, Dr. Sinks explained that defining a cluster 
would only be the first step. It would be followed by the challenge of 
establishing the corrective steps needed to deal with the problem.
    Dr. Sinks elaborated that, unlike breast cancer screening programs, 
there was no health screening program for childhood ALL. He stated that 
requests for cancer cluster investigations were predominantly for the 
more common, screenable cancers and, therefore, targeted the adult 
population.
    To Assemblywoman Leslie's inquiry about the role of arsenic, Dr. 
Sinks stated that it would be impossible to say definitively that it 
would be associated with the Fallon cluster. It had been established 
that the levels exceeded acceptable amounts and that arsenic was known 
to be a human carcinogen. He encouraged the investigative team to 
pursue the examination of other agents, such as volatile organic 
chemicals and ionizing radiation.
    Assemblywoman Gibbons expressed concern as to whether everything 
was being done to minimize risk and exposure. She also asked for 
clarification on the 20 percent mortality rate among ALL victims and 
the significance of the demographics (e.g., age, gender). Dr. Sinks 
responded that it was unknown if all preventative and remedial steps 
were in place. It had been established that the 20 percent mortality 
was seen in older victims where chemotherapy was less effective. Late 
diagnosis was also a negative for survival.
    Clarification was requested by Assemblywoman McClain on whether the 
$500,000 Federal fund would be enough to bring the Nevada Cancer 
Registry up to date. She also expressed concern over the reported 2-
year lag in the registry data and the possibility that there could be 
other undetected clusters. Dr. Sinks stated that the Nevada registry 
was average for reporting lag in comparison to other States. There were 
some state-of-the-art systems developed in other States. Dr. Sinks 
cautioned that having up-to-date cancer registries would not 
necessarily be the answer to early detection of cancer clusters. It 
would likely result in a multitude of unnecessary investigations. 
Generally, the registry data had been judged most useful after 
attention had been drawn to a suspected cluster.
    Assemblywoman McClain commented on the fact that the current ALL 
cluster in Fallon had been identified by the smallness of the community 
and not by the cancer registry. Dr. Sinks concurred and added that the 
current study would likely spur the Nevada Health Division to look at 
the occurrence of ALL across the entire State. The most difficult 
challenge was described as being able to take data from the cancer 
registry and tie it directly to environmental agents.
    In response to Assemblywoman Berman's question regarding 
statistical chance, Dr. Sinks clarified that nobody ever developed 
cancer because of chances. There was always a cause, and the challenge 
in Fallon would be to discover the common denominator among the 11 
children. The unifying cause was not yet known, but eventually science 
would identify the commonality. The probability of the Fallon cluster 
being a chance event was described by Dr. Sinks as being unlikely .
    Chairman de Braga raised a question about ALL cases that occurred 
outside of the identified cluster timeframe of 1995-1999. She requested 
clarification about the upcoming assignments of the panel of experts 
and whether two 1992 cases would be considered for inclusion in the 
panel's discussions. Dr. Sinks explained that the panel of experts had 
been assembled by the Nevada Health Division. As such, the Nevada 
Health Division would charge the panel with direction and 
recommendations for action. Dr. Sinks did agree that it would be 
reasonable to look at the 1992 cases to determine if inclusion would be 
appropriate. He referred the Chairman to Dr. Guinan for specific 
answers.
    Assemblyman Collins posed a question about the thoroughness of the 
health division's investigation. In response, Dr. Sinks stated that it 
would be virtually impossible to look at all suspected agents. The 
accepted process was to narrow the list of hypotheses to a testable 
number and then prioritize them based on probability of involvement.
    Assemblyman Collins, using the example of PCB contamination 
cleanup, reiterated his concern that limiting the investigation could 
limit the answers. Dr. Sinks stated that it would be imperative to 
separate the things that had been known to be hazardous but had 
remedial solutions versus the need to answer scientific questions that 
could not be answered. Preventing the next case of leukemia would 
remain the primary goal.
    Dr. Allan Smith, an arsenic specialist with University of 
California, Berkeley, commenced testimony with a review of various 
domestic and international arsenic research programs. Dr. Smith 
reported on his 8-year research project in Nevada, which included a 
bladder cancer study. The Nevada Tumor Registry was utilized in this 
study as well as in a childhood cancer study.
    Dr. Smith explained that most of his cancer research had been with 
adults and included cluster investigative work. A leukemia cluster in 
North Carolina was determined to be related to solvents in a tire 
producing plant. Most of his cluster investigations did not, however, 
result in the discovery of a definitive agent.
    In his review of the Nevada tumor registry data for Churchill 
County for the years 1979 to 1999, Dr. Smith detected only two cases of 
leukemia. With those statistics in mind, Dr. Smith characterized the 
current cluster as ``remarkable.'' Armed with the knowledge of Fallon's 
levels of arsenic for decades, Dr. Smith stated emphatically that it 
would be highly unlikely that arsenic would be the cause of the 
leukemia cluster.
    In response to a question about handouts, Dr. Smith replied that he 
had not prepared written testimony, and he referred the committees to 
his Web site www.socrates.berkeley.edu/-asrg/.
    Chairman de Braga inquired about Dr. Smith's choice of Fallon for 
his research studies on bladder cancer. Dr. Smith explained that Fallon 
was selected because the area was known to have some of the highest 
arsenic levels in the nation. The Fallon population was judged to be a 
highly exposed group. His researchers looked for genetic damage in 
bladder cells associated with high cancer rates.
    Chairman de Braga asked if his research included the effects of 
arsenic on the immune system. Dr. Smith replied that it did not. His 
research instead focused on the end result of the cancer. He added that 
if he had judged it to be a high priority research question, it would 
have been done. The evidence was not there to support arsenic and an 
adverse effect on the immune system. In response to Assemblyman 
Collins' question regarding the difficulty of discovering combinations 
of causal agents, Dr. Smith acknowledged that this was a significant 
challenge. The synergy between two agents had been investigated, an 
example being the combination of smoking and arsenic. He made the 
distinction, however that the sudden onset of a cancer cluster was 
different and did not fit the classic profile of long-term synergistic 
effects. The sudden introduction of an environmental co-factor 
suggested an infectious agent, for example.
    Assemblywoman Gibbons requested clarification of the list of 
suggested questions that was included in their information packet. 
Chairman de Braga explained that these were supplied as a guideline to 
the committee members.
    Assemblywoman Gibbons posed a question about the levels of arsenic, 
bladder cancer rates, and cure rates in Churchill County compared with 
other areas. Dr. Smith clarified that typical arsenic levels in the 
United States were 2 micrograms per liter. Fallon, Lyon County, and 
Kings County, California had always tested at 90 to 100 micrograms per 
liter. The private wells in Churchill County revealed some of the 
highest arsenic levels in the world.
    In response to the subject of bladder cancer incidence and cure 
rates, Dr. Smith described his long-term study as still in the analysis 
phase. A proposal for the study of lung cancer in Nevada had recently 
been submitted to the National Institutes for Health (NIH). Using a 
method called ``rapid case ascertainment'' with data from the Nevada 
Tumor Registry, Dr. Smith was optimistic of a more rapid identification 
of lung cancer.
    Assemblywoman Gibbons requested clarification on the extremely high 
levels of arsenic in Fallon's private wells and the interplay between 
dosage and individual immunity. Dr. Smith explained that he had 
deliberately studied wells with the highest levels of arsenic, 
selecting 11 families whose wells exceeded 1,000 micrograms per liter.
    Chairman de Braga added that a recurring question among the 
committees was the threshold amount at which arsenic became a problem. 
Dr. Smith elaborated that in their risk assessment studies, at 50 
micrograms per liter, there was an estimated probability of 1 in 100 
people dying of cancer. He concluded that it was an acceptable fact 
that consumption of water with 90 to 100 micrograms of arsenic was 
detrimental to public health.
    Brenda Gross, a Fallon resident and mother of one of the leukemia 
victims, commenced testimony. Mrs. Gross shared the heartbreak and 
stress of dealing with a devastating illness in the family. She 
acknowledged the involvement of the Nevada Health Division and their 
sharing of information. Her specific concerns were centered on the 
difficulty of making treatment choices for her son, constantly having 
to weigh the side effects of treatment against the chances of death. 
Mrs. Gross addressed a further concern regarding the tendency to 
dismiss a cause, such as arsenic. She emphasized that investigation 
into combination agents (e.g., arsenic plus another environmental 
agent) would be imperative.
    Mrs. Gross expressed her certainty that there was a definitive 
cause in Fallon, and she hoped that the Nevada Health Division would be 
aggressive in their pursuit of common denominators. She concluded by 
saying that, with only one of her four children affected, she was 
baffled by what would be so unique about her one son (e.g., genetic).
    On behalf of both committees, Chairman de Braga expressed her 
sincere appreciation to Mrs. Gross for sharing her personal story. 
Assemblywoman Leslie reiterated her appreciation and asked Mrs. Gross 
if, in her judgment, the State of Nevada could be doing more for the 
families and the community. Mrs. Gross added that testing of private 
well water, soil testing, jet fuel studies and air quality studies in 
surrounding areas might be helpful.
    Assemblywoman Leslie added that, as a minimum, establishing a 
central place for questions would be warranted for the community. It 
was emphasized that recommendations would be most welcome from the 
families of Churchill County.
    In response to Assemblywoman Gibbons, Mrs. Gross explained that her 
son's chemotherapy was being done in Fallon on a weekly basis and at 
the University of California, Davis on a monthly basis.
    Dr. James Forsythe, Reno Oncologist, was introduced as the next 
presenter. He distributed a handout (Exhibit F), a 1979 newspaper 
article which described a suspected cancer cluster in northern Nevada. 
At that time, Dr. Forsythe was one of only two oncologists in the area, 
the significance being that he had firsthand knowledge of every cancer 
case in the area. This lead to his discovery of what he considered to 
be a cancer cluster in the Fallon area. His concern was amplified by 
the Veteran's Hospital in Reno.
    In 1979, an investigative study was initiated by the University of 
California, Berkeley, Public Health Service. Their statistical analyses 
revealed significant increases in brain and testicular cancer in the 
Fallon area. The report was delivered to the chairman of the Northern 
Nevada Cancer Council, Dr. John Shields, and the matter was not 
pursued.
    Dr. Forsythe described his ongoing involvement in the diagnosis and 
treatment of Fallon cancer patients. He had long speculated on the 
commonality of the drinking water as the source of the problem, with 
arsenic levels at 20 times the national average. Today, Dr. Forsythe 
stated that his focus was diverted to contamination of water supplies 
by petroleum products originating in industries or perhaps the naval 
base.
    Dr. Forsythe next shared anecdotal stories from various sources 
which he believed could have significance. The first point he 
highlighted was the high water table in Fallon (i.e., less than 50 
feet) in combination with poor water quality. Second, Dr. Forsythe 
commented on the reported practice at the Fallon NAS of routinely 
spraying weeds with jet fuel. His third point centered on reports from 
utility inspectors excavating soil on the naval base and their 
observations of a petroleum stench at the 4 to 6 foot soil level. In 
1995, there was an unofficial report of a large spill of petroleum 
products on the base. Although not revealed in the news media, the EPA 
did respond with remedial efforts.
    Other risk factors included the atomic blast in 1963 (i.e., Shoal 
Project) and electromagnetic field radiation. Dr. Forsythe stated that, 
of all of the risk factors on a long list, childhood Acute Lymphocytic 
Leukemia (ALL) had been known to be induced, in part, by petroleum 
byproducts such as benzene and other gasoline substances. Lymphocyte 
assays of family members, through an analysis called ELISA, had proven 
to be revealing. More than 400 chemicals would be detected with ELISA 
methodology. Hair and urine analyses for heavy metals were also 
recommended by Dr. Forsythe.
    Dr. Forsythe encouraged the expansion of testing by the Nevada 
Health Division to include the victims and families. He stated with 
reasonable certainty that petroleum byproducts had leached through the 
earth and had contaminated the high aquifers of the Churchill area. In 
his judgment, this would prove to be significant in the cluster 
investigation.
    Chairman de Braga requested clarification on the 1979 cluster, 
specifically regarding the reaction of the medical community. Dr. 
Forsythe described the event as being ``clinically suspicious'' and was 
not noticed until Berkeley released their report. Chairman de Braga 
shared her own experience with inquiring about the cancer levels in 
Fallon. In reply, Dr. Forsythe expressed his disappointment in the 
apparent inaccuracy of the Nevada Tumor Board records. This was 
compounded by the fact that, in a small town like Fallon, many cancer 
patients left the area for treatment and were not tracked by the 
registry. Reporting lag time was also cited as a significant factor in 
the inaccuracy.
    Chairman de Braga inquired about the costs and the process to test 
families and neighbors. Dr. Forsythe judged that it would be reasonable 
if a sampling of families was used and not the entire population. Hair 
testing would be non-invasive, and costs were estimated at $50 to $80. 
Urine testing for heavy metals was reported to be approximately $200. 
The ELISA testing for multiple chemical exposure was described as $300 
to $400 per sample, but was the most diagnostic method. The latter test 
was based on the detection of antibodies produced by the body in 
reaction to various foreign substances.
    In response to Chairman de Braga's question about herbicides and 
pesticides, Dr. Forsythe acknowledged that these substances would need 
to be considered, given the extensive agricultural activity in the 
valley. Chairman de Braga requested recommendations for how to proceed 
with the cluster investigation. Dr. Forsythe summarized his 
recommendations as: the testing of the victims for chemicals in the 
hair and urine, testing a control group of friends or neighbors, and 
thoroughly analyzing the drinking water for all possible pollutants. 
Dr. Forsythe clarified that he was not familiar with the list of 
previously tested substances in drinking water.
    Dr. Forsythe reviewed the types of cancers he had handled during 
the last 10 years in the Churchill County area; 40 cases of breast 
cancer, 30 cases of colon cancer, 35 cases of lung cancer, 15 cases of 
Hodgkins/Lymphoma/leukemia, 25 cases of prostate cancer, 20 cases of 
skin cancer, 8 cases of brain cancer, 5 cases of ovarian cancer, and 8 
cases of head/neck cancers. It was notable that these were just the 
cases handled by Dr. Forsythe and did not include the cancer statistics 
from 10 other oncologists in Reno.
    Assemblywoman Koivisto asked for elaboration on the microwaves from 
radar systems at the Fallon Naval Air Station (NAS). Dr. Forsythe 
stated that electromagnetic fields (EMF) must be considered, however 
EMF research to date was inconclusive.
    Chairman de Braga introduced Dr. Gary Ridenour, a Fallon physician. 
He commenced testimony with the topic of jet fuel, in particular JP8. 
It was introduced to Fallon in 1991, and shortly after that, Dr. 
Ridenour noticed an immediate change in the liver function tests (e.g., 
liver damage) in patients. Dr. Ridenour shared his extensive research 
on incidents of jet fuel leakage on the base. He further stated that he 
had not observed intentional malice on the part of the Navy regarding 
the subject of jet fuel. What they know was described by Dr. Ridenour 
as what they were told by the Department of Defense.
    Often dismissed by the military as similar to kerosene, the high 
toxicity of jet fuel, even in minute quantities, had been demonstrated 
in multiple studies and was known to provoke serious health effects 
including skin penetration, decreased immune system response, increase 
in lung permeability, and headaches, to name a few. During the 1990's, 
medical articles abounded on the subject of the toxicity of JP8.
    In terms of fuel dumping and evaporation, the jet fuel would still 
exist in some form when it made contact with the earth. Dr. Ridenour 
cited a recent example of a cloud sighting near the base, described as 
a large brown vapor emitted from the startup of jets. He added that one 
of the biggest problems with JP8 was the low cost of 80 cents per 
gallon, approximately half of the cost of its predecessor fuel JP5.
    JP8 had so far not been allowed on aircraft carriers, a point which 
Dr. Ridenour considered significant. It was utilized extensively during 
the Gulf War, which suggested the need to connect the fuel with the 
highly publicized health problems among the military personnel. Even 
brief contact with JPB fumes resulted in the immediate detectable 
presence of fuel in the breath of the person. Dr. Ridenour cited 
several recent research articles about the negative health effects of 
exposure to jet fuel.
    In regard to the 6-inch fuel line that delivered jet fuel to the 
Fallon NAS, Dr. Ridenour described it as more than 30 years old, made 
of steel, and highly susceptible to corrosion and seismic activity in 
the desert. The integrity of the pipeline would be highly questionable. 
A map of Fallon displayed the path of the pipeline, described as 
running within 10 feet of schools in Fallon and crossing the parking 
lot of the new Baptist Church. The pipeline was further described as 
coming in contact with the Carson River and every ditch and irrigation 
channel across the town. In retrospect, it should have been routed 
around the city of Fallon, and not through it. Vents, located along the 
route, were visibly damaged in certain areas.
    Dr. Ridenour expressed his alarm that, despite the plethora of 
reports and warnings about the hazards of the jet fuel, nothing was 
done about it. Morgan Kinder, the operators of the fuel pipeline, had 
some checks on the integrity of the system. Dr. Ridenour described a 
photo of one of the pipeline test locations. It was covered with spider 
webs, indicating that it had not been disturbed by personnel assigned 
to monitor the pipeline. Morgan Kinder supposedly used pressurization 
tests to detect leaks, with the problem being the unknown amount of 
pressure used during the test. In Dr. Ridenour's judgment, given the 
300-mile length of the pipeline, it would have to be a sizable leak 
before it would be detected as a pressure drop. At a leakage rate of 
one drop per second, the soil contamination in 1 year would be 300 
gallons.
    Dr. Ridenour summarized by saying it generally would take 8-10 
years after introduction of a toxic material before the onset of 
disease. In terms of what had changed in Fallon during the last 10 
years, Dr. Ridenour summarized that insecticide spraying had actually 
declined due to fewer fields. He added there had been no increase in 
radar nor had there been a change in water quality. Whereas literature 
searches on the topics of arsenic and leukemia yielded no matches, the 
topics of bone marrow and JP8 fuel revealed multiple references.
    Despite the military's comparison of JP8 fuel to kerosene, Dr. 
Ridenour cautioned the committees that it would be akin to comparing 
plastic explosives to play dough. He encouraged the committees to 
consider requesting that JP5 be pumped through the pipeline from 
Benecia for an interim period in order to complete testing of JP8. A 
determination of the complete integrity of the line was also 
recommended by Dr. Ridenour. Finally, the aerosol effects of the fuel 
should be studied in greater depth. Air currents in the desert, below 
18,000 feet of altitude, were described as highly unpredictable, and 
jet fuel particles would be very capable of making contact with people 
and soil.
    Dr. Ridenour reemphasized that the change in jet fuels had to be 
considered as one of the most significant new events during the last 10 
years in Churchill County. He once again stated that the Navy itself 
would not necessarily be at fault if they had also been ``sold a bill 
of goods'' on the merits of JP8. Morgan Kinder should be made to 
reroute the pipeline around the town.
    Assemblyman Carpenter inquired about the type of fuel used on 
commercial jets. Dr. Ridenour stated that it was Jet A, a fuel that was 
closer to JP4 in composition. He cautioned that, because of its 
economical cost, some airlines were considering switching to JP8.
    In response to Assemblyman Claborn's comment about the fuel 
pipeline in Las Vegas, Dr. Ridenour cited the distinction between the 
two as being one of age, namely that the northern Nevada line was much 
older. The Fallon line also pumped a greater volume, estimated at more 
than 400,000 gallons per month.
    Assemblyman Neighbors shared his confusion regarding the Helm's Pit 
in Reno, once the site of serious ground contamination and now a family 
recreational area for boating and fishing. Dr. Ridenour agreed that it 
was both suspicious and confusing, and it seemed highly unlikely that 
the fuel oil would be cleaned up in such a short amount of time.
    Chairman de Braga introduced Diane Hansen, a Fallon resident. Ms. 
Hansen sought reassurance from the committees that a systematic and 
thorough cluster investigation would continue. She spoke candidly and 
shared her concerns that the next stage of the Nevada Health Division's 
investigation would not happen. Ms. Hansen expressed her expectations 
that a team of experts would be assembled and that this investigative 
team would receive specific direction and adequate manpower and funding 
to do the job right. She further emphasized the need for the team to 
ask the right questions and to be forthright in their communication 
with the residents of Churchill County.
    Making reference to a 1996 newspaper article, Ms. Hansen shared her 
specific concerns about an industrial plant 12 miles north of Fallon. 
The New American Tec Corporation arrived in Nevada after having been 
cited for severe environmental contamination in Kentucky. Their 
chemical process, a nickel and chrome plating operation, was known to 
utilize known carcinogens. Ms. Hansen was especially concerned that 
there had been no followup publicity on this hazardous industry.
    In an effort to get answers to her questions, Ms. Hansen conducted 
her own research and called various agencies, including NDEP, EPA in 
San Francisco, the Lahontan Valley News, the Reno Gazette, and the 
Churchill County Planning Commission. She was surprised to hear that 
she had been the only person to request followup information on New 
American Tec. What she learned was that Fallon was the only location in 
the Nation that utilized a vaporization process to plate copper using 
nickel carbonyl, a known carcinogen. There was evidence that New 
American Tec had not been totally forthcoming about their history in 
Kentucky in applying for a permit in Nevada.
    Her inquiries to Nevada Department of Environmental Protection 
revealed that New American Tec was permitted to emit 2 pounds of nickel 
components per hour into the air. Neither the State nor the county 
required air monitoring on a regularly scheduled basis. Any air 
emission results were self-issued by the corporation. The possible 
significance of the New American Tec production startup of November 
1996 should not be ignored.
    In closing, Ms. Hansen asked for assurance that the investigation 
would include these small pieces of the puzzle, for example New 
American Tec.
    Chairman de Braga acknowledged that Ms. Hansen represented 
widespread community concern and that the serious nature of the cluster 
dictated a very serious and thorough approach. It was explained that 
the role of the legislators would be to make recommendations. The 
expert panel, comprised of a variety of medical and scientific experts, 
would also make recommendations. Ms. Hansen was reassured that the 
Nevada Health Division was committed to doing as much as possible. 
Congressional, State, and community interest would propel the 
investigation in the right direction.
    Ms. Hansen requested clarification on the issue of NDEP writing a 
requirement for monitoring into their permitting process. The New 
American Tec permit was up for renewal at the current time, and NDEP 
was said to be in negotiation with the attorney for the company to 
require monitoring activities. Ms. Hansen emphasized the sincere 
interest on the part of the Fallon residents to do what ever they could 
to help.
    Assemblywoman de Braga echoed the words of Ms. Hansen and agreed 
that Fallon was, indeed, a wonderful community for families. She 
gratefully acknowledged the testimony of Ms. Hansen.
    The next expert witness called was Peter Washburn, Attorney for 
Senator Reid's office in Washington, DC. Mr. Washburn distributed a 
copy of his written statements (Exhibit G). He commenced his testimony 
by highlighting Senator Reid's senior membership with the Senate 
Environment and Public Works Committee. Mr. Washburn assured the 
committees of Senator Reid's deep concern over the Fallon cluster. He 
commended Chairman de Braga on her foresight in scheduling the special 
legislative hearings and acknowledged the dedication of the two 
committees and Dr. Mary Guinan for their participation.
    Because of Senator Reid's dual membership in both the 
Appropriations and Environmental Committees, he was described as being 
in a unique position to leverage Federal resources to aid the 
investigative work. Senator Reid's first priority was described as in 
the areas of communication, participation, and coordination. Because of 
the multitude of experts and citizens involved in the process, these 
hearings were said to set the stage for the essential communication and 
coordination of information sharing.
    Mr. Washburn described Senator Reid's second priority as pointing 
to the issue of what could and should be done now to reduce 
environmental risk to the citizens of Fallon. Because investigative 
work would likely take years, remedial steps should be implemented 
regardless of conclusions about causal agents. He cited the example of 
arsenic and stated that Federal grants were forthcoming. The Small 
Community Safe Drinking Water Safety Act was slotted for introduction 
by Senator Reid. This bill would make Federal grants, not loans, 
available to small public water systems for purposes of improving the 
quality of the water.
    Mr. Washburn explained that Senator Reid was planning to schedule 
hearings in Nevada for purposes of addressing the leukemia cluster and 
public health concerns. Dates and agenda would be announced. Chairman 
de Braga expressed her thanks to Senator Reid for his early and on-
going involvement in the matter.
    Chairman de Braga introduced Jerry Buk, Regional Director for the 
University of Nevada Cooperative Extension Service in northern Nevada. 
Mr. Buk addressed the Nevada Gold (Guarding Our Local Drinking Water) 
project in Fallon. This program was designed by a water specialist in 
Fallon, Mary Reed. The model employed was a ``train the trainer'' in 
which volunteers from the community were trained to share water safety 
information with the residents, especially those served by private 
wells.
    Due to an unexpected illness of the project leader, the Nevada Gold 
project atrophied and ceased to function by May 2000. Mr. Buk explained 
that the program would be reinstated immediately. The first order of 
business was described as a compilation of all Nevada Gold information 
and dissemination of the data to all agencies and businesses that dealt 
with residents served by private wells.
    Mr. Buk concluded by saying that the program was being reviewed and 
streamlined for implementation in March 2001. The new program would be 
tailored to include the leukemia cluster issue and would focus on 
educating citizens on the need to have water tested, as well as how and 
where to procure testing services.
    In response to Chairman de Braga's question regarding the expansion 
of testing, Mr. Buk shared his knowledge of some grant money connected 
to a Ph.D. dissertation. This was described as a possible source of 
funds for actual water testing for residents. Mr. Buk cautioned that 
the breadth of water testing (i.e., number of substances) was 
overwhelming. The Nevada Gold program had looked specifically at 
nitrates in water, a relatively cheap and easy analysis. This was 
contrasted to the complexity and higher cost of testing newer 
substances.
    The next experts to testify were Juanita Cox and Robert Sonderfan, 
representatives of People To Protect America and Citizens In Action. 
Self-described lobbyists, researchers, and investigative journalists, 
Ms. Cox and Mr. Sonderfan displayed a stack of articles and research 
information (no handouts). Ms. Cox expressed concern over the lack of 
discussion of the water contaminant MTBE. Added to gasoline in the late 
1970's, it had now been known to cause three types of cancer in 
laboratory animals, including leukemia. The amount of contamination of 
drinking water and recreational water was described as extensive, and 
therefore, should be added to the Fallon testing agenda, according to 
Ms. Cox.
    Internet literature searches revealed the 2001 military 
construction program for Fallon NAS, specifically the plan to replace 
military fuel tanks. Underground fuel tanks were described by the 
military as being 45 years old and having known leakage problems. The 
immersion of the tanks in the area's saltwater aquifer caused corrosive 
effects on the metal. Because contamination by various substances could 
be through ingestion, inhalation, or skin contact, Ms. Cox urged the 
expansion of testing. Fluoride was cited as an example.
    Ms. Cox concluded her testimony with her observations of the 3-day 
hearings, described as ``CYA'' and damage control. Because of economic 
reasons or the threat of legal ramifications, some answers would never 
be disclosed. Massive denials and subsequent legal actions were 
predicted by Ms. Cox to be unavoidable.
    Mr. Sonderfan commenced his testimony with a review of Project 
Shoal and Project Faultless. He described the hurdles and red tape he 
faced in researching these topics. Project Faultless was a 13-megaton 
detonation of a classified military warhead near Fallon. In his 
judgment, the military had not been forthcoming in revealing harmful 
practices, such as burying trash for more than 40 years. Nellis Air 
Force Base was described as having 30 tons of depleted uranium, with a 
half-life of more than four billion years.
    Ms. Cox elaborated on the subject of depleted uranium and stated 
that the Pentagon knew in 1995 about the environmental threats posed by 
nuclear weapon waste. The question needed to be asked of the Fallon NAS 
about their use of plutonium, one of the most toxic substances known to 
man.
    Ms. Cox concluded her testimony with an overview of other agents 
for investigation and testing, which included electromagnetic radiation 
(i.e., EMF), Agent White (i.e., Tordon), DDT, nuclear fallout, fuel 
dumping from jets, manganese, ethylene dibromide, and bovine leukemia 
viruses. Research indicated that veterinarians and dairy farmers had 
elevated leukemia rates. Production of milk was reportedly greater in 
cows infected with bovine leukemia.
    Due to the lateness of the hour, Chairman de Braga interjected with 
a request of Ms. Cox to leave one copy of her testimony for 
distribution to the committees. Ms. Cox concurred and added that having 
her testimony cutoff would be expected especially since the topic was 
milk.
    Mr. Sonderfan interjected with a plea for the Fallon NAS to come 
forward with a report of chemicals used and stored on the base. His 
research revealed leaking storage tanks. Arsenic, according to Mr. 
Sonderfan, was just a smokescreen. Leukemia was described as resulting 
from a one-two punch, the first being the lowering of the immune system 
and the second punch some exposure to a trigger agent. Bovine leukemia 
virus in raw milk had the capability of being transmitted to humans.
    Ms. Cox interjected with comments about the synergistic effects of 
chemicals and environmental toxins. She further cautioned that, even if 
causes were suggested by a citizen, it would invite legal entanglement 
for years. She urged the cessation of cover-ups and human 
experimentation. She urged the committees to empower the community 
because it was most likely that the answers would come from the people. 
The public needed a civilian investigative board and a hotline for 
public input that would facilitate the reporting of environmental 
hazards.
    Chairman de Braga explained that there was a hotline in place for 
citizen input. In response to Ms. Cox's concern about reporting an 
incidence of environmental dumping, Chairman de Braga assured the 
witness that the health department in each community was there to 
respond to these concerns.
    Assemblyman Mortensen inquired if anybody in the room knew with 
certainty that the Fallon NAS practiced with depleted uranium shells. 
Chairman de Braga elaborated that this had been suggested in several 
letters from other concerned constituents. It would be included in the 
list of recommendations. A handout (Exhibit H) was received from the 
Department of Energy.
    Chairman de Braga adjourned the meeting at 5:46 p.m.
            Respectfully submitted,
                                               June Rigsby,
                                               Committee Secretary.
                               __________
                                                   April, 19, 2001.
Committee on Environment and Public Works,
Washington, DC.

Subject: Fallon Leukemia Cluster

    Dear Committee Members: I am writing in response to a request for 
public testimony concerning factors to consider connection with the 
Fallon Leukemia cluster. I would like to see this committee carefully 
consider the role of fire in the disbursal of hazardous materials 
through the environment, including fire's role in remobilized 
radioactive isotopes and other contaminates deposited in Nevada as a 
result of weapons testing. I would request the committee to consider 
the dangers associated with fire as a remobilizing agent of 
radionuclides from the Nevada Test Site and other testing ranges in the 
State.
    During the period of above ground testing from 1951 to 1963, 
radioactive releases from the Nevada Test Site emitted over 12 billion 
curies of radioactive material into the atmosphere, 148 times as much 
as the nuclear disaster at Chernobyl. Other pre-1971 nuclear tests 
released 25,300,000 curies, and from 1971-1988, 54,000 curies were 
released, including the 36,000 curies from the Mighty Oak accident, 
which was itself 2000 times greater than the release at Three Mile 
Island. Over half of all underground tests have leaked radiation into 
the atmosphere (DOE Report on Radioactive Effluents, 1988). DOE has 
been out of compliance with Federal and State permit requirements in 
the areas of air emissions, water releases, and solid waste disposal 
(DOE Nevada Operations Office Five Year Plan, 1989).
    There is contamination in soil, air, ground and surface water. 
Strong winds, common to this area of Nevada, can carry plutonium-
contaminated dust across a large area. Fallout from above ground 
nuclear tests in the United States and other countries has 
radioactively contaminated the atmosphere around the Earth. Project 
Faultless in Hot Creek Valley was found to have caused radioactive 
contamination in groundwater. According to EPA Publication 520/4-77-
016, cumulative deposits of plutonium (Pu-239 and Pu-240) have been 
found in soil over 100 miles north of the NTS at levels of 790 mg per 
acre. Plutonium has a half-life of 26,000 years, and plutonium 
contaminants ingested in microscopic amounts are capable of causing 
cancer for 200,000 years. There is no cost-effective technology for 
decontaminating such sites. No surveys have been conducted to determine 
health effects on Native American or other residents from Nevada Test 
Site (NTS) releases. Currently the Nuclear Risk Management for Native 
Communities project is working to answer some of these questions.
    It is known that plutonium translocates to specific radiosensitive 
organs, especially reproductive organs.
    During the years of 1999 and 2000, almost 3,000,000 acres of Public 
Lands in the State of Nevada were subjected to fires, both wild fire 
and prescribed burns. Fire remobilizes contaminants. Particles are 
lifted from the ground into the air, then mobilized through environment 
on wind currents. The particles are resuspended for an indefinite time 
period, finally redeposit onto the earth. This process creates fallout. 
As a result of this process, fire can carry containments across the 
globe.
    We understand that the Nevada BLM oversees management of 1,722,330 
acres of public lands considered contaminated with UXO, (unexploded 
military ordinances). BLM lands border NTS (Nevada Test Site), Nellis 
Bombing and Gunnery Range, Tonopha Air Force Base, together with the 
Fallon Range. No one knows the amount or extent of nuclear 
contamination in the area surrounding the NTS and Nellis Air Force Base 
which tests depleted uranium (DU) bombs. In 1997 it was estimated that 
30 tons of DU had already been deposited in the target area (Draft 
Environmental Assessment Resumption of Use of Depleted Uranium Rounds 
at Nellis Air Force Range Target 63-10), a total of 9,500 combat mix 
rounds (7,900 DU rounds) being expended annually, there.
    Depleted uranium or U-238 has an atomic mass of 238. Its half-life 
is 4.468 billion years (Rokke, 2001). It's natural occurrence is 2.1 
parts per million. Uranium is silver white, lustrous, malleable, 
ductile, and pyrophoric. This makes DU an ideal metal for use as 
kinetic energy penetrators, counterweights, and shielding or armor. 
High density and pyrophoric (catches fire) nature are the two most 
significant physical properties that guided its selection for use as a 
kinetic energy penetrator.
    A study performed at Yucca Proving Grounds found DU residues in all 
components of the environment, that environmental concentrations varied 
widely, that corroded DU residues are soluble and mobile in water, that 
wind dispersal during testing is the prevalent means of dispersal of DU 
particles, and that an unknown degree of risk was posed to human health 
by DU in the environment. Moreover, there appears to be no insight into 
the issue of long-term (100 to 1,000 years and longer). DU forms of 
both soluble and insoluble oxides. The inhalation of the insoluble 
oxides presents an internal hazard from radiation if retained in the 
lungs.
    The long-term effects of internalized depleted uranium are not 
fully known, but the Army has admitted that ``if DU enters the body, it 
has the potential to generate significant medical consequences.'' 
Inhaled DU particles or respirable size may become permanently trapped 
in the lungs. Inhaled DU particles larger than respirable size may be 
expelled from the lungs and ingested. DU may also be ingested via hand-
to-mouth transfer or contamination of water or food supplies. DU, which 
is ingested, or enters the body through wind contamination, will enter 
the bloodstream and migrate throughout the body, with most of it 
eventually concentrating in the kidney, bone, or liver. The kidney is 
the organ most sensitive to DU toxicity.
    More testing of soil and plants needs to be done to determine what 
radionuclides might be released into the air in a fire, since a fire 
and its relationship to the resuspension of contaminants has not been 
the subject of study. Plutonium and radionuclides concentrate in dust, 
thus higher concentrations are found in the dust sampling than in 
regular soil sampling. The standard air monitors and surface water 
samplers usually used are not sufficient to measure submicroscopic 
particles of plutonium. Further, plutonium contamination is not 
homogeneous, so simplistic sampling methods are inadequate (John Till, 
President, Risk Assessment Corp; 2000). Wind-blown particulates must be 
considered. Debris and gas will go somewhere, but where? Into the water 
or the soil?
    Radiation detection devices that detect and measure alpha 
particles, beta particles, x-rays, and gamma rays emissions at 
appropriate levels from 20 dpm up to 100,000 dpm and from .1 mrem/hour 
to 75 mrem/hour must be acquired to assess the distribution of 
particles. Standard rad-meters or Geiger counters do not measure these 
levels.
    In order to assess the health risks and damage due to exposure to 
tritium (radioactive hydrogen), three blood tests must be done. White 
blood cells must be tested for the presence of micronuclei, indicating 
the loss of DNA repair processes and leading to increased cancer risk. 
Red blood cells must be examined for genetic modification of surface 
glycophorin-A molecules, also indicating DNA damage. A study of 
Japanese nuclear bombing victims forty years from the time of the 
blasts showed DNA codes were still unrepaired. In addition, chromosome 
painting allows chromosomes to be stained for identification of 
structural and sequential or numerical abnormalities linked to 
radiation and chemical exposure, cancer, and inherited diseases.
    In addition to the redistribution of containments, we need to 
consider the effects of fire upon other substances. For example, we 
must consider chemical reactions which may take place when multiple 
herbicides are burned together. For instance, one chemical being most 
often utilized on public lands is Tordon. But Tordon is also called 
Grazon, and the active ingredient is picloram, better known as Agent 
White, similar to Agent Orange, and one of several defoliants used in 
Vietnam. In fact, Agent White (picloram) appeared in 5 of the 15 
defoliants used there. Agent White is currently being sprayed by the 
U.S. on the coca fields in Columbia as part of the drug war. In 1998, 
Dow Chemical, manufacturer of Agent White (picloram) tried to halt its 
use, warning that it does not bind well with soil, easily washes into 
the groundwater and could cause irreparable damage to the Amazon 
Rainforest. Yet, U.S.G.S. Pesticide 1992 Annual Use Map showed 
estimated annual agricultural use of Agent White to be less than 0.370 
pounds per square mile per year. The map shows the entire State of 
Nevada has been exposed. This is a lot, and has probably increased 
since that time. If it's dangerous to the water and forest areas of 
Colombia, it is dangerous here in the U.S. The use of Tordon is banned 
in some countries.
    Also commonly used are 2, 4-D which forms poisonous gas in fire. It 
is on the Hazardous Substance List because it is regulated by OSHA. The 
chemical is a mutagen (changes the genetic structure), a teratogen 
causing birth defects, and a carcinogen particularly related to breast 
cancer. Short term effects of its use include the death of animals, 
birds, fish, and plants within 2-4 days after exposure. About 91.7 
percent of 2, 4-D will eventually end up in water. In 1990, the Clean 
Air Act announced 2, 4-D as a hazardous air pollutant. Run off vapors 
can kill non-target plants. Agent Orange was a mix of 2, 4-D and 2, 4, 
5-T. Another name for 2, 4, 5-T is Weedar. And both of these chemicals 
appear on the recommended list of chemicals used on public lands.
    Garlon is also known as triclopyr (both names appear separately on 
the recommended treatment list as if they are different herbicides). 
Triclopyr's chemical structure is very similar to 2, 4, 5-T. The MSDS 
sheet includes the following data: Nitrogen oxides, hydrogen chloride, 
and phosgene may result under fire conditions and NIOSH/MSHA requires 
approved SCBA and full protective equipment for firefighters. Garlon-
treated wood that is burned during forest fires, or in wood stoves at 
home produces a dioxin, one of the most damaging compounds to living 
organisms. Garlon is an endocrine disrupter.
    It mimics a plant hormone, acting systematically to kill the plant 
or tree. The hormone that Garlon mimics is perceived by the human body 
to be estrogen. In women, this may result in breast cancer, 
miscarriages, infertility, birth defects, and possibly ovarian cancer. 
In men, it can cause prostate or testicular cancer and reduction of 
sperm count. It also may aggravate liver and kidney disease. We do not 
know what the effects of burning multiple pesticides and the full 
extent of the risk to public health from such events.
    I suggest that a more appropriate methodology for determining 
causation of the Fallon leukemia clusters would use a multidimensional 
model for analysis. In other words, rather considering singular 
etiologies, as suggested by Prescott from CDC at the hearings, a more 
complex multi-factor dynamic process may be in operation. We might 
hypothesize very generally that exposure to radionuclides such as 
tritium, plutonium, or DU, might cause mitochondrial damage to cells. 
In addition to other functions, mitochondria contribute to a sort of 
``programmed cell-suicide''. For example, in certain stages of fetal 
development, humans have webbed fingers. The mitochondria detect this, 
and at the appropriate time, seek to destroy the web cells, leaving 
humans with fully formed fingers. This cell-suicide is necessary.
    However, when exposed to an error or to toxins or radionuclides, 
the mitochondria engage in a process of ``unprogrammed cell suicide.'' 
Thus, healthy cells are destroyed. Such suicides may lead to 
destruction of critical elements of immune system function, resulting 
in cancers, leukemia, and the inability to fight the effects of various 
viruses and bacteria. The cells may be more vulnerable to effects of 
exposure to chemicals or pesticides. In addition, adequate production 
of certain neurotransmitters and hormones might be disrupted leading to 
diabetes or neurological damage. These medical conditions have been 
reported as increasing in the general population, and though differing 
in appearance, may be reflecting a basic underlying cellular assault 
caused by radiation exposure. I refer you to the work of Guy Brown.
    Thank you for your thoughtful consideration.
            Sincerely,
                                     Bonnie Eberhardt Bobb,
                                                 Shundahai Network.
                               __________
 Statement of General Accounting Office, Health, Education, and Human 
                   Services Division, Washington, DC.
   Toxic Chemicals--Long-Term Coordinated Strategy Needed to Measure 
                          Exposures in Humans
    State and local officials report continuing public concern over the 
health risks posed by exposures to toxic chemicals, ranging from heavy 
metals such as arsenic found at national hazardous waste sites to 
common pesticides used in and around the home. For example, increasing 
rates of cancer in various communities have prompted questions about 
the potential link to residues from pesticides, indoor air pollutants, 
and other toxic chemicals. Historically, estimates of human exposure to 
toxic chemicals have been based on the concentration of these chemicals 
in environmental media--such as air, water, and food--along with 
assumptions about how people are exposed. Federal monitoring efforts 
have primarily focused on this type of measurement. However, according 
to public health experts, measurements of internal doses of exposure--
actual levels of chemicals or their metabolites\1\ in human tissues 
such as blood or urine--can be a more useful measure of exposure for 
some purposes.
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    \1\ Metabolites result from the interaction of the chemicals with 
enzymes or other chemicals inside the body.
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    Over the past decade, advances in laboratory technology have 
provided new tools for measuring a broad range of chemicals in human 
tissues--tools that can help researchers and health officials assess' 
how much of a chemical has been absorbed in the body and provide more 
accurate measurements of exposure to relate to potential health risks. 
When gathered for the U.S. population, such data can help identify new 
or previously unrecognized hazards related to chemical substances found 
in the environment, monitor changes in exposures over time, and 
establish the distribution of exposure levels among the general 
population. These data can also help identify subpopulations--such as 
children, low-income groups, or ethnic minorities--that might be at 
increased risk because they face particularly high levels of exposure. 
State and local health officials can use information on typical 
exposures in the general population to help assess environmental health 
risks for specific sites or populations within their borders and to 
keep local residents informed. For example, local officials in one 
community collected exposure measurements before, during, and after the 
burning of arsenic-contaminated soil and found that no excess 
exposure--as compared to typical levels found in the population--had 
occurred.
    In light of the potential benefits offered by these new 
technologies, you asked us to review efforts to collect and use such 
information at both the State and Federal levels. Specifically, you 
asked us to (1) determine the extent to which State and Federal 
agencies--in particular, the Department of Health and Human Services 
(HHS) and the Environmental Protection Agency (EPA)--collect human 
exposure data\2\ on potentially harmful chemicals, including data to 
identify at-risk populations, and (2) identify the main barriers 
hindering further progress in such efforts.
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    \2\ The scientific community uses varying terminology when 
referring to human exposures. Often, external contacts with chemicals 
are defined as ``exposures,'' and internal measurements of exposure are 
referred to as ``doses.'' Doses are also considered a measure of 
exposure. Our review focused primarily on efforts to gather internal 
exposure measurements through human tissue in the non-occupationally-
exposed population. To simplify reporting, we are referring to such 
internal exposure measurements as ``human exposure'' data.
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    We compiled a list of more than 1,400 naturally occurring and 
manmade chemicals considered by HHS, EPA, and other entities to pose a 
potential threat to human health. These included chemicals prioritized 
for safety testing (based on EPA's findings that the chemicals may 
present unreasonable health risks), chemicals linked to cancer, toxic 
chemicals frequently found at Superfund sites, and certain pesticides 
monitored in foods or thought to be potentially harmful to humans. For 
these chemicals, we assessed the extent to which major HHS and EPA 
survey efforts--specifically HHS' National Health and Nutrition 
Examination Survey (NHANES) and EPA's National Human Exposure 
Assessment Survey (NHEXAS) phase I (pilot surveys)--were collecting 
human exposure data. We also surveyed 93 environmental health officials 
in 50 States and the District of Columbia, receiving responses from 81 
officials in 48 States for a response rate of 87 percent. At the 
Federal level, we focused on survey data collected for the general 
(non-occupationally exposed) population. We excluded federally 
sponsored academic and private sector research. Appendix I explains our 
scope and methodology in more detail. We conducted our work from March 
1999 through March 2000 in accordance with generally accepted 
government auditing standards.

                            RESULTS IN BRIEF

    Federal and State efforts to collect human exposure data are 
limited, despite some recent expansions. HHS and EPA have been able to 
take advantage of improved technology to measure exposures for more 
people and for a broader range of chemicals. Still, with existing 
resources, HHS and EPA surveys together measure in the general 
population only about 6 percent of the more than 1,400 toxic chemicals 
in our review. For those toxic chemicals that we reviewed, the portion 
measured ranged from 2 percent of chemicals prioritized for safety 
testing to about 23 percent of those chemicals most often found at 
Superfund sites and considered to pose a significant threat to human 
health. Even for those chemicals that are measured, information is 
often insufficient to identify smaller population groups at high risk, 
such as children in inner cities and people living in polluted 
locations who may have particularly high exposures. At the State level, 
efforts are similarly limited. Almost all State officials who we 
surveyed said they highly valued human exposure data for populations 
within their borders, and many provided specific examples of how such 
data have provided useful information for interpreting citizens' health 
risks and guiding public health actions. For example, State officials 
in nine States used human samples not only to identify who was exposed 
to a toxic pesticide illegally sprayed in citizens' homes, but to 
identify houses most in need of clean-up. Despite this perceived value, 
most officials reported that they were unable to collect or use human 
exposure data in most of the cases where they thought it was important 
to do so.
    Three main barriers limit Federal and State agencies' abilities to 
make more progress. First, Federal and State laboratories often lack 
the capacity to conduct measurements needed to collect human exposure 
data; additionally, for most of the chemicals on our list, no 
laboratory method has been developed for measuring the chemical levels 
in human tissues. The second barrier, particularly voiced by State 
officials, relates to the lack of information to help set test results 
in context. Public health officials said they need more information on 
typical exposures in the general population so that they can compare 
this information with people's levels at specific sites or with 
specific populations in their States. They also said they needed more 
research to relate exposure levels to health effects for the chemicals 
of concern in their States. The third barrier, of particular concern at 
the Federal level, is that coordinated, long-term planning among 
Federal agencies has been lacking, partly because of sporadic agency 
commitments to human exposure measurement and monitoring. HHS and EPA 
officials indicated that they have been discussing the merits of 
establishing a coordinated interagency human exposure program, but they 
have not yet formalized or agreed upon a long-term strategy. A long-
term coordinated strategy should also ensure adequate linkages between 
collection efforts and agency goals, provide a framework for 
coordinating data collection efforts that considers individual 
agencies' needs and expertise, provide a framework for identifying at-
risk populations, and consider States' needs for information. To 
address these needs, we are recommending that the Secretary of HHS and 
the Administrator of EPA develop a coordinated Federal strategy for the 
short- and long-term monitoring and reporting of human exposures to 
potentially toxic chemicals.

                               BACKGROUND

    EPA projects a continuing upward trend in environmental compliance 
costs for pollution control measures, amounting to an estimated $148 
billion this year. Hundreds of millions of dollars are spent monitoring 
levels of toxic chemicals in the environment--for example, 
approximately $139 million of Federal funding supported national air-
quality monitoring networks in the United States in fiscal year 
1999.\3\ Despite these expenditures, what often is not known is the 
extent to which people are exposed to potentially harmful chemicals in 
their daily lives, the chemicals to which they are most often exposed, 
the levels of such exposure, how exposures change over time in relation 
to regulatory policies, and the sources of exposure. Policymakers, 
regulators, researchers, and public health officials must often rely on 
estimates of human exposure levels for the general population or for 
smaller groups thought to be at risk. Such estimates are often derived 
from data showing the extent the chemicals are found in the air, water, 
food, or other environmental media and assumptions about how and at 
what rate the body absorbs the chemicals it contacts. A variety of 
methods for measuring exposures are considered to be more direct than 
those that measure chemicals in the ambient environment. These methods 
measure exposures in people's more immediate environments and include 
tools such as personal air monitors, which measure chemicals that may 
be inhaled. For several chemicals and purposes, measuring internal 
exposure levels in human tissues is considered the most useful and 
accurate measure and an important piece of the information needed to 
link contaminants in the environment with adverse health effects.
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    \3\ The Role of Monitoring Networks in the Management of the 
Nation's Air Quality, National Science and Technology Council, 
Committee on Environment and Natural Resources, Air Quality Research 
Subcommittee (Mar. 1999).
---------------------------------------------------------------------------
    While officials may be able to collect internal exposure levels at 
a local level, the results are difficult to interpret without 
information such as comparative data to show what exposure levels might 
be considered high or research findings linking exposure levels to 
specific health effects. Because of the need for improved data on 
actual human exposures found in the general population, the National 
Research Council (NRC), an arm of the National Academy of Sciences, 
recommended in 1991 that the Nation adopt a new program to monitor 
chemical residues in human tissues, such as blood. NRC noted that 
determining the concentrations of specific chemicals in human tissues 
could serve to integrate many kinds of human exposures across media 
such as air, water, or food and over time. As one component of an 
effort to manage environmental quality and protect public health, NRC 
reported that a well-designed national program for monitoring toxic 
chemicals in human tissues was needed.\4\ NRC pointed out that human 
exposure data could be used to help monitor changes in the population's 
exposure to chemicals and identify population groups--by factors such 
as age or geographic location--that might be at increased risk because 
they face higher levels of exposure.
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    \4\ According to NRC, human monitoring data alone can signal the 
need to conduct studies on specific environmental chemicals, but these 
data are best viewed as one component of a comprehensive environmental 
monitoring program. Human measurements are best supplemented with 
knowledge of contaminant sources, environmental pathways, environmental 
concentrations, time patterns and locations of exposure, routes of 
entry into the body, material toxicity, and latency. See NRC, 
Commission on Life Sciences, Monitoring Human Tissues for Toxic 
Substances (Washington, DC.: National Academy Press, 1991) .
---------------------------------------------------------------------------
    Direct biological monitoring of human exposure to chemicals has 
been made increasingly possible by recent advancements in analytical 
chemistry and molecular biology. Methods have been developed to measure 
smaller levels of toxicants in body tissues and to do so with smaller 
sample amounts.\5\ For example, a few years ago a laboratory would need 
100 milliliters of blood to detect dioxins in the part-
per-billion range. New test methods use less than 10 milliliters and 
are capable of detecting concentrations in the parts-per-trillion 
range. Single samples can also now be used to detect low concentrations 
of multiple chemicals. Since 1995, for example, laboratory methods have 
been developed to detect polycyclic aromatic hydrocarbons, a group of 
more than 100 chemicals formed during the incomplete burning of coal, 
oil, gas, garbage, tobacco, and other substances.
---------------------------------------------------------------------------
    \5\ Other human biological tissues that might be used for 
measurements of chemical concentrations include fat tissue, breast 
milk, semen, urine, liver specimens, hair, fingernails, or saliva. 
Human breath has also been used to measure exposure to certain 
chemicals.
---------------------------------------------------------------------------
    Lead is an example of a chemical that has been monitored 
extensively by measuring absorption into human tissues--specifically, 
lead levels in the blood. Elevated levels of lead in the blood can 
cause learning problems and, at extreme levels, result in serious brain 
or kidney damage. Data on blood lead levels have been collected for the 
national population since 1976. Public health officials, researchers, 
and others have used lead exposure data from large- and small-scale 
studies in many ways to identify at-risk populations, evaluate 
regulatory actions, improve the models used to estimate exposure, and 
identify significant sources of preventable exposure, as shown in the 
following examples.
     Identifying at-risk populations: National blood lead data 
revealed that low-
income children living in houses built before 1946 had a prevalence of 
elevated blood lead levels of 16.4 percent as compared to 4.4 percent 
for all children ages 1 through 5; non-Hispanic black children in 
similar housing had a prevalence of 21.9 percent--the highest risk of 
elevated blood lead levels of any demographic group. Using this 
information, State and local health of officials can more effectively 
target screening and treatment efforts.
     Establishing and evaluating public health-related 
policies: In the 1980's, EPA was considering whether or not to make 
permanent a temporary ban on lead in gasoline. National data on lead 
exposure showed a decline in average blood lead levels that 
corresponded to the declining amounts of lead in gasoline. Based on 
this and other information, EPA strengthened its restrictions on lead 
in gasoline and required a more rapid removal of lead from gasoline.
     Improving models used to estimate exposure: Experts 
indicate that an increasingly important use of human exposure data has 
been as a ``reality check'' on other indexes of exposure, such as 
questionnaires about activities or work histories, to ascertain whether 
exposures may have occurred. For example, prior to the decision to 
phaseout lead in gasoline, exposure models suggested that eliminating 
lead in gasoline would have only a slight effect on blood lead levels, 
while actual testing showed a more dramatic effect.
     Identifying key sources of exposure: When combined with 
other exposure data, exposure measurements can help reveal the source 
of the exposure--an essential step in developing and monitoring 
intervention strategies designed to reduce or eliminate harmful 
exposures. For example, when no evidence of lead paint--the most common 
source of lead contamination--was found in the home of a child whose 
blood showed abnormal levels of lead, public health officials were 
baffled. Observational data on how and where the child spent time and 
environmental data from the surfaces most often encountered revealed 
that lead-contaminated stuffing in a toy the child chewed likely 
accounted for the high exposure. The child's blood lead level declined 
when the contaminated toy was removed.
    While lead is unique among chemicals in that it has been 
extensively studied--decades of research has shown its harmful effects 
at increasingly lower levels--such research has been possible in part 
because of laboratory advances in measurement technology. Over the 
years, as technology improved the ability to measure smaller and 
smaller amounts of lead in the bloodstream, researchers have been able 
to identify increasingly subtle adverse effects by linking blood lead 
levels and changes in neurobehavioral functioning.

     CURRENT MEASUREMENT EFFORTS COVER FEW CHEMICALS AND SITUATIONS

    Although HHS and EPA each are expanding their survey efforts to use 
new technologies and measure a broader range of exposures in the 
national population, their measurement efforts cover a limited portion 
of the more than 1,400 potentially harmful chemicals we reviewed. These 
surveys also remain of limited value for identifying at-risk 
populations, because in the case of their survey efforts, sample sizes 
to date have been insufficient--and, for most chemicals, not 
representative of the general population. In addition, Federal efforts 
to help assess potential disproportionate exposures by collecting data 
on communities living near Superfund sites have been limited to few 
locations. State agencies reported that their efforts are also limited, 
despite the importance they place on using such data in their studies 
of population- or site-specific situations within their borders. 
According to State environmental health officials, they are often 
unable to collect these data.

Federal Efforts Are Expanding
    In our examination of the HHS and EPA surveys, we found that the 
types of chemicals measured have recently increased. For the past 40 
years, HHS' Centers for Disease Control and Prevention (CDC) has 
collected through a survey nationally representative data on the health 
and nutrition of the U.S. population. Exposure measurements are one 
component of this survey. In the mid-1990s, EPA's Office of Research 
and Development initiated a human exposure survey, which is currently 
in its pilot phase in three locations across the country. A third more 
recent effort to monitor human exposures to select chemicals was 
initiated in 1996 by HHS' National Institute of Environmental Health 
Sciences (NIEHS) of the National Institutes of Health (NIH). For each 
of these Federal efforts, laboratory measurements are largely conducted 
by the laboratory at CDC's National Center for Environmental Health, 
which also developed many of the methods for performing these 
measurements.

CDC's National Health and Nutrition Examination Survey
    CDC collects human exposure data as part of NHANES, which has been 
conducted periodically since 1960 and, beginning in 1999, has been 
conducted annually. NHANES monitors trends in health status by 
conducting interviews and physical assessments on a nationally 
representative sample of about 5,000 people per year. NHANES collects 
blood and urine samples for many purposes, such as assessing 
cholesterol levels and the prevalence of diabetes. Since 1976, these 
samples have also been used to measure exposure to selected chemicals, 
and excess samples are banked for future research. In the past, CDC's 
human exposure monitoring efforts have focused largely on lead, 
cadmium, and a few pesticides and volatile organic compounds--chemical 
compounds which include a number of animal and known or suspected human 
carcinogens found in tobacco smoke, building supplies, and consumer 
products.\6\ Starting with the 1999 NHANES, CDC proposed to measure up 
to 210 chemicals in human tissues as staff and other resources 
permitted. These chemicals include metals such as mercury, which at 
high levels may damage the brain, kidneys, and developing fetus; 
polyaromatic hydrocarbons (a group of compounds found in sources such 
as foods that have been grilled); and volatile organic compounds, such 
as benzene. At the time of our review, a CDC official indicated that 
resources allowed them to include about 74 chemicals for 1999 and 2000. 
The estimated marginal costs for the environmental exposure-related 
components of the NHANES 1999 survey were about $5 million.
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    \6\ Special reference studies supported by the Agency for Toxic 
Substances and Disease Registry were also conducted on 
nonrepresentative samples of a portion of the people participating in 
the most recently completed segment of NHANES (conducted from 1991 
through 1994). These special studies assessed exposure to 45 pesticides 
and volatile organic compounds.
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EPA's National Human Exposure Assessment Survey
    To expand upon and replace its National Human Adipose Tissue Survey 
(NHATS)--a tissue monitoring program, which ended in 1992-EPA initiated 
in 1993 pilot surveys for NHEXAS in three regions of the country.\7\ A 
goal of the NHEXAS pilots is to obtain knowledge on the population's 
distribution of total exposure to several classes of chemicals and to 
test the feasibility of collecting representative survey data on 
people's total exposures. NHATS focused on monitoring human fat tissues 
for persistent organochlorine pesticides and polychlorinated biphenyls 
(PCB); NHEXAS has broadened this focus in two ways. First, in addition 
to measuring chemical levels in samples such as blood or urine, the 
NHEXAS pilot surveys included measurements of chemicals in air, foods 
and beverages, water, and dust in individuals' personal external and 
internal environments. To conduct these measurements, the pilot surveys 
used tools such as questionnaires, activity diaries, air-monitoring 
badges worn by the individual or other air-monitoring devices, and tap 
and drinking water and food samples. Such data are important for 
purposes such as identifying the most important sources or routes of 
exposure and for taking actions to reduce or prevent exposures. Second, 
the NHEXAS pilot surveys included more types of chemicals than 
pesticides, such as lead and other heavy metals. The NHEXAS pilots, 
however, included fewer chemicals than its predecessor--which measured 
about 130 pesticides and PCBs in human fat tissue--in part because 
monitoring levels of any given chemical in personal environments and in 
human tissues requires significantly more laboratory measurements for 
the same chemical. EPA's NHEXAS pilot surveys, which have tested 
biological samples from about 460 participants, have collectively 
measured up to 46 chemicals, including pesticides, heavy metals, and 
volatile organic compounds in blood, urine, or hair. Once data from 
these pilot surveys have been further analyzed, EPA intends to assess 
the feasibility and cost of conducting a national effort to collect 
total exposure data. To date, EPA has invested about $20 million to 
support the pilot surveys. Very preliminary estimates by EPA for a 
national survey range from $20 million to $30 million per year over 10 
years or more.
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    \7\ Specifically, pilot surveys were conducted in Arizona, 
Maryland, and, EPA's region 5 (Illinois, Indiana, Michigan, Minnesota, 
Ohio, and Wisconsin).
---------------------------------------------------------------------------
National Institute Environmental Health Sciences' Human Exposure 
        Initiative
    In 1996, NIEHS began an initiative to collect human exposure data. 
This initiative was started as a collaboration between NIEHS and CDC to 
improve understanding of human exposures to hormonally active agents--
also called ``environmental endocrine disrupters''--for the national 
population.\8\ The effort was intended to build upon the chemical 
monitoring in NHANES by supporting the development of laboratory 
methods and measurement of previously unmeasured chemicals in human 
tissues collected from NHANES and other studies. NIEHS and CDC signed 
an interagency agreement, under which CDC will develop methods for 
measuring and will measure in blood, urine, or both up to 80 chemicals 
thought to be hormonally active agents. For this effort, CDC obtained 
samples of about 200 people--most of whom are from the ongoing sampling 
of the general population under NHANES.
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    \8\ The concern about endocrine disrupters originated from the 
finding that some synthetic chemicals in the environment are associated 
with adverse reproductive and developmental effects in wildlife and 
mimic the actions of female hormones. According to NRC, although it is 
clear that exposures to hormonally active agents at high concentrations 
can affect wildlife and human health, the extent of harm caused by 
exposure to these compounds in concentrations that are common in the 
environment is debated. See NRC, Commission on Life Sciences, 
Hormonally Active Agents in the Environment (Washington, DC: National 
Academy Press, July 1999).
---------------------------------------------------------------------------
    In 1999, officials of NIEHS and the National Toxicology Program 
(NTP)--an interagency effort to coordinate toxicological research and 
testing activities of HHS, which is administratively housed at NIEHS--
proposed to expand upon the initial collaboration and formalized the 
undertaking as the Human Exposure Initiative. Specifically, they 
proposed a broader interagency effort to quantify human internal 
exposures to chemicals released into the environment and workplace. One 
significant purpose of this effort was to help prioritize those 
chemicals and chemical mixtures to be studied by NTP, recognizing the 
limited resources available for toxicological testing and the need for 
better information to prioritize which chemicals should be tested. 
According to NTP officials, although NTP is the nation's largest 
Federal toxicology testing program, it can initiate only 10 long-term 
cancer studies and 10 reproductive studies per year.\9\ NIEHS provided 
a list of 131 chemicals it hoped would be measured through this 
expanded effort. At the time of our review, however, program officials 
told us that NIEHS had not published data from the chemicals CDC had 
measured under this agreement, and CDC was developing the laboratory 
methods needed to measure many of the chemicals identified by NIEHS as 
needed.\10\ (For more information on NHANES, NHATS, NHEXAS, and NIEHS' 
Human Exposure Initiative, see app. II.)
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    \9\ According to NTP officials, chemicals are tested for cancer and 
noncancer endpoints--including effects on reproduction, development, 
nervous system, and immune systems--using traditional bioassays as well 
as newly validated tests. Validation of new tests is achieved through 
an NTP interagency center involving 15 Federal agencies or institutes.
    \10\ CDC officials indicated that, by the end of 1999, it had 
developed laboratory methods to measure more than half of the chemicals 
under the agreement with NIEHS.
---------------------------------------------------------------------------
Despite Expansion, Chemicals Covered in Exposure Measurements Remains 
        Limited
    Despite these expanded efforts, NHANES and the NHEXAS pilot surveys 
cover only about 6 percent (or 81) of the 1,456 potentially harmful 
chemicals in our review. We compared the chemicals measured by these 
surveys to eight selected lists of chemicals of concern.\11\ Our 
selection was based, in part, on our assessment and input from experts 
that these lists contained chemicals of higher concern to human 
health.\12\ However, the listed chemicals represent a small portion of 
those that are regulated or are of potential public health importance. 
For example, there are over 7,000 lists of chemical substances and 
classes that are regulated under the Toxic Substances Control Act and 
the Emergency Planning and Community Right-to-Know Act.
---------------------------------------------------------------------------
    \11\ ``We excluded NHATS and Human Exposure Initiative chemical 
lists from our analysis. NRC's 1991 review of the NHATS program raised 
questions about the representativeness of the results and the methods 
used to handle the tissue specimens, among other questions. The Human 
Exposure Initiative measurements were not available at the time of our 
review and, thus, which chemicals had been or are currently being 
measured was not known.
    \12\ We selected these lists based on input from program officials 
and experts at EPA, HHS, the Association of Public Health Laboratories, 
and the Pew Commission on Environmental Health and our assessment that 
the criteria for listing a chemical demonstrated that exposure could 
potentially be harmful to humans. There are many toxic chemical lists 
maintained by different programs and agencies for different purposes 
that we did not include in our review and, as such, the ones we 
reviewed do not necessarily individually or collectively represent the 
chemicals of highest concern to human health.
---------------------------------------------------------------------------
    For those individual lists that we reviewed, the portion of toxic 
chemicals measured ranged from 2 percent of chemicals prioritized for 
safety testing (based on EPA's findings that the chemicals may present 
unreasonable risks) to about 23 percent of chemicals most often found 
at the nation's Superfund sites and identified as posing the most 
significant threat to human health. See table 1 for each of the lists 
reviewed and the extent to which NHANES or the NHEXAS pilots are 
measuring these chemicals, and appendix I for a discussion of each list 
included in our review.

     Table 1.--Extent to Which Human Exposure Data Are Collected for
Potentially Harmful Chemicals Through NHANES or the NHEXAS Pilot Surveys
------------------------------------------------------------------------
                  Priority chemicals                        Chemicals
-------------------------------------------------------    measured or
                                                         being measured
             Description of list                No. in -----------------
                                                 list     No.    Percent
------------------------------------------------------------------------
Chemicals found most often at the national         275       62      23%
 Superfund sites and of most potential threat
 to human health.............................
EPA's list of toxics of concern in air.......      168       27       16
Chemicals harmful because of their                 368       52       14
 persistence in the environment, tendency to
 bioaccumulate in plant or animal tissues and
 toxicity....................................
Pesticides of potential concern as listed by       243       32       13
 EPA's Office of Pesticide Programs and the
 U.S. Department of Agriculture's Pesticide
 Data Program................................
Chemicals that are reported in the Toxic           579       50        9
 Release Inventory; are considered toxic; and
 are used, manufactured, treated,
 transported, or released into the
 environment.................................
Chemicals that are known or probable               234       17        7
 carcinogens as listed in HHS' Report on
 Carcinogens a...............................
Chemicals most in need of testing under the        476       10        2
 Toxic Substances Control Act (Master Testing
 list).......................................
------------------------------------------------------------------------
Note: Our analysis was based on human exposure data collected through
  NHANES or the NHEXAS pilot surveys through 2000.
a The Report on Carcinogens list may also include pharmaceutical agents,
  substances of primarily occupational concern, and banned substances.
  According to NIEHS officials, this may account for their lower
  inclusion in NHANES or the NHEXAS pilots. NIEHS and NTP officials
  indicated that, in addition to these chemicals, NTP reports results of
  its chronic bioassays for cancer in its technical report series. There
  are now approximately 500 reports, which collectively include nearly
  250 chemicals found to cause cancer in rodents. Officials indicated
  that another useful evaluation would assess the proportion of rodent
  carcinogens for which human exposure data are collected and that NTP
  is planning to conduct such an evaluation.

    While many potentially harmful chemicals in these lists are not 
measured in the population, NHANES or the NHEXAS pilot surveys contain 
a greater portion of chemicals considered of higher priority. Two toxic 
chemical lists we reviewed--one ranking chemicals frequently found at 
Superfund sites and one ranking selected chemicals compiled by EPA--
prioritized chemicals based on their potential to harm human health We 
examined the highest-ranked chemicals on these lists and found that 
higher proportions of these chemicals were or will be measured compared 
to the overall list. A CDC laboratory official also indicated CDG was 
in the process of developing methods to measure a number of the 
chemicals on these lists and planned to measure other chemicals in 
future efforts if they have adequate resources to do so.
     Ranking of chemicals frequently found at Superfund sites: 
Developed by EPA and HHS' Agency for Toxic Substances and Disease 
Registry (ATSDR), which conducts public health assessments or other 
health investigations for populations living around national Superfund 
sites, this list ranks substances that are most commonly found at 
Superfund sites and pose the most significant potential threat to human 
health due to their known or suspected toxicity and potential for human 
exposure. Of the top 40 chemicals on this list, CDC indicated that 9 
were currently being measured in NHANES. CDC hopes to include an 
additional 30 of the top 40 in future efforts; 11 of these 30 
chemicals, however, were included in the NHEXAS pilot surveys.
     Ranking of selected toxic chemicals compiled by EPA: These 
rankings are based on a chemical's persistence, tendency to accumulate 
in plants and animals, and toxicity. CDC indicated 4 of the top 22 
chemicals on this list based on their health hazard\13\ were currently 
being measured in NHANES. CDC hopes to include the remaining 18 in 
future efforts; 6 of the 18 chemicals were included in the NHEXAS pilot 
surveys.
---------------------------------------------------------------------------
    \13\ EPA's prioritized chemical list ranks chemicals based on the 
length of time to break down, the degree to which they accumulate in 
plants and animals, and their toxicity. Both ecological and health risk 
scores are calculated. We used only the health risk scores in our 
analysis.
---------------------------------------------------------------------------
Federal Efforts Are Limited for Identifying At-Risk Subpopulations
    In recent years, Federal agencies have been charged with 
identifying whether certain populations--including minorities, people 
with low incomes, and children--disproportionately face greater health 
risks because they have greater exposure to environmental hazards.\14\ 
Researchers increasingly recognize that the scarcity of adequate and 
appropriate data, especially for exposures and related health effects, 
hinders efforts to more systematically identify groups that may be at 
risk.\15\ Lacking such data, past efforts to identify the exposures of 
certain demographic groups have often relied on measures of chemical 
levels in the surrounding environment. For example, some studies around 
hazardous waste sites and industrial plants have shown that minorities 
and low-income subpopulations are disproportionately represented within 
the geographic area around the sites. Such studies are limited in 
identifying the actual health risk because they must make assumptions 
about how these substitute measures, such as how close one lives to a 
hazardous waste site, relate to actual exposures experienced by people.
---------------------------------------------------------------------------
    \14\ Executive Order 12898 requires that each agency identify and 
address as appropriate disproportionately high and adverse human health 
or environmental effects of its programs, policies, and activities on 
minority populations and low-income populations in the United States 
and its territories and possessions. Executive Order 13045 established 
similar requirements with respect to children.
    \15\ S. Perlin, K. Sexton, and D. Wong, ``An Examination of Race 
and Poverty for Populations Living Near Industrial Sources of Air 
Pollution,'' Journal of Exposure Analysis and Environmental 
Epidemiology, Vol. 9, No. 1 (1999), pp. 29-48.
---------------------------------------------------------------------------
    To identify groups whose exposure is disproportionately greater 
than that experienced by the remainder of the population--and thereby 
provide more definitive assessments of whether certain groups 
potentially face greater health risks--health officials and researchers 
might measure exposure levels for (1) a representative sample and 
analyze the characteristics of subpopulations with the highest 
exposures or (2) a population thought to be at high risk and compare it 
to measurements from a reference population.\16\ We examined the extent 
to which Federal survey data on human exposures collected to date could 
be used to assess characteristics of those groups most exposed. We also 
examined the extent to which human exposure data was collected on a 
population considered to be at higher risk--specifically, those living 
around national priority hazardous waste sites. In each effort, the 
information collected has been limited, as discussed below.
---------------------------------------------------------------------------
    \16\ D. Wagener, D. Williams, and P. Wilson, ``Equity in 
Environmental Health: Data Collection and Interpretation Issues,'' 
Toxicology and Industrial Health, Vol. 9, No. 5 (1993), pp. 775-95.
---------------------------------------------------------------------------
Sampling Not Sufficient to Identify Many Highly Exposed Groups
    Representative sampling is required to identify at-risk 
subpopulations in a non-biased way--that is, without presupposing that 
a certain group is at higher risk. The sample must also be large enough 
to ensure highly exposed subpopulations can be objectively 
identified.\17\ For nearly all chemicals except lead, however, past 
Federal collection of human exposure data in NHANES and the NHEXAS 
pilot surveys has been insufficient to identify whether 
disproportionate exposures are occurring in many demographic groups. In 
the case of NHANES, the sample is generally drawn to reflect the 
national population as a whole.\18\ Consequently, the sample of the 
group of interest may be too small to draw meaningful conclusions about 
characteristics, such as exposures, of the group. In the past, most 
NHANES exposure measurements were conducted among non-randomly-selected 
samples and from only a portion of the surveyed participants, thus 
limiting the ability to identify highly exposed groups. Lead was an 
exception. Data for blood lead levels in children have been the most 
comprehensively collected, and certain characteristics have been 
clearly associated with a higher prevalence of blood lead levels. EPA 
has concluded that the evidence is unambiguous: children of color have 
a higher prevalence of elevated blood lead levels than white children 
do, and children in lower-income families have a higher prevalence than 
children in higher income families. See table 2 for the most recent 
NHANES analysis.
---------------------------------------------------------------------------
    \17\ The feasibility of using a representative survey to identify 
at-risk subpopulations based on individual characteristics (such as 
age, race, or income level) or location (such as a city, county, or 
State) depends on sample design and size--that is, on how the 
participants are selected and how many participants are included. 
Generally, the lower the percentage of the population in question in 
the sample, the less the data can be used to develop precise estimates 
of exposure or to distinguish exposure levels between subgroups.
    \18\ Certain groups may be included at a higher rate or oversampled 
to ensure a greater level of accuracy. For example, between 1988 and 
1994, children ages 2 months through 5 years surveyed in NHANES were 
oversampled.

  Table 2.--Prevalence of Elevated Blood Lead Levels in Children Ages 1
Through 5, by Selected Demographic Characteristics (NHANES, 1991 Through
                                  1994)
------------------------------------------------------------------------
                                                              Percentage
                                                                 with
            Characteristic of children in sample               elevated
                                                              blood lead
                                                                levels
------------------------------------------------------------------------
Race/ethnicity:
  Black, non-Hispanic.......................................       11.2%
  Mexican-American..........................................         4.0
  White, non-Hispanic.......................................         2.3
Income level:
  Low.......................................................         8.0
  Middle....................................................         1.9
  High......................................................         1.0
Age group:
  1 through 2...............................................         5.9
  3 through 5...............................................         3.5
                                                             -----------
    Total age 1 through 5...................................        4.4%
------------------------------------------------------------------------
Source: CDC, ``Update: Blood Lead Levels--United States, 1991-1994,''
  ``Morbidity and Mortality Weekly Report, Vol. 46, No. 7 (1997), pp.
  141-5.

    CDC officials told us that representative data, such as that 
collected for lead, would be collected for a larger number of chemicals 
starting in 1999. However, CDC plans indicated that for most chemicals 
monitored, only a portion of NHANES survey participants--generally one-
third or fewer, depending on the type of chemical--would be tested. For 
some chemicals, only certain groups thought to be at higher risk may be 
tested. For example, NHANES will include measurement of certain 
persistent pesticides known as organochlorines in one-third of the 
survey participants ages 12 through 19. Children under 12 will not be 
assessed.\19\ CDC officials indicated that people over 19 may be 
assessed if adequate resources are available to do so. Although most 
organochlorines are banned in the United States, some are still used in 
home and garden products, such as products for treating lice and 
controlling agricultural and structural pests and flame retardants used 
in synthetic fabrics.\20\ NHANES data from a one-third subsample will 
be useful for establishing reference ranges within the population and 
illuminating exposure levels nationally; they will also be useful for 
identifying exposures of broad demographic groups, such as males and 
females. But these data are not enough to enable researchers to assess 
exposure levels of or characterize many potentially at-risk groups, 
such as the exposures of inner-city children in low-income 
families.\21\ According to a CDC laboratory official, targeted studies 
should be considered for groups that represent a small portion of the 
population.
---------------------------------------------------------------------------
    \19\ According to CDC officials, children under 12 will not be 
assessed because the volume of tissue samples needed to perform the 
measurement will not be available. Other measurements--such as those 
for lead, mercury, and cotinine (a metabolite of nicotine illustrating 
exposure to cigarette smoke)--will be performed for many in this age 
group.
    \20\ According to CDC laboratory officials, other NHANES exposure 
measurements planned for 1999 and 2000 for a subsample of participants 
includes volatile organic compounds, mercury, nonpersistent pesticides, 
phthalates, and trace metals. Air toxic exposures to selected volatile 
organic compounds will be measured in personal measurements--such as 
chemical levels in the air, measured through badges, and chemicals in 
water samples--and in blood samples from a subsample of people ages 20 
through 59. Mercury will be measured in the hair and blood of 
participants ages 1 through 5 and women ages 16 through 49. 
Nonpersistent pesticides or their metabolites are planned for 
measurement in one-half of participants ages 6 through 11 and one-third 
of participants ages 12 and over. Surveys and focused research indicate 
that household use of certain pesticides may be extensive, but little 
information is available concerning residential or household exposures 
among the general population. Phthalates are planned for measurement in 
one-third of the participant ages 6 and older. Seventeen trace metals 
will be measured in one-third of participants ages 6 and older. Trace 
metals such as barium and beryllium have been associated with adverse 
health effects in occupational or laboratory studies but have not been 
monitored in the general population.
    \21\ The current design of NHANES samples allows several years of 
data to be combined. If exposure for chemicals is measured consistently 
over several years, then assessing risk factors may be increasingly 
possible over time. CDC officials indicated that for any annual NHANES 
full sample, a limited number of estimates for broad population 
subgroups can be developed. More detailed measures for smaller 
subgroups (for example, analyses by age, gender, and race and 
ethnicity) will require more years of data, generally 3 through 6 
years--and even longer if a subsample is used--of data collected for 
all participants. Based on an annual sample of one-third of the 
participants, CDC indicated that estimates may be possible for very 
broad subgroups, such as males or females; participants ages 6 through 
19 or over 20; or a few major race and ethnicity groups, depending on 
the prevalence of the condition examined.
---------------------------------------------------------------------------
    Similarly, the NHEXAS pilot surveys included representative samples 
of participants in the three geographic locations covered. However, 
because of the smaller sample sizes, the work to date has also been too 
limited for much analysis of at-risk populations.\22\ The pilot surveys 
included biological measurements for about 200 people in six Midwestern 
States, about 180 people in Arizona,\23\ and about 80 people in 
Baltimore.
---------------------------------------------------------------------------
    \22\ One assessment of the data from Midwestern States provided 
some indication of potential differences in personal exposures between 
age groups, races, income segments, and house construction dates. 
Researchers cautioned that the data for some categories examined were 
small. This assessment did not report on exposure measurements from 
biological sampling in this survey. (See E.D. Pellizzari, R.L. Perritt, 
and C.A. Clayton, ``National Human Exposure Assessment Survey: 
Exploratory Survey of Exposure Among Population Subgroups in EPA Region 
V,'' ``Journal of Exposure Analysis and Environmental Epidemiology,'' 
Vol. 9 (1999), pp. 49-55.
    \23\ These participants provided biological samples, such as blood 
and urine. Larger participant groups in the study areas provided 
environmental and food monitoring samples and responded to 
questionnaires. This excludes a related but separate study done in 
Minnesota reviewing pesticide exposures that was not one of the three 
formal pilot surveys.
---------------------------------------------------------------------------
Federal Efforts to Identify Communities of Concern Valuable, but Human 
        Exposure Data Are Limited
    A second method to identify a subpopulation disproportionately at 
risk of adverse health effects is to compare exposure levels for a 
group thought to be at high risk with baseline measurements from a 
reference population.\24\ This method can be used to determine, for 
example, the extent to which people in a neighborhood, community, or 
geographic location are exposed relative to others. In cases where 
exposure levels have been identified as high compared to reference 
populations but potential health effects associated with those levels 
have not been researched, public health actions can help prevent 
further or increasing exposures, and these groups can be assessed for 
any subsequent health outcomes.
---------------------------------------------------------------------------
    \24\ Determining the distribution of chemical exposure among a non-
occupationally-exposed population establishes a ``reference range'' 
that shows what can be considered background exposure and what can be 
considered high. With reference range information, officials concerned 
about exposures of groups can compare the groups' exposures to those of 
the general population and determine whether public health action is 
warranted to prevent or reduce high levels of exposure.
---------------------------------------------------------------------------
    One Federal effort, conducted by ATSDR, analyzes risks faced by 
communities near hazardous waste sites. ATSDR estimates that 12.5 
million people live within 1 mile of the nation's 1,300 Superfund 
sites. The agency can collect biological samples through exposure 
investigations as part of the public health assessment process or in 
response to requests from the public.\25\ ATSDR officials said that 
human exposure data collected at Superfund sites have been useful in 
deciding on actions such as stopping or reducing exposures, relocating 
residents, referring residents for medical follow-up, reducing 
community anxiety, influencing priorities on site-specific clean-up, 
making referrals to researchers for assessing health links, and 
educating community and other health providers. As evidence, they 
pointed to the conclusions of an expert review panel, which stated in 
March 1997 that human exposure data were as important to exposure 
investigations and public health assessments as environmental 
monitoring results at the sites of concern.\26\ However, the number of 
investigations that included human exposure data has been limited. 
Between 1995 and July 1999, ATSDR had gathered biological samples at 
only about 47 of the more than 1,300 Superfund sites. At least 34 of 
these investigations detected contaminants in people and 16 found 
elevated levels.
---------------------------------------------------------------------------
    \25\ ATSDR conducts exposure investigations when (1) people have 
likely been exposed to a contaminant, (2) more information is needed on 
the exposure, (3) an exposure investigation will provide that 
information, and (4) that investigation will affect public health 
decisions.
    \26\ In its report, panel members suggested many improvements to 
ATSDR's exposure investigations, including creating a technical 
planning group to review emerging and innovative technologies and 
establishing a national clearinghouse of collected data. ATSDR 
officials indicated that they had not been able to act on some of the 
panel's suggestions because of limited staff and resources and other 
barriers to collecting data, such as the lack of laboratory methods for 
testing chemicals of interest ATSDR has nine staff to conduct exposure 
assessments for sites across the nation and can only respond to 
requests from communities or State or local officials for assistance 
rather than conducting such assessments as part of every new 
investigation.
---------------------------------------------------------------------------
    Other federally conducted efforts designed to monitor or collect 
data on the exposures of populations within selected communities or 
geographic regions have also been infrequent.\27\ One such regional-
scale effort under way is collecting data on exposures within selected 
communities along the border between Texas and Mexico. Officials from 
Mexico and Federal and State agencies in the United States are 
comparing exposures of people in the border area with those in areas 
away from the border. Another study examined the exposures of people 
along the Arizona border compared to the exposures of people elsewhere 
in the State. This study collected environmental samples for 
pesticides, metals, and volatile organic chemicals. Blood and urine 
samples were also tested to relate the environmental measurements to 
the measurements in human tissues for these chemicals.
---------------------------------------------------------------------------
    \27\ Federal agencies also might fund academic research that is 
designed to identify communities of concern. Assessing the extent that 
federally supported academic research included or focused on human 
exposure data to identify at-risk population was beyond the scope of 
our review.
---------------------------------------------------------------------------
State Officials Value Human Exposure Data for Studies and 
        Investigations but Do Not Often Include Them
    Most State officials who we surveyed highly valued human exposure 
data. However, most could not include it in their exposure-related 
health studies, investigations of concerns such as disease clusters, or 
surveillance efforts. Almost half of the officials responding to our 
survey estimated that they had participated in 10 or more exposure-
related studies or investigations since 1996, with about 16 percent 
estimating they participated in 50 or more. However, about half of the 
officials indicated they could seldom if ever collect exposure data 
through human samples in their efforts. When data were developed, 
officials listed five main uses: (1) environmental health epidemiologic 
studies, (2) surveillance of diseases or conditions with suspected 
environmental causes, (3) investigations of citizen concerns, (4) 
planned or accidental chemical releases, and (5) disease clusters (see 
table 3).\28\ State officials we spoke with noted that human exposure 
data are often the most valid and persuasive evidence available to 
demonstrate whether, and to what extent, exposure has occurred or 
changed over time. In highly charged situations, where community trust 
has eroded, such data may be the only evidence acceptable to area 
residents.
---------------------------------------------------------------------------
    \28\ Since most States conduct surveillance for lead exposure, we 
asked officials to not include these efforts in their responses. See 
app. III for a copy of our survey.

    Table 3.--Examples of How State Officials Use Human Exposure Data
------------------------------------------------------------------------
                Purpose                              Example
------------------------------------------------------------------------
Environmental health epidemiologic       Using blood and urine samples
 studies.                                 from people who ate sport fish
                                          and were concerned about undue
                                          exposure to dioxins,
                                          pesticides, and other
                                          chemicals, health officials
                                          determined these people had
                                          exposure to some chemicals
                                          from 2 to 10 times higher than
                                          levels in a reference
                                          population. Based on these
                                          results, officials will focus
                                          a larger health effects study
                                          on exposure to those
                                          chemicals.
Surveillance of diseases or conditions   Virtually all States collect
 with suspected environmental causes.     information on blood lead
                                          levels in children to monitor
                                          and prevent lead poisoning.
                                          Some also monitor exposure to
                                          pesticides and other chemicals
                                          such as mercury and arsenic.
Investigation of citizen concerns......  Health officials used human
                                          tissue measurements and
                                          citizens' reports of illnesses
                                          to demonstrate that the
                                          combined effect of chemicals
                                          released into the environment
                                          posed a health hazard severe
                                          enough to warrant evacuating
                                          nearby residents. State and
                                          Federal officials subsequently
                                          closed a manufacturing plant
                                          because of the harmful health
                                          effects of its chemical
                                          releases.
Investigation of planned or accidental   Officials in nine States asked
 chemical releases.                       CDC to test tissue samples
                                          from almost 17,000 individuals
                                          thought to have been exposed
                                          to methyl parathion, a deadly
                                          pesticide. CDC's ability to
                                          measure the pesticide in human
                                          tissue and compare exposures
                                          across States was critical to
                                          identifying individuals with
                                          high exposures and houses most
                                          in need of clean-up. Because
                                          relocating residents and
                                          removing the pesticide from
                                          homes cost up to $250 000 per
                                          household, the exposure data
                                          helped officials avoid
                                          spending limited funds on
                                          houses that did not pose a
                                          health risk to the people
                                          living in them. One State
                                          official said the exposure
                                          results reduced the number of
                                          houses needing pesticide
                                          removal from hundreds to fewer
                                          than 10.
Investigation of disease clusters......  State health officials reviewed
                                          data on individual cases of
                                          cancer in one community and
                                          for the entire State. When
                                          available data on known risk
                                          factors did not account for
                                          the increased incidence of
                                          breast cancer, officials began
                                          a more detailed study that
                                          included human tissue
                                          analysis. Blood samples were
                                          obtained from women before and
                                          after treatment began and from
                                          women in a control group.
                                          Results will be compared to
                                          reference range data developed
                                          by CDC. One goal of such
                                          studies is to help identify
                                          environmental factors that
                                          contribute to breast cancer
                                          risk.
------------------------------------------------------------------------

    While mercury, arsenic, and pesticides were most often reported as 
being studied in human samples, some State officials reported using 
human exposure data for chemicals that CDC has since 1991 developed 
methods to measure. For example, about 15 percent of officials 
conducted studies of human exposure to volatile organic compounds, and 
almost 30 percent reported studies of exposure to PCBs using data from 
tissue analysis.
    Regardless of whether State officials had collected or used human 
exposure data in the past 4 years, about 90 percent of those officials 
responding to our survey said human exposure data from tissue samples 
was extremely or very important for addressing environmental health 
concerns. Despite the perceived value of such data, almost two-thirds 
of officials said they could include human exposure data in fewer than 
half of the exposure-related studies, investigations, and surveillance 
efforts where they considered it important. More than one-third said 
they seldom could include such data.
    Several State health and laboratory officials whom we interviewed 
expressed frustration at the missed opportunities for collecting 
biological samples as part of their studies and investigations for 
reasons such as limited laboratory capacity. For example, health 
officials in one State could not examine the role played by methyl t-
butyl ether (MTBE)--an additive designed to promote more efficient 
burning of gasoline--in a major respiratory disease outbreak because 
State staff lacked the expertise and CDC staff lacked the time to 
conduct the needed tests. In 1995, after MTBE was added to gasoline and 
thousands of citizens reported becoming ill, State officials wanted to 
measure MTBE or its by-products in blood from samples of individuals 
with and without symptoms to determine whether MTBE exposure might be 
the cause or a contributing factor. Objective measures of individual 
exposure might have allowed public health officials to conclusively 
demonstrate or rule out a link between the outbreak and exposure, 
something that was not possible with environmental data and 
epidemiologic surveys. The chemicals officials most often cited as 
wanting to study using human exposure data, but could not, were 
pesticides and volatile organic compounds.

   SIGNIFICANT INFORMATION AND INFRASTRUCTURE GAPS POINT TO NEED FOR 
                  STRATEGIC PLANNING AND COORDINATION

    As part of our survey and interviews, we asked public health 
experts and State and Federal officials to identify barriers they 
considered significant to structure their efforts to collect and use 
human exposure data. Officials cited two primary barriers: the lack of 
laboratory capacity or methods to analyze tissue samples and the lack 
of information to help set exposure test results in context. Addressing 
these barriers takes time and resources. In that regard, we identified 
a third barrier to more effective use of existing resources: HHS and 
EPA lack a long-term strategic plan to address infrastructure and 
science barriers, coordinate efforts to meet Federal and State needs, 
and address the many questions about how to set priorities given their 
limited resources.

Laboratory Capacity and Methods to Measure More Chemicals Needed
    State officials frequently said insufficient laboratory capacity in 
their States and at the Federal level hindered their ability to obtain 
human exposure data in cases where they thought such data were 
important. Over half of the officials said their States lacked 
sufficient numbers of trained laboratory staff, sufficient laboratory 
capacity to analyze samples, or sufficient laboratory equipment. Many 
officials attribute such capacity limitations to funding constraints 
because tissue analyses can be time-consuming and expensive to perform. 
For example, according to a CDC official, each test to measure dioxins 
in a sample requires (1) a laboratory free from chemicals that could 
compromise test results, (2) specialized equipment that costs about 
$500,000, and (3) highly trained and experienced staff to complete. 
Officials of a professional organization representing public health 
laboratories told us that, although many State laboratories perceive 
they have a role in conducting tests to detect toxic substances in 
humans, very few currently have such capacity.\29\
---------------------------------------------------------------------------
    \29\ This organization actively supports expanding State and local 
laboratory capacity to participate in a human biomonitoring program to 
provide human exposure data that would enhance the effectiveness of 
environmental policy and regulatory decisions. In addition this group 
helped States apply for the four grants CDC offered to increase State 
and local laboratory capacity to detect in human fluids and issues 
chemicals that could be used in a terrorist attack. Illustrating their 
interest in developing such laboratory capacity, 31 State and 2 local 
health departments applied for the four grants.
---------------------------------------------------------------------------
    State and Federal officials we interviewed told us that because few 
State laboratories have the necessary equipment and expertise, they 
often rely on CDC's environmental health laboratory staff to analyze 
tissue samples. Given the specialized laboratory requirements, CDC's 
environmental health laboratory is generally considered the best-suited 
to analyze tissue samples for a range of chemicals and has, in fact, 
developed many of the methods to do so, according to Federal and State 
officials. CDC's laboratory performs measurements for most Federal and 
many State efforts to gather human exposure data. Many officials said 
CDC's laboratory capacity is essential to their efforts and needs to 
expand to meet growing needs. A few State officials said CDC's 
laboratory consistently returned test results when people's lives were 
at risk but was less able to help States assess health risks more 
generally. An official in one State said that, while CDC's assistance 
is invaluable, the State's laboratory capacity allowed public health 
officials to obtain human exposure data and investigate citizen's 
concerns more frequently than they could if they had to rely soley on 
CDC's laboratory capacity.
    Another significant issue is the lack of analytical laboratory 
methods to measure chemicals of concern. Despite advances over the past 
2 decades in analytic chemistry and molecular biology, laboratory 
methods have not been developed to measure about 88 percent of the 
1,456 chemicals in our review, according to information provided by CDC 
and EPA officials. Although laboratory staff at CDC have quickly 
applied scientific and technological advances to develop new and more 
efficient laboratory methods, they are concerned about the lack of 
methods to test a single human sample for several related toxics. For 
example, a method exists to measure arsenic in blood but not to measure 
arsenic and other heavy metals at the same time. Such methods make more 
efficient use of the samples that are gathered and greatly reduce the 
time and money needed to test large numbers of samples. While CDC's 
laboratory continuously develops new chemical testing methods, current 
resources limit the number to about 10 annually.
    Even when analytical methods exist, efforts to gather human 
exposure data are sometimes limited by problems with the methods used 
to gather the samples. This is especially true for young children, a 
group thought to be particularly susceptible to harmful effects from 
exposure. In some cases, existing laboratory methods require sample 
volumes that can only be obtained through invasive techniques. That is, 
blood samples must be obtained by puncturing a vein rather than by 
pricking a finger. Many people will not allow their children to 
participate in studies that require such techniques. Similarly, urine 
samples can be difficult to obtain from children who wear diapers. For 
example, substances in the diapers can compromise test results.

Information Needed to Interpret Human Exposure Measurements
    To help interpret the results of laboratory analysis and determine 
what actions, if any, are needed to protect the public's health, State 
and Federal officials cited the need for two types of context-setting 
data: comparative (or reference range) information that shows exposure 
levels among the general population and research that links exposure to 
adverse health effects. At the State level, where many of the specific 
actions regarding at-risk situations are taken, almost three-fourths of 
responding officials cited the lack of such information as a problem.
    State officials said that reference range data, when available, 
allowed them to determine whether exposures are sufficiently high to 
merit action to reduce or prevent further exposure. For example, in one 
State, public health officials, with help from CDC, responded to 
citizens' reports of foul odors from leaking tanks at a waste cleanup 
site by gathering and analyzing blood samples from those living nearby. 
CDC's analysis of the blood samples showed that residents near the site 
had exposure levels at the high end of a CDC-developed reference range. 
State and Federal officials ordered the contractor to move the cleanup 
operations to another location. Over 60 percent of State officials 
responding to our survey said the lack of reference range data 
prevented them from using human exposure data in their work. State 
officials said the problem for research about adverse health effects 
was similar. Much of the data linking exposure to health effects 
concerns high-level occupational exposures or higher doses administered 
to laboratory animals. Consequently, translating the results of such 
research to lower-level exposures of people and determining how best to 
advise people about potential effects is problematic.
    Federal health officials and researchers also cited a need for both 
types of information in their investigations, particularly for 
federally supported work in specific geographic areas. ATSDR officials 
said the lack of reference ranges was a particular reason they could 
not generate human exposure data more often in public health 
assessments and exposure investigations. When data allow officials to 
put exposure into context, concerns can be investigated and addressed. 
For example, in one community, where citizens were concerned about 
exposure to dioxins from nearby chemical manufacturing plants, ATSDR 
officials had CDC's laboratory analyze blood samples and found that 
some residents had levels of several dioxins above the highest levels 
in a CDC-ATSDR-developed reference range. In response, ATSDR helped 
residents obtain assistance from medical professionals expert in 
dioxins and, working with State and Federal environmental agencies, 
began environmental testing to locate the exposure source.

Stronger Interagency Efforts Needed for Strategic Planning and 
        Coordination
    The barriers outlined above present daunting challenges to State 
and Federal agencies. The number of chemicals that remain to be 
investigated and the kinds of information needed are substantial, the 
research is often expensive, and progress is often slow. At the same 
time, the level of resources available for dealing with the issue is 
limited, and responsibilities are fragmented among many State and 
Federal agencies. Many studies have pointed to the need for better 
coordination. While HHS and EPA efforts have been coordinated through, 
for example, participation on advisory committees and the use of CDC's 
laboratory for performing the actual measurements, such coordination 
falls short of what is needed for long term planning. This need is 
illustrated by the growing convergence of interest in the planned 
expansions of NHANES and NHEXAS. To ensure as much progress as possible 
with available resources, HHS and EPA need a strategic planning effort 
that reflects a clear set of priorities, a framework for coordinating 
data collection and reporting efforts, and a tie to performance goals.

Agreement About Need for Better Planning and Coordination of Efforts Is 
        Widespread
    In 1991, NRC reported that ``although a successful monitoring 
program must be highly relevant to regulatory needs, it could and 
should serve a wide range of client programs and must not be dominated 
by any one of them.'' NRC reported that the approaches of EPA, CDC, and 
ATSDR are each important in the identification and control of 
environmental hazards to human health and that coordination among the 
programs would enhance Federal monitoring efforts and benefit 
researchers, health professionals, and the public.\30\
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    \30\ While NRC found EPA in the best position to house a human 
exposure monitoring program, it also found that the ambivalence within 
EPA about the National Human Monitoring program's future indicated that 
the match of program goals, potential benefits, and EPA mandates was 
not perfect.
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    Officials and experts agree that interagency interaction is needed 
to take advantage of all approaches and information available to 
develop the most cost-effective, least burdensome approach for 
collecting needed exposure data. Toward this end, HHS agencies and EPA 
have at various times attempted to collaborate in their respective 
exposure monitoring efforts. For example, EPA solicited broad 
interagency input into the design of NHEXAS and established interagency 
agreements with CDC and others to assist in performing laboratory 
measurements, quality control, and other support functions. Also 
through interagency agreements, CDC has broadened the exposure 
monitoring component of NHANES to incorporate the needs of EPA 
researchers.
    Outside reviews and involved researchers and officials indicate 
that even with recent efforts, coordination has fallen short in 
ensuring adequate interaction and linkages between agencies. For 
example, EPA's scientific advisers reviewed the NHEXAS pilot surveys 
and concluded that, while NHEXAS was an excellent project and highly 
relevant for providing needed information, a strategic plan was needed 
for follow-up studies. They also urged that EPA link NHEXAS exposure 
data with biological data from NHANES, where possible, and develop a 
more collaborative process for gathering input for chemical selection. 
Attendees at a September 1999 NIEHS conference on the Role of Human 
Exposure Assessment in the Prevention of Environmental Disease also 
called for a coordinated interagency effort in assessing human 
exposure.\31\ One theme and recommendation from the discussions was the 
need to bridge scientific disciplines and agency missions to address 
knowledge gaps in assessing human exposure.
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    \31\ The NIEHS-supported conference addressed many opportunities 
and challenges in exposure assessment research including exposure-
analysis methodology, exposure-disease relationships, regulatory and 
legislative issues, gene-environment interactions, disease prevention 
and intervention and some current Federal initiatives related to 
exposure assessment. One area of discussion was the need for and 
limitations of biological measures of exposure.
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    State officials and others have also indicated that better linkages 
and partnering are needed between Federal, State, and local agencies. 
For example, an official of the Association of Public Health 
Laboratories told us that one way to improve States' involvement in a 
national exposure monitoring program would be to further their 
capability to assess levels of toxic chemicals in their own populations 
relative to national levels. This would require, in this official's 
view, the transfer of new monitoring technology to State public health 
laboratories, along with the resources necessary to support that 
technology. Improved capacity at the State level would allow Federal 
laboratories to concentrate on developing more and faster analytical 
methods for measuring chemicals in tissues and on responding to crisis 
situations. Other experts have also called for better linkages between 
Federal efforts and communities and community concerns. For example, 
the NHEXAS reviewers recommended that EPA improve communication between 
NHEXAS investigators and State and local health officials. Another 
theme of the conference on human exposure assessment was that efforts 
to assess human exposure be in line with public health goals and 
community concerns.

Individual Priorities Contribute to Difficulties in Coordinating 
        Efforts
    The challenges Federal and State agencies face in setting 
priorities for which chemicals to assess in their individual programs 
likely contribute to the difficulties they have in collaborating with 
one another. The expense of conducting exposure measurements in ongoing 
surveys--especially for the number of samples required to establish 
national or regional trends and levels--necessitates that priorities be 
set. However, agreeing on priorities--or even agreeing on the process 
for setting priorities--is challenging and resource-intensive. For 
example, to identify chemicals to measure in NHEXAS, EPA undertook an 
extensive selection process, soliciting input from regional and program 
offices.\32\ EPA's scientific advisers, while supportive of the 
program, cited the criteria for selecting target chemicals as a 
weakness. NHANES is even less formal in this regard, with no documented 
priority-setting process for chemicals to be measured. Chemicals 
measured are largely determined by CDC's laboratory scientists based on 
such factors as the availability of analytical methods for measuring 
the chemical and the laboratory's capacity to perform the 
measurements.\33\ According to a CDC official, CDC's limited staff and 
laboratory resources cannot develop the administrative infrastructure 
to establish a scientific review process for selecting priority 
chemicals.
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    \32\ Because of its emphasis on evaluating total human exposure, 
NHEXAS emphasized those chemicals that can be measured In multiple 
environmental media (for example in air, water, and food) as well as 
human tissues.
    \33\ CDC's laboratory officials indicated that their choice of 
chemicals is determined by the availability of high-quality analytical 
methods with adequate throughput, whether the chemical is a known or 
suspected cause of health problems, whether the chemical is on EPA and 
ATSDR priority lists, the number of persons likely exposed, and the 
availability of funding from collaborators.
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    Another challenge in setting priorities, according to some 
officials, is the appropriate balance between gathering exposure 
information on chemicals about which little is known and gathering 
information on those already considered to be toxic. NHANES and NHEXAS, 
for example, focus largely on chemicals that are considered to be toxic 
at some level. By contrast, the National Toxicology Program's Human 
Exposure Initiative is intended to help set priorities for chemical 
toxicological testing and might gather baseline information on 
chemicals and chemical mixtures occurring in the population that are 
not necessarily already known as harmful.
    Officials we interviewed raised many other concerns that would need 
to be addressed when trying to coordinate efforts among multiple 
Federal and State agencies and programs:
     For what specific purpose(s) will these data be collected?
     What chemicals should be measured, in what order, how 
frequently, and in what specific tissues?\34\
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    \34\ Several officials pointed to the importance of developing a 
breast milk monitoring program. Many environmental agents are fat 
soluble and are released into breast milk at significant 
concentrations. Examples include dioxins and PCBs. According to NIEHS 
researchers, 6 months of nursing could result in dioxin or PCB 
concentrations in infants which are 10 times higher than in the mother. 
Breast milk monitoring programs operate in several European countries 
including Sweden, Germany, and the Netherlands.
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     What chemicals should be measured concurrently with or 
only through personal environmental measurements?
     What is the best way to identify populations that might be 
at higher risk of exposure?
     What chemicals should be monitored in humans nationally, 
versus regionally or locally?\35\
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    \35\ EPA's scientific advisers' review of the NHEXAS pilot surveys 
illustrates some of the trade-offs in determining the appropriate 
balance between large population surveys and more targeted follow-up 
surveys. The advisers reported that population studies are the only 
means for collecting baseline information for such uses as trend 
analysis. NHANES is an example of such a probability study. On the 
other hand, more targeted special studies tend to assess high-end 
exposure groups more precisely. Additionally, the review illustrated 
how total exposure data may be unnecessary to collect for chemicals at 
a national level, depending on the chemical. The advisers pointed out 
that targeted special studies can be used to identify sources and 
factors associated with high-end exposures. While identification of 
major sources, media and pathways for populations experiencing high 
exposures are essential to reduce unacceptably high risks, if the 
majority of the national population is exposed to pollutants at levels 
under health-related benchmarks, source identification for such 
exposures is not a priority from a health standpoint.
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     How can exposure data be coupled with our increasing 
knowledge about the effect genetic factors have on risk from exposure 
to improve the understanding about an individual's risk from chemical 
contaminants?
     What role should State agencies have in conducting human 
exposure measurements and in planning Federal efforts?
    The fragmentation of responsibilities and efforts for assessing 
human exposure reflect larger issues in the fragmentation of 
responsibility for environmental health. For over a decade, a number of 
studies have pointed to the need for improved coordination between 
regulatory and health agencies (see table 4).

 Table 4.--Examples of Reports Calling for Coordination in Environmental
                                 Health
------------------------------------------------------------------------
                 Report                            Description
------------------------------------------------------------------------
Environmental Health Data Needs: An      Called for the Federal
 Action Plan for Federal Public Health    Government to facilitate
 Agencies (Public Health Foundation,      stronger ties between
 1997).                                   environmental protection and
                                          public health agencies,
                                          perhaps by strengthening
                                          organizational links and
                                          coordinating funding for
                                          Federal (EPA and HHS)
                                          programs. Also indicated that
                                          priority environmental health
                                          information needs included
                                          more complete exposure data,
                                          including laboratory data such
                                          as biological measurements.
Burke, Shalauta, and Tran, The           Found that progress in
 Environmental Web: Impact of Federal     understanding the relationship
 Statutes on State Environmental Health   between human health and the
 and Protection (Public Health Service,   environment will require,
 Jan. 1995).                              among other actions, improved
                                          cooperation between the many
                                          health and environmental
                                          agendas at the Federal, State,
                                          and local levels.
Researching Health Risks (Office of      Reported that although agendas
 Technology Assessment, 1993).            are expanding their research
                                          efforts, few incentives exist
                                          for them to collaborate, and
                                          the lack of collaboration can
                                          only hinder progress in
                                          applying newly developed
                                          techniques and knowledge to
                                          understanding the potential
                                          links between exposure and
                                          adverse health effects.
The Potential for Linking Environmental  Reported that linkage of
 and Health Data (National Governors'     environmental and health data
 Association, 1990).                      to investigate possible
                                          connections between exposure
                                          and adverse health effects
                                          cannot occur without
                                          interagency communication and
                                          cooperation, which rarely
                                          evolves naturally.
The Future of Public Health (Institute   Found that separating
 of Medicine, 1988).                      environmental health from
                                          public health programs impeded
                                          desirable coordination and
                                          could limit the depth of
                                          analyses given to the health
                                          implications of environmental
                                          hazards.
------------------------------------------------------------------------

Potential for Convergence of Effort Is Increasing
    The importance of planning and coordination is magnified by the 
possible overlap in current plans to expand human exposure monitoring 
efforts. This potential can be seen in HHS' and EPA's plans for NHANES 
and proposed expansions of the NHEXAS pilots. Although nearly two-
thirds of the chemicals measured in the NHEXAS pilot surveys are 
currently measured or planned for NHANES, the two efforts have taken 
differing approaches in the past to monitoring the population's 
exposure to these chemicals.\36\ The NHEXAS pilots have focused on 
``total'' exposure, which entailed measurements in human tissues, 
water, air, food, dust, and other potential sources in participants' 
living environments, and data-gathering has focused on three selected 
regions of the country. Total exposure measurements can help identify 
those sources that most contribute to exposure--a critical part of 
determining how to take action to reduce or prevent exposures. However, 
measuring total exposure requires several types of laboratory 
measurements and is thus more expensive. By contrast, NHANES has 
focused its exposure monitoring on human biological measurements and on 
a sample that is generally representative of the Nation as a whole. 
Biological monitoring data demonstrate exposure from all sources, but 
determining exposure sources usually requires additional environmental 
measurements. Other than the few chemicals it covered, NHANES has 
historically been considered an awkward vehicle for including exposure 
monitoring--in large part because of its wide range of competing goals 
and lack of a primary commitment to monitoring tissues for exposures.
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    \36\ The follow-up to the NHEXAS pilots has not been planned, so 
the identity of the chemicals to be measured is not known.
---------------------------------------------------------------------------
    Changes to the 1999 NHANES, such as the following, show a greater 
emphasis in environmental health. These changes along with EPAs plans 
to expand NHEXAS suggest a convergence of the two approaches and a 
growing and overlapping interest among agencies in exposure measurement 
and monitoring.
     NHANES now has a goal of monitoring exposures. Starting 
with NHANES 1999, CDC formalized its commitment to monitoring trends in 
the nation's environmental exposures by establishing this as a Stated 
goal of NHANES.\37\ In line with this goal, CDC's laboratory plans to 
issue this year a ``National Exposure Report Card'' using NHANES 
samples.\38\ This goal is similar to EPA's goal as proposed for NHEXAS' 
follow-up survey--to document the status and trends of the national 
distributions of human exposure to potentially high-risk chemicals.
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    \37\ At this writing, NHANES' goals are to (1) estimate the number 
and percentage of persons in the United States and designated subgroups 
with selected diseases and risk factors: (2) monitor trends in the 
prevalence, awareness, treatment, and control of selected diseases; (3) 
monitor trends in risk behaviors and environmental exposures; (4) 
analyze risk factors for selected diseases; (5) study the relationship 
between diet, nutrition, and health; (6) explore emerging public health 
issues and new technologies; and (7) establish a national probability 
sample of genetic material for future genetic research. CDC official 
told us that the emerging focus in NHANES on environmental health 
issues reflects advances in technology as well as the public's 
increasing priority for understanding the impacts of environment on 
health. Part of CDC's responsibility is to report on environmental 
hazards and determinants of health. Section 306 of the Public Health 
Service Act (42 U.S. C. 242k) directs the National Center for Health 
Statistics, the CDC agency that conducts NHANES, to collect statistics 
on subjects such as the extent and nature of illness and disability of 
the population; environmental, social, and other health hazards; 
determinants of health; health resources; and utilization of health 
care.
    \38\ According to CDC laboratory officials, the first report card 
will provide data on exposure levels of the population to 25 chemicals 
that have not yet been determined. These might include selected heavy 
metals, indoor air pollutants, nonpersistant pesticides, and 
phthalates.
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     NHANES will include selected environmental measurements. 
Starting with NHANES 1999, environmental measurements, such as 
contaminant levels in water and house dust, and levels measured through 
personal air monitors worn by participants will be included in the 
survey to help identify potential sources of exposure.\39\
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    \39\ Because of the wide range of other health and nutrition 
questions addressed in NHANES, environmental measurements currently 
included are less extensive than those included in NHEXAS because, for 
example, food and beverage samples are not conducted.
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     NHANES will be conducted continuously rather than 
periodically, allowing for more flexibility in the measurements it 
includes. According to CDC officials, the new annual sampling design 
will enable them to include emerging and changing priorities in the 
data collected through the survey and thus allow for a broader 
collection of data than in previous surveys, including exposure and 
measurements in people's personal environments.
    Other planned changes to NHANES and NHEXAS also indicate a growing 
overlap in approaches and interests. For example, pending analysis and 
evaluation of its pilot surveys, EPA is proposing to expand NHEXAS 
beyond the regional focus of its pilot to include a nationally 
representative sample similar to the framework of NHANES. Also, both 
CDC and EPA would like to eventually include a component in NHANES and 
NHEXAS to monitor special populations. EPA's proposed expansion of 
NHEXAS would eventually include ``special studies'' to examine high-end 
exposures in more detail and with greater precision Small populations 
for further study would be identified through the national survey. CDC 
also plans to add a component to NHANES that will gather selected 
NHANES health and nutrition data, possibly including exposure 
measurements, on specific subpopulations in geographic areas of 
interest or among specific racial or ethnic minority populations. This 
effort to add a subpopulation component to NHANES was initiated in 
response to the needs of State health officials and others for local 
level data.

Funding Is Sporadic, and Funding Priorities Change
    Part of the difficulty in collaborating and in planning human 
exposure monitoring efforts to meet longer-term needs may also arise 
from issues of sporadic funding and resources to support these efforts. 
As compared to the hundreds of millions spent on monitoring 
contaminants in environmental media, we estimate that less than $7 
million was spent collectively by CDC (including ATSDR) and EPA on 
their respective human exposure efforts in 1999.\40\
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    \40\ NIEHS-CDC interagency agreements document that NIEHS had 
provided about $3.3 million to CDC between fiscal years 1996 and 2000 
for performing environmental exposure measurements for its Human 
Exposure Initiative. No funding was provided in fiscal year 1999.
---------------------------------------------------------------------------
    Neither CDC nor EPA has provided a dedicated funding stream for 
their exposure measurement efforts. Funding for efforts has, to a large 
extent, depended on priorities established year to year. For example, 
funding for the exposure and other environmental components of NHANES 
depends to some extent on the interests of other Federal agencies and 
their willingness to pay for related data gathering and analysis.\41\ 
CDC estimated it would spend about $4.7 million for laboratory 
measurements and laboratory staff costs in 1999 for NHANES-related 
exposure measurements such as lead, mercury, cotinine, heavy metals, 
pesticides, volatile organic compounds, and other chemical classes. 
Interagency agreements document the receipt of about $1.2 million from 
collaborators for some of those laboratory measurements. If other 
agencies do not pay CDC to conduct laboratory tests--with the exception 
of some ``core'' measurements, such as lead--CDC performs tests as time 
and laboratory resources allow. For example, although CDC initially 
proposed for the survey starting in 1999 to measure up to 210 chemicals 
in tissues of a subset of NHANES survey participants, CDC officials 
indicated that those chemicals could be measured only as resources 
allowed.\42\ At the time of our review, a CDC laboratory official 
indicated that resources might allow them to include about 74 chemicals 
in 1999 and 2000.
---------------------------------------------------------------------------
    \41\ NHANES 1999, for example, received $15.9 million in 
appropriated funding and, according to CDC officials, an additional 
$6.8 million from collaborating institutions. Interagency agreements 
related to environmental measurements performed in conjunction with 
NHANES document the receipt of about $1.4 million from collaborators at 
EPA and other agencies for environmental exposure measurements. In 
addition to EPA's support for measurement of certain chemicals in human 
tissues, an estimated $125,000 was received from the Department of 
Housing and Urban Development for performing dust sampling and an 
estimated $30,000 from the Mickey Leland National Urban Air Toxics for 
personal measurements of volatile organic compounds. CDC laboratory 
officials indicated that the increase to their fiscal year 2000 funding 
for the environmental health laboratory has improved their ability to 
support needed laboratory measurements for NHANES and other efforts. 
This funding increased by about $5 million between fiscal years 1999 
and 2000.
    \42\ According to CDC officials, uncertain funding may limit their 
ability to perform NHANES measurements for dioxins, furans, 
coplanercoplanar PCBs, phytoestrogens, certain heavy metals, 
phthalates, and polyaromatic hydrocarbons.
---------------------------------------------------------------------------
    EPA's commitment to funding NHEXAS also remains uncertain. EPA 
officials estimated that approximately $20 million was spent on NHEXAS 
from 1993 through 1999--with a decreasing amount designated to the 
project in 1999 and 2000. While EPA's independent scientific advisers 
commended the design for NHEXAS and said it could be the basis for an 
effective national program, they expressed concerns about the limited 
resources allocated to analyze the data gathered in the pilot 
projects.\43\ At national level, EPA has dedicated approximately three 
full-time positions to evaluate the data from the NHEXAS pilots and 
design future expansions.
---------------------------------------------------------------------------
    \43\ EPA officials indicated that at the individual study level, 
approximately $250,000 was allocated for analyses of the NHEXAS pilot 
data in fiscal year 1999; EPA plans to spend approximately $170,000 in 
fiscal year 2000.
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Better Linkages to Program Goals and Performance Monitoring Needed
    The Government Performance and Results Act of 1993 (Results Act) 
provides Federal agencies a structured frameswork to coordinate efforts 
in crosscutting programs when agency missions overlap. The Results Act 
requires Federal agencies, as part of their mandated responsibilities, 
to prepare annual performance plans that discuss agency goals and 
performance measures. Past reviews have shown that EPA, HHS, and other 
Federal agencies have not fully used the Results Act planning process 
to explain how each would coordinate crosscutting efforts with other 
agencies. Few agency plans attempt the challenging task of discussing 
planned strategies for coordination and establishing complementary 
performance goals and common or complementary performance measures.
    A major weakness of EPA's fiscal year 2000 Annual Performance Plan 
was the lack of sufficient detail describing crosscutting goals and 
activities or how EPA planned to coordinate with other Federal agencies 
on related strategic or performance goals.\44\ For example, under its 
plan's ``safe food'' objective, EPA discusses coordinating with HHS and 
other agencies to reduce health risks from pesticides. However, it did 
not outline specific projects and strategies, responsibilities, and 
products that must be coordinated for EPA to accomplish its goals. 
Similarly, HHS' performance plan lacked details regarding how 
crosscutting activities and goals would be coordinated with other 
agencies.
---------------------------------------------------------------------------
    \44\ See Observations on the Environmental Protection Agency's 
Fiscal Year 2000 Performance Plan (GAO/RCED-99-237R) July 20, 1999.
---------------------------------------------------------------------------
    In their fiscal year 2001 performance plans, EPA and CDC make 
limited use of human exposure data to measure or validate performance, 
and neither agency describes how data collection efforts relate to 
complementary goals of other Federal agencies. For example, EPA and CDC 
have the common goal of reducing childhood lead poisoning, but only CDC 
uses data on blood lead levels to validate progress toward this goal. 
Although EPA has goals that are clearly related to reducing human 
exposure to other toxic chemicals, the human exposure data collected by 
EPA and CDC have largely not been linked with or used to measure 
progress. Such data show potential for helping elucidate Federal 
progress in environmental efforts, but EPA has not yet acted to fully 
realize such potential. For example, NHEXAS data are used to help 
assess children's exposure to pesticides. However, a related goal to 
reduce public exposure to pesticides does not use human exposure data; 
instead, it relies on the number of activities to educate agricultural 
workers and the public. The effectiveness of these efforts could be 
assessed, in part, through measured reductions in actual human exposure 
to specific pesticides. During 1999, CDC maintained a goal to develop 
methods to measure toxic substances in humans and added a goal to 
measure and report on human exposure to toxic substances. However, 
neither goal discusses how CDC will coordinate with EPA and other 
Federal programs in meeting these goals and ensuring that newly 
developed methods and measured substances meet priority data needs.

Successful Models for Planning and Coordination Point to the Need for 
        High-Level Mandate, Process for Inclusion, and Mechanism for 
        Reporting
    Program officials at HHS and EPA told us in early 2000 that they 
were discussing the merits of establishing a new interagency program in 
human exposure monitoring.\45\ At the time of our review, the proposal 
was in early stages of discussion and officials had not clarified how a 
new program would consider States' information needs, differ from or 
relate to NHANES and the NHEXAS pilot surveys, or resolve past issues 
about differing agency goals and priorities.
---------------------------------------------------------------------------
    \45\ This effort was coordinated through the White House Office of 
Science and Technology Policy.
---------------------------------------------------------------------------
    Several experts and agency officials have pointed to successful 
models of interagency collaboration in environmental health issues that 
could help shape an HHS-EPA interagency effort. One such model is the 
collaboration on children's environmental health issues. In this case, 
Executive Order 13045, signed by the President on April 21, 1997, 
established a Task Force on Environmental Health Risks and Safety Risks 
to Children to develop and recommend Federal strategies for children's 
environmental health and safety. Among the elements that have been 
cited as contributing to success were a clear mandate to collaborate 
and a process to respond to the input and data needs of different 
stakeholders. According to involved officials, a high-level interagency 
work group has worked closely to address its charges. These charges 
include developing general policy and annual priorities; a coordinated 
Federal research agenda; recommendations for partnerships among 
Federal, State, local, and tribal governments and the private, 
academic, and nonprofit sectors; and identifying high-priority 
initiatives to advance protection of children's environmental 
health.\46\
---------------------------------------------------------------------------
    \46\ Executive Order 13045 also indicates such strategies are to 
include proposals to enhance public outreach and communication and a 
statement regarding the desirability of new legislation to fulfill or 
promote the purposes of the order.
---------------------------------------------------------------------------
    A second model with a top-down mandate and a process to respond to 
stakeholders is NTP, established in 1978 as an HHS-wide effort to 
provide regulatory and research agencies needed information about 
potentially toxic and hazardous chemicals nationwide and to strengthen 
the science base in toxicology. According to officials, part of NTP's 
success in fostering collaboration are an inclusive executive committee 
and an established process for decisionmaking. The NTP Executive 
Committee, which provides policy oversight of NTP, includes agencies 
outside of HHS, such as EPA and the Consumer Product Safety Commission. 
The NTP Executive Committee also serves as a decisionmaking body, in 
that members cast votes on key issues, such as prioritization of 
chemicals for study and for listing in NTP's Report on Carcinogens.\47\ 
Involved officials believe the voting requirement helps move key issues 
forward and provides an effective means of resolving disagreements. NTP 
also has an inclusive process for identifying chemicals to be 
considered by the Executive Committee. NTP's chemical testing 
nominations are solicited from sources in academia, Federal and State 
regulatory and health agencies, industry, and unions, as well as 
environmental groups and the general public.
---------------------------------------------------------------------------
    \47\ The Director of NTP issues the Report on Carcinogens pursuant 
to a 1978 amendment, section 301 (B) (4) of the Public Health Services 
Act. which requires the Secretary of HHS to publish a list of all 
substances that are either known to be human carcinogens or may 
reasonably be anticipated to be human carcinogens and to which a 
significant number of persons residing in the United States are 
exposed. NTP issues a revised Report on Carcinogens every 2 years.
---------------------------------------------------------------------------
    Several officials indicated that reports on exposures in the 
national population to toxic chemicals are needed to help inform 
policymakers, researchers, and the public. Specifically, such reports 
can help identify serious human health risks, help officials link 
exposures to sources, determine appropriate interventions to help 
reduce these risks, and document the effectiveness of interventions in 
reducing exposures. Moreover, agencies could use such reports to 
validate or measure progress in meeting goals established under the 
Results Act. A key element of NTP is its biennial reports. As 
informational scientific and public health documents, these reports are 
not only used by Federal and State agencies but are considered an 
important medium for informing the public and policymakers on the 
status of substances considered likely to be carcinogenic for humans.

                              CONCLUSIONS

    The Nation has a long way to go in measuring human exposures to 
potentially harmful chemicals. While Federal efforts are increasingly 
covering chemicals of 
potential concern, there are substantial gaps in current information on 
exposure 
levels, the health risks that result, and those who may be most at 
risk. Recent advances in laboratory technology show promise for 
improving the collection and analysis of some of the information needed 
to understand and measure human exposures. However, a more long-term 
and concerted effort to address infrastructure and scientific 
limitations in measuring exposure will be required if substantive 
progress is to be made. Applying and continually improving upon these 
advances to cover an increasing number of chemicals and issues will 
require both time and resources. CDC's laboratory to date has been able 
to meet many demands for human exposure data for Federal and State 
measurement and monitoring efforts. However, its capacity, given 
current resources, will continue to limit progress to develop new 
methods and include more people and chemicals in Federal and State 
efforts.
    Federal agencies are currently planning whether and how they can 
expand existing programs to meet the significant needs for human 
exposure data. Collaboration in such planning is essential, because 
agencies have different capacities and skills, and separate attempts 
have fallen short of supporting the large efforts that are needed. So 
far, no clear strategy has emerged for how to carry out this major 
task, particularly given the growing and overlapping interests among 
many agencies for understanding and measuring human exposures to 
potentially harmful chemicals. In our view, developing such a strategy 
is a challenging but necessary first step.
    In the meantime, State and local health officials must try to 
understand and communicate the risks from environmental contaminants to 
concerned citizens--a difficult, if not impossible, task when 
information is unavailable to help them interpret the risks from the 
exposures citizens face in their daily environments. State officials 
indicate they need more of the information that is collected through 
Federal efforts to help interpret those levels faced by citizens in 
their States. And to collect measurements for their studies and 
investigations, State officials are faced with finding laboratories 
that have the equipment and capacity to perform the complex 
measurements. Federal capacity, largely centered at CDC, cannot meet 
States' needs in many situations, and laboratory capacity is lacking in 
most States.
    To help meet the gaps in environmental exposure data at all levels 
of government, EPA and the various HHS agencies with environmental 
health responsibilities need to work closely together to forge a 
strategic plan laying out the necessary next steps for addressing human 
exposure information and concerns. In addition to considering States' 
needs and capacities for collecting human exposure data, such a plan 
could:
     provide long-term structure to human exposure monitoring 
as an interagency effort,
     establish a mechanism for setting program priorities in 
line with agency goals and performance measures,
     clarify agency roles and minimize duplication, and
     help agencies share expertise.
    Policymakers, agencies, and the public seek many types of 
information on exposure trends and levels in the national population as 
well as for groups considered potentially at risk of disproportionate 
exposures. Resolution is also needed on what information should be 
reported on national trends and levels of exposure. A strategic plan 
could help agencies resolve the many different informational needs to 
determine what exposure information should be reported and how agencies 
can work together to report such information.

  RECOMMENDATIONS TO THE SECRETARY OF HHS AND THE ADMINISTRATOR OF EPA

    We recommend that the Secretary of HHS and the Administrator of EPA 
develop a coordinated Federal strategy for the short- and long-term 
monitoring of human exposures to potentially toxic chemicals. In and 
the Administrator developing such a strategy, the Secretary and the 
Administrator should of EPA assess the need for an interagency program 
to collect and report data on human exposures, the extent current 
surveys and agency efforts can be used as part of such an effort, and 
the funding needs and sources to sustain a viable program for 
monitoring human exposures to toxic substances.
    Such a strategy should:
     address individual agency needs and expertise,
     provide a framework for coordinating efforts to gather 
data needed to improve understanding of human exposures,
     assess needed Federal and State laboratory capacity,
     establish research priorities for laboratory methods 
development and a mechanism or process for setting chemical monitoring 
priorities,
     develop a framework for identifying at-risk populations, 
and
     consider States' informational needs.
    We further recommend that the agencies identify common or 
complementary performance goals or measures to reduce, monitor, or 
develop methods for measuring human exposures to toxic chemicals. Such 
goals or measures can be a basis for structuring and supporting 
interagency collaborations to collect and use human exposure data.
    As part of this coordinated strategy, we recommend that the 
Secretary of HHS and Administrator of EPA periodically publish a report 
on levels and trends in the national population of exposures to 
selected toxic substances.

                            AGENCY COMMENTS

    We provided HHS and EPA an opportunity to comment on a draft of 
this report. Both agencies generally concurred with our conclusions and 
recommendations--that a long-term coordinated Federal strategy was 
needed for monitoring human exposures to potentially toxic chemicals 
and that such efforts could be linked through common or complementary 
performance goals--and indicated that they would work together to 
implement our recommendations. (See apps. IV and V respectively.) HHS 
and EPA also both stressed the importance, as discussed in our report, 
of expanding the scope of their efforts to monitor and measure human 
exposures to toxic chemicals beyond the limited number of chemicals 
covered today. To support such expansions, HHS noted the importance of 
additional resources for improving laboratory capacity and methods.
    HHS and EPA provided several other comments raising points that one 
or both agencies consider important to monitoring human exposures to 
toxic chemicals. These included the need to: (1) coordinate any 
exposure monitoring in the general population with monitoring of 
occupational exposures; (2) consider adding the monitoring of breast 
milk in a national program; (3) depending on the chemical and the 
purpose for the data collection, consider measures of human exposure 
other than the concentration in human tissues for collection; and (4) 
consider the option of expanding the scope of NHANES as a means of 
improving data needed to identify potentially at-risk subgroups. We 
agree that the points raised in these comments are important and that 
they should be considered during development of any coordinated Federal 
strategy.
    EPA also said that additional Federal partners, including the 
Departments of Defense, Transportation, and Energy should participate 
in developing and supporting a coordinated Federal strategy. We agree 
that it would be appropriate to obtain input from all involved and 
interested agencies. HHS and EPA also provided a number of clarifying 
and technical comments, which we incorporated where appropriate.
    We are sending copies of this report to the Honorable Donna E. 
Shalala, Secretary of HHS, and the Honorable Carol M. Browner, 
Administrator, EPA. We are also sending copies to Jeffrey P. Koplan, 
Director, CDC, and Administrator, ATSDR; Ruth Kirschstein, Acting 
Director; NIH; Kenneth Olden, Director, NIEHS; Richard J. Jackson, 
Director, National Center for Environmental Health; Edward J. Sondik, 
National Center for Health Statistics; Norine Noonan, Assistant 
Administrator for Research and Development, EPA; and other interested 
parties. We will make copies available to others upon request.
    If you or your staff have any questions, please contact me at (202) 
512-7119. Other major contributors are included in appendix VI.
                                            Janet Heinrich,
     Associate Director, Health Financing and Public Health Issues.
                               __________

                               Appendix I

                   Objectives, Scope, and Methodology
    Nine Members of the Congress asked us to study the nation's data 
collected to assess human exposure to potentially toxic chemicals in 
the environment. As agreed with our requesters, we focused our work 
primarily on efforts to measure chemical exposures in human tissue 
samples, such as blood, hair, and urine. This report discusses (1) the 
extent to which State and Federal agencies--specifically, HHS and EPA--
collect human exposure data on potentially harmful chemicals, including 
data to identify at-risk populations, and (2) the main barriers 
hindering further progress in such efforts.

                          SCOPE OF OUR REVIEW

    Although laboratory measurements of chemical exposure are only one 
part of the data collected to address environmental health concerns, 
they merit attention because new technology makes it increasingly easy 
to measure the degree to which a chemical has been absorbed into human 
tissues. Such measurements are often a more accurate and useful 
approach to assessing exposure than environmental measurements, 
according to public health experts.
    Because Federal agencies that collect human exposure data collect 
these data for different purposes, we were not able to assess the 
overall adequacy of the nation's efforts to address environmental 
health concerns. Therefore, we focused our work at the Federal level on 
the efforts of two agencies--HHS and EPA--and the subcomponents of 
these agencies involved in exposure measurement and monitoring in the 
U.S. population:
     EPA's Office of Research and Development,
     HHS' National Center for Environmental Health (NCEH),
     HHS' National Center for Health Statistics (NCHS),
     HHS' Agency for Toxic Substances and Disease Registry 
(ATSDR), and
     HHS' National Institute of Environmental Health Sciences 
(NIEHS).
    We focused our work mainly on nonoccupational environmental 
exposure to chemical agents known or thought to pose a health hazard by 
one or more of these agencies.
    To gather information about activities of State officials, we 
surveyed environmental health officials in State public health agencies 
and conducted site visits to six States.

                       METHODOLOGY OF OUR REVIEW

    To assess the extent to which the Federal agencies we reviewed have 
collected human exposure data, we met with key officials responsible 
for efforts intended to collect human exposure data at each agency. We 
focused on what we identified as being the most significant Federal 
efforts in human exposure assessment at EPA and HHS related to 
nonoccupational human exposure to environmental contaminants. We 
reviewed four major activities: EPA's National Human Exposure 
Assessment Survey (NHEXAS), CDC's National Health and Nutrition 
Examination Survey (NHANES), NIEHS' Human Exposure Initiative, and 
ATSDR's exposure investigation activities around hazardous waste and 
other sites. We also obtained information on EPA's National Human 
Adipose Tissue Survey (NHATS), which ended in 1992.
    We also interviewed officials and obtained documentation on how 
these various programs were planned and organized and to assess the 
extent data were collected in a manner that allows the identification 
of at-risk subpopulations by such factors as income, race and 
ethnicity, age, and geographic location. We obtained relevant budget 
information for 1999 and reviewed related agency performance plans.
    To assess barriers to progress in collecting or using human 
exposure data, we interviewed Federal officials involved in such 
efforts about past and current views on such barriers. In addition, we 
reviewed the general literature on human exposure to environmental 
chemicals and interviewed officials from organizations representing 
State epidemiologists, State public health laboratory directors, local 
public health officials, the chemical industry, environmental 
advocates, and public health experts.
    To gather nationwide data on the views of State public health 
officials, we surveyed officials with environmental health 
responsibilities related to chemical exposure in State public health 
agencies. We identified 93 officials in each of the 50 States and the 
District of Columbia--referred to collectively as States--with 
assistance from the Council of State and Territorial Epidemiologists 
and officials in each of the 51 States.
    We also conducted onsite work at EPA, CDC agencies, and NIEHS and 
in six States--California, Louisiana, Massachusetts, North Carolina, 
Oregon, and Washington. These six States were selected to represent 
diverse geographic areas and environmental health programs. In the six 
States, we interviewed State public health officials. We also 
interviewed officials in State environmental protection and agriculture 
agencies, academic and independent researchers, and representatives of 
community advocacy organizations.
    We excluded efforts to collect human exposure data within 
occupational settings from the scope of our review. Similarly, we 
excluded federally supported academic and private sector research 
efforts.
    Our work was conducted from March 1999 through March 2000 in 
accordance with generally accepted government auditing standards.
Methodology for Chemical List Analyses
    To assess the extent to which human exposure data are available for 
chemicals of high concern to human health, we analyzed a number of 
chemical lists maintained by HHS and EPA agencies. We also identified 
chemicals measured through HHS and EPA representative surveys. Chemical 
data were gathered from various sources, including EPAs Offices of 
Pesticide Programs, Air and Radiation, Pollution Prevention and Toxics, 
and Research and Development; the National Toxicology Program (NTP) 
headquartered at NIEHS; CDC's ATSDR; and NCEH and NCHS within ATSDR. 
Several toxic chemical lists were identified through a review of 
related reports and literature on environmental exposure issues. To 
narrow the scope, we also contacted staff in relevant offices within 
these agencies and asked them to identify key lists of chemicals of 
concern. We consulted experts and public health laboratory officials at 
the Pew Commission for Environmental Health and the Association for 
Public Health Laboratories.
    From the many available chemical lists, we judgmentally selected 
eight based on our assessment that each list contained chemicals 
thought to have a high potential for causing harm to human health and 
input and recommendations from experts. These eight lists, which 
contained more than 1,400 unique chemicals, provide a conservative 
number of the chemicals agency officials consider a concern for human 
health. To ensure that chemicals with more than one name were not 
included more than once, we used Chemical Abstract Service numbers, a 
unique identifier. These lists, whether singly or combined, do not 
necessarily reflect the highest priorities of the Federal Government or 
the agencies or programs we contacted. The lists we reviewed are 
described below.
     Chemicals found most often at the nation's Superfund 
sites: HHS' ATSDR, which conducts public health assessments or other 
health investigations for populations living around national priority 
hazardous waste sites, and EPA prepare a list, in order of priority, of 
hazardous substances. This list contains substances that are most 
commonly found at facilities on the National Priorities List 
(Superfund) and pose the most significant potential threat to human 
health due to their known or suspected toxicity and potential for human 
exposure.
     EPA's list of toxics of concern in air: The Congress 
established the original list of 188 hazardous air pollutants that EPA 
would regulate through the Clean Air Act. EPA periodically must revise 
the list to add or, when warranted, remove substances. EPA adds 
substances that it determines to be air pollutants that are known to 
cause or may reasonably be anticipated to cause adverse effects to 
human health or adverse environmental effects.
     Chemicals harmful because of their persistence in the 
environment, tendency to bioaccumulate in plant or animal tissues, and 
toxicity: EPA's Office of Solid Waste and Office of Pollution 
Prevention and Toxics created this list of persistent, bioaccumulative, 
and toxic (PBT) chemicals. PBT chemicals do not readily break down or 
decrease in potency after they are released into the environment, even 
if released in quantities that are very small and legally permitted. 
Over time, these chemicals are likely to accumulate in soils or other 
environmental media, be absorbed or ingested by animals and plants, 
accumulate in animal and plant tissue, pass through the food chain, and 
potentially cause long-term human health or ecological problems.
     Priority pesticides of potential concern: We combined two 
lists of potentially harmful chemicals to develop this list. EPA's 
Office of Pesticides Programs provided a list of pesticides of concern 
that were classified as organophosphates; carbamates; or group B1, B2, 
or C carcinogens. According to a program official, these classes of 
pesticides are generally considered among the most potentially harmful 
to human health. We combined this list with the U.S. Department of 
Agriculture's Pesticide Data Program list of pesticides that are 
measured in selected commodities or foods. Pesticides monitored by the 
program in 1997 included insecticides, herbicides, fungicides, and 
growth regulators in fresh and processed fruit and vegetables, whole 
milk, and grains.
     Chemicals that are known or probable carcinogens: HHS' 
Report on Carcinogens includes substances known or reasonably thought 
to be cancer-causing based on evaluations of substances performed by 
scientists from NTP, other Federal health research and regulatory 
agencies, and nongovernment institutions. The list of substances in the 
report represents an initial step in hazard identification. Substances 
listed as ``known to be human carcinogens'' are those for which there 
is sufficient evidence of carcinogenicity (cancer-causing potential) in 
humans to indicate a causal relationship between exposure to the agent, 
substance, or mixture and human cancer. Substances listed as 
``reasonably anticipated to be human carcinogens'' are those for which 
there is limited evidence of carcinogenicity in humans, insufficient 
evidence of carcinogenicity in experimental animals, or both.
     Chemicals that are considered toxic and used, 
manufactured, treated, transported, or released into the environment: 
EPA publishes the Toxics Release Inventory containing information on 
the release and other waste management activities of toxic chemicals by 
facilities that manufacture, process, or otherwise use them. This data 
base is made available to the public and is considered useful to 
citizens, businesses, and governments for purposes of working together 
to protect the quality of their land, air, and water and for evaluating 
the probability that chemical releases could impact human health in 
communities.
    Chemicals most in need of testing required by the Toxic Substances 
Control Act: The Master Testing list contains those chemicals that are 
prioritized for safety testing based on EPA's finding that (1) a 
chemical may present an unreasonable risk of injury to human health or 
the environment and/or the chemical is produced in substantial 
quantities that could result in significant or substantial human or 
environmental exposure, (2) the available data to evaluate the chemical 
are inadequate, and (3) testing is needed to develop the required data.
    We compared the combined list of these chemicals, totaling 1,456, 
and each individual list with those chemicals identified by EPA and CDC 
officials as measured in the NHEXAS and NHANES human exposure efforts 
through 2000. We excluded NHATS' and the Human Exposure Initiative's 
chemical lists from our analysis. NRC's 1991 review of the NHATS 
program raised questions about, for example, the representativeness of 
the results and the methods used to handle the tissue specimens. NIEHS' 
Human Exposure Initiative measurements were not complete at the time of 
our review and thus it was not known which chemicals had been or are 
currently being measured.

Survey Development and Distribution and Analysis
    To develop survey questions, we reviewed documentation on 
environmental health programs prepared by HHS and EPA agencies, 
professional organizations representing State epidemiology and public 
health laboratory officials, and public health experts. We also spoke 
with officials and representatives from each of these groups.
    We pretested our survey in person with State environmental health 
officials in two States and in teleconferences with officials in two 
additional States. We asked knowledgeable people in EPA and CDC and in 
the environmental and public health fields to review the survey 
instrument. We refined the questionnaire in response to their comments 
to help ensure that potential respondents could provide the information 
requested and that our questions were fair, relevant, answerable with 
readily available information, and relatively free of design flaws that 
could introduce bias or error into our study results. We mailed 
questionnaires to the 93 officials in August 1999. We sent at least one 
follow-up mailing and conducted telephone follow-ups to nonrespondents. 
We ended data collection in December 1999; had received responses from 
81 officials in 48 States for a response rate of 87 percent.
    In preparing for our analysis, we reviewed and edited the completed 
questionnaires and checked the data for consistency. We tested the 
validity of the respondents' answers and comments by comparing them 
with data we gathered through interviews with public health experts and 
other public health officials and with documentation obtained at 
Federal agencies and in case study States.
    The survey and survey results are presented in appendix III.

                              Appendix II

  Reported Gaps in Human Exposure Data and History of Federal Efforts

    Since the 1980's, reports reviewing environmental health data needs 
have recommended the broader collection of human data showing actual 
human exposures to chemical contaminants in the environment. Various 
Federal agencies have collected such human exposure data for a number 
of purposes; historically, these collection efforts have been limited 
to selected chemicals, subpopulations, and time periods.

    VARIOUS REPORTS DISCUSS THE GAPS IN HUMAN DATA SHOWING MEASURED 
                   EXPOSURE TO CHEMICAL CONTAMINANTS

    Data on actual levels of chemicals in humans has been a 
longstanding gap in the information needed to establish human health 
risks from exposures to environmental contaminants. While data on the 
concentration of chemicals in environmental media--such as air, water, 
and food--have historically been used to estimate human exposure to 
harmful chemicals, this approach to detect or define human health risks 
has limitations. According to the NRC, there are too many chemicals, 
too many sources, and too many routes of exposure to rely solely on 
environmental monitoring. Measurements of internal doses of exposure--
actual levels of chemicals or their metabolites found in human tissues, 
such as blood or urine--are generally considered an accurate measure of 
human exposure. Such measurements can reflect exposures from all routes 
and that may be accumulated over time, modified by individual 
differences in physiology, and difficult or impossible to assess by 
environmental measurements (such as hand-to-mouth ingestion in young 
children). In 1991, NRC reported that a program of human tissue 
monitoring is critical to the continued improvement of understanding of 
exposure to toxic chemicals and recommended that such a program be 
given high priority for funds and other resources.\1\
---------------------------------------------------------------------------
    \1\ NRC, Commission on Life Sciences, Monitoring Human Tissues for 
Toxic Substances.
---------------------------------------------------------------------------
    Several other Federal reviews have pointed to information needs in 
this area. An interagency assessment of federally supported data bases 
conducted in the early 1990's concluded that Federal data systems 
generally lacked data on actual human exposures, including information 
about contact between the chemical and the human body (personal 
exposures) and the amount of the chemical absorbed (internal doses). 
The review also found substantial value in collecting and analyzing 
these data in a comprehensive and systematic manner and that the costs 
associated with establishing and maintaining appropriate data bases 
were justified.\2\ A discussion of some of these reviews follow.
---------------------------------------------------------------------------
    \2\ See K. Sexton and others, ``Estimating Human Exposures to 
Environmental Pollutants: Availability and Utility of Existing Data 
bases,'' ``Archives of Environmental Health, Vol. 47, No. 6 (1992), pp. 
398-407.
---------------------------------------------------------------------------
     HHS, NCHS, Environmental Health: A Plan for Collecting and 
Coordinating Statistical and Epidemiologic Data (Washington, DC: 
Government Printing Office, 1980): This report found that ``acceptable 
ranges of physiologic measurements and normal levels of trace elements 
must be determined before any attempt can be made to associate health 
outcomes with environmental exposures. Many of these baseline data do 
not exist for particular populations of interest or for specific 
pollutants. In addition, early indicators and symptoms of disease that 
might be environmentally related are not dearly understood.'' The 
report identified a number of research directions to help define the 
association between health effects and specific environmental 
exposures, including the establishment of baseline data on 
physiological measurements of trace elements in tissue and blood for 
the population.
     HHS, NIEHS, Issues and Challenges in Environmental Health 
(Washington, DC: National Institutes of Environmental Sciences, 1987): 
This report found that due to ``gaps in data systems established for 
monitoring and surveillance of environmental exposure, effort should be 
made to foster better linkage among existing systems . . . Existing 
data systems should be expanded to include biochemical and cellular 
indicators of early stages of disease. . . . The group found there is a 
need for more research and more systematic collection of data on the 
exposure of human populations to harmful substances. Reliable exposure 
data are necessary for assessing the probability that exposed 
populations will develop adverse health effects and the likelihood of 
success in intervening to reduce those risks.''
     K. Sexton and others, ``Estimating Human Exposures to 
Environmental Pollutants: Availability and Utility of Existing Data 
bases'': This report found that while ``the evidence suggests that 
existing data systems contain a substantial amount of information that 
is relevant to exposure estimation . . . the quality of the data is 
inconsistent and difficult to assess and that understanding and 
accessing the information is often difficult. Furthermore, these 
systems demonstrate a striking absence of data on actual human 
exposures, including a lack of information about contact between the 
agent and the human body (exposure) and about the amount of the agent 
or its metabolites that enters the body (dose).''
     NRC, Hormonally Active Agents in the Environment: This 
report found that 
``determining the risk of environmental hormonally active agents to 
humans and wildlife is difficult because exposure to these agents has 
not been routinely monitored. . . . Background concentrations of 
hormonally active agents in humans, particularly in adipose (fat) 
tissue and blood, and other biota need to be established. In 
particular, routes of exposure and the effects of diet need to be 
assessed to provide a framework for examining the effects of these 
compounds in the general population and in highly exposed 
subpopulations.''

       HISTORY OF FEDERAL EFFORTS TO COLLECT HUMAN EXPOSURE DATA

    Since 1967, HHS and EPA have conducted Federal surveys to assess 
the U.S. population's exposures to toxic chemicals from the analysis of 
human tissue samples. While their efforts measured some of the same 
exposures and covered some of the same time periods, their goals 
differed and most did not include a nationally representative sample of 
citizens. EPA's efforts first monitored exposure to pesticides and, 
more recently, have attempted to link human exposure data to specific 
routes of exposure. CDC's periodic surveys are intended to monitor 
trends in the health and nutrition status of the population but, over 
time, have included exposures to environmental toxics as one component 
of the general survey. NIEHS' Human Exposure Initiative, established in 
the late 1990's, is intended to help the agency prioritize chemicals 
for further toxicology and carcinogenicity testing. Within these 
studies, various subgroups have been used to develop human exposure 
estimates, but in most cases, sampling has not been for all participant 
groups or random. Consequently, the results cannot be projected to the 
U.S. population as a whole for most chemicals. See table 5 for the 
timeframes and numbers of chemicals covered for major Federal efforts.

                    Table 5.--Number of Chemicals and Time Frames for Select Federal Efforts
----------------------------------------------------------------------------------------------------------------
                                                                                                       No. of
                                                                                        No. of        chemicals
                                                                                       chemicals    measured for
                    Duration                       No. of participants providing     measured for        all
                                                         biological samples               any       participants
                                                                                    participations   (ages 1 and
                                                                                                       older)
----------------------------------------------------------------------------------------------------------------
Second National Health and Nutrition
 Examination Survey (NHANES II):
  1976-1980....................................  20,000 examined a................            36              1
Third National Health and Nutrition Examination
 Survey (NHANES III)
  1988-1994....................................  30,000 examined a................            47              1
National Health and Nutrition Examination
 Survey, 1999 (NHANES)
  1999-ongoing.................................  5,000 per year b.................          74 c            2 d
National Human Adipose Tissue Survey (NHATS):
  1967-1992....................................  14,000...........................           128           20 e
National Human Exposure Assessment Survey
 (NHEXAS) Pilot Study:
  1995-1999....................................  460 f............................          46 c              6
----------------------------------------------------------------------------------------------------------------
a The number of participants in NHANES II and NHANES III who received physical examinations is used as a proxy
  for the number providing biological samples, as the latter number was not readily available.
b The number of persons examined in a calendar year is planned to be about 5,000.
c For NHANES, the list of potentially toxic chemicals covered was provided by CDC laboratory officials. For
  NHEXAS, the list of potentially toxic chemicals covered was provided by EPA NHEXAS officials.
d According to a CDC laboratory official, lead and cadmium are measured in all participants. Cotinine will also
  be measured in many participants--specifically, those ages 4 and older.
e Chemicals analyzed by NHATS varied over time. NHATS collected data on 20 pesticides between 1970 and 1981.
  NIEHS chemicals are not included because data were not available at the time of our review.
f Excludes a related but separate study done in Minnesota reviewing pesticide exposures that was not one of the
  three formal pilot surveys.

    A description of these Federal efforts to collect human exposure 
data follows.
     CDC's National Health and Nutrition Examination Surveys: 
NHANES, conducted multiple times since 1960 by NCHS, is designed to 
provide national estimates of the health and nutrition status of the 
noninstitutionalized civilian population of the United States. 
Estimates are obtained by examining randomly selected participants in a 
manner that accurately reflects the demographic characteristics of the 
U.S. population. Participants are given comprehensive physical 
examinations (including tissue samples) and are interviewed on issues 
such as their nutritional habits, health conditions, and housing 
characteristics. NHANES data are used for a number of purposes. For 
example, in addition to monitoring changes in blood lead levels, uses 
of NHANES include development of national standards for blood pressure 
and cholesterol levels and for determining infection rates for 
diseases. CDC's laboratory housed at NCEH performs the measurements of 
chemicals in human tissues for NHANES.
     Second National Health and Nutrition Examination Survey: 
NHANES II was designed to provide national estimates of the health and 
nutritional status of the civilian noninstitutionalized population of 
the United States for persons aged 6 months to 74 years. Children, the 
elderly and people classified as living at or below the poverty level 
were oversampled in order to increase the reliability of the estimates 
for these groups. Measurements of pesticide residues were taken from 
participants who were between the ages of 12 and 74 years of age.\3\ 
Blood lead measurements were taken from participants in all age groups 
in the survey.
---------------------------------------------------------------------------
    \3\ Data were not publicly available, as CDC is resolving some 
methodological issues associated with data collection.
---------------------------------------------------------------------------
    Third National Health and Nutrition Examination Survey: NHANES III 
was designed to provide national estimates of health and nutritional 
status of the civilian noninstitutionalized population of the United 
States ages 2 months and older. Children ages 2 months through 5 years, 
blacks, Mexican-Americans, and persons ages 60 or older were 
oversampled to increase the reliability of the estimates for these 
groups. Blood lead measurements were taken from all particiapants ages 
1 year or older. Cadmium measurements were taken from all participants 
ages 6 years or older. In addition, some participants ages 20 through 
59 years had measurements taken for volatile organic compounds and 
pesticides. Participants volunteered for these additional measurements, 
so the results cannot be projected to the population as a whole. 
However, the results still serve as the reference ranges for these 
chemicals.
    National Health and Nutrition Examination Survey, 1999: In 1999, 
NCHS changed the design of NHANES so that it will now be conducted as a 
continuous survey of about 5,000 participants annually. Like the 
previous surveys, NHANES will yield nationally representative results 
for the civilian noninstitutionalized population. The NHANES design 
will allow for oversampling to vary between years; persons aged 12 to 
19, persons aged 60 and over, blacks, and Mexican-Americans are being 
oversampled. It will be tied to related Federal government data 
collections conducted on the general U.S. population, in particular, 
the National Health Interview Survey.\4\ NCHS also plans to release 
results from the survey every year after the first 3 years of data 
collection. More than 1 year of data will be required for many 
estimates, particularly among detailed subgroups of the population. 
While lead and cadmium will be the only potentially toxic chemicals 
measured for all participants ages 1 and older (although cotinine, a 
metabolite which illustrates exposure to environmental tobacco smoke, 
will be measured for most age groups--those ages 4 and over), NCHS and 
NCEH plan to get nationally representative data for specific chemicals 
for persons in specific demographic groups, such as mercury 
measurements in women ages 16 through 49. NCHS will also measure 
household lead dust, drinking water contaminants, and exposure to 
volatile organic compounds for selected participants. In addition to 
conducting an annual national survey, NCHS is developing a smaller, 
more targeted health survey--the Defined Population Health and 
Nutrition Examination Survey (DP-HANES). NCHS recognizes that NHANES 
cannot collect information that would be directly useful at the local 
or State level or for small populations. DP-HANES is intended to 
address this issue through the use of small mobile examination centers 
that would visit areas of interest and examine 2,000 to 3,000 
participants for each special study. DP-HANES participants would not 
receive the full range of tests given under NHANES; rather, the DP-
HANES examination would be tailored to the specific needs of the 
population under study.
---------------------------------------------------------------------------
    \4\ The sampling will be conducted on different people, but some 
questions asked in each survey will be the same.
---------------------------------------------------------------------------
     EPA's National Human Adipose Tissue Survey: NHATS was 
intended to be a continuously operating survey that would collect, 
store, and analyze samples of autopsy and surgical specimens of human 
adipose tissue from major metropolitan areas of the country. It was 
established by HHS in 1967 and was transferred to EPA in 1970. During 
its existence, NHATS data documented the widespread and significant 
prevalence of pesticide exposures in the general population. NHATS data 
also showed that reduced use of polychlorinated biphenyls (PCB) and DDT 
and dieldrin (common insecticides) resulted in lower tissue 
concentrations of these compounds. A trend analysis for 1970 through 
1981 of NHATS data showed a dramatic decline in PCB concentrations 
after the regulation of PCBs in 1976. During the 1980's, problems with 
NHATS' survey design, management, and goals were compounded by 
insufficient financial support and caused the usefulness and quality of 
NHATS to deteriorate. In 1991, NRC conducted a study to review and 
evaluate the effectiveness and potential applications of NHATS.\5\ The 
study concluded that a more comprehensive national program of human 
tissue monitoring was a critical need for understanding human exposures 
to environmental toxics. In addition, EPA needed a human tissue 
monitoring program in order to evaluate the need and effectiveness of 
EPA's regulatory programs. The study recommended that NHATS be 
completely redesigned to provide more useful data based on probability 
samples of the whole U.S. population and that funding be increased to 
permit the program to fulfill its mission. EPA ended the NHATS in 1992 
and replaced it with the NHEXAS pilot surveys.
---------------------------------------------------------------------------
    \5\ NRC, Commission on Life Sciences, Monitoring Human Tissues for 
Toxic Substances.
---------------------------------------------------------------------------
     EPA's National Human Exposure Assessment Survey Pilot 
Surveys: The NHEXAS pilot surveys were designed to obtain knowledge on 
the multiple pathways and media population distribution of exposures to 
several classes of chemicals and to test the feasibility of conducting 
a national survey to provide estimates on the status of human exposure 
to potentially high-risk chemicals. NHEXAS was also designed to measure 
``total exposure''--the levels of chemicals participants take in 
through the air they breathe; the food, drinking water, and other 
beverages they consume; and in the soil and dust around their homes. 
Measurements have also been made of chemicals in biological samples 
(such as blood and urine) provided by some participants. Participants 
completed questionnaires to help identify possible sources of exposure 
to chemicals. As designed, NHEXAS has three phases. Phase I is intended 
to develop and validate NHEXAS methods, phase II is designed to obtain 
nationally representative exposure data in a manner similar to that 
used by NHANES to get health data, and phase III is designed to follow 
up on information developed from phase II and will study selected 
subpopulations. EPA conducted NHEXAS phase I (pilot) surveys in 
Arizona, Maryland, and EPA's region 5 (Illinois, Indiana, Michigan, 
Minnesota, Ohio, and Wisconsin). About 460 participants in the pilot 
surveys provided biological samples; examinations measured a variety of 
chemicals, such as volatile organic compounds, heavy metals, and 
pesticides. Human tissue measurements were performed under interagency 
agreement by CDC's environmental health laboratory. EPA has completed 
most of the fieldwork for the NHEXAS phase I surveys and is now 
analyzing the results. Based on these results, EPA will finalize the 
scope and methods for NHEXAS phases II and III.
    ATSDR's Exposure Investigations: As part of its health assessment 
process or in response to requests, ATSDR may conduct limited 
biological monitoring at hazardous waste sites or other locations 
through a process called exposure investigations. In response to the 
recognition that the conclusions drawn from indirect methods of 
measuring exposures were often not accurate and not reliable for 
assessing potential health impacts and the need for more direct 
measures of exposures, ATSDR formally established an exposure 
investigation unit within its Division of Health Assessments and 
Consultation. The Exposure Investigation Section was established in 
1995 and is comprised of nine staff members who respond to requests to 
conduct exposure investigations around hazardous waste sites. These 
investigations involve gathering biological samples, conducting 
personal monitoring for site-related contaminants and their byproducts, 
and analyzing environmental data using computational tools.
    In 1996, ATSDR convened an expert review panel to comment on 
ATSDR's exposure investigation program, including whether ATSDR was on 
the right track in providing exposure information to improve public 
health decisionmaking intended to address environmental releases from 
hazardous waste sites. The panelists endorsed many aspects of ATSDR's 
investigative process, including the following:
     Conducting exposure investigations prior to preparing 
public health assessments, which makes agency responsibilities easier 
because information is provided that enables Federal agencies to take 
action and respond to community concerns in a timely manner.
     Considering exposure determinations to be as important as 
obtaining environmental monitoring results.
     Emphasizing the human element of exposure investigations, 
which illustrates that the Federal Government responds to community 
concerns.
    The panel also made several suggested improvements to the process, 
including establishing a national clearinghouse of exposure 
investigation data and results and developing site criteria and a 
protocol for identifying who will decide onsites to target for exposure 
investigation.
    ATSDR's exposure investigations have been valuable but limited in 
scope. ATSDR used biological monitoring in conducting 47 exposure 
investigations between 1995 and July 1999. Of these investigations, 17 
were done in support of the 460 health assessments done at that time. 
Unlike NHANES and the NHEXAS pilot surveys, exposure investigations 
usually have a small number of participants (less than 100) who 
volunteer to participate in the study. While the exposure 
investigations are not intended to be used for generalizations about 
larger populations, the studies have proven very useful in ATSDR's 
community outreach and intervention activities.
     NIEHS' Human Exposure Initiative: In 1996, this 
initiative, a collaboration between NIEHS and CDC, was started to 
improve understanding of human exposures to hormonally active agents--
also called ``environmental endocrine disrupters''--for the national 
population. CDC's environmental health laboratory under an interagency 
agreement is developing methods for and measuring up to 80 chemicals 
thought to be hormonally active agents in blood, urine, or both. Human 
tissue samples used for these measurements are largely obtained from 
the ongoing sampling of the general population under NHANES and total 
about 200 in number.
    In 1999, NIEHS and NTP officials proposed to expand the initial 
collaboration between NEHS and CDC by quantifying human internal 
exposures to selected chemicals that are released into the environment 
and workplace. NTP officials indicated this information would benefit 
public health and priority-setting in a number of ways. First, it would 
strengthen the scientific foundation for risk assessments by allowing 
(1) the development of more credible relationships between exposure and 
response in people thereby improving cross-species extrapolation, (2) 
the development of biologically based dose-response models, and (3) the 
identification of sensitive subpopulations and for estimates of risk 
based on ``margin of exposure.'' Second, it would provide the kind of 
information necessary for deciding which chemicals should be studied 
with the limited resources available for toxicological testing. For 
example, there are 85,000 chemicals in commerce today, and NTP can 
provide toxicological evaluations on 10 to 20 per year. Third, the 
information could be used to identify and help focus research on those 
mixtures of chemicals that are actually present in people's bodies. 
Fourth, the types and amount of chemicals in children and other 
potentially sensitive subpopulations would be identified. 
Determinations of whether additional safety factors need to be applied 
to children must rest in part upon comparative exposure analyses 
between children and adults. Fifth, this initiative, taken together 
with the environmental genome initiative, will provide the science base 
essential for meaningful studies on gene and environment interactions, 
particularly for strengthening the evaluation of epidemiology studies. 
Finally, efficacy of public health policies aimed at reducing human 
exposure to chemical agents could be evaluated in a more meaningful way 
if human exposure data were available over time, including remediation 
around Superfund sites and efforts to achieve environmental equity.

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                               __________

 Statement of Stephen M. Prescott, M.D., Executive Director, Huntsman 
                            Cancer Institute

    This year, approximately 2,400 children in the United States will 
be diagnosed with acute lymphoblastic leukemia (ALL), the most common 
form of childhood cancer. Their chances for cure are significantly 
better than they were three decades ago. Due to breathtaking progress 
in research, close to 75 percent of these children will grow up to lead 
healthy productive lives. The results are improving each year and 
childhood ALL is one of the most curable forms of human cancer.
    Despite this success, many challenges remain and the first is 
obvious--the cure rate isn't 100 percent. And, until it is we must work 
toward this goal. A second goal is to develop treatments with fewer 
side effects. To achieve these goals we must discover the root causes 
of childhood leukemia. In this regard, the future is bright. We are 
beginning to unravel the events that cause a single cell to become 
cancerous. These results can be attributed to significant advances in 
basic research, especially in the area of genetics. When we talk about 
cancer genetics we mean two different things. The first, which is 
readily understood, means inheriting a high risk of cancer from one's 
parents. This is only a small minority of all cancer cases and is very 
rarely the cause of childhood cancer. The second meaning of genetic is 
that the cancer cell has acquired damage to its genes, while the rest 
of the body's cells have a perfectly normal genetic make-up.
    In the case of ALL, we know that a single normal cell, destined to 
become a normal white blood cell called a lymphocyte, develops a 
mistake in the genetic code. In the case of leukemia, this is a swap of 
genetic material between two chromosomes and is called a translocation. 
These translocations occur in genes that control growth under normal 
circumstances. When such growth-promoting genes are damaged, the cell 
will continue to grow even when the body is trying to send a message to 
tell it to stop growing. Through the development of powerful techniques 
we now know the location of many of these defects and researchers at 
many centers are working to unravel the complexity of the cancer cell 
to understand specifically changes that allows the cancer to grow.
    Perhaps the most difficult questions for a physician to answer are, 
``Doctor, why did my child get leukemia? And, was there anything I 
could have done to prevent it''? The answer to the second is a 
resounding ``no.'' The answer to ``why'' is that we don't yet know the 
fundamental cause of ALL.
    When clusters, or dramatic increases in cancer cases in small 
geographic areas, occur, we always revisit the issue of whether a 
cancer-causing agent from the environment or an infection resulted in 
the increased number of cases. Unfortunately, this approach has not 
identified any causes for ALL. But it is possible that we are missing 
subtle relationships if an environmental or infectious cause is present 
but only affects individuals with a certain genetic makeup and not all 
members of the population.
    The recent sequencing of the human genome provides us with 
unprecedented opportunities to understand cancer and to use that 
knowledge to develop new treatment and prevention. The major focus of 
the Huntsman Cancer Institute (HCI) is to understand this genetic 
blueprint of cancer. Using a new technology called ``DNA chips'' 
investigators in our childhood cancer program have uncovered genetic 
pathways that are active in cancer cells but not normal blood cells. 
Using this information it may be possible to develop drugs that could 
interfere with these active pathways. Since these changes are limited 
to the cancer, new drugs targeted to these pathways might avoid the 
side effects seen with conventional drugs.
    We also now know that certain pathways are unique to groups of 
patients that have a greater risk of relapse after treatment. It may be 
possible to use the genetic ``fingerprint'' of the leukemia someday to 
``tailor'' therapy so that patients with a high likelihood of cure can 
be treated without exposing them to unnecessary more toxic therapy, 
while patients with high risk disease can be more effectively treated 
before the leukemia comes back. This approach is still experimental and 
leukemia samples from children treated at children's hospitals 
throughout the United States will be sent to us to test further this 
genetic approach to classifying leukemia. We believe that the same 
approach could be applied to studies of clusters of ALL to try to 
understand why they occur. For example, is there a specific genetic 
pathway damaged in children from Fallon who have ALL. If so, this would 
suggest that an infection or environmental agent initiated a common 
form of damage.
    The Children's Oncology Group, a consortium of all major children's 
hospitals in North America, is embarking on a massive effort to 
identify a subset of patients who might be especially vulnerable to 
environmental risks because of inherent susceptibility to damage from 
chemicals. This effort will use the approach I've described and will be 
led by Dr. Bill Carroll, the deputy director of the Huntsman Cancer 
Institute.
    Although these projects are just underway, progress is being 
achieved at a remarkable rate. By combining sophisticated genetic 
analysis of patients and their tumors with the best treatments 
available, we hope to reach that goal of uniform cancer cure and 
ultimately, prevention.

Environmental Exposures and Childhood Cancer: Our Best May Not Be Good 
                                 Enough
    Childhood cancer ranks high among public concerns, evoking the 
public's fear of cancer as well as the special emotional attention that 
is focused on children. Although it is rare, its priority is elevated 
on the basis of years of life lost and its prominence among life-
threatening diseases of children. Despite great success in the 
treatment of childhood cancers such as Wilms' tumor and leukemia, 
cancer continues to be life threatening in children.
    For several decades, clusters of childhood leukemia have been 
investigated, in a search first for an infectious etiology and then for 
an environmental etiology,1 both without success. Childhood 
cancer clusters continue to generate public concern and consume health 
department resources, but there has been little progress in 
understanding the etiology or identifying preventive measures. The 
focus often turns to the role of environmental pollutants such as 
pesticides, electromagnetic fields, and chemicals found in hazardous 
wastes. The rationale for seeking exogenous, modifiable causes of 
childhood cancer that can be avoided leading to a reduction in the risk 
of disease, is compelling. The negative consequence of such public 
demand and support for epidemiologic research is the temptation to 
overinterpret every shred of fallible evidence that emerges. The public 
and media tend to place much more faith than is warranted in isolated 
findings, to the detriment of sound policy and the credibility of 
researchers.
    Epidemiologic research into potential environmental contributors to 
the etiology of childhood leukemia, brain cancer, and other pediatric 
malignancies has been pursued intensively for over 20 years. Motivated 
by scientific interest and public concern, a number of studies have 
evaluated the role of pesticides,2 ionizing 
radiation,3 nonionizing radiation,4-5 and a wide 
range of occupational and environmental exposures.6-7 Dozens 
of epidemiologic studies have been conducted on these topics, some with 
sophisticated designs, large populations, and attention to exposure 
assessment, such as the report in this issue by Freedman et 
al.8 on solvent exposure and childhood acute lymphoblastic 
leukemia.

    SCIENTIFIC CHALLENGES TO IDENTIFYING CAUSES OF CHILDHOOD CANCER

    The scientific challenges to identifying environmental contributors 
to the etiology of childhood cancer are daunting. We are uncertain 
about the relative importance of exposures of the mother, father, and 
child in disease etiology. Although the time frame is narrower than the 
half century of potential relevance in the etiology of adult cancer, 
the origins of childhood cancer may lie anywhere between conception and 
diagnosis. The appropriate disease entities for study cannot be defined 
with confidence, so histology, age of onset, and tumor biology are all 
potential markers of etiologic heterogeneity. The goal of creating 
ever-finer case subgroups must be reconciled with the overall variety 
of cancers in children. The trade-off is between potential gains in 
validity achieved by creating more homogeneous case groups and a 
definite loss of precision as the group size is reduced.
    Because childhood cancers are so rare, true prospective studies are 
virtually impossible, necessitating continued reliance on case-control 
studies. As noted by Freedman et al.,8 the 2 key challenges 
associated with that design are control selection and exposure 
assessment. Except in locations with complete birth registries or 
population rosters (mostly in northern Europe), identifying and 
recruiting a sample of the case-generating study base pose great 
challenges.
    Hospital-based studies make it impossible to define the source of 
cases, particularly for diseases that result in referrals from a wide 
geographic area. Because few children are hospitalized for any reason, 
finding ``exposure-neutral'' diagnostic groups of children as a source 
of controls is even more challenging than it is for adults. In 
population-based studies, nonresponse is inevitable, often reaching 
levels of 20 percent to 40 percent of the eligible population. As a 
reminder that this nonresponse is capable of distorting measures of 
association, virtually all case-control studies of childhood leukemia 
in the United States, including the study by Freedman et al., have 
found higher risk in the lower social classes, despite there being an 
established, though modest, positive correlation between higher social 
class and risk for child cancer on the basis of registry information. 
The overrepresentation of upper-social-class controls, stronger than 
the corresponding trend among cases, appears to be the source of this 
effect, replicated across studies. Adjustment for social class can be 
made, but this consistent observation suggests that other aspects of 
nonresponse (particularly among controls) may well have more insidious 
effects.
    The second consequence of conducting case-control studies is the 
loss of information associated with retrospective exposure assessment. 
Until the cancer is identified (or the control child reaches the 
equivalent age), we can not ascertain exposure and are thus faced with 
reconstructing exposure throughout the potential etiologic period. 
Studies that identify the cases as they are diagnosed, as was done by 
Freedman et al.,8 avoid the additional time delay associated 
with recruiting cases diagnosed before the initiation of data 
collection, but there is still a limit to the accuracy of exposure 
assessment for periods extending back as far as 15 years. Biological 
markers of exposure are clearly not applicable, and direct measurement 
of environmental agents in the physical locations of interest is of 
uncertain relevance owing to the passage of time. We are forced to 
relay on memory, which itself is limited in accuracy and objectivity 
with regard to the important details about workplaces and the home 
environment that can affect exposure.

                    SOLVENTS AND CHILDHOOD LEUKEMIA

    Recognizing all these limitations, the report by Freedman et al. 
reflects the ``state of the art'' in childhood cancer epidemiology with 
regard to study size (640 cases included in the analysis), homogeneity 
of disease classification (all acute lymphoblastic leukemia), method of 
control selection (random-digit dialing), and approach to exposure 
assessment (structured questionnaire addressing frequency and duration 
of exposure). As would be predicted, the greatest concerns with bias 
arise from nonresponse and exposure misclassification. Only 64 percent 
of eligible controls were enrolled, and despite some evidence against 
the available measures of social class being associated with solvent 
exposure, that level of nonparticipation leaves open the possibility of 
distorted results. Relative to an ideal measure of actual solvent 
exposure, as might be obtained through personal monitoring, the 
effectiveness of the exposure assessment questions is uncertain. The 
investigators focus on differential error, which could contribute to 
elevated measures of association, but nondifferential misclassification 
is more certain to be present and can be invoked as an argument that 
observed associations are more likely to be underestimates of any 
underlying causal association.
    This study advances the hypothesis that solvent exposure may 
contribute to the etiology of childhood leukemia, moving it from a 
plausible hypothesis with no direct epidemiologic support to one with 
very limited epidemiologic support. The total evidence supporting the 
hypothesis that household solvent exposures cause childhood leukemia 
nevertheless remains weak but deserving of further study. Perhaps the 
most disconcerting challenge posed by the study is how to make progress 
in evaluating the hypothesis further. The very strengths of the study 
by Freedman et al. make it difficult to suggest improvements. 
Certainly, pure replication, assessing whether the same study design 
generates the same results in other settings, would be welcome. There 
is clearly some room for refinements in the approach to exposure 
assessment, with more detailed query pertaining to exposure 
determinants. Those who are already engaged in such studies would do 
well to include pertinent questions regarding household solvent 
exposure. However, given the rarity of the disease and the expense 
associated with studies of this size, it is difficult to advocate 
initiating new studies with household solvent exposure as a primary 
justification.
    Even though the epidemiologic studies directly tackle the exposure 
and disease of interest, more insight may be generated by strong 
findings of indirect relevance than by more weak findings of direct 
relevance. Research that addresses the impact of self-reported 
activities on measured solvent exposure would be highly beneficial to 
interpreting this study and could lead to improved methods of 
retrospective exposure assessment. Toxicologic studies of implicated 
agents, such as methylene chloride and benzene, focusing on animal 
models of childhood leukemia may help in the interpretation of these 
results. For a possible paternally mediated pathway linking solvent 
exposure to childhood leukemia, further work on sperm-mediated genetic 
alterations associated with solvent exposures could be contributory. 
With regard to childhood exposure, focus might shift to endpoints that 
can measured prospectively in modest populations, ideally, biomarkers 
of early effect such as cytogenetic damage. If we are to attain the 
conclusive results pertaining to solvent exposure (or pesticides, 
nonionizing radiation, etc.) and leukemia (or other childhood 
cancers)--an elusive goal so far--it is very unlikely to come through 
sheer weight of replicated findings from conventional epidemiologic 
studies.
                                      David A. Savitz, PhD.

                            ACKNOWLEDGMENTS

    I would like to thank Dr. Andrew Olshan for his review and helpful 
comments on the manuscript.
                               references
    1. Alexander FE. Clusters and clustering of childhood cancer: A 
review, Eur J. Epidemiol. 1999; 15:847-852.
    2. Daniels JL, Olshan AF, Savitz DA. Pesticides and childhood 
cancers. Environ Health Perspect. 1997; 105:1068-1077.
    3. Laurier D, Bard D. Epidemiologic studies of leukemia among 
persons under 25 years of age living near nuclear sites. Epidemiol Rev. 
1999; 21:188-206.
    4. Ahlboin A, Day N, Feychting M. et al. A pooled analysis of 
magnetic fields and childhood leukemia. Br J. Cancer. 2000; 83:692-698.
    5. Little J. Epidemiology of Childhood Cancer. Lyons, France: 
International Agency for Research on Cancer; 1999. LARC Scientific 
Publication 149.
    6. McBride ML. Childhood cancer and environmental contaminants. Can 
J. Public Health. 1998; 89:S53-S62.
    7. Colt JS, Blair A. Parental occupational exposures and risk of 
childhood cancer. Environ Health Perspect. 1998; 106:909-926.
    8. Freedman DM, Stewart P, Kleinerman RA, et al. Household solvent 
exposures and childhood acute lymphoblastic leukemia. Am J Public 
Health. 2001; 91:564-567.
                                 ______
                                 
            Household Solvent Exposures and Childhood Acute 
                         Lymphoblastic Leukemia

                                ABSTRACT

    Objectives.--This study explored the risk of childhood acute 
lymphoblastic leukemia (ALL) associated with participation by household 
members in hobbies or other home projects involving organic solvents.
    Methods.--Participants in this case--control study were 640 
subjects with ALL and 640 matched controls.
    Results.--Childhood ALL was associated with frequent (>4 times/
month) exposure to model building (odds ratio [OR]=1.9; 95 percent 
confidence interval [95 percent CI]=0.7, 5.8) and artwork using 
solvents (OR=4.1; 95 percent CI=1.1, 15.1). We also found elevated risk 
(OR=1.7; 95 percent CI=1.1, 2.7) among children whose mothers lived in 
homes painted extensively (>4 rooms) in the year before the children's 
birth.
    Conclusions. In this exploratory study, substantial participation 
by household members in some common household activities that involve 
organic solvents was associated with elevated risks of childhood ALL. 
(Am J Public Health. 2001;91:564-567)
    Little is known about the role of environmental exposures in 
childhood leukemia.1 Several epidemiologic studies have 
described elevated risks of childhood leukemia associated with parents' 
exposure to occupational chemicals, 2-10 including solvents 
3,6,8,9 and paints.3,5,7,10 Children may also be 
exposed to solvents and paints at home through their own or their 
parents' hobbies and household maintenance activities. To our 
knowledge, few studies \10\ have examined the risks of childhood 
leukemia associated with exposures to solvents in the home other than 
pesticides.
    As part of a large comprehensive case-control study of potential 
risk factors for childhood acute lymphoblastic leukemia (ALL) conducted 
by the Children's Cancer Group, we undertook an exploratory study to 
examine the relationship between childhood leukemia and exposure to 
selected household chemicals during childhood, as well as indoor house 
painting during preconception, pregnancy, and childhood. We focused on 
common home activities likely to result in exposures to 
solvents.11-14

                                METHODS

    Case subjects were children, aged birth to 14 years, who were newly 
diagnosed with ALL between 1989 and 1993, resident in any of 9 
midwestern and mid-Atlantic States, and enrolled through the Children's 
Cancer Group, a cooperative clinical trials group.15,16 
Eligibility criteria included a residential telephone and an English-
speaking biological mother available for an in-person interview. 
Control subjects were selected through random-digit dialing and were 
individually matched to the case subjects by age (within 25 percent of 
the case's age at diagnosis), the first 8 digits of the telephone 
number, and race.17 The overall participation rates were 88 
percent for case subjects and 64 percent for control subjects. After 
exclusion of patients with Down syndrome, which has been associated 
with a high risk of ALL,18 there were 640 matched case-
control pairs.
    For each of 3 hobbies (model building, artwork using solvents, and 
furniture stripping) and 2 household maintenance activities (motor 
vehicle and electronic equipment repair), interviewers asked mothers 
whether household members engaged in any of the 5 activities in and 
around their home. Because pretesting revealed that many mothers could 
not remember early activities or gave identical answers for each year 
of the child's life, the interview focused on activities during the 
reference year (the year preceding the date of diagnosis for the case 
and its matched control). Interviewers asked the mother about which 
household members participated in the activities, as well as the 
frequency and duration of each episode. Interviewers also asked 
questions about painting inside the subjects' homes within 3 months of 
conception, during the pregnancy, and after the subjects' birth, 
including the specific rooms painted, the frequency of the painting, 
who painted (mother or others), and whether members of the family 
remained at home overnight during the house painting.
    For each hobby or household activity other than house painting, we 
analyzed 2 measures of exposure: frequency (defined as the number of 
times engaged in the activity per month) and cumulative exposure 
(defined as the product of the frequency of the activity and its 
duration per episode). Because fewer control than case mothers provided 
information about duration, our analysis emphasized frequency as a more 
unbiased exposure measure. Before any analysis, we arbitrarily 
classified frequency and cumulative exposure into common time 
categories. We categorized frequency of exposure as low (<1 time/
month), medium (1-4 times/month), and high (>4 times/month); we 
categorized cumulative exposure as low (<10 minutes over a month), 
medium (10 minutes-1 hour over a month), and high (>1 hour over a 
month). For house painting, exposure was classified by the total number 
of rooms painted (1-2, 3-4, >4 rooms), as well as the frequency (1-2, 
3-5, >5 times since birth) among those painting after the child's 
birth.
    We computed odds ratios by unconditional logistic regression so as 
to maximize the number of cases and controls included in this 
exploratory analysis. We confirmed our main findings by conditional 
logistic regression. Odds ratios were adjusted for age at the reference 
date, sex, mother's education level, and family income. We compared 
subjects by whether they ever or never participated in a given activity 
and by the 2 measures of exposure. We analyzed the total population, as 
well as 2 age strata: younger than 5 years (the peak ages are 2-4 years 
for ALL) and 5 years and older. Except for model building, there was an 
insufficient number of children participating in the various activities 
to assess the risk of ALL among child participants. For house painting, 
we investigated the timing of painting before and after birth.
    We also examined 2 strata based on length of time between diagnosis 
and interview (24 months vs >24 months). We explored trends 
in risk by entering exposure variables ordinally into the models.

                                RESULTS

    Case subjects and control subjects were demographically similar, 
except that the former came from families with lower income and had 
mothers with less formal education. Both groups were predominantly 
White (Table 1).
Exposures From Hobbies, Vehicle Maintenance, and Electronic Repair
    No significant excess risk of childhood ALL was observed with ever 
vs never participation in any of the activities by a household member 
(Table 2). Moreover, neither automotive and truck maintenance nor 
electronic repairs reflected a pattern of risk with increasing 
exposure.
    Elevated risks of childhood ALL, however, were associated with the 
highest levels of participation in some activities (Table 2). Risks 
were elevated for model building in the highest-frequency category 
(odds ratio [OR] = 1.9; 95 percent confidence interval [CI]=0.7, 5.8) 
but did not vary by age group or the child's involvement. Artwork 
requiring solvents was linked with significantly elevated risks of 
childhood ALL in the highest-frequency exposure category (OR=4.1; 95 
percent CI=1.1, 15.1), and risks increased as exposure rose (P 
trend=.07). Although the numbers were small, similar risks were 
observed in both age groups (data not shown). The associations with 
high cumulative exposure were similar to those with frequent exposures 
for both model building and artwork (data not shown).
    For furniture stripping, risk was not elevated among children in 
families with the highest frequency of exposure. Risk was, however, 
significantly elevated among children in those families with the 
highest cumulative exposures (OR=2.9; 95 percent CI=1.1, 9.1).
    In general, when the subjects were stratified by time between 
diagnosis and interview dates, the odds ratios among those interviewed 
close to the diagnosis date were about the same as or stronger than the 
unstratified odds ratios.

   TABLE 1.--Characteristics of 840 Children With Acute Lymphoblastic
    Leukemia and 640 Matched Controls,a From Interview Data on Use of
                       Household Solvent Exposures
------------------------------------------------------------------------
                                                   Cases  N    Controls
                 Characteristics                      (%)        N (%)
------------------------------------------------------------------------
Sex:
  Male..........................................  333 (52.0)  337 (52.7)
  Female........................................  307 (48.0)  303 (47.3)
Age at diagnosis/reference date, y:
  <2............................................   68 (10.6)   85 (13.3)
  2-4...........................................  312 (48.8)  289 (45.2)
  5-9...........................................  179 (28.0)  185 (28.9)
  510...........................................   81 (12.7)   81 (12.7)
Race:
  White.........................................  585 (91.4)  612 (95.8)
  Black.........................................    20 (3.1)    16 (2.5)
  Other.........................................    35 (5.5)    12 (1.9)
Household income during reference year, $:
  <20,000.......................................  113 (17.7)   77 (12.0)
  20,000-29,999.................................  122 (19.1)   86 (13.4)
  30,000-39,999.................................  133 (20.8)  112 (17.5)
  40,000-49,999.................................   98 (15.3)  105 (16.4)
  50,000........................................  168 (26.2)  255 (39.8)
  Missing.......................................     6 (0.9)     5 (0.8)
Mother's education:
  a Excludes 11 pairs in which 1 member of the air had Down syndrome.


TABLE 2.--Distribution of Cases and Controls by Frequency a of Hobby and
   Household Maintenance Activity During Year of Diagnosis, With Odds
            Ratios b (ORs) and 95% Confidence Intervals (Cls)
------------------------------------------------------------------------
                                       Cases   Controls     OR(95% CI)
------------------------------------------------------------------------
                                Hobbies
Model building:
  Never c...........................     549         555             1.0
  Ever d............................      90          83  1.1 (0.8, 1.5)
  Low...............................      51          60  0.9 (0.6, 1.3)
  Medium............................      29          18  1.5 (.08, 2.8)
  High..............................      10           5  1.9 (0.7, 5.8)
  P trend...........................  ......  ..........             .21
Artwork (using solvents):
  Never c...........................     566         571             1.0
  Ever d............................      73          65  1.3 (0.9, 1.8)
  Low...............................      34          35  1.1 (0.7, 1.8)
  Medium............................      28          27  1.2 (0.7, 2.0)
  High..............................      11           3       4.1 (1.1,
                                                                   15.1)
  P trend...........................  ......  ..........             .07
Furniture stripping:
  Never c...........................     574         579             1.0
  Ever d............................      65          59  1.1 (0.8, 1.6)
  Low...............................      32          35  0.9 (0.6, 1.5)
  Medium............................      24          14  1.8 (0.9, 3.6)
  High..............................       8           8  1.0 (0.4, 2.7)
  P trend...........................  ......  ..........            .33
                          Household maintenance
Auto/truck maintenance:
  Never c...........................     378         383             1.0
  Ever d............................     260         255  0.9 (0.7, 1.2)
  Low...............................     121         129  0.9 (0.7, 1.2)
  Medium............................     107         107   0.9 (0.6, 1.2
  High..............................      31          19  1.5 (0.8, 2.7)
  P trend...........................  ......  ..........             .91
Electronic repair:
  Never c...........................     604         612             1.0
  Ever d............................      35          25  1.4 (0.8, 2.4)
  Low...............................      20          14  1.5 (0.7, 3.0)
  Medium............................      13           5  2.7 (1.0, 7.7)
  High..............................       2           6  0.3 (0.1, 1.5)
  P trend...........................  ......  ..........             .50
------------------------------------------------------------------------
a Frequency refers to occasions per moth: ``low'' is less than once a
  month, ``medium'' is 1 to 4 times a month, and ``high'' is more than 4
  times a month.
b Adjusted for child's age at the reference date, sex, household income
  at the reference date, and maternal education.
c Referent category.
d Not all respondents reporting participation specified frequency.


   TABLE 3.--Distribution of Cases and Controls by Indoor House Painting in Subject's Home During Year Before
                        Birth, With Odds Ratiosa (ORs) and 95% Confidence Intervals (CIs)
----------------------------------------------------------------------------------------------------------------
                                                                     Cases     Controls       OR        95% CI
----------------------------------------------------------------------------------------------------------------
Ever painted:
  No............................................................         346         359         1.0
  Yes...........................................................         289         278         1.2    0.9, 1.5
No. of rooms painted:
  Never painted.................................................         346         359         1.0
  1-2...........................................................         161         188         1.0    0.8, 1.3
  3-4...........................................................          62          48         1.4    0.9, 2.1
  >4............................................................          64          40         1.7    1.1, 2.7
  P trend.......................................................  ..........  ..........         .01
Family stayed at home overnight:b
  Never painted.................................................         346         359         1.0
  Not at home...................................................          25          17         2.3    0.6, 8.9
  At home.......................................................         102         109         1.9    0.6, 6.4
Painter:
  Never painted.................................................         346         359         1.0
  Mother........................................................         160         152         1.1    0.9, 1.5
  Other.........................................................         128         124         1.3    0.9, 1.7
----------------------------------------------------------------------------------------------------------------
Note. Not all respondents who reported painting provided information about the number of rooms painted, whether
  family stayed at home overnight, or who performed the painting.
a Adjusted for child's age at the reference date, sex, household income at the reference date, maternal
  education, and painting during other periods.
b Also adjusted for number of rooms painted.

Exposure From Household Painting
    We observed no significant overall increase in risk (OR=1.2; 95 
percent CI=0.9, 1.5) of childhood ALL associated with interior house 
painting during the 12 months before the subject's birth, although the 
risk was elevated among children whose mothers lived in homes in which 
more than 4 rooms were painted during this period (Table 3). Risk of 
ALL was not higher among children whose mothers, rather than other 
people, did the painting (Table 3).
    When risk was analyzed by 3-month periods in the year before birth, 
we also found no significant risk during each period except for a small 
borderline risk in the 3 months before conception (data not shown). 
However, when the study population was analyzed by length of time from 
diagnosis to interview, this association appeared to be due to 
responses from those interviewed at a more distant time from the 
reference date.
    Among children residing in homes painted after the subject's birth, 
a small, but borderline significant, excess risk was seen (OR=1.3; 95 
percent CI=1.0, 1.6). Risk was elevated for painting more rooms (for >4 
rooms, OR= 1.6; 95 percent CI=1.2,2.2) and painting more frequently 
(for >5 times, OR=1.8; 95 percent CI=1.1, 2.8). When the associations 
among those interviewed close to the diagnosis date were examined, risk 
remained about the same, but those associations disappeared among 
subjects interviewed later.

                               DISCUSSION

    This study found elevated risks for childhood ALL associated with 
substantial postnatal exposure to some household activities and 
prebirth and postnatal exposure to indoor house painting. There are, 
however, several limitations to this study. As in any retrospective 
interview study, exposures are likely to be misclassified owing both to 
imperfect respondent recollections and to the crudeness of the 
information requested. The questionnaire obtained only limited 
information on the child's proximity to the activity and none on other 
activities that may involve solvents, particularly home renovation, 
such as floor refinishing. Moreover, little is known about the relevant 
time frame for exposure--whether exposures occurred before conception 
(germ cell mutations), during pregnancy (transplacental fetal 
exposure), or after birth. With the exception of house painting, the 
survey was restricted to postnatal exposures.
    Our greatest concern in interpreting the findings is the 
possibility that differential reporting errors by case and control 
mothers exaggerated estimates of effect.12 The weaker 
association with house painting before conception among mothers 
interviewed near the reference date substantially weakens the 
credibility of an association with preconception painting. However, the 
consistency between the other odds ratios and those limited to mothers 
interviewed close to the reference date supports the findings. 
Unfortunately, the disproportionate delay in interviewing control 
mothers limited our ability to check the consistency of associations at 
interview times very close to the events in question.
    Selection bias due to differential socioeconomic status potentially 
could have resulted from use of random-digit dialing for control 
selection. Family income, however, was not associated with substantial 
participation in model building, artwork using solvents, or furniture 
stripping. Moreover, indoor house painting was more common among high-
income controls, which suggests that a selection bias could have 
underestimated the association with house painting. Finally, 
socioeconomic factors do not appear to have confounded the relationship 
between ALL and the activities assessed, because controlling for family 
income and maternal education did not appreciably affect the results.
    Despite the study limitations, there are several arguments for the 
plausibility of the findings. Some epidemiologic studies have shown an 
association between paternal occupational exposure to organic solvents 
and childhood leukemia in the postnatal period.2,3,10 
Exposure of children could occur through inhalation of solvents used at 
home or brought home from the workplace on the parents' 
breath.19 Previous epidemiologic studies have found positive 
associations between childhood leukemia and painting on the job during 
the prenatal 7,10,20 and postnatal \10\ periods.
    Each of the activities associated with an elevated risk of 
childhood ALL involves exposure to organic solvents, some of which are 
known or possible human carcinogens. Benzene, a typical constituent in 
hobby glues in model building\11\ and in paints,\12\ is an established 
adult leukemogenic solvent.\21\ There is a case report of childhood 
leukemia following intense exposure to toluene-containing glues used in 
model building.\22\ Methylene chloride, the main constituent of 
furniture strippers,\13\ is also a possible carcinogen,\23\ and 
trichloroethylene, which may be found in paints and varnishes,\24\ has 
been found to cause cancer in animals.\23\
    As the first large case--control study of childhood ALL evaluating 
associations with hobbies and household activities that may involve 
carcinogenic solvent exposures, our study is primarily exploratory. 
Because of the number of exposures examined, confirmation is required 
to rule out false-positive results. Further study is also warranted of 
additional household activities involving solvents, with exposure 
information for individual chemicals and levels and better delineation 
of specific time frames of exposure (prenatal vs. exclusively 
postnatal) to illuminate the relevant biological pathways.

                            ACKNOWLEDGMENTS

    This study was supported in part by grants from the National Cancer 
Institute (R0I CA 48051 and U01 CA 13539) and by the University of 
Minnesota Children's Cancer Research Fund.
    The authors gratefully acknowledge Dr. Robert Hoover of the 
National Cancer Institute for his thoughtful comments on the 
manuscript.
    The study was approved by the National Cancer Institute Special 
Studies Institutional Review Board and obtained the consent of 
participants.

                               REFERENCES

    1. Chow W-H, Linet MS, Liff JM, Greenberg RS. Cancers in children. 
In: Schottenfeld D, Fraumeni JF Jr, eds. Cancer Epidemiology and 
Prevention. New York, NY: Oxford University Press; 1996:1331-1369.
    2. Colt JS, Blair A. Parental occupational exposures and risk of 
childhood cancer. Environ Health Perspect 1998; 106:909-926.
    3. Buckley JD, Robison LL, Swotinsky R, et al. Occupational 
exposures of parents of children with acute nonlymphocytic leukemia: a 
report from the Children's Cancer Study Group. Cancer Res. 
1989;49:4030-4037.
    4. Fabia J, Thuy TD. Occupation of father at time of birth of 
children dying of malignant diseases. Br J Prev Soc Med. 1974;28:98-
100.
    5. Hemminki K, Saloniemi I, Salonen T, Partanen T, Vainio H. 
Childhood cancer and parental occupation in Finland. J Epidemiol 
Community Health. 1981;35:11-15.
    6. Cocco P, Rapallo M, Turghetta R, Biddau PF, Fadda D. Analysis of 
risk factors in a cluster of childhood acute lymphoblastic leukemia. 
Arch Environ Health. 1996;51:242-244.
    7. Van Steensel-Moll HA, Valkenburg HA, Van Zanen GE. Childhood 
leukemia and parental occupation, a register-based case-control study. 
Am J Epidemiol. 1985;121:216-224.
    8. McKinney PA, Alexander FE, Cartwright RA, Parker L. Parental 
occupations and children with leukaemia in west Cumbria, north 
Humberside, and Gateshead. BMJ 1991;302:681-687.
    9. Feingold L, Savitz DA, John EM. Use of a job-exposure matrix to 
evaluate parental occupation and childhood cancer. Cancer Causes 
Control. 1992;3:161-169.
    10. Lowengart RA, Peters JM, Cicioni C, et al. Childhood leukemia 
and parents' occupational and home exposures. J Natl Cancer Inst. 1987; 
79:39-46.
    11. Rastogi SC. Organic solvent levels in model and hobby glues. 
Bull Environ Contam Toxicol. 1993;51:501-507.
    12. Wallace LA. Comparison of risks from outdoor and indoor 
exposure to toxic chemicals. Environ Health Perspect. 1991;95:7-13.
    13. Stewart RD, Hake CL. Paint-remover hazard. JAMA. 1976;235:398-
401.
    14. Thomas TL, Stolley PD, Stemhagen A, et al. Brain tumor 
mortality risk among men with electrical and electronics jobs: a case-
control study. J Natl Cancer Inst. 1987;79:233-238.
    15. Kleinerman RA, Linet MS, Hatch EE, et al. Magnetic field 
exposure assessment in a casecontrol study of childhood leukemia. 
Epidemiology. 1997;8:575-583.
    16. Hatch EE, Linet MS, Kleinerman RA, et al. Association between 
childhood acute lymphoblastic leukemia and use of electrical appliances 
during pregnancy and childhood. Epidemiology. 1998;9:234-245.
    17. Robison LL, Daigle A. Control selection using random digit 
dialing for cases of childhood cancer. Am J Epidemiol. 1984;120:164-
166.
    18. Robison LL, Neglia JP. Epidemiology of Down syndrome and 
childhood acute leukemia. In: McCoy EE, Epstein CJ, eds. Oncology and 
Immunology of Down Syndrome. New York, NY: Alan R Liss; 1987:19-32.
    19. Monster A, Regouin-Peeters W, van Schijndel A, van der Tuin J. 
Biological monitoring of occupational exposure to tetrachloroethene. 
Scand J Work Health. 1983;9:273-281.
    20. Shu XO, Stewart P, Wen W-Q, et al. Parental occupational 
exposure to hydrocarbons and risk of acute lymphoblastic leukemia in 
offspring. Cancer Epidemiol Biomarkers Prev. 1999;8: 783-791.
    21. Linet MS, Cartwright RA. The leukemias. In: Schottenfeld D, 
Fraumeni JF Jr, eds. Cancer Epidemiology and Prevention. New York, NY: 
Oxford University Press; 1996:841-892.
    22. Caligiuri MA, Early AP, Marinello MJ, Preisler HD. Acute 
nonlymphocytic leukemia in a glue sniffer. Am J Hematol. 1985;20:89-90.
    23. Lynge E, Anttila A, Hemminki K. Organic solvents and cancer. 
Cancer Causes Control. 1997; 8:406-419.
    24. Tas S, Lauwerys R, Lison D. Occupational hazards for the male 
reproductive system. Crit Rev Toxicol. 1996;26:261-307.
                                 ______
                                 
                              AUTHOR NOTE

    D. Michal Freedman, PhD, Patricia Stewart, PhD, Ruth A. Kleinerman, 
MPH, Sholom Wacholder PhD, Elizabeth E. Hatch, PhD, Robert E. Tarone, 
PhD, Leslie L. Robison, PhD, and Martha S. Linet, MD.
    D. Michal Freedman, Patricia Stewart, Ruth A. Kleinerman, Sholom 
Wacholder, Elizabeth E. Hatch, Robert E. Tarone, and Martha S. Linet 
are with the Division of Cancer Epidemiology and Genetics, National 
Cancer Institute, Bethesda, Md. Leslie L. Robison is with the Division 
of Pediatric Epidemiology and Clinical Research, Department of 
Pediatrics, University of Minnesota, Minneapolis.
    Requests for reprints should be sent to D. Michal Freedman, PhD, 
Radiation Epidemiology Branch, Division of Cancer Epidemiology and 
Genetics, National Cancer Institute, Executive Plaza--South, Room 7087, 
6120 Executive Blvd, Bethesda, MD 20892-7238 (e-mail: [email protected]).
    This brief was accepted July 18, 2000.

                              CONTRIBUTORS

    D.M. Freedman was principal author and analyst of the paper. P 
Stewart and R. E. Tarone were involved in interpretation of data, 
analysis, and revisions of the paper. R.A. Kleinerman was involved in 
data collection, interpretation of data, analysis, and revisions of the 
paper. S. Wacholder was involved in the design of the entire study of 
which this study is a part, interpretation of data, and revision of the 
paper. E.E. Hatch was involved in data collection, the design of the 
study--including selection of cases and controls--interpretation of 
data, and revisions of the paper. L.L. Robison and M.S. Linet were 
involved in the design of the entire study of which this study is a 
part, data collection, interpretation of data, and revisions of the 
paper.
    Reproduced with permission of the copyright owner. Further 
reproduction or distribution is prohibited without permission.
                               __________
   Statement of Mary Guinan, MD., Ph.D., Nevada State Health Officer

                              INTRODUCTION

    I am Dr. Mary Guinan, Nevada State Health Officer. I have been 
asked to speak today on the status of the continuing investigation and 
Federal agency roles in the investigation of cancer clusters.
Status of Investigation
    An Expert Panel was convened on February 15, 2001 to guide the next 
steps of the investigation. The panel made the following 
recommendations:
    1. Expand case-finding efforts.--In progress with Navy. Health 
Division continues to review cases of leukemia, cancer and other bone 
marrow diseases reported to us. All reports are kept on file. Expansion 
of search through the Children's Oncology group and California Cancer 
Registry will proceed when funding becomes available. (Chronic disease 
epidemiologist, part time pediatric oncologist).
    2. Categorize the Acute Lymphocytic Leukemia (ALL) cases by 
clinically relevant biomarkers.--Need services of pediatric oncologist 
and funding for locating tissue and determining what phenotypic and 
genetic tests need to be done and identify laboratory to do testing.
    3. Identify potential excess environmental exposures unique to the 
community.--Test the drinking water of case families whose water supply 
is from private wells. Health Division is in process of testing. Nevada 
State Health Division has requested assistance from the Centers for 
Disease Control and Prevention and the Agency for Toxic Substances and 
Disease Registry Human. Representatives of these Agencies will be 
coming to Nevada during the week of April 16th to review next steps on 
the following issues: (a) Collection of blood and urine samples from 
cases and family members for testing for environmental chemicals, (b) 
Advisability of dust studies from homes of affected families for 
environmental chemicals, (c) Environmental pathways assessment, (d) 
Radiologic assessment of milk produced in Churchill County.
    4. Collect and Bank Biologic Samples for Future Study.--On hold 
until funding is made available and storage sites located.
    5. Determine time course and characteristics of population movement 
into the Fallon area.--This is part of a bigger picture to provide 
evidence for population mixing theory. Although some efforts have 
begun, this is much larger research study than State can support. 
Federal funding should be made available for this research.
    6. Maintain Expert Panel.--Panel members have agreed to continue in 
an advisory role.
    In addition the State Health Division has: (a) Enhanced access to 
public information about the ALL cluster and environmental concerns 
through multiple public community meetings in Fallon, the Health 
Division website (health2K.state.nv.us) and a dedicated call-in 
telephone line. (b) Developed with the Division of Mental Health a 
mental health crises counseling and community assistance initiative. 
This has received funding from the Nevada Emergency Management Division 
and the first steps have been implemented.

  LESSONS LEARNED FROM INVESTIGATION OF CLUSTER OF ALL WITH REGARD TO 
                         FEDERAL AGENCIES ROLE

    1. Investigation of Cancer Clusters.--Although hundreds of cancer 
clusters have been recognized and investigated during the past 30 years 
by State and local health departments and Federal agencies, little 
information is available on appropriate scientific methods of study 
especially with regard to determining causative factors or associated 
risk factors. Well over 90 percent of these investigations have found 
no associated suspect causative factor. No Federal agency wants to 
expend scarce resources in investigation of cancer clusters that are 
likely to show nothing. However State (or local) health departments 
must investigate clusters to ensure that a dangerous environmental 
agent is not present in the community contributing to the increase in 
cancer cases.
    While several Federal agencies have expertise in some part of 
cancer cluster investigations, no one agency has a comprehensive 
mandate. We have identified gaps in information available to States as 
follows:
    1. No repository of information exists on the occurrence of cancer 
clusters (i.e., surveillance of cancer of clusters) or to record the 
results of these investigations.
    2. Lack of a standard or a ``best-practices guidance'' for the 
investigation of cancer clusters.
    3. No information to identify characteristics of clusters that 
might be most productive to investigate.
    4. No resources available to State to implement investigations of 
clusters with the most promise of advancing the science of cancer 
causation.
    Bringing together all the relevant Federal Public Health Agencies 
(National Cancer Institute, Centers for Disease Control and Prevention, 
Agency for Toxic Substances and Disease Registry) and Environmental 
agencies to develop a comprehensive approach to the study of cancer 
clusters (which would include at minimum the 4 activities listed above) 
would greatly enhance the speed, efficiency and scientific validity of 
cluster investigations. A guidance for best practices for investigation 
of clusters would reassure the community that standards do exist for 
these investigations and that health departments efforts can be 
evaluated in comparison to the standard. Recognition of clusters that 
may be most productive in finding evidence for causation of cancer and 
providing resources for the appropriate study of such clusters would 
prevent lost opportunities and maximize the probability of advancing 
the science of cancer causation.
    2. Environmental Factors.--The cause or causes of acute lymphocytic 
leukemia are largely unknown. Theories of causation have focused on two 
main theories, (a) environmental agents such as chemicals or radiation 
or (b) infection with a virus or bacteria that results in genetic 
damage that eventually causes leukemia. Studies of suspect infectious 
and environmental agents for the most part have not been fruitful.
    What the environmental factors should be monitored by health 
departments in a systematic way? No consensus exists on the minimum 
standards for environmental surveillance. It would be of immense value 
to the States if all the involved Federal agencies could be brought 
together (perhaps by ASTHO, an organization of State health officials 
or another non-governmental agency) and come to consensus on what 
constitutes the minimum standard for environmental surveillance for 
State health departments.
    The Environmental Protection Agency is often in conflict with 
Federal Public Health Agencies on assessment of risks to health of 
environmental contaminants. This results in a bizarre mixture of 
conflicting standards for which States are held accountable. EPA should 
be required to work with Federal Public Health agencies to resolve 
conflicts on interpretation of scientific data before implementing 
regulations for the States.
    In the Churchill County area many environmental agents are present 
that may constitute a risk for health, including excess arsenic in the 
drinking water supply. A great deal of information is available about 
arsenic in the water and steps have been taken by the city of Fallon to 
reduce the arsenic in the municipal drinking water. However, community 
concerns have surfaced about other agents in the environment for which 
we have much less information. These include jet fuel from Naval Air 
Station, radioactive substances that may resulted from nuclear testing 
that was done in 1963 about 20 miles away from Fallon (Project Shoal 
conducted by Department of Energy), pesticides used for insect control 
and agriculture, chemical pollutants from industries in the area and 
air contamination with radioactive or chemical debris from the Sierra 
Army Depot in California which is about 3 miles from the Nevada border. 
One of the requirements for the explosion or burning of munitions at 
this depot is that the wind is blowing toward Nevada at a certain speed 
before the explosions can take place. There has been no monitoring of 
the contamination of the air that blows into Nevada from the depot. 
Therefore no data are available on this potential source of 
environmental contamination. Despite numerous requests the 
Environmental Protection Agency has not required California to be 
accountable to Nevada to ensure that toxic substances are not blown 
into Nevada from the operation of this depot.
    Like all States Nevada does not have jurisdiction over private well 
water used for drinking water, nor does any Federal agency. The safety 
of drinking water from these wells is unknown. Churchill County has 
many households whose water supply comes from private wells. How to 
ensure the safety of drinking water from private wells is a critical 
issue for all States. Federal agencies may have a role in providing 
guidance on solutions to this public health issue.
    3. Community Mental Health.--Recognition of a cancer cluster in a 
community is associated with increased stress for the community. The 
need for preventive mental health services must be assessed. The Nevada 
Health Division and Mental Health Division have partnered to begin a 
community mental health initiative in Fallon to assess the need for and 
to provide the necessary mental health services for the affected 
families and the community at-large.
    It would be of great value to have a model for providing such 
services for communities experiencing cancer clusters. The National 
Institute for Mental Health and other Public Health agencies have a 
role in providing guidance for determining mental health needs and 
providing resources for these services during crises.
                                 ______
                                 
                               ATTACHMENT

             Review and Recommendations of the Expert Panel

    The expert panel was convened on February 15, 2001 in Reno, Nevada 
by Dr. Mary Guinan, Nevada State Health Officer. The panel reviewed the 
State health department's investigation of acute lymphoblastic leukemia 
(ALL) cases that had been diagnosed in Churchill County, Nevada. The 
panel considered possible followup actions and priorities by the Nevada 
Health Division. The meeting of the expert panel was attended by panel 
members and staff from the Nevada Health Division, University of Nevada 
School of Medicine, Nevada Governor's Office, U.S. Senate (Senator John 
Ensign's Office and Senator Reid's staff on U.S. Senate Committee on 
Environment and Natural Resources), and the Fallon Naval Air Base. This 
report summarizes the panel's review and recommendations.
    The expert panel recognized the difficulty in evaluating and 
investigating excess occurrences of ALL. The panel members acknowledged 
that the cause(s) of ALL are insufficiently understood to single out a 
specific factor as explaining the observed excess in Fallon, Nevada. 
The panel members were familiar with previous investigations of ALL 
clusters, all of which had failed to uncover an explanation of the 
cause of these excesses. At the same time, the panel members confirmed 
that the excess occurrence of ALL in Fallon, Nevada is unusual; not 
only because of it's large number of observed cases among so small a 
population-at-risk over a short time period, but also because further 
observed ALL cases had been diagnosed after the initial recognition of 
the ALL excess. The members of the expert panel acknowledged the 
excellent work of the staff of the Nevada Health Division on this 
investigation.
    Scientific understanding of the biology of ALL prevented the 
committee members from predicting the cause of the observed excess of 
cases in Fallon. The committee is aware of at least three distinct sets 
of possibilities. The first set of theories collectively point toward a 
cancer causing chemical contaminant (e.g., human carcinogen) as the 
causal agent for the ALL epidemic. Theories about a chemical in the 
environment have received the greatest amount of public attention and 
community concern. The expert panel recognizes the need to address 
community concern regarding the presence of a hazardous chemical 
contaminant. However, the absence of cases of acute myeloid leukemia, 
the type of leukemia most commonly associated with toxic chemical 
exposure (1-3), argues against the Fallon cases being the result of 
toxic exposures. The panel members were skeptical that a chemical 
exposure could explain the excess cases of ALL in Fallon, Nevada. A 
second possible explanation relates to the theory of what is called 
population mixing in which clusters of ALL have been reported 
associated with unusual mixing of people, often in relatively isolated 
rural areas (4-11). The population mixing theory initially focused on 
the possibility of an unidentified infectious agent (i.e., a virus). 
However, the current consensus is that exposure to a variety of 
infectious agents (i.e., viral and bacterial) may trigger an unusual 
and rare reaction that affects a very small number of children within 
the susceptible population. The hypothesis suggests that ALL is not 
infectious, spreading from one person to another; but an unusual 
complication to a common infection within a susceptible population. The 
population-mixing theory is supported by the observation that excesses 
of ALL eventually subside, presumably because of increased population 
immunity. This theory requires further examination. The panel believes 
it reasonable to test this hypothesis by calculating rates of ALL in 
other rural areas of the U.S. having significant population mixing. 
However, such an effort falls outside the mandate of the Nevada Health 
Division. Finally, the possibility that the excess of ALL cases is due 
to random chance cannot be totally excluded as an explanation. The 
panel acknowledges, however, that the excess of ALL cases in Fallon, 
Nevada is not likely to represent a ``chance'' occurrence.
    The expert panel recommends to the Nevada Health Division six 
followup steps in the investigation of the excess occurrence of ALL in 
Fallon, Nevada (see Table 1).
    The purpose of these next steps are to: (1) efficiently expand 
case-finding efforts, (2) categorize the observed ALL cases by 
clinically relevant disease biomarkers, (3) identify potential excess 
environmental exposures unique to the community by a cross-sectional 
exposure assessment of selective contaminants and an evaluation of 
contaminant releases into the local environment with assessment of 
completed pathways for the case families, (4) collect and bank biologic 
specimens for future scientific investigations, (5) determine the time 
course and characteristics of population movements into the Fallon area 
for the period 1990 to 2000, and (6) maintain an expert panel to peer 
review investigative protocols and study results, consider future use 
of banked specimens, and provide ongoing consultation to the Nevada 
Health Division.
    The expert panel also discussed the importance of high 
concentrations of arsenic in municipal and private drinking water 
supplies. The panel members expressed doubt that arsenic consumption in 
drinking water, by itself, could explain the observed ALL excess for 
several reasons: (1) The excess occurrence of ALL began in 1999, 
whereas the arsenic concentrations in drinking water have been 
consistently elevated for many years. (2) The case children who make-up 
the excess occurrence of ALL differ in respect to their consumption of 
arsenic contaminated drinking water. (3) Epidemiologic studies of 
arsenic exposed populations have not linked arsenic exposure with adult 
or childhood leukemia. One recent article suggests a weak association 
between childhood leukemia risk and exposure to low levels of arsenic 
in drinking water (12). The panel has reviewed the article and believes 
that the study is inadequate to support a conclusion that ALL is 
related to arsenic in drinking water. Each panel members expressed 
concern that the ongoing exposure to excess levels of arsenic in 
drinking water was a human health hazard, regardless of its 
relationship to the excess of ALL. The Fallon municipal water supply is 
contaminated with arsenic (As) at a level 10 times the EPA recommended 
standard for arsenic in drinking water. The panel was also aware that 
an unknown proportion of Churchill County drinking water wells, 
unregulated by the Federal Safe Drinking Water Act (SDWA), are at least 
as contaminated as the Fallon municipal water supply. Arsenic is 
recognized by the Report on Carcinogens of the National Toxicology 
Program as a known human carcinogen on the basis of epidemiologic 
studies that have linked arsenic exposure with an excess of skin, 
bladder, and lung cancers in exposed human populations.
    The expert panel recommends that arsenic concentrations in the 
Fallon municipal drinking water be reduced to a level no more than that 
currently recommended by EPA (e.g.; 10 g/L) as soon as 
possible. The panel strongly encourages the Nevada Health Division, and 
other State agencies, to proceed with recommendations for testing 
arsenic in all drinking water wells in Churchill County that are 
unregulated by the SDWA. The State health division should work to 
create a process providing this service when necessary and develop a 
set of recommendations for preventing arsenic exposure based on 
reported test results. The State health division should consider 
maintaining a listing of wells that have been tested along with test 
results.
    Table 1: Investigating the excess occurrence of Acute Lymphoblastic 
Leukemia in Fallon, Nevada: Phase II Recommendations of the Expert 
Panel (February 15, 2001)
    Priority Task/Timeframe/Collaborators
    1. Efficiently expand case-finding efforts. The panel members 
encourage the Nevada Health Division to continue limited case-finding 
strategies. The panel members recommended limited expansion of case-
finding by linking to:
    A. The national Childhood Oncology Group (COG) data bases(s) to 
identify all children with ALL having a residence at time of diagnosis 
in the State of Nevada. The purpose of this would be to evaluate 
completeness of the Nevada tumor registry and identify additional ALL 
cases from Churchill County.
    B. An ongoing case-control study of ALL being conducted in 
California to review residential history of cases for previous 
residence in Churchill County, Nevada.
    C. The California State Tumor Registry to identify any children 
with ALL with a Nevada residence at time of diagnosis.
    Timeframe.--These additional steps could be done within 2 months 
after satisfactory negotiations regarding patient confidentiality are 
completed.
    Potential Collaborators.--Clinical Oncology Group, California Tumor 
Registry, California ALL research team.
    2. Categorize the observed ALL cases by clinically relevant disease 
biomarkers. Cancer cells from each case-child have probably been 
collected and undergone immunophenotyping and cytogenetic testing. The 
health division should collect this information. If testing has not 
been done and tumor cells have been stored, the health division should 
secure samples and have them tested. These materials could be reviewed 
or tested at two independent laboratories. The distribution of these 
results among the case-children from Fallon can be compared against 
other children with ALL to determine if these distributions are similar 
or if the distribution among the Fallon case-series is unique.
    Timeframe.--The health division should proceed to determine 
availability of data or tumor cells as soon as possible.
    Potential Collaborators.--Pediatric oncologists, Childhood Oncology 
Group, National Cancer Institute.
    3. Identify potential excess environmental exposures unique to the 
community. The health division should conduct limited testing for 
current exposures in environmental media or human samples as well as 
evaluate contaminant releases into the local environment and assess the 
potential for human exposure to such contaminants. This analysis would 
be used to identify chemicals that are (and are not) elevated in the 
community and to consider if additional data collection is required.
    A. A cross-sectional exposure assessment of selective contaminants 
would include examination of drinking water, human blood and urine of 
family members, and possibly dust collected from homes where case-
children did and did not live. Testing should be limited to compounds 
for which normative data are available. The expert panel recommended 
testing for volatile organic compounds in drinking water and human 
tissues; radioactive isotopes in drinking water; selected heavy metals 
in drinking water, household dust, and human tissues; and pesticides in 
human tissues and in household dust.
    B. An evaluation of contaminant releases into the local environment 
with assessment of completed pathways for the case families. The expert 
panel recommends collecting environmental release data, including that 
from local industry and the Fallon Naval Air Station. An assessment of 
the potential for environmentally released chemicals to result in human 
exposure should also be conducted, including potential for case-
children to have been exposed.
    Timeframe.--These activities will require development of survey and 
sampling protocols and appropriate review of consent forms and 
confidentiality agreements. The committee anticipates startup of these 
activities during the months of March or April and available results 
within 1 year.
    Potential Collaborators.--National Center for Environmental Health, 
Centers for Disease Control and Prevention; Agency for Toxic Substances 
and Disease Registries; Jonathan Buckley (University of Southern 
California) for input on measuring housedust for pesticide residues, 
heavy metals, PAHs. .
    4. Collect and bank biologic specimens for future scientific 
investigations. The members of the panel recognize how limited our 
knowledge is of the cause(s) of ALL and the difficulty investigators 
have had in identifying the causes of similar ALL excesses. The panel 
members believe that collection of biologic specimens from case-
children and family members may be useful for future research 
investigations into the cause(s) of ALL. A small amount of blood and 
urine, and perhaps buccal cells, should be collected, maintained, and 
made available for future research.
    Timeframe.--Collection of specimens could occur simultaneously with 
the exposure assessment (see 3A) or include samples taken during 
clinical care. A protocol for collection, storage, and access to 
samples must be developed and reviewed by an Institutional Review Board 
for compliance with human subject research.
    Potential Collaborators.--Nevada Public Health Laboratory, National 
Center for Environmental Health, Centers for Disease Control and 
Prevention, National Cancer Institute as possible repositories for the 
tissue bank.
    5. Determine the time course and characteristics of population 
movement into the Fallon area for the period 1990-2000. The expert 
panel recommends collecting demographic data concerning changes in the 
population of Fallon, specifically looking for evidence of large 
migration of new long-term residents into the community during this 
time period. The appended table illustrates the kind of first-level 
information that is relevant to this issue.
    Timeframe.--Initial data collection within 2 months.
    Potential Collaborators.--Public school systems and Fallon Naval 
Airbase (for information concerning migration patterns), Drs. Les 
Robison and Malcolm Smith (for consultation to identify the specific 
data required).
    6. Maintain the expert panel to peer review investigative protocols 
and study results, review proposals for future use of banked specimens, 
and provide ongoing consultation to the Nevada Health Division.

                             Reference List

    1. Felix CA. Secondary leukemias induced by topoisomerase-targeted 
drugs. Biochim Biophys Acta 1998;233-55.
    2. Bennett JM, Moloney WC, Greene MH, Boice JD. Acute myeloid 
leukemia and other myelopathic disorders following treatment with 
alkylating agents. Hematol.Pathol. 1987;99-104.
    3. Rothman N, Smith MT, Hayes RB, Traver RD, Hoener B, Campleman S, 
Li GL, Dosemeci M, Linet M, Zhang L, Xi L, Wacholder S, Lu W, Meyer KB, 
Titenko-Holland N, Stewart JT, Yin S, Ross D. Benzene poisoning, a risk 
factor for hematological malignancy, is associated with the NQO1 609C--
>T mutation and rapid fractional excretion of chlorzoxazone. Cancer Res 
1997;2839-42.
    4. Kinlen LJ. Epidemiological evidence for an infective basis in 
childhood leukaemia [editorial]. Br. J. Cancer 1995;1-5.
    5. Kinlen LJ, Clarke K, Hudson C. Evidence from population mixing 
in British New Towns 1946-85 of an infective basis for childhood 
leukaemia. Lancet 1990;577-82.
    6. Kinlen LJ, Hudson C. Childhood leukaemia and poliomyelitis in 
relation to military encampments in England and Wales in the period of 
national military service, 1950-63. BMJ 1991;1357-62.
    7. Kinlen LJ, O'Brien F, Clarke K, Balkwill A, Matthews F. Rural 
population mixing and childhood leukaemia: effects of the North Sea oil 
industry in Scotland, including the area near Dounreay nuclear site. 
BMJ 1993;743-8.
    8. Kinlen LJ, Petridou E. Childhood leukemia and rural population 
movements: Greece, Italy, and other countries. Cancer Causes Control 
1995;445-50.
    9. Kinlen LJ. High-contact paternal occupations, infection and 
childhood leukemia: five studies of unusual population-mixing of 
adults. Br. J. Cancer 1997; 1539-1545.
    10. Alexander FE, Chan LC, Lam TH, Yuen P, Leung NK, Ha SY, Yuen 
HL, Li CK, Li CK, Lau YL, Greaves MF. Clustering of childhood leukaemia 
in Hong Kong: association with the childhood peak and common acute 
lymphoblastic leukaemia and with population mixing. Br. J. Cancer 
1997;457-63.
    11. Petridou E, Revinthi K, Alexander FE, Haidas S, Koliouskas D, 
Kosmidis H, Piperopoulou F, Tzortzatou F, Trichopoulos D. Space-time 
clustering of childhood leukaemia in Greece: evidence supporting a 
viral aetiology. Br. J. Cancer 1996; 1278-83.
    12. Infante-Rivard et al. Drinking water contaminants and childhood 
leukemia. Epidemiology 2001; 12:13-19.
                               __________

     Statement of Randall Todd, State Epidemiologist, Nevada State 
                            Health Division

    Good morning Mr. Chairman and members of the committee. For the 
record my name is Dr. Randall Todd. I am the Nevada State 
Epidemiologist and work for the Nevada State Health Division. I would 
like to briefly describe the Health Division's investigation into the 
cluster of childhood leukemia in Churchill County and discuss the role 
of Nevada's Central Cancer Registry.
    The initial phase of our investigation consisted of confirming the 
diagnosis of each reported case and conducting an interview with each 
case family to identify any potentially common characteristics or 
environmental exposures that might point to a preventable cause. We are 
indebted to the Centers for Disease Control and Prevention as well as 
the Massachusetts Department of Public Health for their assistance in 
providing us with model interview instruments.
    The case family interviews were conducted face-to-face with each 
family. This involved a detailed review of the family's residential 
history from the date of diagnosis back to a point in time 2 years 
prior to conception of the ill child. For each residence we inquired as 
to the source of water, in-home treatment of water, and uses of water. 
We also inquired about known exposures to chemicals from agricultural 
or home use of herbicides and pesticides as well as indoor uses of 
chemicals and solvents. For each parent, we also inquired about 
occupation and occupation-related exposures to chemicals, fumes, dust, 
or radiation. We conducted a detailed review of the child's medical 
history and the mother's pregnancy and breast-feeding histories. 
Finally, we asked case families about any hobbies, sports activities, 
or typical travel destinations that might have brought them into 
contact with chemicals, fumes, dust, or radiation.
    From this interview process we learned that half of the case 
families had spent 2 years or more in the Fallon/Churchill County area. 
The others had resided in the area for shorter periods of time. The 12 
case families had resided in a total of 88 different homes over their 
respective time periods of interest. Of these, 22 were located within 
Churchill County. Of these 22 local residences, half were served by 
public water systems while the others obtained their water from 
domestic wells.
    Our initial analysis of the occupational, medical, environmental, 
and other historical information provided by the case families has not 
suggested any particular common denominator that would link these cases 
together. We recognize, however, that some of our data is subject to 
recall limitations on the part of the families. Specifically, they may 
not have known of an environmental exposure that did, in fact, exist, 
or may have forgotten about it. For this reason we are currently taking 
steps to obtain additional data through objective environmental 
sampling. This constitutes a second phase of the investigation.
    We are now in the process of obtaining water samples from those 
current and former case residences in Churchill County that are served 
by domestic wells. These samples are being subjected to the analyses 
that are routinely done for public water systems. In other words, any 
test required by the safe drinking water act for public water systems 
is also being conducted on the water samples obtained from the wells of 
residences where case families have lived. The results of these 
analyses are pending at this time.
    We have also invited the Centers for Disease Control and Prevention 
as well as the Agency for Toxic Substances and Disease Registry to 
assist us in identifying and analyzing completed pathways for other 
sources of environmental contamination. This would include industrial, 
agricultural, military, or other sources.
    On a parallel tract with these environmental studies we are also 
collecting data on the overall population dynamics in Churchill County. 
This includes looking at size of various age cohorts over the last 10 
years, school enrollment information, and military populations. This 
analysis will help to determine if Churchill County matches the profile 
of other communities around the world where population mixing has been 
suggested as a possible explanation for increased rates of childhood 
leukemia.
    In closing, I would like to make some brief comments as to the 
importance of cancer registries in the conduct of cancer cluster 
investigations. Nevada has maintained a population-based cancer 
registry since 1979. This activity has been funded, in part, through a 
grant from the Centers for Disease Control and Prevention since 1995.
    All disease reporting systems, including cancer registries, 
experience a lag in time between the diagnosis of a case and the 
reporting of that case. With a disease such as cancer, the patient 
record may not be complete enough to warrant abstracting information 
until about 6 months from the date of diagnosis. Additional delays in 
obtaining information beyond this 6-month time period relate to work 
load and staffing. In the more rural parts of Nevada, this situation is 
made even more difficult due to the distances involved and the 
relatively low number of acute hospital beds in each facility making it 
a costly and time consuming process to collect rural data. For these 
reasons, if a cancer cluster is identified through a cancer registry it 
is likely to have been going on for some time.
    The increased incidence of childhood leukemia in Churchill County 
was not identified through analysis of cancer registry data. The local 
hospital, physicians, and community leaders noted the cases and 
perceived the numbers to be unusually high. Nevertheless, Nevada's 
cancer registry has been invaluable in helping to place the observed 
number of childhood leukemia cases in historical and geographic 
context. Only through analysis of cancer registry data have we been 
able to calculate the usual rate of childhood leukemia and determine 
that the local cases represent a significant excess over the expected.
    I hope this overview of our investigation to date and the role of 
cancer registries has been helpful. I would be happy to answer any 
questions the committee may have.
                               __________

 Statement of Rear Admiral Richard J. Naughton, U.S. Navy, Commander, 
                  Naval Strike and Air Warfare Center

    Good Morning. My name is RADM Richard J. Naughton and I am the 
Commander of the Naval Strike and Air Warfare Center located at Naval 
Air Station, Fallon, NV. Here with me this morning is CAPT David A. 
Rogers, the Base Commander. We welcome the opportunity to testify 
before the Environmental and Public Works Committee on military 
activity in the Fallon area, particularly as it may pertain to 
Churchill County's recent childhood Leukemia cluster situation.
    I will begin with a short discussion of the mission and operations 
at Fallon followed by some remarks on items I know are of special 
interest to the committee members. I will then be happy to entertain 
questions. Let me assure the committee members that the United States 
Navy is committed to public health and assisting this continuing 
investigation in any way possible. One of the cases in question is the 
child of a military member stationed at Fallon and three fourths of our 
base population of 7200 personnel and their family members live off 
base. The Navy's Bureau of Medicine has just completed an extensive 
screen of Naval Cancer cases which might be related to being stationed 
at Fallon. Their review of over 12 million records from 1997 to the 
present revealed just the one Navy case already identified. The Navy is 
also committed to exploring the Expert Panel's Population Mixing Theory 
and has shared data on transient activity at NAS Fallon with the State. 
While further examination of similar demographic data in other military 
locales (i.e. small isolated communities near military bases with large 
numbers of transients in training) would appear prudent, it will take a 
coordinated effort by the entire Department of Defense to conduct such 
a study.
    As many of you know, NAS Fallon has been in operation since 1942. 
The focus of the base was squadron level air-to-ground combat training 
until 1984, when the Navy established the Naval Strike Warfare Center 
(``Strike University'') and began focusing on training entire air wings 
(1500 personnel and 70 aircraft) in an integrated fashion. The mid-
eighties also saw the development of the Fallon Range Complex--an 
instrumented Military Operating Area flown over 6.5 million acres East 
of Fallon. The majority of the land we fly over is managed by the 
Bureau of Land Management, as the Navy only directly controls 204,000 
acres. The third major change in the mid-eighties was the outsourcing 
of many of the functions on the base, which is reflected in our current 
percentage of contractors (55 percent). 1996 saw the consolidation of 
all graduate level aviation flight programs at Fallon with the arrival 
of ``Topgun'' and ``Topdome'' from Southern California and the 
establishment of a senior two-star Flag officer on the base as Naval 
Strike and Air Warfare Center, or NSAWC. As NSAWC, I report directly to 
the Chief of Naval Operations and provide oversight for training of 
approximately 55,000 sailors a year. The base has conducted an average 
of 40,000 flights a year for the past 5 years, with a 4 to 5 percent 
increase over that time. The investment in NAS Fallon since 1984 has 
been almost $300 million dollars.
    I would like to discuss some of our specific operating issues as 
they might pertain to this investigation. First, the consolidation of 
all of our training here in 1996 did not appreciably change the way we 
conduct operations. We fly the same aircraft and the number of flights 
has only increased by 4 to 5 percent. In fact, our two biggest years in 
terms of flight generation at NAS Fallon occurred in 1990 and 1991 in 
preparation for Operation's Desert Shield/Storm. The type of flight 
training NSAWC conducts has remained unchanged, particularly from an 
environmental perspective.
    Second, NAS Fallon's Environmental, Safety, Operations and Weapons 
Departments are responsible for the administration of all of our 
environmentally sensitive materials. For anything we use, there's a 
program for safely handling and disposing of it where applicable. We 
follow guidelines established by Federal, State, Department of Defense 
and the U.S. Navy and arguably more heavily regulated than the private 
sector. Programs such as Fuel Handling, Air Emissions, Hazardous 
Materials Disposal, Electromagnetic Radiation Effects and Installation 
Restoration are all inspected on a regular basis and have received high 
marks for compliance. We have shared the details of each program with 
the State Health Division and Expert Panel and are prepared to do the 
same with the Agency for Toxic Substances and Disease Registry when 
they visit next week.
    Third, NAS Fallon's drinking water supply services the 3000 
personnel who work on the base and up to 2000 transients at any one 
time. It is separate from the city of Fallon's but taps the same Basalt 
Aquifer with the resultant water chemistry being identical. The base 
tests our water supply routinely and also monitors for contamination of 
the 8000 acres of base property through the use of 218 environmental 
monitoring wells. No DoD activity-related contaminants have ever been 
detected in the Basalt aquifer or leaving base property. While the 
State and Select Panel investigations have not established a link 
between Fallon water arsenic levels and the Leukemia cluster, these 
levels are a matter of concern to the Navy. We are working on a joint 
DoD/city of Fallon water treatment facility.
    My detailed written statement previously submitted for the record 
contains further information on NAS Fallon activity as it might relate 
to this investigation. It also lists points of contact for additional 
information if required. Thank you for your attention. I will now 
entertain any questions.
                                 ______
                                 
Statement of RADM Richard J. Naughton, USN Commander, Naval Strike and 
 Air Warfare Center and CAPT David A. Rogers, USN Commanding Officer, 
                             NAS Fallon 12
    The following paragraphs are designed to provide the reader with 
background on operational activity at NAS Fallon, NV as it relates to 
the environment in general and the leukemia cluster in specific. The 
Navy is committed to public health and will assist the State-led 
investigation in any way desired. Specific points of contact are listed 
for further detail if required.

         1. MILITARY TRAINING ACTIVITY AT FALLON WITH POSSIBLE 
                       ENVIRONMENTAL CONSEQUENCES

A. Fuels
    1. NAS Fallon's fuel is supplied by the Kinder-Morgan Company of 
Sparks, NV, through a 70-mile pipeline. The pipeline is cathodically 
protected with induced current and monitored. It is also visually 
inspected by air weekly, visually inspected by truck bi-weekly and kept 
under pressure even when fuel is not being pumped so as to monitor for 
leakage. No leaks have ever been detected. The point of contact at 
Kinder-Morgan is Mr. Girard Gonyeau at 775-358-6971.
    2. Spills.--The Nevada Division of Environmental Protection 
strictly regulates fuel spills. There are reporting requirements for 
spills over 25 gallons, spills that contaminate three cubic yards of 
soil, or spills of any amount that contaminate surface water.
    3. More than 95 percent of fuel spills are confined to paved areas 
on the flightline, runways or taxiways. The average spill is about 15 
gallons, and there have been an average of 60 of those per year over 
the last 10 years. Spills on paved areas are cleaned-up immediately 
using absorbent pads or absorbent media. Spills on soil are cleaned by 
excavating and subsequent proper disposal of the contaminated soil. 
These procedures and amount of spillage are similar to procedures and 
amounts at any commercial airport with a similar operating tempo.
    4. The largest spill in the last 5 years was approximately 400 
gallons. The spill resulted from a break in an underground fuel 
delivery pipeline. All soil contaminated by the spill was excavated and 
transported to an authorized treatment facility near Mustang, NV.
    5. Fuel venting.--This is also heavily regulated. We must report 
all incidents and must vent fuel above 6000 feet above ground level. 
Above 6000 feet, 99 percent of fuel is vaporized. Fuel may be vented/
jettisoned below 6000 feet only in an actual aircraft emergency. The 
last 15 years worth of data show an average yearly vent of 3.5 
occurrences above 6000 feet (1500 gallons total). There have been three 
occurrences in 15 years where fuel was vented below 6000 feet (800 
gallons total)--each was east of the base on BLM property and nowhere 
near population centers (the nearest settlement East/Southeast of the 
base is Middlegate Station located 32 miles East/Southeast.
    6. Aircraft mishaps (crashes).--Of the 12 mishaps in the last 15 
years, nine were in the operating area on BLM land or on Navy property, 
the remaining three were on private property. Ten of 12 had fire 
associated with the crash that consumed residual fuel. State Health 
department personnel have determined that there were no long term 
environmental impacts from any of those events.

B. Air Emissions
    (1) NAS Fallon has just completed an extensive modeling effort for 
base air emissions endorsed by the State Environmental Division. The 
modeling shows that NAS Fallon meets all Nevada ambient air quality 
standards.
    (2) The base has many detailed reports on the composition of jet 
exhaust, which varies by type of aircraft. Each of these is monitored 
by the Nevada Division of Environmental Protection and United States 
Environmental Protection Agency to assure public safety. While the 
quantities of materials released into the atmosphere vary according to 
aircraft type, they essentially involve a mix of the following five: 
Carbon Monoxide, Nitrogen Oxide, Sulfur Oxide, Hydrocarbons and 
Particulate Matter, each of which are relatively common at most 
industrial sites, particularly airports. The total amount of all 
contaminants released into the atmosphere equates to 1500 parts per 
million per day at an average operating tempo (115 flights per day). 
This equates to approximately half that of the Reno-Tahoe International 
Airport. Commercial ``Jet-A'' fuel is composed of the same basic 
materials and burns in an almost identical fashion to that of military 
``JP-8'', the primary difference being the addition of an anti-icing 
agent in JP-8.
    (3) The fire department open burns approximately 30,000 gallons of 
jet fuel per year in training permitted under the Nevada Division of 
Environmental Protection Bureau of Air Quality. The fuel is burned no 
more than four times per month and/or two times in any week. When it 
occurs it is also dependent on the winds, which must be blowing at 
least five knots from the West to avoid blowing the smoke toward the 
community. The chemicals contained in fire smoke are roughly twice that 
contained in jet engine exhausts. The total amount released into the 
atmosphere equates to 1/1000th of that released by the jet traffic at 
the airfield. Other fire departments around the country routinely burn 
fuel for training.

C. Other Hazardous Materials (HAZMAT)
    Other HAZMATs (cleaning solvents, paints, pesticides, photo 
processing, vehicle fluids, etc.) are routinely used on base. An 
extensive HAZMAT handling facility and program is managed by the NAS 
Fallon Supply Department with oversight from the Industrial Hygiene 
Office, the Safety Office, the Environmental Office and the Weapons 
Department. All hazardous waste generated by station operations is sent 
to permitted treatment, storage and disposal facilities. Details are 
available from the NAS Fallon Supply Officer, CDR Troy Brannon, 426-
2750, or NAS Fallon Environmental Division Head, Mr. Doug Bonham at 
426-2772.

D. Electromagnetic Radiation (EMR) Hazards
    (1) A survey of electromagnetic radiation hazard for NAS Fallon is 
conducted approximately every 3 years by the Department of Defense 
Inspector General Office. No significant hazards of electromagnetic 
radiation to personnel situations were detected on the Naval Air 
Station. The systems used at NAS Fallon include aircraft navigational 
aids, radar for aircraft and weather, radios, cell phones, electronic 
warfare (EW) equipment and aircraft. Equipment used at NAS Fallon 
adhere to the DOD radio frequency safety standards and the Institute of 
Electrical and Electronics Engineers recommended practice for the 
measurement of potentially hazardous electromagnetic fields and 
microwave. (The standard developed by representatives of industry, 
government agencies, scientific communities and the public.)
    (2) Standard operating procedures are used to protect Navy 
personnel and the public from EMR hazards. These procedures include 
setting the height and angle of transmission to avoid direct exposure, 
posting warning signs, activating warning lights when the radar are 
operational, and/or securing sites with fencing. EMR from EW systems is 
the same type as emitted by cell phones, hand-held radios, walkie-
talkies, commercial radio, and television stations. EMR from a typical 
EW site averages less and 0.325 milliwatts per square centimeter; EMR 
from a cell phone is 1.19 milliwatts per square centimeter. Other 
sources of EMR include navigation aids and radar. These systems are the 
same or similar to civilian navigation aids and radars at airports, TV 
weather stations, and aircraft navigation aids throughout the United 
States. All systems have safety limits to prevent potential hazard. 
Measures are also in place to prevent hazards from EMR emitted by 
military aircraft. The majority of EMR is emitted in the training 
airspace east of the Naval Air Station.

E. Depleted Uranium (DU) Ammunition.
    Depleted uranium is the inert, low-radioactivity uranium which 
remains after more-radioactive isotopes have been separated from 
natural uranium or spent reactor fuel. DU is used globally in private 
industry as radiation shielding, ballast and counterweights in 
commercial and military aircraft. The U.S. Military continues to use DU 
projectiles because of their extraordinary effectiveness as anti-armor 
munitions. Chemically and toxically, DU is no different than the 
natural uranium found in air, soil and water everywhere on earth. DU 
ammunition has never been used, nor is it authorized for any of the 
Fallon ranges.

F. Chaff
    (1) Radio Frequency (RF) chaff is a glass fiber substrate with a 
thin coating of aluminum. Typical chaff rounds contain 200,000 fibers 
(.001 inches in diameter) and weigh five ounces. Chaff is expended on 
our ranges east of Fallon to train aircrew on vital defensive 
countermeasures when encountering enemy surface-to-air missiles. As a 
chaff bundle is deployed from an aircraft, it ``blossoms'' to attract 
or decoy the enemy radar. The fibers will disperse with the prevailing 
wind.
    (2) Historical concerns about chaff have revolved around its 
potential harm to the environment. In March 2000, an independent study 
on the environmental effects of RF chaff by a team of research 
scientists from various universities concluded that existing chaff 
systems are environmentally benign and not a health hazard. The 
chemical composition is very similar to that of desert dust. A copy of 
this report is available from the NSAWC Range Department, LCDR Lynn 
Tawney at (775) 426-2108.
    (3) The total amount of chaff expended on the Fallon ranges amounts 
to \1/4\ ounce per acre per year. This amount is several orders of 
magnitude less than EPA standards for dust, vehicle exhaust, power 
generation and industry.

                2. INSTALLATION RESTORATION (IR) PROGRAM

    A site investigation to determine the nature and extent of possible 
contamination at NAS Fallon was begun in 1988. Past practices had 
resulted in contamination by fuels such as gasoline, diesel and jet 
fuel; solvents containing PCE and TCE; and landfills containing 
garbage, trash, and demolished building materials including asbestos. 
Fuels and solvents have contaminated the shallow groundwater (between 
4' to 10' below ground surface) beneath portions of the base. Over 100 
wells are systematically sampled to monitor these contaminants and 
ensure that the contaminants are controlled before they could effect 
human health or the environment. The program is designed to prevent 
contaminated groundwater from leaving the base boundary and to date 
none has.
    The city of Fallon and the Paiute-Shoshone Tribe pump drinking 
water from the deep basalt aquifer near Rattlesnake Hill, over 7 miles 
northwest of the base. Due to the nature of the groundwater system in 
the Carson desert and the location of NAS Fallon there is no 
possibility for the contamination beneath NAS Fallon to reach the 
drinking water supply used by the City, Navy and the tribe. The closest 
drinking water wells to the main base boundary belong to the Navy and 
they are located over 3 miles to the northwest of the base, which, is 
the southernmost point of the basalt aquifer. The water in the shallow 
aquifer (ground surface to 50 feet) underlying the base flows to the 
south away from drinking water supplies. The nearest settlement is 32 
miles away.
    For questions call John Dirickson at (775) 426-3184.

                      3. WATER INFORMATION UPDATE

    The current EPA arsenic standard is 50 parts per billion (ppb). A 
new EPA arsenic standard was finalized at 10 ppb in January 2001. The 
EPA Administrator has announced her intention to review the technical 
basis for the rule and to extend the effective date for it. NAS Fallon 
and the city share the same basalt aquifer water source with resultant 
naturally occurring arsenic levels of 90-110 ppb. An EPA Notice of 
Violation was issued to NAS Fallon in January 2000 to reduce the amount 
of arsenic in the base's drinking water system. In September 2000 the 
EPA issued an administrative order requiring NAS Fallon to meet at 
least the current 50 ppb maximum contaminant level for arsenic in 
drinking water by late 2004. NAS Fallon has three wells that are each 
approximately 500 feet deep. The water chemistry for the NAS Fallon 
wells and the city of Fallon wells is essentially the same.
    Arsenic treatment is required for the city of Fallon in 2003 and 
NAS Fallon in 2004. NAS Fallon is conducting pilot studies to select 
the best treatment technology. A joint NAS/City effort to construct a 
water treatment facility is under consideration. Interim measures at 
NAS Fallon consist of:
    (1) Free Reverse Osmosis (R.O.) filtered water available at 37 
locations on base. All units are tested twice annually to ensure we 
meet drinking water standards for arsenic (the R.O. units routinely 
test to less than 1 ppb for arsenic).
    (2) Commercial bottled water is available in work spaces and at the 
Child Development Center.
    (3) A free bottled water machine is available 24-hours a day in the 
Sierra House of the BOQ.
    (4) Free water testing can be obtained by military members not 
living in base housing or on the city water system.
    (5) R. O. filtered water systems will be installed in base housing 
commencing approximately May 1, 2001.
    The point of contact for water issues is Mr. Mark Jones (775) 426-
2785.
                               __________

            Statement of Ken Tedford, Jr., Mayor, Fallon, NV

    Recognizing that my time is brief, let me begin by saying that the 
city of Fallon sincerely appreciates the efforts of the Senators, 
Congressman and your staffs--just as we appreciate the work being done 
by the Governor's Office and the State Health Division. These are 
trying times for our community and, while we have pulled together in 
the only way we know how, it is comforting to know that others want to 
help.
    I'm not going to spend any time discussing the cluster's cause, or 
possible links between the children. I believe the State Health 
Division and others will cover that. The city has cooperated in every 
way we know, first as the steward of the municipal water system and 
later as we have begun to assess other city-owned facilities. Thus far, 
nothing has been found. We recognize that the Health Division's expert 
panel believes that an environmental link may not be found, due in part 
to the fact that the ALL found in this cluster is not typically caused 
by environmental triggers. Nonetheless, we will continue to cooperate 
in that search.
    Our efforts have been focused on the children, the affected 
families, and public education. The City Council and I have formed a 
group called ``Fallon Families First'', comprised of local community 
leaders and social service providers, to coordinate these efforts. I 
asked my wife Jennifer to chair the committee, and they are doing a 
yeoman's work. Please realize that our city does not have a social 
service infrastructure. We are too small. So we have had to reach out 
to groups like the FRIENDS Family Resource Center, the local hospital, 
mental health professionals, the clergy, the school district, the 
County and others.
    Today there is a single source of assistance for the families, the 
Family Resource Center. Patient services are coordinated by the Nevada 
Health Advocates in Carson City, and hopefully soon with the National 
Leukemia and Lymphoma Society Chapter in Sacramento. Fundraising is 
handled through the Mayor's Youth Fund. You can see the white ribbons 
worn by guests here today, a suggestion by a mom of one of the 
patients. It's the latest step in our effort, and we plan to continue 
raising funds as long there are needs.
    Fallon Families First recently held its first public meeting, a 
panel discussion focused on the disease itself. Local physicians, a 
mother of a stricken child, and a mental health professional, who 
people know and trust, helped answer the questions weighing on the 
minds of those attending. Efforts like this will continue as they are 
needed. A series of informational mailings is also being coordinated 
with the County and the local telephone company. This week the city 
launched its first Web site. Part of this effort has been driven by the 
need to communicate about the leukemia cluster, and part by our desire 
to be generally more accessible.
    So what remains to be done?
    I can tell you without hesitation that the most frustrating part of 
this process has been the lack of information. People want answers, and 
I don't have them. The investigation is ongoing, but it's bound to take 
a long time. Where do people go for answers? I believe, in cluster 
situations like this, a clear sense of communication needs to be 
established early in the process. Perhaps if the State Health Officer 
declares a cluster to be in existence, that could trigger a Federal/
State/local partnership. The mayor's office seems to be the place 
people automatically go, but in small towns like ours we don't always 
have the information. I have assembled my own team of local citizens 
and other experts who can help the city. But in other towns, the mayor 
might not be so fortunate. I think a standard support team or ombudsman 
should be made available to towns like ours.
    Finally, I would be remiss if I didn't speak briefly about the 
arsenic in our water. I KNOW the Senators are aware of this situation, 
just as I know the experts will testify that the arsenic is probably 
not linked to the leukemia cluster. But the two things have become 
linked in the media and in earlier meetings, so I feel we owe you at 
least an update.
    Fallon's municipal water supply contains arsenic at levels of 100 
parts per billion. The U.S.E.P.A. has ordered us to remove the arsenic, 
which is naturally occurring here. As you are well aware, the EPA 
standard has long been under review. It was 50 parts per billion. It 
was temporarily lowered to 10. Now it is back at 50. We have no idea 
where it will finally be set. For the city of Fallon it doesn't matter 
any more.
    The city of Fallon, through its environmental engineering firm 
Shepherd-Miller, has begun pilot testing the technology we will use to 
remove the arsenic. It appears that a process called '`enhanced 
coagulation'' is working best. We will finish the pilot testing by the 
end of May. Then we will design and site a treatment facility. Our goal 
is to have construction finished in time to comply with the EPA order, 
which gives Fallon until September 2003. This date is significantly 
earlier than any other public water system, and it's still not clear 
how much arsenic we will have to remove. Nonetheless, we are 
proceeding. And we are doing so without regard to costs, or where the 
money will come from. We have also been in consultation with U.S. Navy 
officials about a joint plant.
    My suggestion to this body today is that you make Fallon a test 
case. The issue of the EPA standards revolves around ``best available 
science'' and the fact that there is no ``off the shelf '' technology 
to remove arsenic on a municipal scale. Things like household reverse 
osmosis systems won't work on the scale we're talking about here. We 
believe that since Fallon is required to remove its arsenic more 
quickly than other municipalities, there may be benefits to those who 
follow from learning from what we do. Perhaps the Federal Government 
could pay for the cost of Fallon's treatment facility, in exchange for 
the availability of the science and treatment methods resulting here 
that can be utilized by all those who follow.
    We're dedicated to treating city water. Others will have to address 
the many private county wells that have high arsenic levels. And all of 
us will have to respond to public education issues and outside media 
attention that now surround the arsenic. But with your help, we can put 
this chapter in our history behind us and focus all our energies on the 
leukemia cluster, the children and their families.
    We must maintain our focus on these families. As I said earlier, 
this is a lonely time for our town. Many people want to speculate, many 
others are well intentioned in their scrutiny. Others are just curious. 
But when the camera lights are off and the media attention fades, our 
town will be left to care for our children and assess the long-term 
impacts of this unusual cluster. Your presence here today is a chance 
to change that. I hope you will be able to stick with us, and I thank 
you for taking the time to come here today.
                               __________

   Statement of Gwen Washburn, Chairman, Churchill County Commission

    Good morning, Honorable Senators. First, as Chairman of the County 
Commission, I want to tell you that the County Administration is first 
and foremost concerned about the health and well being of the people. I 
am happy to have the opportunity this morning to address the issue of 
the leukemia cluster identified in this community, and to discuss ways 
to investigate and mitigate the problem. I will give you a little 
information about Churchill County and what the County Commission is 
doing at this time.
    Churchill County has sustained a steady growth of about 3 percent 
over the years and now is home to about 26,000 people. The population 
is expected to double in the next 15 years. We are a progressive small 
community, boasting modern schools, a community college, an arts center 
and the most modern hospital in western Nevada. We have a mix of long 
time agricultural-oriented families, military personnel, young working 
families and retired people. Many people are born and grow old here 
with nothing more than average health problems, so the community is 
alarmed and feels helpless in the face of a childhood leukemia 
epidemic.
    The community has reacted to this crisis in a quick and calm 
manner, working cooperatively together with all agencies in an attempt 
to find any answer or common link between the cases. The County 
Commission is very concerned about the health and welfare of not only 
our 26,000 residents, but also those that visit us each year as 
military personnel or tourists. Certainly, none of us are experts in 
the health field, nor are we research scientists. We have no choice but 
to leave the investigations to the experts. What we can do, have done, 
and will continue to do is support all scientific and responsible 
efforts to find an answer.
    We have actively participated in Governor Guinn's investigation and 
in Assemblywoman de Braga's investigation. We joined forces with the 
city of Fallon and Churchill Community Hospital in development and 
distribution of a fact sheet (Attachment #1) that attempts to answer 
the most commonly asked questions about leukemia and what the community 
is doing about it. We also support Mayor Tedford and the Community 
Hospital in their individual efforts to assist the families of the 
victims with the Fallon Families First organization, and the health 
information center.
    I, personally, have spent many hours in consultation with personnel 
of the University of Nevada, Reno, Extension Service to update and 
reactivate a drinking water safety program known as Nevada GOLD (Guard 
Our Local Drinking water). The University responded favorably and 
quickly by hiring a research specialist to locate and correlate all 
existing water studies in an attempt to find any possible cause of 
cancers in our local (outside the city of Fallon) shallow wells. 
Studies have shown that water from the shallow aquifer is variable and 
may contain Magnesium, Sulfates, Chloride, Nitrates, Fluoride, Arsenic, 
Iron, Manganese and other minerals above levels recommended by EPA. 
(Attachment #2) Nevada GOLD is also teamed with the local hospital to 
provide water sample bottles, instructions and transportation of water 
samples to the State Health Laboratory giving all well owners the 
opportunity to have their water tested for bacteria and heavy metals. 
(Attachments #3-7). They also are, rightfully, taking the lead in 
educating the public about drinking water safety.
    Our local water quality, whether the causative agent or not, was 
immediately pointed to as the cause of leukemia by the general 
population, encouraged and perpetuated by the media. The matter has not 
remained local. We see copies of news articles from across the Nation 
with headlines proclaiming Fallon and Churchill County to be an 
unhealthy place to live. This press coverage has resulted in damage to 
our community. People are turning down jobs, houses go unsold, business 
has declined, our sales tax revenues are down and we were recently 
listed as a depressed area by EDA, (Economic Development 
Administration). (Attachment #8-11).
    One of the first questions raised by the general public concerned 
the use of chemicals and chemical processes in the county, and what 
regulations were in effect to assure public safety. Churchill County 
relies on the Nevada Department of Environmental Protection to issue 
any emissions and/or discharge permits relative to any business or 
industry that locates in our county. The only county requirement other 
than proper zoning, until recently, was a business license. Out of 
concern for the health and well being of our citizens we now require a 
Special Use Permit. This helps county officials and haz-mat experts 
know what chemicals are being used in the community. The information 
required for a Special Use Permit is also intended to assist emergency 
responders, if the need should arise.
    We asked ourselves, what has changed in the community since the 
early 1990's? Several things emerged. We have no way of knowing which, 
if any, of them singly or in combination are to blame until more 
research is done. Less irrigation water in the valley to recharge our 
shallow aquifers: Are toxins building up in the shallow aquifer? More 
people on one-acre lots: Are deep soil disturbances related to 
building, more fertilizers and pesticides used for landscaping and 
lawns, or nitrates from septic leach lines to blame? The 1997 flood: 
Was more Mercury or some other toxin that had previously been 
undisturbed released into the Carson River to end up in Lahontan 
Valley? The Gulf War: Was some toxic or carcinogenic substance 
introduced to the community when personnel and/or equipment returning 
from the war came to NAS Fallon? Transportation of hazardous material: 
How much hazardous material is being transported through the city of 
Fallon in trucks traveling the Highway 95 North/South route, and is it 
properly contained? Petroleum based products: Were there changes made 
to the chemical formulations of fuels, paints, tars, asphalt, 
fertilizers, lubricants, etc?
    We are anxious to locate and take reasonable corrective action for 
any environmental cause that may be found to contribute to the 
incidence of leukemia or like diseases in our community. A thorough and 
accurate scientific study of all possibilities will take many years and 
millions of dollars. The medical experts have already expended many 
resources examining the patients and their families. The community, and 
individuals have lent their support. The State of Nevada is considering 
committing money. Now I will ask you to do the same.
     First and foremost is the proper health care for victims 
of leukemia and related illnesses. Provide special assistance funds to 
be administered through Social Service programs or special insurance 
underwriting.
     We need to have thorough scientific research underwritten 
by Federal Grants. The studies should seek out information on leukemia 
trends before the cluster appeared for the sake of comparison. There is 
no doubt that information gathered and analyzed in this area will 
provide benefit for other areas also.
     Grants to the University of Nevada and Churchill Community 
Hospital that will enable them to continue public education programs in 
drinking water safety and nutrition and disease prevention is 
essential.
     Provide low interest, long-term loans to small business 
affected by loss of sales through the leukemia scare.
    If water is identified as the cause of ANY health risk to our 
citizens we need Federal help to build a system to bring safe water to 
those who live outside the city limits of Fallon. County Commissioners 
have been considering this for a long time and have developed a plan 
for the system including a source of supply. (A Draft Copy of the plan 
was delivered to Senator Reid in the fall of 2000). The estimated total 
cost is in the $200,000,000-$250,000,000 range, obviously far beyond 
the means of a small community, even if our population doubles as 
predicted. We know the government is developing a plan to assist small 
community water systems for towns under 10,000 population. Our 
population outside the city of Fallon is about 16,000, too large to 
qualify for that assistance, leaving the people who reside in rural 
Churchill County in a ``no win'' situation at this time. As a side 
note, for many years qualified Veterans have not been able to exercise 
their right to guaranteed home loans in this area because of the water 
quality. We urge the Federal Government to look at ways to assist areas 
such as ours to develop safe water supplies.
     In the short term, Federal assistance to help residents 
with the cost of testing all existing domestic wells and installing 
treatment systems if the water test results deem a system necessary, 
would be a blessing to this community. It is estimated that there are 
about 4500 domestic wells in use at this time, and complete water 
analysis costs about $120 or more per sample. Cost of various in-home 
treatment systems range from several hundred to several thousand 
dollars, amounts beyond the means of many homeowners.
    Churchill County Commissioners have approved a proposed hazardous 
materials by-pass route for this community, with the idea of beginning 
to acquire rights-of-way for future construction. (Attachment #12) At 
this time all trucks that travel north/south on US 95 must travel about 
a mile through the city, turn 90 degrees, travel three blocks and turn 
90 degrees again on the three busiest streets in town. There are no 
truck stops on this stretch of highway for several hundred miles, so 
hungry, tired truckers must stop beside the street in town where 
thousands of people pass by. This route is very near four schools. The 
east/west route is US 50, straight through the heart of town, and 
passes near two schools and the hospital. If hazardous waste 
transportation should prove to cause ANY health hazard to our community 
the Federal Government would be obligated to provide assistance to 
build a route that keeps the threat of exposure to a minimum.
    On behalf of the Churchill County Commissioners, I thank you for 
taking time to listen to our concerns and ideas. We sincerely hope that 
you will be able to assist our community in some way to ease the 
suffering of the leukemia victims and their families and to help us 
find the ways and means to lessen or better yet, prevent more 
occurrences of this and other cancers.
                                 ______
                                 
 Responses by Ken Tedford, Jr., Mayor, Fallon, NV to Frequently Asked 
            Questions about Churchill County Leukemia Cases
    Question 1. The city of Fallon prepared this document as a public 
service. The City is not considered an expert on the subject of 
leukemia. Sources of information include the State Health Division, 
National Cancer Institute, Leukemia & Lymphoma Society and American 
Cancel Society. In addition, information was taken from newspaper 
articles, Web sites and reports prepared by the City's own 
environmental consultants. This information is not provided as medical 
advice or as an official report of scientific research, but as public 
information.
    What are the current findings about the leukemia cases in Churchill 
County?
    Response. A preliminary investigation was conducted by the Nevada 
State Health Division to ensure that public health officials were aware 
of all cases of childhood leukemia in the area and to identify any 
common characteristics among the case families. Case families were 
asked about their residential history, sources of water for drinking 
and cooking, medical history, family history, and potential sources of 
chemical and radiation exposure.
    Eight of the eleven cases have been diagnosed in the last 10 
months. Patients' ages at time of diagnosis range from 0 to 19 years 
old. The cases are scattered throughout Churchill County. All the 
patients have acute lymphocytic leukemia (ALL). Nationally, 2,000 new 
cases of ALL are diagnosed each year. None of the children from 
Churchill County has died from the disease.
    State Health officials have completed interviews with 10 case 
families and data has been examined for eight of the families. Based on 
an initial analysis, there does not appear to be a common 
characteristic among the case families. All of them lived in Fallon for 
varying lengths of time between 1996 and 1999. The families had various 
sources of drinking water (some drank tap water from the municipal 
system, some drank tap water from domestic wells, and some drank 
bottled water) and reported no consistent exposures to any particular 
environmental hazard. It is however, important to note that people may 
not always be aware of their exposure to an environmental hazard.

    Question 2. What is leukemia?
    Response. Leukemia is a form of cancer. Childhood acute lymphocytic 
leukemia (ALL) is a disease in which too many underdeveloped infection-
fighting white blood cells, called lymphocytes, are found in a child's 
blood and bone marrow. ALL is the most common form of leukemia in 
children, and the most common kind of childhood cancer. It is also 
referred to as acute lymphobastic leukemia.

    Question 3. What is a cancer cluster?
    Response. A disease cluster of any kind is the occurrence of a 
greater than expected number of cases of a particular disease within a 
group of people, geographic area, or a period of time. Cancer clusters 
may be suspected when people report that several family members, 
friends, neighbors or coworkers have been diagnosed with cancer.
    Various statistical methods are used to determine whether the 
reported number of cancer cases is really a larger number than would 
normally be expected to occur. True clusters are difficult to define 
and, if they turn out to be real, the causes are often obscure. Most 
non-occupational cancer clusters turn out to be the result of the 
random nature of the disease.
    Clusters have been identified throughout the world but only one 
case can positively be linked with a contaminant. Some high-profile 
cancer/leukemia cluster cases include: Tom's River, NJ; Hinkley, CA; 
Woburn, MA; La Hague, France; and Seascale, Britain.

    Question 4. How are cancer clusters investigated?
    Response. Epidemiologists, scientists who study the frequency and 
distribution of diseases in populations, may investigate reported 
disease clusters, including suspected cancer clusters. Investigations 
of suspected cancer clusters can be limited by the current status of 
scientific knowledge and tools related to genetics; effects of 
environmental factors on humans; the availability of statistics on 
cancer and other diseases by local area; and resources.

    Question 5. What causes leukemia?
    Response. The cause is unknown.

    Question 6. What are the risk factors for childhood leukemia?
    Response. For the most part, lifestyle risk factors such as diet 
and exercise, while important in adult cancers, are not linked to 
childhood cancers.

    Question 7. What are the symptoms of leukemia?
    Response. Early signs of ALL may be similar to those of the flu or 
other common diseases. General symptoms can include feeling tired or 
weak all the time, weight loss, fever and loss of appetite. Most 
symptoms of acute leukemia are caused by a shortage of normal blood 
cells. Anemia is a result of a shortage of red blood cells. Anemia 
causes shortness of breath, fatigue and a pale skin color. Not having 
enough white blood cells can increase the risk of infection. Not having 
enough platelets can lead to bruising, bleeding, frequent or severe 
nosebleeds and bleeding from the gums.

    Question 8. What should I do if I think my child may have leukemia?
    Response. Immediately consult your physician or healthcare provider 
for assistance, evaluation, and early intervention. Your physician will 
complete tests he or she determines to be needed to make an accurate 
diagnosis and begin treatment, if necessary. A blood test is required 
to diagnose leukemia.

    Question 9. How is leukemia treated?
    Response. Treatment decisions for each child are based on a number 
of individual factors. It is generally treated with chemotherapy. 
Chemotherapy refers to the use of anticancer drugs that enter the 
bloodstream and spread throughout the body to kill cancer cells.
    More than 95 percent of children with ALL enter remission after 1 
month of treatment. Remission means that about 99 percent of the cancer 
cells have been killed; but there are still some leukemia cells in the 
body. That's why further phases of treatment are needed.
    Bone marrow transplants are also used in the early stages of some 
types of leukemia.

    Question 10. Can children who have leukemia be cured?
    Response. The overall 5-year survival rate for children with ALL is 
80 percent. The aim of treatment is to bring about a complete 
remission. Complete remission means that there is no evidence of the 
disease and the patient returns to good health with normal blood and 
marrow cells. Relapse indicates a return of the cancer cells and return 
of other signs and symptoms of the disease. For leukemia, a complete 
remission that lasts 5 years after treatment often indicates cure. 
Treatment centers are reporting increasing numbers of patients with 
leukemia in complete remission at least 5 years after diagnosis of 
their disease.

    Question 11. Where can I get more information about leukemia?
    Response. State Health Division officials have set up a Community 
hotline, open weekdays between 8am and 6pm for inquiries: 1-888-608-
4623.
    State Health Division Web site, Health2k.state.nv.us
     Leukemia and Lymphoma Society of America, www.leukemia.org 
or 1-800-955-4572
     Childhood Leukemia Center, ww.patientcenters.com
     National Cancer Institute, www.nci.nih.gov or 1-800-4-
CANCER
     American Cancer Society, www.cancer.org or 1-800-ACS-2345
     Department of Health and Human Services, www.os.dhhs.gov/
     Centers for Disease Control, www.atsdr.cdc.gov/

    Question 12. What caused these cases of leukemia in the Fallon 
area?
    Response. The Fallon leukemia cases are the State Health Division's 
top priority and investigators are looking into many theories for the 
unexpected concentration of cases. During a public meeting on February 
5, officials from the Health Division stated that they are not ruling 
out the possibility of a cause, but acknowledged that this occurrence 
could be happenstance, a statistical anomaly.

    Question 13. Is there an elevated rate of other types of cancer in 
Fallon?
    Response. The State's Cancer Registry has been analyzed and 
Churchill County does not have an increased rate of any other types of 
cancer.

    Question 14. What is being done to investigate these cases?
    Response. The State Health Division is conducting an extensive 
epidemiological investigation. The investigation, which began 6 months 
ago, centers on collecting and analyzing data. Much of the data 
consists of statewide statistics and information from the 11 children 
and teens with leukemia as well as their families. The Health Division 
is including experts from the Centers for Disease Control and 
Prevention (CDC) and other States to assist with this investigation. 
Environmental sampling and other testing may follow.
    The city of Fallon has retained a nationally recognized 
environmental and engineering consulting firm, Shepherd Miller, to 
conduct chemistry testing of the city's water.

    Question 15. Are other government officials getting involved?
    Response. The Nevada Legislature is holding hearings in Carson 
City. The goal of these hearings will be to unite data, resources and 
information in an effort to share information and address concerns. 
Participating in the effort is the city of Fallon, the Environmental 
Protection Agency (EPA), Nevada State Health Division, Nevada Division 
of Environmental Protection and the Nevada Department of Agriculture. 
Also testifying will be experts on arsenic, leukemia, drinking water 
and pesticides.
    U.S. Senator Harry Reid has said that Federal officials, including 
representatives of the Centers for Disease Control in Atlanta and a 
congressional health committee are expected to get involved in the 
investigation. Reid said he would send environment committee staff 
members and an eco-toxicologist to Fallon to conduct preliminary 
interviews and gather information. An initial investigation is 
scheduled for mid-February with a field hearing to be held in the 
spring.

    Question 16. How long will it take to determine the cause?
    Response. Hundreds of cancer clusters have been investigated, some 
for many years, and only one clearly identified a cause. Although this 
is discouraging, the Health Division believes it is important to 
properly investigate these cases.

    Question 17. Could Navy jet fuel be the cause?
    Response. According to the commander of the Fallon Naval Air 
Station jet fuel spills and fuel dumping by planes are so rare and well 
documented that the fuel cannot be a contribution factor in the 
childhood leukemia cases. The base has 100 monitoring wells and no fuel 
contamination has been recorded off Navy property.
    No jet fuel has contaminated the municipal water supply.

    Question 18. Is there a link between atomic tests and leukemia?
    Response. Department of Energy officials say that radiation from 
the test has not migrated from the site to Fallon. The test wells have 
been monitored since 1963 and the EPA checks the wells annually. 
Scientists from the energy department, EPA and Desert Research 
Institute use eight onsite wells and a dozen offsite wells to search 
for radioneuclides like tritium. The ground water below the test site 
does not connect with the basalt aquifer, Fallon's source of drinking 
water. Fallon is 28 miles from the site of a 1963 nuclear bomb test.

    Question 19. Where does the City of Fallon's water come from and 
why is arsenic in the water?
    Response. The city's water source has been an underground basalt 
aquifer for the past 58 years. Water is withdrawn from the aquifer 
through four deep wells. Arsenic is a naturally occurring mineral. The 
amount of arsenic in Fallon's drinking water is 100 parts per billion.
    The city of Fallon Municipal Water System routinely monitors for 
constituents according to Federal and State laws. The City monitored 
for 49 synthetic organic compounds and 56 volatile organic compounds 
and there were no detected quantities of any of these contaminants.

    Question 20. Is there a link between the arsenic and leukemia?
    Response. There is currently no evidence that arsenic causes 
childhood leukemia. Dr. Randall Todd, the State epidemiologist, says 
it's unlikely the longstanding occurrence of arsenic caused a sudden 
spike in the area's leukemia rate. The water has been tapped from the 
same source for 58 years with no reported clusters of any type in the 
past.

    Question 21. What is the City doing to take the arsenic out of the 
water?
    Response. In 1990, The city of Fallon entered into a Compliance 
Schedule Agreement to remove arsenic from its public water supply once 
a standard was set. The City has been waiting for a permanent Federal 
standard on acceptable levels; that standard appears to have been set 
by the outgoing Clinton administration.
    The City has been distributing quarterly notices to customers that 
advise using alternative sources for drinking water, including bottled 
water, filtered water available for purchase at grocery stores or water 
filtered at home through a reverse osmosis system.
    In April 2000, the City retained a nationally recognized 
environmental and engineering consulting firm, Shepherd Miller, to 
conduct chemistry testing of the city's water. These tests are ongoing 
in order to rule out suspected leukemia causing agents. The next phase 
includes testing for three other substances in order to exhaust all 
possibilities.
    The City has exceeded required testing requirements, in both the 
frequency of testing and the types of contaminants. Additional tests 
have been completed on contaminants, that are linked, or suspected to 
be linked, to leukemia. Water tests show no contamination from fuel, 
radiation, pesticides, or herbicides.
    The City is working with Shepherd Miller to determine which arsenic 
treatment technologies are best suited to Fallon's water chemistry and 
will be installing a treatment system to meet all Federal requirements.
    The design of a treatment facility is scheduled for completion by 
June 30, 2002 and startup testing will begin June 15, 2003. Initial 
compliance for arsenic removal should commence September 15, 2003. The 
City is on target to make these EPA deadlines.

    Question 22. Should I have my private well for drinking water 
tested?
    Response. If you don't know what's in your well, you should have it 
tested. You should know the arsenic levels, bacteria levels, and other 
contaminants present. You should contact the Health Division hotline at 
1-888-608-4623 or Bureau of Health Protection Services in the Nevada 
State Health Division, 775-687-4750 extension 237.

    Question 23. What can I do to help the families?
    Response. West End Elementary School is participating in the 
Pennies for Patients campaign to raise funds for the Leukemia and 
Lymphoma Society. Additional information on fundraisers and community 
support activities will be provided as it becomes available.

              Table 5.2.--Historical Lahontan Valley Underground Water Quality & MCL Exceedence\1\
----------------------------------------------------------------------------------------------------------------
                                                                              No. of Records       Percent of
                      Constituent                            MCL (ppm)         Which Exceed      Records Which
                                                                                 MCL's\2\         Exceed MCL's
----------------------------------------------------------------------------------------------------------------
TDS....................................................                500               1103                 40
Magnesium..............................................                150                 30                  1
Sulfate................................................                250                368                 13
Chloride...............................................                400                117                  4
Nitrate................................................                 10                590                 21
Flouride...............................................                  2                203                  7
Arsenic:
  Current Standard.....................................               0.05                955                 34
  Anticipated EPA Standard.............................               0.01               1898                 68
  Detection Level......................................              0.002               2656                 95
Iron...................................................                0.6                188                  7
Manganese..............................................                0.1                810                 29
Copper.................................................                  1                  2                  0
Zinc...................................................                  5                  1                  0
Barium.................................................                  2                  0                  0
Color..................................................                 15                342                 12
pH.....................................................            6.5-8.5                506                 18
----------------------------------------------------------------------------------------------------------------
\1\ See Appendix 5.2 which is a tabulation of the water quality records sorted by Township, Range & Section
\2\ There are a total of 2,792 records in the data base, however some of them are duplicate wells sampled at
  different dates.

    Dixie Valley Ground Water.--Based upon current MCLs, the water 
quality of the ground water in the Settlement area within Dixie Valley 
is good. Based upon 13 well analyses, the average TDS is 264 ppm and 
individual wells vary from 152 ppm to 355 ppm. Higher TDS (in the order 
of 800 ppm to 1000 ppm) is reported in 2 wells located 17 to 20 miles 
north of the settlement area. (These areas to the north near the playa 
are not included in the proposed well field for the Dixie Valley Ground 
Water Development Project.).
                                 ______
                                 
                    HOW TO TEST YOUR DRINKING WATER

    The Nevada State Health Division recommends that individuals with 
private wells do a bacterial analysis every 6 months and a chemical 
analysis once a year. When testing for personal reasons, a chemical 
test costs $100 and a bacterial test costs $12.
    To Prepare Water for Bacterial Testing: 423-2281.--You can get 
sterile bottles from the Churchill Community Hospital (Business Office) 
located at 801 E. Williams in Fallon or the Nevada State Health 
Laboratory (address on attached forms). Carefully follow the directions 
on the form for taking samples. These can be mailed in a mailer 
provided with the bottle.
    To Prepare Water for Chemical Test.--Use a clean 1-gallon plastic 
container. You can purchase a bottle of distilled water in your grocery 
store, empty it and refill with your water as outlined in the attached 
directions.
    Where to take Samples: (775) 688-1335.--Take your sample to the 
State Lab on the University of Nevada, Reno, campus. The lab is located 
just west of the Medical school and north of Lawlor Events Center. The 
address is 1660 N. Virginia. Take Virginia Street north to Seventeenth 
Street, turn right, go 0.1 mile to the second stop sign, turn left, and 
the lab is immediately on the left after the left turn.
    Reading Your Test.--Enclosed are samples of the report sheets that 
will have the results from your test. If you need help understanding 
the results or have questions, contact the local health department 
(423-2281) or your County Extension Office (423-5121).
    When you receive test results compare them with the Federal 
drinking water standards found below.

                    Federal Drinking Water Standards
               [Primary and Secondary Contaminate Levels]
------------------------------------------------------------------------
                Contaminant                           Max Level
------------------------------------------------------------------------
Primary Regulations:
Inorganic Chemicals
  Arsenic.................................  0.05 mg/L
  Barium..................................  1 mg/L
  Cadmium.................................  0.010 mg/L
  Chromium................................  0.05 mg/L
  Lead....................................  0.05 mg/L
  Mercury.................................  0.002 mg/L
  Nitrate (as N)..........................  10 mg/L
  Selenium................................  0.01 mg/L
  Silver..................................  0.05 mg/L
  Flouride (depending on temperature).....  1.4-2.4 mg/L
Organic Chemicals:
  Endrin..................................  0.0002 mg/L
  Lindane.................................  0.004 mg/L
  Methoxychlor............................  0.1 mg/L
  Toxaphene...............................  0.005 mg/L
  2,4-D...................................  0.1 mg/L
  2,4,5-TP Silvex.........................  0.001 mg/L
  TTHM....................................  0.10 mg/L
Turbidity.................................  1 TU-5 TU
Coliform Bacteria.........................  1/100 ml (mean)
Radiological:
  Radium 226 and 228......................  5 pCi/L
  Gross Beta..............................  4 mrem/year
                                            (50 p Ci/L)
  Gross Alpha.............................  15 pCi/L
Sodium & Corrosivity......................  Monitoring only
Secondary Regulations:
  Chloride................................  250 mg/L
  Color...................................  15 color units
  Copper..................................  1 mg/L
  Foaming Agents..........................  0.5 mg/L
  Iron....................................  0.3 mg/L
  Manganese...............................  0.05 mg/L
  Odor....................................  3 threshold odor number
  PH......................................  6.5-8.5
  Sulfate.................................  250 mg/L
  TDS.....................................  500 mg/L
  Zinc....................................  5 mg/L
------------------------------------------------------------------------

                               __________
     Bacteriological Test, Nevada State Health Laboratory, Reno, NV

                  DIRECTIONS FOR TAKING WATER SAMPLES

    Caution.--Bottle is sterile and contains a bit of necessary powder. 
Do not open bottle until Step 5 below and Do not wash out bottle.
Procedure
    1. Select sampling outlet closest to the water source (pipe, 
kitchen faucet, etc.)
    2. Remove aerators, hoses, sprinklers, etc., from the fixture.
    3. Turn on valve and let water run for 2 to 3 minutes.
    4. While water is still running, unscrew the bottle cap carefully. 
Do not touch mouth of bottle.
    5. Do not rinse bottle, but fill to the shoulders; replace the cap 
and tighten firmly. 100 mls of water are required for testing.
    6. For samples from an open reservoir, make a quick pass with mouth 
of bottle forward at a depth of one foot. Tighten cap firmly.
    7. Complete information slip with your name, location, county, 
date, time of sampling, and return mailing address.
    8. Submit sample(s) to laboratory within 30 hours of collection and 
maintain temperature below 20+ C (68+ F) during 
shipment or sample is unsatisfactory. (Do not allow to freeze.
    9. Do not mail sample(s) on Friday, because our laboratory is 
closed on the weekend. Samples mailed on Friday and received on Monday 
cannot be tested because the 30-hour time limit will be exceeded.
    10. Please do not bring Fecal Streptococci water samples on Friday.

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Statement of Mary E. Reid, Area Specialist, Water Resources, University 
                    of Nevada, Cooperative Extension

                              INTRODUCTION

     Common Problems with presence of arsenic in drinking water 
See Health effects below.
     Drinking Water Standards: Federal Standard for Maximum 
Contaminant Level (MCL)
    0.05 milligrams per liter (mg/l)
    0.05 parts per million (ppm)
     Special characteristics (odors, colors, etc.)
    None
     To identify. Actions to take if thought to be present.
    No simple home test available. If thought to be present, bottled 
water is an option.
    To ascertain presence and levels in water. Sampling procedure.
    If known to occur in the general geographical area, an inorganic 
chemistry test for presence and level of arsenic present must be done 
in a laboratory. In Nevada, a standard inorganic water analysis done by 
the Nevada State Laboratory includes testing for arsenic.
     Areas in Nevada where arsenic is found in drinking water
    Carson Valley, Cold Springs, Eagle Valley, eastern sides of the 
Truckee Meadows, Fallon, Fernley, Hazen, Hidden Valley, Topaz, Verdi, 
and Virginia Foothills.

                                SOURCES

    Arsenic occurs naturally in rocks, soils and sediments. High levels 
may occur in some coals. High levels of arsenic have been found in 
water from areas with geothermal activity. Marine algae and seaweed 
usually contain considerable amounts of arsenic.
    Arsenic is used in the manufacture of pesticides and is also used 
in making glass and glassware. Other industrial uses for arsenic 
include copper and lead alloys and pharmaceuticals. Trace amounts of 
arsenic may be found in some fertilizers.
    The burning of coal and smelting of metals are major sources of 
arsenic in air. Industrial waste from electroplating can be a source of 
arsenic in water. Water used for geothermal energy production may 
contain high levels of arsenic.

                             HEALTH EFFECTS

    Arsenic is a poison in humans at 100 milligrams or more and has 
proved lethal at 130 milligrams. Health effects of long term exposure 
to elevated arsenic are vague and not clearly defined. Acute and 
chronic toxic effects may include chronic gastro-intestinal upset and 
diarrhea, liver damage, nervous system changes, blood imbalance, and 
skin changes. Exposure to inorganic arsenic can cause skin cancer, 
mainly tumors of low malignancy.
    Arsenic has been associated with pulmonary cancer in the 
manufacture and use of arsenic-containing pesticides and in the 
smelting of copper.
                      removal form drinking water
    Distillation and reverse osmosis are two practical methods of home 
treatment for drinking water that contains arsenic.


------------------------------------------------------------------------
                 Treatment type                   Average Purchase Cost
------------------------------------------------------------------------
Distillation...................................                $100-$800
Reverse Osmosis................................                 $90-$800
------------------------------------------------------------------------

                                SUMMARY

    Arsenic has been shown to affect health and is an undesirable 
constituent in drinking water. If drinking water exceeds the Federal 
standard for arsenic, there are methods for treating the drinking water 
that will reduce the arsenic level. No home treatment method should be 
considered without having a laboratory test of the water first.
    As with any home treatment method for water, it is not possible to 
install a reverse osmosis or a distillation unit and forget it. Both 
require ongoing monitoring and maintenance. The only way to tell that a 
unit is functioning properly is to do regular water tests.

                               REFERENCE

    De Zuane, John. 1990. Handbook of Drinking Water Quality. Van 
Nostrand Reinhold, New York.
    McGowan, Wes. 1987. Water Processing for Home, Farm and Business. 
Water Quality Association, Lisle, Illinois.
    Shelton, Theodore B. 1991. Interpreting Drinking Water Quality 
Analysis; What Do the Numbers Mean? Rutgers Cooperative Extension, New 
Brunswick, New Jersey.
    U.S. Environmental Protection Agency, Office of Drinking Water. 
1982. Manual of Individual Water Supply Systems.
    World Health Organization. 1981. Environmental Health Criteria 18: 
ARSENIC. World Health Organization, Geneva, Switzerland.
                                 ______
                                 
Churchill Economic Development Authority and Small Business 
                                        Development Center,
                                         Fallon, NV, April 6, 2001.
Hon. Gwen Washburn, Chairman,
Churchill County Commissioner,
Fallon, NV.

Ref: Childhood Leukemia Business Impact

    Dear Chairman Washburn: In reply to your questions in regards to 
impacts to the Fallon, Churchill County business community.
    Our office has received calls from several businessman stating that 
they see a decline in their business, due to the adverse publicity that 
has proliferated as a result of the leukemia cluster in Fallon, 
Churchill County. they have concerns for the viability of their 
business if the publicity is sustained over a long period.
    It goes without saying that the most important concern of Churchill 
Economic Development Authority is the welfare of the leukemia victims, 
however we also have concerns for our local business community as well. 
Should the adverse publicity in regard to our arsenic problems, coupled 
with the acute lymphocytic leukemia cluster continue, there is no doubt 
that some local business will suffer.
    In checking with banks, rental estate and title companies there 
definitely is a slow down in the sale of homes, and many of the Navy 
personnel wives do not want to move to Fallon.
    I hope this answers your question. If our office can be of further 
assistance, please feel free to contact us at your convenience.
            Sincerely,
                                         Shirley G. Walker,
                                                Executive Director.
                                 ______
                                 
                                          Fallon Auto Mall,
                                      Fallon, NV, February 8, 2001.
Mayor Ken Tedford,
City Hall,
Fallon, NV.
    Dear Ken: I am writing you today purely on an informational basis 
only.
    In regards to the recent publicity Fallon has been receiving over 
it's water quality, (arsenic content), child leukemia cases, and now 
our most dangerous Hwy. 50, I feel it is important to rely the impact 
these pubic images are playing on our local economy.
    In our dealership, which commonly does 50 to 60 percent of our 
business to folks outside our county, we have found this business to be 
off as much as 40 percent.
    In comments we receive regularly we believe much of this loss is 
directly due to the new image of Fallon by outsiders.
    Now, I am sure you are treating these issues with the highest 
priority possible, but I felt that you should know directly the 
economic impact this publicity is having on local business.
    I trust you will do everything possible in your power to address 
these issues and promote Fallon as a great place to lie and do 
business.
            Sincerely,
                                              Kurt Henning,
                                                         President.
                                 ______
                                 
                                             [Name deleted]
                               Attorney & Counselor at Law,
                                                  January 21, 2001.
Arthur Mallory,
Thom Stockard,
365 S. Maine Street,
Fallon, NV.
Re: Current Status

    Dear Mr. Mallory and Mr. Stockard: I wanted to write this letter so 
that I could inform you of my decision as soon as possible. I will be 
working all day Monday and will not have the chance to speak with you. 
I am concerned about the water in Fallon. We addressed it briefly when 
I was out there but since then I have read a few other reports, lastly 
one in our paper here saying that two more cases of childhood illness 
could be linked to Fallon.
    I am concerned because of the possibilities. My wife and I have two 
kids, she is pregnant with a third and we anticipate having at least 
one more. I do not know that the water is a problem, but I could not 
live with myself if we moved there knowing that there was a possibility 
for problems and then something were to happen.
    The problem is I was looking forward to receiving an offer and 
working out in Fallon. I wanted to let you know that if something could 
be worked out I would still like to work there, I know that you are 
looking for someone who will live in Fallon. I understand the reasons 
and if I was in your position I would want the same thing. If you 
cannot find someone that you like, I would propose something else. I 
could live in Sparks and commute. I could commit to be there for the 
months that I am on call by either renting a place or making other 
arrangements. I could also commit to stay for at least 5 years. That 
would let the water situation sort itself out, and as an incentive it 
would also be the time period for any retirement to vest.
    I know that your first option is someone to live out there, however 
if you cannot work that out please consider this proposal. I will not 
be coming out on Thursday, as we have decided that we cannot live in 
Fallon until we know more about the water situation and that will 
probably take some time to sort out. If something cannot be worked out 
it was a pleasure to have met you both and I appreciate your 
hospitality. If there are any questions please do not hesitate to call 
or write. I hope to hear from you.
            Sincerely,
                                             [Name deleted]
                               __________

  Statement of Henry Falk, M.D., Assistant Administrator, Agency for 
  Toxic Substances and Disease Registry, Public Health Service, U.S. 
                Department of Health and Human Services

    Good afternoon Mr. Chairman and members of the committee. My name 
is Dr. Henry Falk, Assistant Administrator of the Agency for Toxic 
Substances and Disease Registry (ATSDR).
    Thank you for inviting ATSDR to speak with you today. We share your 
concerns about the health and well being of children and families in 
Fallon and across the country. We also share your desire to adequately 
address the concerns expressed about illness and disease that might be 
associated with the environment. In fact, addressing these types of 
concerns is at the root of ATSDR's creation.
    ATSDR is a Federal agency created by Congress in 1980 by the 
Comprehensive Environmental Response, Compensation, 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 
nature and extent of health problems at Superfund sites including 
Federal Superfund sites, and advising the U.S. Environmental Protection 
Agency (EPA) and State health and environmental agencies on needed 
clean-up and other actions to protect the public's health.
    ATSDR works in close collaboration with the EPA, other Federal, 
State, local, and tribal governments, health care providers and 
affected communities. As an agency of the U.S. Department of Health and 
Human Services (DHHS), ATSDR has made a difference to all of these 
partners by providing new information to assist in remedial 
decisionmaking and evaluation. Our work includes answering the health 
questions of impacted community members, recommending preventive 
measures to protect public health, and providing diagnosis and 
treatment information to local health care providers. ATSDR administers 
public health activities through: partnerships; public health 
assessment and consultation activities; exposure investigations; health 
studies and registry activities; development of toxicological profiles 
and attendant research; emergency response; health education and health 
promotion; and community involvement.
    ATSDR works in particularly close coordination with our DHHS sister 
agency, the Centers for Disease Control and Prevention. Jointly we have 
worked with the Nevada Health Division to investigate the cancer 
cluster in Fallon. For our part, ATSDR will assist in the investigation 
by reviewing all relevant environmental data for toxic substances and 
assessing whether people have been exposed to any of these contaminants 
at levels of concern.
    Unfortunately, the cancer cluster in Fallon is not a unique 
situation. Increasingly, ATSDR is being asked by State and local health 
departments to help respond to compelling community concerns about 
apparent outbreaks of serious, noninfectious disease with unknown 
cause. As a small agency, responding to these requests would be 
impossible for ATSDR alone. To supplement our own staff, ATSDR works in 
close collaboration with State health departments, and 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. 
Because of our Superfund mandates, most of our cancer cluster 
investigations and assistance are related to concerns about Superfund 
sites, hazardous waste, and exposure to toxic substances.
    The site work we do directly or through our State partners has 
changed over time. Our original mandate under Superfund called for 
public health assessments at all National Priorities List (NPL) sites 
and these originally constituted the great majority of our workload. 
While we still actively work at NPL sites, it now constitutes a smaller 
proportion of our site activities. Increasingly, our site work now is 
at immediate removal sites, active waste sites, occasionally 
Brownfields sites, and, like Fallon, sites where communities, States or 
congressional officials have petitioned ATSDR to investigate or assist 
in evaluating their health concerns related to toxic substances.
    Activities related to the vermiculite mine in Libby, Montana, 
provide a very good example of a current site where ATSDR's work has 
made a difference, which also began with a reported cluster of disease. 
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 mine employees as well as others in the 
community with no connection to the mining operations. They were 
suffering (or dying) from asbestosis, mesothelioma, and lung cancers 
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. The latency period for mesothelioma, for example, is 40 
years. This means that the health care community could be seeing the 
effects of exposure to asbestos-contaminated vermiculite from Libby for 
an entire generation.
    In 2000, ATSDR conducted a medical testing program to assess the 
public health implications of past human exposure to tremolite asbestos 
in Libby. More than 6,100 Libby-area residents and former mine workers 
were screened. This number included 70 from Elko, Nevada, who met the 
screening criteria for Libby. They all answered an extensive 
questionnaire about their possible exposures and received both chest x-
rays and pulmonary function tests.
    ATSDR recently reported a preliminary analysis of the medical 
testing results from the first 1,078 participants, or 18 percent of the 
total number of participants in the medical testing program. These 
results showed a very high percentage of individuals reporting contact 
with the vermiculite, and evidence of health impacts, particularly in 
the form of thickening and scarring of the outer pleural lining of the 
lung.
    ATSDR will soon complete the evaluation of the Libby medical 
screening program and is working with local, State, and Federal health 
care providers to address health issues that are identified. 
Specifically, to help local residents obtain medical care, ATSDR has 
worked closely with the DHHS Regional Health Administrator and other 
DHHS agencies, such as the Health Resources and Services Administration 
(HRSA), and the State of Montana to ensure appropriate treatment is 
available.
    Such partnerships are critical to providing needed health services 
at Libby, Elko, and now Fallon. Such partnerships are also critical to 
fully assessing the true existence and potential cause of disease 
clusters. As a part of the latter, ATSDR and CDC are reviewing and 
responding to the Pew Environmental Health Commission Report. The 
report recommends strengthening Federal, State and local public health 
capacity to tackle environmental health problems and establish a 
nationwide Health Tracking Network on chronic diseases and related 
environmental hazards. ATSDR has made significant progress in 
developing registries of individuals exposed to specific substances and 
tracking them over time to assess health status and provide updated 
information over time to exposed individuals. At the request of Sen. 
Baucus (D-MT) and others, we plan to establish a registry of 
vermiculite exposed individuals from the Libby area. The agency also 
has considerable experience working with State health departments and 
communities to conduct epidemiologic investigations of specific health 
outcomes in communities near environmental sources of hazardous 
substances.
    In keeping with the Superfund mandate to ``. . . establish and 
maintain a national registry of serious diseases and illnesses . . .'', 
we at ATSDR see ourselves as having a direct responsibility under 
CERCLA to participate with CDC and others in developing disease 
surveillance or tracking systems, particularly for diseases with known 
or potential relationships to hazardous waste and toxic substances. In 
addition, because of our close working relationship with EPA, we are 
interested in how to link environmental data bases with developing 
health tracking data. Although we are very far from a comprehensive 
system at this point, ATSDR does have some ongoing, albeit limited, 
efforts underway as part of our Superfund work. These include an 
epidemiologic study investigating the cause of childhood cancers in 
conjunction with Superfund sites in four States, and a pilot program to 
develop health tracking of multiple sclerosis in a number of 
circumstances where concern about the frequent occurrence of this 
disease arose in relation to adjacent hazardous waste sites.
    But we recognize that more can be done. Mr. Chairman, 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, or when women who do not smoke and 
who did everything right during their pregnancy give birth to small or 
sick babies. Sadly, in a country as large as ours, these unusual 
occurrences are not so unusual at all. All over the country, citizens 
turn to their local, State and Federal health authorities and ask what 
could be causing these and other types of clusters of health problems. 
In communities near obvious sources of environmental contamination, 
people understandably worry that somehow environmental pollution might 
be playing a role.
    At ATSDR we are committed to doing what we can to address these 
very real concerns.
     As I've stated earlier, we are working every day at sites 
around this Nation to address the health concerns of communities 
affected by toxic exposures.
     We are working with our colleagues at CDC to address the 
issue of health and disease tracking.
     And, we continue to strengthen our ongoing partnerships 
with Federal, State and local agencies, which is integral to answering 
these questions.
    Mr. Chairman, on a personal note, I started my professional career 
as a pediatrician at the Centers for Disease Control in 1972, and my 
first investigation was of a leukemia cluster in Elmwood, Wisconsin. I 
did several more such investigations over the next 18 months, none of 
which revealed an obvious cause for the clusters. However, my fourth or 
fifth such investigation was of 4 cases of liver cancer in a factory 
which turned out to be the first reported cases of vinyl chloride 
induced liver angiosarcoma in polyvinyl chloride polymerization 
workers. This subsequently led to much improved and safer working 
conditions for the entire industry worldwide. I have seen how 
agonizingly frustrating this work can be; but I also feel that if we 
are in the mode of carefully scrutinizing health data, then we will be 
positioned correctly to detect new problems when they arise.
    Mr. Chairman this concludes my testimony. I will be happy to answer 
any questions that you or members of your committee might have.
                               __________

   Statement of Thomas Sinks, Ph.D., Associate Director for Science, 
 National Center for Environmental Health, Centers for Disease Control 
        and Prevention, Department of Health and Human Services

    Good morning, Mr. Chairman and members of the committee. I am Dr. 
Thomas Sinks of the Centers for Disease Control and Prevention (CDC) 
where I am the Associate Director for Science within the National 
Center for Environmental Health. I am pleased to review CDC's 
assistance to the Nevada State Health Division's investigation of acute 
lymphoblastic leukemia (ALL) in Fallon, Nevada. I will discuss how CDC 
provides the technical assistance and infrastructure in responding to 
disease investigations, and briefly characterize cancer clusters, the 
roles of State and Federal agencies in investigating them, and 
coordination between agencies.
    I want to begin by assuring the parents of Fallon, and all parents 
whose children are diagnosed with cancer, that we at CDC are deeply 
concerned about the health and well being of children. We are 
encouraged by the wonderful improvements in the clinical treatment of 
ALL--today 80 percent of children with ALL will have healthy and 
productive lives. However, we need to identify the causes of ALL to 
prevent it and decrease the number of children who suffer from it.
    State health departments are on the front line in responding to 
cancer clusters and other disease clusters, and the CDC plays an 
important role in providing infrastructure and technical assistance. 
CDC has a close relationship with our sister agency ATSDR (the Agency 
for Toxic Substances and Disease Registry) and we coordinate our 
response to cancer and disease cluster inquiries. Cancer and disease 
cluster activities at CDC have included field investigations, convening 
a national conference on the clustering of health events, publishing 
recommendations for the epidemiologic investigation of disease 
clusters, and providing technical assistance to health departments 
involved in specific cluster investigations.
    Last month CDC released the first National Report on Human Exposure 
to Environmental Chemicals, an important new research tool that will 
provide better information on levels of exposure to environmental 
chemicals, and over time what these levels mean for public health. 
Using a technology known as biomonitoring, CDC's environmental health 
laboratory measures chemicals directly in blood and urine samples 
rather than estimating population exposure using measurements from air, 
water or soil samples. By showing what the U.S. population is exposed 
to under ``normal conditions,'' the report can become a vital tool for 
epidemiologists to compare blood and urine levels of chemicals in 
suspected disease cluster areas to the baseline exposure data for the 
general population. We will be using this same type of biomonitoring 
technology to assist the Nevada State Health Department in 
investigating these cases of ALL. We are working to be able to transfer 
this technology to State public health laboratories so that they can do 
their own biomonitoring of chemical exposures.

                     TECHNICAL ASSISTANCE TO NEVADA

    CDC has worked with the Nevada Health Division since July 2000, 
providing technical assistance in each phase of the investigation. CDC 
helped plan, and participated on, the expert panel review last February 
15th. The panel commended the Nevada Health Division's work and 
recommended six followup steps; four of which involve active assistance 
from CDC and ATSDR. I recently met with CDC and ATSDR staff to 
coordinate our agencies' assistance to the State. CDC and ATSDR will 
help the State complete: (1) a cross-sectional exposure assessment of 
environmental contaminants in drinking water, house dust, and the blood 
and urine of county residents, (2) an assessment of environmental 
contaminants and possible pathways leading to human exposure, (3) the 
establishment of a tissue bank for future research into the causes of 
ALL, and (4) the continuation of the expert panel to provide 
independent review of the investigation.

                            CANCER CLUSTERS

    Cancer clusters provide opportunities as well as challenges for 
public health agencies. The phrase ``cancer cluster'' implies that more 
cancer cases or cancer deaths have occurred in a specific geographic 
region than expected. A cancer excess may, or may not, be the result of 
an exposure to a unique carcinogen.
    Public health agencies are challenged by cancer clusters because of 
the number of public inquiries--probably thousands of perceived cancer 
clusters have been reported. For example, more than 2000 published 
newspaper articles from January 1990 to January 2000 contained the 
words ``cancer cluster.'' A survey of 41 State health departments found 
they registered about 1900 cancer inquiries in 1996 alone. An 
additional challenge is the unrealistic expectation placed upon public 
health officials to identify and remove the cause of each cancer 
cluster. In reality, 85 to 90 percent of evaluated cancer cluster 
inquiries do not find an excess number of cancer cases. Although 10 to 
15 percent of cancer clusters have involved an excess in cancer cases, 
only a handful led to important discoveries of preventable causes of 
cancer.
    Cancer clusters can provide an opportunity for cancer prevention 
and control. Cancer education and screening programs are important 
tools in the fight to prevent and control cancer and can be used 
effectively in some cancer cluster circumstances. Scientific 
investigations of cancer clusters and local environmental concerns, 
however, may take years to complete and the findings are often 
inconclusive. If a cancer cluster and hazardous levels of an 
environmental contaminant coexist, removal of the health hazard seems 
prudent, regardless of its role in causing cancer.

          CDC AND STATE ROLES IN RESPONDING TO CANCER CLUSTERS

    At CDC, three centers are involved in responding to cancer 
clusters. Our National Center for Chronic Disease Prevention and Health 
Promotion supports statewide, population-based cancer registries 
through the National Program of Cancer Registries (NPCR.) Cancer 
registries and their use to identify and monitor cancer trends are an 
essential tool for evaluating cluster inquiries. The Nevada Cancer 
Registry (NCR) received more than $1,480,000 from CDC's NPCR from 1994 
through 2000 to track cancers including ALL. CDC's National Center for 
Environmental Health conducts exposure assessments and epidemiologic 
studies that evaluate how people are exposed to environmental hazards 
and identify preventable environmental causes of cancer. The CDC's 
environmental health laboratory measures known and suspected cancer 
causing agents in human blood and urine. CDC's National Institute for 
Occupational Safety and Health (NIOSH) addresses exposures to cancer 
causing agents in the workplace by conducting laboratory science and 
epidemiological investigations in fields like toxicology and 
immunology. NIOSH also responds to requests from employers, employees, 
and other government agencies for investigations involving possible 
work-related cancer. Finally, CDC's sister agency ATSDR plays a 
critical role in responding to clusters as you will hear from ATSDR 
Assistant Administrator, Dr. Henry Falk.

                  ENHANCING CANCER CLUSTER EVALUATIONS

    Three key ingredients needed for an adequate response to public 
concerns about cancer clusters are sufficient infrastructure, assurance 
of scientific credibility, and coordination between agencies. State 
infrastructure requirements include cancer registration and tracking, 
cancer prevention and control, and a mechanism for rapidly identifying 
hazardous levels of environmental contaminants; recommendations 
supported by The Pew Environmental Health Commission. A significant 
advance in children's cancer surveillance is taking place with the 
consolidation of pediatric cancer specialists within the Children's 
Oncology Group with funding from the National Cancer Institute. 
Scientific credibility requires that experts from many fields work 
together. Independent review by expert panels also ensures the 
credibility of State investigations. Scientific credibility could be 
further enhanced by developing investigative priorities from hypotheses 
for why certain cancers might cluster. A work group to establish such 
investigative priorities is needed.
    Coordination between agencies is essential. The successful 
collaboration in Fallon, Nevada involves multiple departments within 
the State, the Federal Government, and academic institutions. Agencies 
involved from the Department of Health and Human Services include not 
only CDC, but also ATSDR and the National Cancer Institute. 
Representatives of the Fallon Naval Air Station have also volunteered 
their complete cooperation in the investigation.
    CDC is currently in the process of assessing the nation's public 
health infrastructure and its needs. CDC has convened an agency-wide 
workgroup, along with ATSDR, to review and respond to the Pew 
Environmental Health Commission Report. This report recommends the 
strengthening of Federal, State and local public health capacity to 
tackle environmental health problems and establish a Nationwide Health 
Tracking Network to identify and track chronic disease and potential 
environmental factors. CDC is working to establish a nationwide 
laboratory network to assist communities in evaluating toxic 
emergencies and human chemical exposure. This will help communities 
monitor disease trends and evaluate whether these are linked to 
exposures in the environment. In addition, CDC has recently released a 
report focusing on a broader perspective of the current status of 
public health infrastructure. The report is entitled Public Health's 
Infrastructure: Every health department fully prepared; every community 
better protected, and is available on CDC's website. Assessment of the 
nation's public health infrastructure will help us to determine how to 
best target resources to build capacity at the State and local level, 
and will enhance our ability to interact with communities to address 
their local public health needs.
    I applaud the people of Fallon for their positive response during 
this stressful time. Strong communities are strengthened by people 
drawing together to help one another through difficulty. I assure you 
that the CDC will continue to collaborate with our Federal partners and 
assist the State of Nevada. Thank you, Mr. Chairman and members of the 
committee, for the opportunity to testify before you today. I would be 
happy to answer any questions you might have.
                               __________

  Statement of Ramona Trovato, Director, Office of Children's Health 
              Protection, Environmental Protection Agency

    Good Morning. My name is Ramona Trovato and I am the Director of 
the Office of Children's Health Protection at the U.S. Environmental 
Protection Agency. Thank you for inviting me here today to discuss our 
response to environmentally-related health problems. It is deeply 
distressing to know that a number of children in this community have 
developed leukemia. Even one child with leukemia is one too many.
    The Environmental Protection Agency's mission is to protect human 
health and safeguard the environment. We protect human health by 
limiting peoples' exposure to contaminants in the air we breathe, the 
water we drink, and the food we eat. The Environmental Protection 
Agency works through the States to protect public health. About half of 
the Environmental Protection Agency's budget is sent directly to the 
States for their use in environmental and public health protection. In 
fiscal year 2001, the Environmental Protection Agency is providing $3.5 
billion to the States for all environment programs. This same year, 
Nevada received more than $6 million in clean water State revolving 
funds and $7.8 million for drinking water State revolving funds.
    The protection of human health requires a partnership at the local, 
State and Federal level. I would like to begin by addressing the 
government's response to environmentally-related health problems 
through some past examples, and then talk about how we can address some 
of the issues facing your community. Given the unique roles of each of 
the different agencies, it is essential for environmental officials at 
all levels of government to work with their public health counterparts 
to address the environmental health needs of our citizens.
how does the environmental protection agency respond to cancer clusters
    We currently address potential cancer clusters through an informal 
agreement among government agencies. Through this partnership, each 
agency brings their particular expertise to the investigation as 
needed. The current process is as follows: State public health 
departments perform the initial phases of cancer cluster investigations 
according to defined protocols. If further investigation is warranted, 
the Centers for Disease Control and Prevention may be asked to provide 
technical assistance to States on a case-by-case basis. Additional 
assistance may be provided by the Agency for Toxic Substances and 
Disease Registry and the National Cancer Institute.
     If findings indicate a suspected environmental linkage, 
the National Institute of Environmental Health Sciences, and/or the 
Environmental Protection Agency may be consulted.
    Through its participation in this partnership of Federal, State, 
and local agencies, the Environmental Protection Agency has a long 
history of dealing with environmentally-related health problems in 
communities. I'd like to give you a specific example of how the 
Environmental Protection Agency has partnered with other agencies to 
address a real problem.

Case Study: Community Confronts Childhood Cancer
    In 1996, due to public concerns about high rates of certain types 
of cancer among children in the Dover Township/Toms River area of New 
Jersey, a study was conducted by the Agency for Toxic Substances and 
Disease Registry and the New Jersey Department of Health and Senior 
Services. They found a previously unidentified contaminant in two 
drinking water wells. These agencies then asked for the Environmental 
Protection Agency to identify the contaminant. Through a cooperative 
effort led by the Environmental Protection Agency's Las Vegas 
laboratory, the contaminant mixture, called SAN trimer, was identified. 
This contaminant was found in low part-per-billion levels in the two 
wells already known to have been impacted by a local Superfund site. 
The existing treatment system at these wells was not effective at 
removing the contaminant. Because this area is part of a Superfund 
site, the Environmental Protection Agency directed Union Carbide, the 
site's potentially responsible party, to install a carbon treatment 
system on the two contaminated wells to supplement the existing 
treatment. The new carbon treatment system removes the contaminant to 
non-detectable levels. The Environmental Protection Agency, with the 
National Institute of Environmental Health Sciences, is overseeing 
long-term chronic studies to determine if this contaminant causes 
cancer.

HOW DOES THE ENVIRONMENTAL PROTECTION AGENCY RESPOND TO SUPERFUND SITES

    Working under the mandate of the Superfund legislation, the 
Environmental Protection Agency works closely with the Agency for Toxic 
Substances and Disease Registry to perform the necessary activities to 
respond to environmental hazards and associated health threats in 
communities. The Agency for Toxic Substances and Disease Registry 
performs health assessments around Superfund sites, as well as in 
communities upon request. The Agency for Toxic Substances and Disease 
Registry's public health assessment process determines those 
potentially exposed and makes recommendations to reduce exposure and 
mitigate potential health outcomes. The Environmental Protection Agency 
responds to these recommendations and intervenes where possible to stop 
exposures. Communities can petition the Agency for Toxic Substances and 
Disease Registry for a community health assessment and can petition the 
Environmental Protection Agency to request a preliminary assessment. If 
the preliminary assessment indicates a problem, then the Environmental 
Protection Agency can take immediate action and begin the process of 
cleanup.

Case Study: Citizen Complained of Strange Odor--Methyl Parathion 
        (Pesticide)
    In 1994, a resident of Lorain County, Ohio, was worried about a 
strange odor in his home. He called the local State agriculture 
department to find out what it was and what to do about it. The citizen 
had recently had his home sprayed to eliminate cockroaches and other 
pests. State sampling revealed the presence of methyl parathion in his 
home. Methyl parathion is a highly potent pesticide used on cotton and 
food crops. It was registered only for outdoor use, not for indoor use. 
The State agricultural representative turned to the Environmental 
Protection Agency, who investigated the illegal indoor application of 
methyl parathion and found an unlicensed applicator had been spraying 
inside homes and distributing bottles of this pesticide to homeowners. 
With help from the media and churches, citizens were alerted and people 
who had their homes treated were asked to come forward and have their 
homes tested for methyl parathion. The Environmental Protection 
Agency's Superfund program, with the Agency for Toxic Substances and 
Disease Registry, provided $21 million and expertise to decontaminate 
and restore 233 homes in Lorain County. Similar incidents turned up in 
Michigan, Mississippi, Louisiana, Tennessee, Illinois, Arkansas, and 
Alabama. After contaminating hundreds of homes in six States, the 
individuals responsible for the problem were identified, prosecuted and 
convicted.
    In these cases, the Environmental Protection Agency and the Agency 
for Toxic Substances and Disease Registry issued a joint public health 
advisory about the problem, produced public outreach and educational 
material, and coordinated a Federal response. The two agencies also 
worked together on procedures for testing the presence of methyl 
parathion residues in homes and in the urine of residents, developed 
criteria for relocation of residents and procedures for cleanup of 
contaminated homes. The Agency for Toxic Substances and Disease 
Registry is still following the exposed children to determine residual 
health problems.
    On a final note, the Environmental Protection Agency canceled the 
use of methyl parathion on many food crops because it was found to 
present acute dietary risks, especially in children.

        HOW DOES THE ENVIRONMENTAL PROTECTION AGENCY RESPOND TO 
                          WATERBORNE ILLNESS?

    The Environmental Protection Agency also responds to cases of 
illness that are believed to be associated with contaminated drinking 
water. The Environmental Protection Agency works through a formal 
agreement with other agencies to resolve the problem that caused the 
illness. The State health department responds first and if they need 
assistance, they call on the Centers for Disease Control and 
Prevention. The Centers for Disease Control and Prevention may then 
request consultation or participation by the Environmental Protection 
Agency in detecting, monitoring, sample testing, and providing 
engineering assistance for water supply pathways or water treatment 
plants.

Drinking Water Infrastructure: Meeting the needs of small communities
    The Environmental Protection Agency also helps communities address 
public health threats through the Drinking Water State Revolving Loan 
Fund, established to provide States with a continuing source of 
financing for drinking water infrastructure projects. Last year, the 
Environmental Protection Agency provided more than $880 million to 
States to finance the costs of infrastructure improvements. The program 
places a particular emphasis on the needs of small systems that serve 
10,000 or fewer residents. Congress required that at least 15 percent 
of the funds be provided to small systems.

Case Study: Cryptosporidium A waterborne intestinal parasite
    In 1993, hospitals and schools in Milwaukee, Wisconsin began 
reporting widespread absenteeism among employees and students due to 
gastrointestinal illness. The medical community and local health 
departments, together with the Centers for Disease Control and 
Prevention recognized that this outbreak was too widespread for a food-
borne illness. The Milwaukee public water system was contacted and high 
levels of turbidity were identified in the drinking water. These high 
levels were estimated to have lasted for 16 days before the problem was 
identified and corrected. It was later estimated that during the 
outbreak, Cryptosporidium levels in treated water may have exceeded 100 
oocytes per 100 liters. During that time, an estimated 400,000 
individuals in Milwaukee became ill from Cryptosporidium and at least 
50 cryptosporidiosis-associated deaths were reported.
    Scientists and water treatment engineers from the Environmental 
Protection Agency and the Wisconsin Department of Natural Resources 
provided assistance by evaluating and correcting problems with the 
treatment plant. Together the team identified that the problem arose 
from a change in treatment practices, lack of familiarity with these 
new practices, unusually high levels of Cryptosporidium in the source 
water, and delays in correcting the problem when it first occurred. 
Together with local, State and Federal Government agencies, experts 
restored the quality of the drinking water and introduced additional 
safeguards to help ensure the future safety of drinking water for 
Milwaukee residents. What else are Federal agencies doing to address 
environmental health concerns?
    Since 1997, the Environmental Protection Agency, the Department of 
Health and Human Services, the Department of Housing and Urban 
Development, and many other Federal agencies have joined together to 
focus on environmental health threats to children. The interagency 
group first identified those diseases and disorders that affect 
children's health and may be associated with an environmental 
contaminant. The diseases and disorders selected were: asthma; 
developmental disorders, including lead poisoning; and childhood 
cancer. Asthma affects about five million children and is the leading 
cause of hospitalization in children. Developmental disorders are the 
leading cause of lifelong disability. Childhood cancer is the leading 
cause of disease-related mortality in children ages 1 to 14. Each year, 
more than 8,000 cases of childhood cancer are diagnosed.
    The specific causes and confluence of factors that contribute to 
asthma, developmental disorders, and childhood cancer are generally 
unknown. Therefore, the decision was made to focus on research to help 
us better understand the influences, mechanisms and interactions of 
environmental factors that contribute to childhood disease. Where we 
have sufficient knowledge to act, we have developed strategies to 
address environmental health concerns. The national asthma strategy was 
launched in January 1999; the national lead strategy was released in 
2000; and the Environmental Protection Agency and the Department of 
Health and Human Services have jointly funded research centers to 
investigate children's environmental health concerns. (An additional 
center is funded by the Environmental Protection Agency). Five of the 
nine centers conduct research related to asthma; the remaining four 
conduct research on development disorders. Also, the National Cancer 
Institute is conducting research into childhood cancer and developing a 
national registry of all children with cancer.

Asthma Strategy
    There is an epidemic of asthma in the United States. Nearly 1 in 13 
school-aged children has asthma. Asthma is one of the leading causes of 
school absenteeism, accounting for more than 10 million missed school 
days each year. Asthma is the leading cause of hospitalization for 
children. Asthma symptoms that are not severe enough to require a visit 
to the emergency room can still prevent a child from living a fully 
active life.
    The Environmental Protection Agency and the Department of Health 
and Human Services developed a strategy that focuses on research and 
public health preventive programs. Twenty-four million dollars was 
provided in fiscal year 2000 to expand the Environmental Protection 
Agency's research and public information programs to address indoor and 
outdoor asthma triggers. This effort is closely coordinated with the 
Department of Health and Human Services program which has committed 
$128 million to address asthma. We've just begun to work with State 
environmental and health departments to address this epidemic.

                             LEAD STRATEGY

    Another collaborative effort on behalf of the Federal Government is 
the Federal strategy to eliminate lead paint hazards in homes where 
children under age six live. Childhood lead poisoning is entirely 
preventable, yet today it remains a serious environmental health risk 
facing children. Lead is highly toxic to young children and can cause 
reduced intelligence, impaired hearing, and behavioral difficulties, 
and at higher levels can harm a child's internal organs. In the United 
States, almost one million children under the age of six have toxic 
levels of lead in their bodies. The strategy attempts to decrease this 
number to virtually zero in 10 years. It coordinates measures in many 
Federal departments and agencies aimed at preventing lead poisoning by:
     Acting before children are poisoned by eliminating and 
preventing residential lead paint hazards;
     Identifying and caring for children already poisoned;
     Conducting research to drive down remediation costs; and
     Continuing surveillance and monitoring programs.
    The Department of Housing and Urban Development provides grants to 
cities and States to address lead paint hazards in low-income housing.

                       LONGITUDINAL COHORT STUDY

    Last year, Congress enacted the Child Health Act of 2000 that 
authorizes the National Institute for Child Health and Human 
Development to conduct a longitudinal cohort study to examine the 
impact of environmental pollutants on children. This long term study 
will evaluate the link between environmental factors and developmental 
disorders, from conception through early adulthood. It will help the 
Federal Government understand how the environment, family, and society 
interact with the genetic makeup of the developing fetus and child. The 
goal is to identify specific areas where prevention, intervention, and 
treatment will make a difference for America's children. As the 
Framingham study provided us much of what we know about heart disease, 
this study could be the watershed in children's environmental health 
protection. It will require the dedicated and determined effort of all 
our partners in the environmental and health communities to complete 
this effort.

                            HOW CAN EPA HELP

    EPA has scientific and technical experts throughout the country 
experienced in environmental monitoring, sampling, laboratory analyses, 
modeling, remediation and emergency response. We can work closely with 
the citizens of Fallon, the Agency for Toxic Substances and Disease 
Registry, the Centers for Disease Control and Prevention, and the State 
of Nevada to conduct environmental assessments. Our assessment 
activities could include environmental testing, surveying industrial, 
mining, and waste disposal activities in and around Fallon, searching 
records to understand historical uses of the area and inspecting 
potential release sites.
    Moreover, EPA has more than 40 hot lines and websites, that provide 
assistance on a variety of topics, from acid rain to safe drinking 
water. In addition, the EPA has a number of websites that provide 
information for professionals and families regarding a wide variety of 
environmental topics including pesticides and children's environmental 
health.
    In addition, the Agency for Toxic Substances and Disease Registry 
and the Environmental Protection Agency jointly fund the Pediatric 
Environmental Health Specialty Units in each of the 10 regions. The 
pediatric units provide a clinical referral resource for health care 
providers and parents. Health care professionals diagnose and evaluate 
health threats associated with exposure to hazardous substances. In 
addition, children can be seen at these units by health care 
professionals. These units serve an important role in the health care 
community due to their expertise in recognizing environmental health 
problems and treating children with these problems. The closest site to 
Fallon, NV is located in San Francisco at the University of California. 
This pediatric unit can be reached at (415) 206-4320.

                              CONCLUSIONS

    Thank you for allowing me to address the committee and the 
community of Fallon. I am so sorry that your children are suffering. I 
hope that together we can make a difference. I have a few suggestions:
      Replicate the waterborne disease response model, which I 
mentioned earlier, to address other environmental health problems.
      Bolster the State and local public health infrastructures 
to monitor and respond to environmental health threats and put in place 
preventive health programs that alert us to problem areas that are 
likely to occur and to take the appropriate actions before communities 
suffer.
      Strengthen the partnerships among environment and health 
agencies at Federal, State, and local levels.
      Establish a national health tracking system for chronic 
diseases such as asthma, birth defects, cancer and developmental 
disorders, to ensure a rapid response to emerging environmental related 
health concerns.
      Conduct the national longitudinal cohort study on 
environmental factors affecting child health.
    Children are our future and we should do everything in our power to 
protect them.
                               __________

    Statement of Dr. Shelley Hearne, Executive Director, Trust for 
                            America's Health

    Mr. Chairman, Senator Reid, and members of the committee, thank you 
for the opportunity to come to Nevada to provide real perspective to 
our nation's ability to respond to health crises like the pediatric 
leukemia cluster you are facing here in Fallon.
    My name is Dr. Shelley Hearne and I serve as the executive director 
of the Trust for America's Health--a new nonprofit health advocacy 
organization committed to preventing disease and protecting the health 
and safety of our communities. I am very proud to have former Governor 
Lowell Weicker, Representative Louis Stokes, and Chairman John Porter, 
along with many other national leaders in public health serve on our 
Advisory Council.
    By way of background, I am an environmental health scientist--
serving for almost 20 years in government, non-profits and as a faculty 
of the Johns Hopkins School of Public Health. Most recently, I was the 
executive director of the Pew Environmental Health Commission--a blue 
ribbon independent panel charged with developing recommendations to 
improve the nation's health defenses against environmental threats.
    Let me start by being candid. Our public health service is falling 
short in its duty to watch over the safety and health of the Americans, 
particularly when it comes to chronic diseases that may be associated 
with environmental factors.
    Chronic diseases are responsible for 7 out of 10 deaths in this 
country. More than a third of our population, over 100 million men, 
women and children suffer from chronic diseases. These diseases cost 
our citizens and government, $325 billion a year. By 2020 chronic 
diseases are estimated to afflict 134 million Americans and cost $1 
trillion a year. And the CDC estimates that 70 percent are preventable.
    But our Federal Government is not actively pursuing how to prevent 
this epidemic of chronic diseases.
    As a Nation, we have been increasing our research into how to treat 
disease. As a result, we have some good news here. More children with 
leukemia survive today than ever before. But there is bad news. The 
rates of childhood leukemia have been steadily rising for the past two 
decades. As a Nation, we have not invested in preventing chronic 
diseases.
    This health crisis in Fallon is a tragedy. My heart goes out to 
these families, this community. But as a health scientist, I grow more 
angry as I watch this story increasingly repeated in communities all 
across the country. In 1997, there were almost 1,100 requests by the 
public to investigate suspected cancer clusters. Many of these are 
preventable diseases, preventable tragedies and our public health 
resources are insufficient to effectively respond to these challenges.
    Let me give you an example from my home State of New Jersey. 
Parents in Brick Township complained to politicians and health 
officials for years about a feared autism cluster in their community. 
But health agencies could not even confirm the cluster for years 
because they lacked the most basic investigative tools. New York has a 
similar story. In Elmira, New York, the State health officials have 
been investigating an unusually high incidence of cancer among children 
who attended the Southside High School. Fifty-three (53) cases of 
cancer have been reported from the 7,500 current and former students 
who attended the high school since it opened in 1979. Thirteen of the 
cases were reported in the past 3 years. The high school was built on 
land that has served as an industrial site since the Civil War. No one 
knows why this is happening.
    Even though we know about the increasing numbers of chronic disease 
clusters and the staggering human and financial toll they have on our 
country, we have no systems in place to detect chronic disease clusters 
nor do we have the capability to respond to these health crises. Our 
Federal, State, and local agencies only coordinate tracking and 
responding to infectious diseases such as polio, yellow fever and 
typhoid. Diseases that a national tracking and response system helped 
to eradicate back in the late 1800's.
    Over a century later, we never modernized our public health system 
to respond to today's health threats. As a result, we are hamstringing 
our health specialists from finding solutions and effectively taking 
action--regardless if it's childhood leukemia in Fallon or a nationwide 
asthma epidemic.
    Let me give you some examples of our scattered State health 
tracking systems from the State of Nevada.
     Even though birth defects are the No. 1 cause of infant 
mortality, Nevada does not track birth defects. The Pew Commission gave 
Nevada and 16 other States an F in its report, ``Healthy from the 
Start'' which was released in late 1999.
     Nevada does not track developmental diseases such as 
cerebral palsy, autism and mental retardation even though the National 
Academy of Science estimates that 25 percent of these diseases in 
children are caused by environmental factors.
     Even though studies have shown autoimmune diseases like 
Lupus to be increasing, Nevada does not have a system to track these 
diseases.
     Nevada's cancer registry has been severely neglected for 
years. It is the only State that charges hospitals to report cancer 
cases--a perfect formula to ensure poor participation.
    Unfortunately Nevada is not unusual, it is the norm. This is 
because our Federal Government has failed to establish a comprehensive 
national approach to tracking and responding to chronic disease.
    The Pew Environmental Health Commission based out of the Johns 
Hopkins School of Public Health studied our nation's capacity to 
identify and respond to chronic disease clusters for 2 years and 
proposed creating a nationwide Health Tracking Network to solve this 
problem.
    The Nationwide Health Tracking Network is based on four principles: 
(1) building a coordinated system of tracking chronic diseases and 
associated environmental factors; (2) providing the resources and 
training to local health departments to analyze the data; (3) 
immediately responding to health problems identified through the 
system; and (4) providing the national leadership to coordinate health 
and environmental activities throughout the Federal Government so that 
these programs do not operate in isolation of one another.
    The Nationwide Health Tracking Network consists of five components:
    1. Establishing essential data collection systems.--The first 
component builds on existing health and environmental data collection 
systems and establishes data collection systems where they do not 
exist. The Network will coordinate with the local, State and Federal 
health agencies to collect this critical data.
    In all 50 States, the Network would track:
     Asthma and other respiratory diseases;
     Developmental diseases such as autism, cerebral palsy, and 
mental retardation;
     Neurological diseases such as Alzheimer's, multiple 
sclerosis, and Parkinson's;
     Birth defects; and
     Cancers, especially in children.
    The Network also would track exposures to:
     Heavy metals such as mercury and lead;
     Pesticides such as organophosphates and carbamates;
     Air contaminants such as toluene and carbamates;
     Organic compounds such as PCB's and dioxins; and
     Drinking water contaminants, including pathogens.
    Building upon the existing systems for infectious diseases, the 
Federal Government will establish the standards for the health and 
exposure data collection necessary to create uniformity throughout the 
system. With Federal resources such as funding, training and lab 
access, State and local public health agencies will collect, report and 
analyze the data.
    2. Creating an Early Warning System.--The second component is an 
Early Warning System that would immediately alert communities of health 
crisis such as lead, pesticide and mercury poisonings. The existing 
system of local health officials, hospitals and poison centers that 
alert our communities to outbreaks like food illness and the West Nile 
virus would also alert our communities to these health crises.
    3. Improving response to chronic disease emergencies.--The third 
component consists of improving our response to identified disease 
clusters and other health crises. The Network would coordinate Federal, 
State and local health officials into rapid response teams to quickly 
investigate these health problems, providing the teams with trained 
personnel and the necessary equipment.
    4. Addressing unique local health problems.--The fourth component 
is a pilot program consisting of 20 regional and State programs that 
would investigate local health crisis and clusters that are currently 
not part of the Nationwide Health Tracking Network. These programs 
would alert the public and health officials to new developing disease 
clusters outside of the Nationwide Health Tracking Network. These 
pilots programs also would serve as models for tracking systems for 
inclusion in the Network.
    5. Creating community and academic partnerships.--The fifth 
component establishes relationships with five Academic centers and with 
our communities. Our community relationships would ensure that the 
tracking data is accessible and useful on a local level, and our 
research relationships would train the work force, analyze data, and 
develop links between the tracking results and preventive measures.
    [The background and basis for this Network and other Commission 
findings and recommendations are attached as part of the written 
testimony. These are also available on the website at http://
pewenvirohealth.jhsph.edu or http://health-track.org]
    This Network would provide our communities, scientists, doctors, 
hospitals and public health officials with missing data on where 
chronic diseases are clustering and associated environmental factors 
that would enable us to develop prevention strategies. Over 30 key 
health organizations have endorsed this recommendation, ranging from 
Aetna US Health Care to the American Cancer Society to the American 
Academy of Pediatrics to the Association of State and Territorial 
Health Officers (ASTHO).
    The American Chemistry Council supports the concept, noting that 
``. . . data generated by a national tracking program can shift the 
focus from debate and speculation about disease trends to intervention 
and prevention based on scientific evidence.''
    Developing prevention strategies are critical to reducing the $325 
billion a year Americans spend on chronic diseases. In less than 15 
years, the estimated cost of chronic disease is predicted to rise to $1 
trillion. The estimated cost of the Network is about $275 million or 
less than 1 dollar per every man, woman and child.
    These data will allow us to spend our limited treatment and 
research dollars more effectively by identifying which chronic diseases 
are increasing. We have doubled our research dollars in the National 
Institutes of Health, yet these scientists do not have even the most 
basic information about why these diseases occur, where they strike, 
whom they choose as their victims, and how to take action to prevent 
future clusters.
    Without a Network, we will remain in the dark; still unable to 
answer these questions.
    The most cost effective use of tax dollars today would be to invest 
in preventing the leading killers in this country. And the American 
public agrees. The American public is so concerned about this issue 
that 63 percent feel that public health spending is more important than 
cutting taxes. Seven out of ten registered voters (73 percent) feel 
that public health spending is more important than spending on a 
national missile defense system.
    A recent public opinion poll by Princeton Survey Research 
Associates revealed that nine out of ten (89 percent) registered voters 
support the creation of a national system.
    Most local health departments face declining funding, inadequate 
training for staff, limited or no laboratory access, and outdated 
information systems. CDC and ATSDR have not been able to adequately 
help. For instance, there is no Federal funding for an environmental 
health specialist or even chronic disease investigator in Nevada. This 
is true for almost all States. Nor could CDC or the Agency for Toxic 
Substances and Disease Registries (ATSDR) give Nevada written guidance, 
standards or protocols on how to investigate this childhood cluster. 
The health agencies have never developed a concrete response program to 
these growing cluster demands.
    Due to concerns of Bioterrorism, the CDC is taking many steps 
toward developing a public health infrastructure including upgrading 
computer and communications systems for collecting and sharing 
infectious disease data among local public health departments. We could 
simultaneously build on these initiatives and enhance these efforts to 
ensure a nationwide strategy for chronic disease prevention. These are 
the diseases that Americans are dying from today, not tomorrow's 
theoretical threats.
    On a Federal level, there are a few programs that relate to chronic 
diseases, but do not track and respond to the chronic disease clusters. 
The irony is the Administration's proposed budget recommends severe 
cuts for the nation's chronic disease prevention programs. We need to 
be going in the exact opposite direction. Health defense should be the 
country's No. 1 commitment.
    Who is guarding our health? The answer is that the public health 
service has fallen short of its duty--lacking the tracking, troops and 
leadership. This is exactly where our Federal Government is needed--to 
develop the tracking and monitoring systems, supply the troops and 
offer the leadership to prevent chronic disease.
    To modernize our public health resources so that we can identify 
clusters before they grow, we must take rapid action to control their 
spread and find solutions to prevent diseases. CDC must be given the 
direct mandate to aggressively respond to communities' concerns like 
those in Fallon, with modern tools and health-tracking systems. And 
Congress must prioritize $275 million per year, less than a dollar per 
person to make this happen. It is just a tenth of 1 percent of the 
overall spending of health care dollars in this country.
    Without this type of investment, we will only watch asthma, certain 
cancers and other chronic disease rates continue to rise. There will be 
many more Fallons. And that will be the greatest tragedy of all.
                               __________
                                         Shundahai Network,
                                        Pahrump NV, April 19, 2001.
Committee on Environment and Public Works,
U.S. Senate,
Washington, DC.

Subject: Fallon Leukemia Cluster

    Dear Committee Members: I am writing in response to a request for 
public testimony concerning factors to consider connection with the 
Fallon Leukemia cluster. I would like to see this committee carefully 
consider the role of fire in the disbursal of hazardous materials 
through the environment, including fire's role in remobilized 
radioactive isotopes and other contaminates deposited in Nevada as a 
result of weapons testing. I would request the committee to consider 
the dangers associated with fire as a remobilizing agent of 
radionuclides from the Nevada Test Site and other testing ranges in the 
State.
    During the period of above ground testing from 1951 to 1963, 
radioactive releases from the Nevada Test Site emitted over 12 billion 
curies of radioactive material into the atmosphere, 148 times as much 
as the nuclear disaster at Chernobyl. Other pre-1971 nuclear tests 
released 25,300,000 curies, and from 1971-1988, 54,000 curies were 
released, including the 36,000 curies from the Mighty Oak accident, 
which was itself 2000 times greater than the release at Three Mile 
Island. Over half of all underground tests have leaked radiation into 
the atmosphere (DOE Report on Radioactive Effluents, 1988). DOE has 
been out of compliance with Federal and State permit requirements in 
the areas of air emissions, water releases, and solid waste disposal 
(DOE Nevada Operations Office Five Year Plan, 1989).
    There is contamination in soil, air, ground and surface water. 
Strong winds, common to this area of Nevada, can carry plutonium-
contaminated dust across a large area. Fallout from above ground 
nuclear tests in the United States and other countries has 
radioactively contaminated the atmosphere around the Earth. Project 
Faultless in Hot Creek Valley was found to have caused radioactive 
contamination in groundwater. According to EPA Publication 520/4-77-
016, cumulative deposits of plutonium (Pu-239 and Pu-240) have been 
found in soil over 100 miles north of the NTS at levels of 790 mg per 
acre. Plutonium has a half-life of 26,000 years, and plutonium 
contaminants ingested in microscopic amounts are capable of causing 
cancer for 200,000 years. There is no cost-effective technology for 
decontaminating such sites. No surveys have been conducted to determine 
health effects on Native American or other residents from Nevada Test 
Site (NTS) releases. Currently the Nuclear Risk Management for Native 
Communities project is working to answer some of these questions.
    It is known that plutonium translocates to specific radiosensitive 
organs, especially reproductive organs.
    During the years of 1999 and 2000, almost 3,000,000 acres of Public 
Lands in the State of Nevada were subjected to fires, both wild fire 
and prescribed burns. Fire remobilizes contaminants. Particles are 
lifted from the ground into the air, then mobilized through environment 
on wind currents. The particles are resuspended for an indefinite time 
period, finally redeposit onto the earth. This process creates fallout. 
As a result of this process, fire can carry containments across the 
globe.
    We understand that the Nevada BLM oversees management of 1,722,330 
acres of public lands considered contaminated with UXO, (unexploded 
military ordinances). BLM lands border NTS (Nevada Test Site), Nellis 
Bombing and Gunnery Range, Tonopha Air Force Base, together with the 
Fallon Range. No one knows the amount or extent of nuclear 
contamination in the area surrounding the NTS and Nellis Air Force Base 
which tests depleted uranium (DU) bombs. In 1997 it was estimated that 
30 tons of DU had already been deposited in the target area (Draft 
Environmental Assessment Resumption of Use of Depleted Uranium Rounds 
at Nellis Air Force Range Target 63-10), a total of 9,500 combat mix 
rounds (7,900 DU rounds) being expended annually, there.
    Depleted uranium or U-238 has an atomic mass of 238. Its half-life 
is 4.468 billion years (Rokke, 2001). It's natural occurrence is 2.1 
parts per million. Uranium is silver white, lustrous, malleable, 
ductile, and pyrophoric. This makes DU an ideal metal for use as 
kinetic energy penetrators, counterweights, and shielding or armor. 
High density and pyrophoric (catches fire) nature are the two most 
significant physical properties that guided its selection for use as a 
kinetic energy penetrator.
    A study performed at Yucca Proving Grounds found DU residues in all 
components of the environment, that environmental concentrations varied 
widely, that corroded DU residues are soluble and mobile in water, that 
wind dispersal during testing is the prevalent means of dispersal of DU 
particles, and that an unknown degree of risk was posed to human health 
by DU in the environment. Moreover, there appears to be no insight into 
the issue of long-term (100 to 1,000 years and longer). DU forms of 
both soluble and insoluble oxides. The inhalation of the insoluble 
oxides presents an internal hazard from radiation if retained in the 
lungs.
    The long-term effects of internalized depleted uranium are not 
fully known, but the Army has admitted that ``if DU enters the body, it 
has the potential to generate significant medical consequences.'' 
Inhaled DU particles or respirable size may become permanently trapped 
in the lungs. Inhaled DU particles larger than respirable size may be 
expelled from the lungs and ingested. DU may also be ingested via hand-
to-mouth transfer or contamination of water or food supplies. DU, which 
is ingested, or enters the body through wind contamination, will enter 
the bloodstream and migrate throughout the body, with most of it 
eventually concentrating in the kidney, bone, or liver. The kidney is 
the organ most sensitive to DU toxicity.
    More testing of soil and plants needs to be done to determine what 
radionuclides might be released into the air in a fire, since a fire 
and its relationship to the resuspension of contaminants has not been 
the subject of study. Plutonium and radionuclides concentrate in dust, 
thus higher concentrations are found in the dust sampling than in 
regular soil sampling. The standard air monitors and surface water 
samplers usually used are not sufficient to measure submicroscopic 
particles of plutonium. Further, plutonium contamination is not 
homogeneous, so simplistic sampling methods are inadequate (John Till, 
President, Risk Assessment Corp; 2000). Wind-blown particulates must be 
considered. Debris and gas will go somewhere, but where? Into the water 
or the soil?
    Radiation detection devices that detect and measure alpha 
particles, beta particles, x-rays, and gamma rays emissions at 
appropriate levels from 20 dpm up to 100,000 dpm and from .1 mrem/hour 
to 75 mrem/hour must be acquired to sess the distribution of particles. 
Standard rad-meters or Geiger counters do not measure these levels.
    In order to assess the health risks and damage due to exposure to 
tritium (radioactive hydrogen), three blood tests must be done. White 
blood cells must be tested for the presence of micronuclei, indicating 
the loss of DNA repair processes and leading to increased cancer risk. 
Red blood cells must be examined for genetic modification of surface 
glycophorin-A molecules, also indicating DNA damage. A study of 
Japanese nuclear bombing victims 40 years from the time of the blasts 
showed DNA codes were still unrepaired. In addition, chromosome 
painting allows chromosomes to be stained for identification of 
structural and sequential or numerical abnormalities linked to 
radiation and chemical exposure, cancer, and inherited diseases.
    In addition to the redistribution of containments, we need to 
consider the effects of fire upon other substances. For example, we 
must consider chemical reactions which may take place when multiple 
herbicides are burned together. For instance, one chemical being most 
often utilized on public lands is Tordon. But Tordon is also called 
Grazon, and the active ingredient is picloram, better known as Agent 
White, similar to Agent Orange, and one of several defoliants used in 
Vietnam. In fact, Agent White (picloram) appeared in 5 of the 15 
defoliants used there. Agent White is currently being sprayed by the 
U.S. on the coca fields in Columbia as part of the drug war. In 1998, 
Dow Chemical, manufacturer of Agent White (picloram) tried to halt its 
use, warning that it does not bind well with soil, easily washes into 
the groundwater and could cause irreparable damage to the Amazon 
Rainforest. Yet, U.S.G.S. Pesticide 1992 Annual Use Map showed 
estimated annual agricultural use of Agent White to be less than 0.370 
pounds per square mile per year. The map shows the entire State of 
Nevada has been exposed. This is a lot, and has probably increased 
since that time. If it's dangerous to the water and forest areas of 
Colombia, it is dangerous here in the U.S. The use of Tordon is banned 
in some countries.
    Also commonly used are 2, 4-D which forms poisonous gas in fire. It 
is on the Hazardous Substance List because it is regulated by OSHA. The 
chemical is a mutagen (changes the genetic structure), a teratogen 
causing birth defects, and a carcinogen particularly related to breast 
cancer. Short term effects of its use include the death of animals, 
birds, fish, and plants within 2-4 days after exposure. About 91.7 
percent of 2, 4-D will eventually end up in water. In 1990, the Clean 
Air Act announced 2, 4-D as a hazardous air pollutant. Run off vapors 
can kill non-target plants. Agent Orange was a mix of 2, 4-D and 2, 4, 
5-T. Another name for 2, 4, 5-T is Weedar. And both of these chemicals 
appear on the recommended list of chemicals used on public lands.
    Garlon is also known as triclopyr (both names appear separately on 
the recommended treatment list as if they are different herbicides). 
Triclopyr's chemical structure is very similar to 2, 4, 5-T. The MSDS 
sheet includes the following data: Nitrogen oxides, hydrogen chloride, 
and phosgene may result under fire conditions and NIOSH/MSHA requires 
approved SCBA and full protective equipment for firefighters. Garlon-
treated wood that is burned during forest fires, or in wood stoves at 
home produces a dioxin, one of the most damaging compounds to living 
organisms. Garlon is an endocrine disrupter.
    It mimics a plant hormone, acting systematically to kill the plant 
or tree. The hormone that Garlon mimics is perceived by the human body 
to be estrogen. In women, this may result in breast cancer, 
miscarriages, infertility, birth defects, and possibly ovarian cancer. 
In men, it can cause prostate or testicular cancer and reduction of 
sperm count. It also may aggravate liver and kidney disease. We do not 
know what the effects of burning multiple pesticides and the full 
extent of the risk to public health from such events.
    I suggest that a more appropriate methodology for determining 
causation of the Fallon leukemia clusters would use a multidimensional 
model for analysis. In other words, rather considering singular 
etiologies, as suggested by Prescott from CDC at the hearings, a more 
complex multi-factor dynamic process may be in operation. We might 
hypothesize very generally that exposure to radionuclides such as 
tritium, plutonium, or DU, might cause mitochondrial damage to cells. 
In addition to other functions, mitochondria contribute to a sort of 
``programmed cell-suicide''. For example, in certain stages of fetal 
development, humans have webbed fingers. The mitochondria detect this, 
and at the appropriate time, seek to destroy the web cells, leaving 
humans with fully formed fingers. This cell-suicide is necessary.
    However, when exposed to an error or to toxins or radionuclides, 
the mitochondria engage in a process of ``unprogrammed cell suicide.'' 
Thus, healthy cells are destroyed. Such suicides may lead to 
destruction of critical elements of immune system function, resulting 
in cancers, leukemia, and the inability to fight the effects of various 
viruses and bacteria. The cells may be more vulnerable to effects of 
exposure to chemicals or pesticides. In addition, adequate production 
of certain neurotransmitters and hormones might be disrupted leading to 
diabetes or neurological damage. These medical conditions have been 
reported as increasing in the general population, and though differing 
in appearance, may be reflecting a basic underlying cellular assault 
caused by radiation exposure. I refer you to the work of Guy Brown. 
Thank you for your thoughtful consideration.
            Sincerely,
                                         Dr. Bonnie Eberhardt Bobb.
                                 ______
                                 
      [Pew Environmental Health Commission Report, September 2000]
Companion Report on America's Environmental Health Gap: Why the Country 
               Needs a Nationwide Health Tracking Network

          FOREWORD BY COMMISSION CHAIRMAN LOWELL WEICKER, JR.

    With the mapping of the human genome, we are on the verge of a new 
wave of advances in health. With this remarkable achievement, 
researchers will be able to shed new light on the links between genetic 
predisposition and such factors as behavior and exposures to pollutants 
in the environment in order to prevent many of the chronic diseases 
that today cause so much suffering.
    But there is a catch. We must have the basic information about the 
health of Americans and our environment before we can make the fullest 
use of this exciting genetic knowledge. The way to get this basic data 
is to track it--systematically, comprehensively, on a coordinated basis 
at all levels from the local community to the Nation as a whole. We 
have to track what and where the hazards are in the environment, 
whether people are at risk from exposures to these hazards, and the 
health of our communities. Our information about environmental factors 
must run as deep and comprehensive as our knowledge of the genome.
    This report examines our current public health response 
capabilities to environmental threats, and recommends the establishment 
of a Nationwide Health Tracking Network. The Pew Environmental Health 
Commission is charged with developing a blueprint to rebuild the 
Nation's public health defenses against environmental threats. We know 
there are pollutants entering our air and water each year with 
suspected or known adverse effects on the health of our communities. 
What we are limited in knowing if there is a link between that 
pollution and the increases we are seeing in chronic diseases because 
we aren't tracking environmental health factors.
    We need to gather the facts now. Americans have a right, and the 
need, to know.

                           EXECUTIVE SUMMARY

    At the dawn of the 21st century, America is facing an environmental 
health gap. This is a gap in critical knowledge that hinders our 
national efforts to reduce or eliminate diseases that might be 
prevented by better managing environmental factors. This is especially 
true for chronic diseases and conditions, such as birth defects, asthma 
and childhood cancer, which strike hundreds of thousands of American 
families each and every year.
    What is the environmental health gap? It is the lack of basic 
information that could document possible links between environmental 
hazards and chronic disease. It is the lack of critical information 
that our communities and public health professionals need to reduce and 
prevent these health problems. While overt poisoning from environmental 
toxins has long been recognized, the environmental links to a broad 
array of chronic diseases of uncertain cause is unknown.
    The national cost of chronic disease is staggering: 4 of every 5 
deaths annually, 100 million people suffering each year and $325 
billion in annual healthcare and lost productivity. While our 
healthcare system is one of the best in the world in treating disease, 
the environmental health gap is crippling our ability to reduce and 
prevent chronic disease and help Americans live longer, healthier 
lives.
    The Pew Environmental Health Commission proposes a Nationwide 
Health Tracking Network to close this critical gap. With a 
comprehensive tracking network, we can advance our ability to:
     Identify populations at risk and respond to outbreaks, 
clusters and emerging threats;
     Establish the relationship between environmental hazards 
and disease;
     Guide intervention and prevention strategies, including 
lifestyle improvements;
     Identify, reduce and prevent harmful environmental risks;
     Improve the public health basis for policymaking;
     Enable the public's right to know about health and the 
environment; and
     Track progress toward achieving a healthier Nation and 
environment.
    The proposed Network would be comprised of five key components:
    (1) national baseline tracking network for diseases and exposures;
    (2) nationwide early warning system for critical environmental 
health threats;
    (3) State pilot tracking programs to test diseases, exposures and 
approaches for national tracking;
    (4) Federal investigative response capability; and
    (5) tracking links to communities and research.
    Investing in prevention through these five components is estimated 
to cost the Federal Government $275 million annually--less than 0.1 
percent of the current annual economic cost of treating and living with 
chronic disease--a very modest investment in a healthier America.
      the grim picture--an environmental health and prevention gap
    Americans today are sophisticated about their health. More of us 
are asking if there is something in the air, water or diet that could 
be making us sick. Is it our behavior--or something in our genes? 
Unfortunately, we are left with too many unanswered questions.
    Recently, a major research study found that most types of cancer 
are not inherited genetic defects, but are explained mainly by 
environmental factors. Environmental factors include environmental 
tobacco smoke, toxic chemicals, dietary habits and viral infections.\1\ 
Despite many years of effort, scientists still are searching for 
answers about the relationship among the factors in our behavior, genes 
and the environment that cause disease and disability.
---------------------------------------------------------------------------
     \1\ Published in the July 13, 2000, edition of the New England 
Journal of Medicine, the study examined the medical histories of 44,788 
pairs of twins listed in the Swedish, Danish and Finnish twin 
registries in order to assess risks of cancer at 28 anatomical sites 
for the twins of persons with cancer. It concluded that genetic factors 
make a minor contribution to susceptibility to most types of neoplasms, 
and the environment has the principal role in causing sporadic cancer.
---------------------------------------------------------------------------
    Earlier this year, it was announced that researchers have mapped 
the human genome, a breakthrough that is expected to open new doors to 
understanding chronic disease. Scientists will use this emerging 
genetic knowledge to fight disease. But if we are going to prevent 
disease, researchers also need more complete information about 
environmental factors, their effect on people, and the resulting health 
outcomes. In this way, scientists will have the capability to link 
genetic and environmental information and could begin to answer our 
questions about the complex causes and prevention of chronic disease.
    Few would dispute that we should keep track of the hazards of 
pollutants in the environment, human exposures, and the resulting 
health outcomes--and that this information should be easily accessible 
to public health professionals, policymakers and the public. Yet even 
today we remain surprisingly in the dark about our Nation's 
environmental health.
    We have as a Nation invested heavily in identifying and tracking 
pollutants in the environment, particularly for regulatory and 
ecological purposes, but only minimally in tracking exposures and the 
distribution of disease and its relationship to the environment. As a 
result of decades of neglect, we have a public health system that is 
working without even the most basic information about chronic disease 
and potential environmental factors. The Commission found that 
information on trends in health conditions potentially related to the 
environment is largely unavailable. Here are a few illustrations of 
what this environmental health gap means:
      Only four States report tracking autoimmune diseases, 
such as Lupus, even though there is increasing evidence to believe 
rates of these diseases are rising and the environmental links remain 
unknown.
      Despite evidence that learning disabilities have risen 50 
percent in the past 10 years, only six States track these disorders and 
we have no answers about causes or possible prevention strategies. Most 
States do not track severe developmental disabilities like autism, 
cerebral palsy and mental retardation. A recent report of the National 
Academy of Sciences estimates that 25 percent of developmental 
disorders in children are caused by environmental factors.
      Endocrine and metabolic disorders such as diabetes, and 
neurological conditions such as migraines and multiple sclerosis, have 
increased approximately 20 percent between 1986 and 1995, based on 
surveys by the Centers for Disease Control and Prevention (CDC). Most 
States do not systematically track these diseases and conditions.
      For most of the United States, there is no systematic 
tracking of asthma despite the disease having reached epidemic 
proportions and being the No. 1 cause of school absenteeism. Between 
1980 and 1994, the number of people with asthma in the United States 
jumped by 75 percent. Without prevention efforts that include a strong 
tracking component, the Commission has estimated that the number of 
asthma cases will double by 2020.
      Birth defects are the leading cause of infant mortality 
in the United States, with about 6,500 deaths annually. Since the mid-
1980's, rates of low birth weight and pre-term births have been rising 
steadily despite increased prevention efforts. The causes of 80 percent 
of all birth defects and related conditions remain elusive even as 
evidence mounts that environmental factors play an important role. The 
Commission found that less than half the Nation's population is covered 
by State birth defect registries, which inhibits our ability to find 
solutions.
    The tracking programs that do exist at the State and local levels 
are a patchwork because there are no agreed-upon minimum standards or 
requirements for environmental health tracking. The Commission found 
different standards, created to meet different objectives or regulatory 
requirements, and little synchronization in the collection, analysis 
and dissemination of information. In addition, much of the data that is 
collected is never analyzed or interpreted in a way that could identify 
targets for further action. Most of this data is never released to the 
public.
    There is limited ability to take action at the State level without 
additional resources and leadership from the Federal Government. For 
decades, State and local health agencies have faced declining 
resources, with the result that many now face the 21st century with 
outdated information systems, limited laboratory access, inadequate 
staff training and an inability to develop viable tracking programs. 
The Commission's survey of State and local agencies found a critical 
lack of funding for these activities despite unprecedented public 
demands.
    Environmental tracking for pollutants is crucial, because often the 
hazards can be removed or abated before they cause harm. But such 
monitoring is not sufficient by itself. Tracking actual human exposures 
to hazards in the environment is frequently the missing link between 
public health efforts to evaluate a risk nationally and the ability to 
respond to a health threat in a specific community. This should include 
improving national efforts to track population exposures to 
contaminants and providing the investigative tools for local health 
officials.
    Finally, there is a national leadership void, resulting in little 
or no coordination of environmental health activities. As a result, 
public health prevention efforts are fragmented and too often 
ineffective at reducing chronic and disabling diseases and conditions.
    The CDC and EPA have some basic building blocks of a tracking 
network in place, but much more needs to be done. Currently 50 
infectious diseases are tracked on a national basis. We need a 
comparable modern network to track chronic diseases and discover the 
environmental contributions to them.

                       THE PUBLIC'S EXPECTATIONS

    The public understands that we are not doing enough to protect our 
communities. A recent national survey of registered voters found that 
the majority are concerned about risks to their health from pollutants 
in the environment, and believe that government is tracking these 
hazards and possible links to chronic health problems.\2\ When they 
learn that in reality there is no disease tracking, they are 
concerned--seriously concerned. Most Americans surveyed say that taking 
a national approach to tracking environmental health should be a 
priority of government at all levels.
---------------------------------------------------------------------------
    \2\ Health-Track is a project supported by The Pew Charitable 
Trusts through a grant to Georgetown University. The survey, by 
Princeton Survey Research Associates, was conducted in April 2000 of 
1,565 registered U.S. voters and has a margin of error of 3 
percent for results based on a full sample.
---------------------------------------------------------------------------
    Without comprehensive environmental health tracking, policymakers 
and public health practitioners lack information that is critical to 
establishing sound environmental health priorities. In addition, the 
public is denied the right to know about environmental hazards, 
exposure levels and health outcomes in their communities--information 
they want and have every reason to expect.
    At the same time Americans demand a right to know about these 
hazards, they also expect government to gather health information in a 
way that protects citizens' privacy. Americans understand the 
importance of population-based health tracking as well as the need to 
keep individual health records private. Fortunately, public health 
agencies have an outstanding track record for zealously guarding the 
public's confidentiality and privacy. To ensure this continued balance, 
the Pew Commission established a set of principles for Protecting 
Privacy and Confidentiality and Our Environmental Health Right-to-Know 
(listed in the back of this report). The Commission believes that 
adherence to these principles will enable public health agencies to 
continue their traditional commitment to the confidentiality of 
individually identifiable health records without significantly 
hampering their obligations to the public health.
    The Federal Government tracks many things all the time. It knows 
how many women dye their hair every year (three out of five), but has 
only rough estimates of how many people have Parkinson's disease, 
asthma, or most other chronic diseases that cause four of every five 
deaths in the U.S. each year. We have the right to know more.

 THE PEW ENVIRONMENTAL HEALTH COMMISSION'S RECOMMENDATION--A RIGHT TO 
                     KNOW OUR ENVIRONMENTAL HEALTH

    To fill the Environmental Health Gap, the first step is to 
establish a tracking capacity for chronic diseases and environmental 
exposures that also link to hazard data. To this end, the Commission 
offers the following comprehensive recommendation:
    Create a federally supported Nationwide Health Tracking Network 
with the appropriate privacy protections that informs consumers, 
communities, public health practitioners, researchers, and policymakers 
on chronic diseases and related environmental hazards and population 
exposures. This will provide the capacity to better understand, respond 
and prevent chronic disease in this country.
    This tracking network would be a tiered approach, with a national 
baseline of high-priority disease outcomes and exposures that allows 
flexibility at the State and local level for specific concerns. At a 
minimum, all information would include race, ethnicity, gender, age and 
occupation. The blueprint for the Nationwide Health Tracking Network 
involves five components of information and action:

Tier 1: National Baseline Tracking of Diseases and Exposures
    This will be a nationwide network of local, State and Federal 
public health agencies that tracks the trends of priority chronic 
diseases and relevant environmental factors in all 50 States, including 
Washington, DC, Puerto Rico and U.S. territories. The information will 
allow us to identify populations at high risk, to examine health 
concerns at the State level, to recognize related environmental 
factors, and to begin to establish prevention strategies.
    The Federal Government will have the responsibility to establish 
minimum national standards for health and exposure data collection. The 
State and local public health agencies, with Federal support and 
guidance, would be responsible for the collection, reporting, analysis 
and response.
    As a starting point, the Commission identified certain diseases and 
exposures that should be collected by all 50 States, based on review of 
the scientific literature, environmental data, reported health trends 
and targets identified by public health agencies. These are:
    Diseases and Conditions: Birth defects; Developmental disabilities 
such as cerebral palsy, autism and mental retardation; Asthma and 
chronic respiratory diseases such as chronic bronchitis and emphysema; 
Cancer, including childhood cancers; and Neurological Diseases, 
including Parkinson's, Multiple Sclerosis and Alzheimer's.
    Exposures: Persistent organic pollutants such as PCBs and dioxin; 
Heavy metals such as mercury and lead; Pesticides such as 
organophosphates and carbamates; Air contaminants such as toluene and 
fine particles; and Drinking water contaminants, including pathogens.
    To translate this information into action will require a 
revitalization of the public health infrastructure by providing 
adequately trained health professionals to collect and interpret the 
data at the local, State and national levels; to respond to concerns 
and to ensure a healthy environment. The information produced by the 
network will be widely disseminated and easily accessible--
simultaneously protecting both the public's right to know and 
individuals' privacy.
    Finally, all of these efforts will be coordinated and made 
available to our communities and public health researchers. To ensure 
the information is accessible and useful in evaluating the progress of 
disease prevention efforts, a National Environmental Report Card should 
be jointly developed by CDC and EPA by 2003. It would provide an annual 
overview of key environmental factors and health outcomes, allowing all 
interested parties to track progress and shape national goals. It 
should be adaptable so that State and local agencies can build on this 
for their own Environmental Health Report Cards.

Tier 2: National Early Warning System
    This early warning system would act as a sentinel to allow rapid 
identification of immediate health problems, including chemical 
catastrophes. This would build on the existing infectious disease 
monitoring network around the country by including environmental 
sentinel exposures and health outcomes. The existing partnership of 
hospitals, poison centers and public health agencies that make up the 
tracking network for outbreaks like food and waterborne illnesses and 
bioterrorism attacks also should identify and track early warning signs 
of outbreaks of health effects that may result from environmental 
factors. This would be the first stage in an environmental outbreak 
response capability. At minimum, the Commission recommends that this 
should include: Acute sensory irritation such as eye and respiratory 
problems, Heavy metal poisoning, and Pesticide poisoning.
    For example, if a terrorist or accidental event occurred involving 
misuse or release of toxic chemicals, an early warning system with 
environmental capacity could quickly recognize the episode, identify 
the chemical exposure and more rapidly initiate effective treatment and 
response.

Tier 3: State Pilot Tracking Programs
    The Network also would support a coordinated series of 20 State 
pilot programs in order to respond to regional concerns and test for 
exposures and disease outcomes that could be tracked on a national 
level. These pilots would be ``bellwethers'' for better understanding 
potential health and environmental problems.
    Selecting appropriate health and environmental indicators is 
essential to the success of a national network. This requires 
systematic development of tracking methods that are flexible, practical 
and adaptable to the unique public health needs of States.
    States may be interested in developing pilot tracking capacity for 
certain disorders, diseases and exposures in order to strengthen the 
response to local health concerns. For example, there have been 
increasing concerns about environmental links to attention deficit 
disorder, lupus and endocrine disorders, such as diabetes.
    Pilot programs covering specific health problems also would provide 
the Network with a broad reach for rapidly addressing many different 
health concerns, while at the same time testing methods and evaluating 
the need for broader tracking of certain health problems.

Tier 4: Public Health Investigative Response
    Trained public health officials at the Federal, State and local 
level need to be able to respond to health concerns that are identified 
through this network. The Federal Government must provide States and 
localities with the support and capacity to assure a coordinated 
response to investigate threats linked to the environment.
    By developing the capacity to track trends at the national level 
and conduct investigative surveys anywhere in the nation, the Network 
would be prepared to respond to outbreaks, clusters and emerging 
threats. While this is a routine response for infectious outbreaks, we 
presently lack a similar ability to respond to chronic disease 
investigations.
    There are many needs for a response capacity. For example, the 
recent National Academy of Sciences study on mercury and its 
neurodevelopmental effects on children exposed in utero underscored the 
need to study exposures and health outcomes of pregnant women across 
America. This capability also would permit quick response at the local 
level to citizens' concerns about potential problems, such as 
spontaneous abortions among women who live near hazardous waste sites.

Tier 5: Tracking Links to Communities and Research
    The Network would depend on a strong community and scientific 
foundation to ensure its relevance, effectiveness and vitality.
    The public has a right to know the status of our environmental 
health at the national, State and local level. It is paramount that the 
Network be grounded in community groups so that local concerns are 
adequately addressed in the design of the system, that tracking data is 
readily accessible and that this information is useful for local level 
activities. To insure this interaction, the Network should support 
community-based organizations to routinely evaluate the tracking 
systems with regard to individual and local needs and to ensure 
dissemination and interpretation of the Network data.

               ACTION STEPS NEEDED TO DEVELOP THE NETWORK

    To establish this Nationwide Health Tracking Network, the 
Commission calls on the Administration, Congress, the Secretary of 
Health and Human Services, and the Administrator of the Environmental 
Protection Agency to support and implement the following action plan:
     The Administration and Congress should provide funding 
support within 1 year to develop and establish the Nationwide Health 
Tracking Network. This should include support and incentives for State 
and local agencies, healthcare providers, community-based agencies and 
insurers to become active partners in tracking population health and 
identifying, treating, and preventing health problems related to the 
environment. The Commission estimates that the annual cost for a 
Nationwide Health Tracking Network is $275 million.
     The Administration and Congress should guarantee public 
access to the Nationwide Health Tracking Network to better understand 
community environmental exposure and health outcome information. As 
part of this right-to-know requirement, the EPA, CDC and the Surgeon 
General should jointly develop a National Environmental Health Report 
Card by 2003, which will give all Americans an annual overview of key 
hazards, exposures, and health outcomes in order to gauge progress and 
shape national goals. The approach should be adaptable to the needs of 
State and local agencies to facilitate similar report cards at the 
State and local levels.
     The Secretary of Health and Human Services, in 
collaboration with the EPA Administrator, should by 2001:
         LDesignate a national lead authority for environmental 
        health tracking to oversee development of a nationwide network 
        and coordinate all related health and exposure monitoring 
        activities, including those of EPA, CDC and the Agency for 
        Toxic Substances and Disease Registry (ATSDR); and
         LEstablish a Council on Environmental Health Tracking 
        to work with the HHS, EPA and State tracking leadership to set 
        up science-based criteria, minimum State standards and privacy 
        and confidentiality guidelines for a tiered approach that 
        supports both national priorities and State flexibility.
     Every Governor should appoint an environmental health lead 
in the State health department.
     CDC/ATSDR should help build State capacity to launch the 
Network, monitor the data, and respond to potential health concerns by:
         LPlacing an Environmental Health Investigator in every 
        State;
         LExpanding the CDC Epidemic Intelligence Service and 
        Public Health Prevention Service to recruit and train public 
        health officers in environmental epidemiology and tracking;
         LWorking with the National Association of County and 
        City Health Officials to develop similar leadership capacity at 
        the local level with support and guidance from HHS; and
         LProviding technical resources to local and State 
        public health agencies, including improvement of regional, 
        State and local laboratory capacity to evaluate community 
        exposures and complement State investigative abilities.
                                 ______
                                 
                       The Case of Libby, Montana
    Last November, Federal agencies began investigating what is 
believed to be the single most significant source of asbestos exposure 
in the United States. Residents of the small town of Libby, Montana, 
have watched for decades as neighbors, friends, and loved ones fell ill 
with respiratory problems. Many died. Townspeople thought it might have 
something to do with the vermiculite mine that was the town's largest 
employer from its opening in the 1920's until it was shut down in 1990. 
But until the Federal health investigation this year, no one knew for 
certain. As far back as the mid-1950's, State health officials had 
reported on the toxic asbestos dust in the mine, but no one followed up 
on possible exposures or health impacts to the town's 2,700 residents.
    It turned out that along with vermiculite, the mine also was 
releasing tons of tremolite, a natural but rare and highly toxic form 
of asbestos, into the region's environment. It takes 10 to 40 years for 
asbestos exposure to manifest in chronic, and often fatal, respiratory 
diseases, including asbestosis, rare cancers and emphysema. Therefore, 
early intervention as soon as potential or actual exposures were 
detected could have prevented these long-term harms.
    So far, nearly 200 people reportedly have died from diseases 
connected to the 
asbestos-tainted vermiculite. Newspapers account that another 400 have 
been diagnosed with asbestos-related disease, including mesothelioma, a 
rare and fatal cancer of the lung lining associated with asbestos 
exposure. Every month, more Libby area residents are diagnosed with 
asbestos-related diseases. As many as 5,000 people are expected to 
undergo medical testing for asbestos-related diseases by Fall 2000.
    ``Active [tracking] of asbestos-related disease might have picked 
this up much sooner, and started preventive activities 10-20 years 
ago,'' said Dr. Henry Falk, administrator of the Agency for Toxic 
Substances and Disease Registry. In that case, more lives would have 
been saved and the severity and possible spread of the outbreak 
reduced.
    Now, public health officials have to cope not only with ensuring 
that Libby residents are protected from this environmental hazard, but 
also investigating other sites and possible worker exposures around the 
country where this asbestos-laden vermiculite was shipped, processed 
and used in large quantities.
    Clearly, this case illustrates the tragedy of not tracking the 
environmental health of our communities. Every year there are towns and 
cities across the United States where residents are asking themselves, 
their health officials and elected leaders, why they or their children 
are getting sick. Until we establish a national tracking network 
capable of bringing together in a coordinated fashion the information 
about environmental hazards in the community, the exposures of people, 
and data on health problems, we will risk having more cases like Libby, 
Montana.
                                 ______
                                 
                 The Case of Pesticides in Mississippi

    In November 1996, one of the nation's worst and most costly public 
health disasters involving pesticide misuse was discovered in rural 
Jackson County, Mississippi. The event in Jackson came on the heels of 
similar events in Ohio and Michigan.
    Initially, health officials became aware of a possible problem when 
church members reported a noxious odor and yellowed walls in their 
church after fumigation. Before long, numerous residents began 
complaining of various symptoms, mainly resembling influenza. Suddenly, 
officials were facing a possible pesticide threat potentially larger 
than any in Mississippi's history.
    The initial investigation revealed that illegal pest control 
spraying in homes and businesses had taken place, potentially exposing 
thousands of residents in the area to methyl parathion (MP), an 
organophosphate insecticide intended for outdoor use that attacks the 
central nervous system, causing nausea, dizziness, headaches, vomiting 
and in severe cases, death. EPA officials began considering relocation 
of residents and decontamination of homes at what would be a staggering 
cost.
    Fortunately, public health officials had a health-tracking tool 
that was able to pinpoint who was at immediate risk and allowed for a 
more targeted, rapid response. Using biomonitoring--the direct 
measurement of human exposure to a contaminant by measuring biological 
samples, such as hair, blood or urine--health officials could determine 
individuals' exposure levels to MP. In this case, biomonitoring allowed 
scientists to identify the residents who were most at risk and 
prioritize evacuation and cleanup in the most dangerous situations, not 
just every house suspected.
    Armed with this information, EPA, ATSDR and State health officials 
were able to implement an effective health defense plan. In Mississippi 
and Alabama, over 1,700 residents had to be temporarily relocated and 
nearly 500 homes and businesses had to be decontaminated at a cost of 
almost $41 million. While no one died or was seriously injured in the 
short term, many of the early victims were misdiagnosed with the 
influenza virus--a fact that only underscores the need for a nationwide 
health tracking network to monitor environmental threats.
    A national early warning system for pesticide poisoning might have 
detected this problem sooner and led to a quicker halt of the illegal 
pesticide applications in other States. In turn, this would have 
prevented widespread exposures, and in some cases, evacuations, and 
higher human and financial costs. This case also points to the 
importance of another feature of a network--the laboratory resources 
and other infrastructure to conduct rapid and effective biomonitoring 
to protect the health of our communities.

               THE COMMISSION'S HEALTH TRACKING ANALYSIS

    In the 1970's and 1980's, the nation's environmental regulatory 
infrastructure was built, fueled by the passage of Federal laws aimed 
at cleaning up the environment. Unfortunately, these same laws failed 
to support core public health functions of environmental health. More 
than a decade ago, the Institute of Medicine report, The Future of 
Public Health sounded a warning, saying the Nation had ``lost sight of 
its public health goals'' and allowed the public health system to 
``fall into disarray.'' With diminishing authority and resources, 
public health agencies at all levels of government grew detached from 
environmental decisionmaking, and the infrastructure failed to keep 
pace with growing concerns about health and environment.
    The Commission's study of health tracking found that today, there 
still is no cohesive national strategy to identify environmental 
hazards, measure population exposures, and track health conditions that 
may be related to the environment. Just as important, there is a 
national leadership void, resulting in little or no coordination of 
environmental health tracking activities.
    The few existing environmental health tracking efforts are a widely 
varied mix of programs across multiple Federal, State and local 
agencies. These programs have evolved, often in isolation from each 
other, to respond to disparate regulatory mandates or program needs. 
Unfortunately, there are no identifiable linkages between hazard, 
exposure and outcome tracking, and there is limited coordination in the 
collection, analysis, or dissemination of information. The combination 
of lack of leadership, planning, coordination and resources have left 
important questions about the relationship between health and the 
environment unanswered. For example:
     Are environmental exposures related to clusters of 
childhood cancer and autism?
     What are the impacts of pesticide exposure on children's 
health?
     What proportion of birth defects is related to 
environmental factors?
     Are changes in the environment related to the dramatic 
increase in asthma?
     Are adult-onset diseases like Parkinson's and Alzheimer's 
related to cumulative environmental exposures?
     Are there increases in Systemic Lupus Erythmetosis (SLE) 
and multiple sclerosis (MS) in communities with hazardous waste sites?
     Are learning disabilities related to environmental 
factors?
     Is attention deficit disorder (ADD) related to exposures 
that occur in a child in the womb?
     Are endocrine disrupting pollutants in the environment 
related to the increasing incidence of breast and prostate cancers?
     How does particulate air pollution increase the risk of 
death in the elderly?
     What is the relation of diet and lifestyle to chronic 
disease?
    With the exception of childhood blood lead screening, there have 
been few systematic efforts to track individual levels of exposure to 
any hazardous substance. CDC and EPA have developed the methodologies 
for biological and environmental monitoring of a wide range of 
substances. However, inadequate support and inconsistent funding have 
restricted their application and availability. These findings were 
underscored in a recent report of the U.S. General Accounting Office 
that calls for a long-term coordinated strategy to measure health 
exposures to pollutants. With the goal of improving the public health 
response to environmental threats, the Pew Environmental Health 
Commission conducted an examination of the national capacity for 
tracking environmental hazards, exposures and health outcomes. The 
study had the following objectives:
     To examine the existing public health capacity for 
environmental health tracking;
     To identify the environmental health priorities of the 
nation's public health agencies;
     To examine the coordination among agencies, healthcare 
providers and researchers on environmental health tracking efforts; and
     To develop recommendations for implementing an effective 
national strategy for environmental health tracking.
    The complete study is available at the Commission's website: http:/
/pewenvirohealthJhsph.edu.

                A LOOK AT NATIONAL CAPACITY FOR TRACKING

    ``Tracking'' is synonymous with the CDC's concept of public health 
surveillance, which is defined as ``the ongoing, systematic collection, 
analysis and interpretation of health data essential to the planning, 
implementation, and evaluation of public health practice, closely 
integrated with the timely dissemination of these data to those who 
need to know (Thacker et al., 1988).'' Effective environmental health 
tracking requires a coordinated approach that identifies hazards, 
evaluates exposures, and tracks the health of the population.
    Figure 1 provides a schematic representation of the steps in 
environmental health tracking.

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Hazard Tracking
    What are the hazards to health in our environment? Environmental 
hazard tracking identifies potential hazards and examines their 
distribution and trends in the environment. It is an essential 
component in prevention strategies, particularly in the absence of 
definitive knowledge about the health impacts of environmental 
exposures. EPA and the State environmental agencies have primary 
responsibility for hazard tracking, which includes networks for data 
collection on water and air quality, environmental emissions, hazardous 
and radioactive waste generation, storage, and disposal, and the use of 
toxic substances and pesticides. These efforts are the foundation of 
our national environmental protection efforts.
    The EPA Toxics Release Inventory (TRI) is an example of an 
effective and publicly accessible hazard tracking program. The TRI 
contains data on annual estimated releases of over 644 toxic chemicals 
to the air and water by major industries. Data are reported as annual 
total releases by chemical. TRI is an innovative way to provide 
communities with information about the nature and magnitude of 
pollution in their neighborhoods. While there are many pollution 
sources not covered and a 2-year time lag in making the data public, 
TRI provides the best snapshot of local and national environmental 
releases of key toxins by major industries.
    The Commission analyzed the 1997 TRI data to determine the ranking 
of 11 categories of associated possible toxicological effects (Table 
1)\3\. Substances with potential respiratory effects were released in 
the largest amount in 1997. Neurotoxicants and skin toxicants were next 
highest in total pounds released. Actual population exposures to these 
toxicants are not currently tracked and their relationship to disease 
is unclear. This approach to hazard tracking provided the Commission 
with an important starting point for identifying needs for tracking 
exposure and health outcomes.
---------------------------------------------------------------------------
    \3\ This analysis includes both suspected and recognized toxicants. 
An agent is listed as a recognized toxicant if it has been studied by 
national or international authoritative and scientific regulatory 
agency hazard identification efforts. Suspected agents are included if 
they are shown to have target organ toxicity in either humans or two 
mammalian species by a relevant route of exposure.

                  Table 1.--Ranking of Toxicants based on 1997 Toxics Release Inventory (TRI)3
----------------------------------------------------------------------------------------------------------------
                                                                 Ranking based on 1997      Total Air & Water
                   Types of health effects                            TRI release           Releases (pounds)
----------------------------------------------------------------------------------------------------------------
Respiratory..................................................                        1             1,248,977,984
Neurologic...................................................                        2             1,211,458,945
Skin or sense organ..........................................                        3             1,109,718,312
Gastrointestinal or liver....................................                        4             1,086,264,404
Cardiovascular or blood......................................                        5               823,375,664
Developmental................................................                        6               811,686,192
Reproductive.................................................                        7               498,142,705
Kidney.......................................................                        8               488,554,582
Immunological................................................                        9               234,713,891
Carcinogenesis...............................................                       10               209,271,142
Endocrine....................................................                       11               173,331,065
----------------------------------------------------------------------------------------------------------------
Reference: Environmental Defense Scorecard (www.scorecard.org)

    While the Nation has developed a hazard tracking network, little 
has been done to link these findings to efforts to track actual 
population exposure levels or track the health of communities where 
these releases occur.

                           EXPOSURE TRACKING

    Are communities being exposed to harmful levels of pollutants? 
Understanding exposure levels is essential in understanding and 
preventing environmentally-related disease. Ideally, exposure tracking 
includes the systematic measurement of harmful environmental agents to 
which individuals are exposed. Exposure tracking also helps evaluate 
the effectiveness of public health policies. It should be closely 
coordinated with ongoing hazard tracking.
    The National Health and Nutrition Examination Survey (NHANES) 
illustrates a national approach to exposures. The survey examines a 
nationally representative sample of about 5,000 Americans each year. 
Environmental exposure measurements are only one part of NHANES, a 
broad-based national survey of nutrition and health.
    One of its strengths is that it allows policymakers to evaluate 
public health intervention policies. For example, NHANES data showed a 
drop in average blood lead levels between 1976 and 1980, a period that 
corresponded with the removal of lead from gasoline. These data enabled 
policymakers and regulators to determine that the ban on leaded 
gasoline was effective. NHANES has also provided a national profile of 
exposure to environmental tobacco smoke, thus supporting initiatives to 
reduce exposures.
    Unfortunately, NHANES is not designed to track exposures at the 
State and local level, and so does little to help public health 
professionals in responding to a community's local concerns about a 
possible cluster of health problems related to the environment.
    There is potential for progress, however, given advances in 
sampling and detection for a broad array of human monitoring 
techniques. But the failure to develop and support a national capacity 
for exposure tracking and coordinate with ongoing environmental hazard 
tracking has left a large gap in our approach to environmental 
protection. The GAO underscored the need to close this gap in a report 
that called for a national approach to measuring Americans' exposures 
to pollutants in order to strengthen prevention efforts.

                        HEALTH OUTCOME TRACKING

    Are environmental exposures and population exposures related to 
increased disease? Understanding trends in the incidence of diseases 
that may be related to environmental exposures is fundamental to 
protecting public health. The Commission reviewed a number of national 
health outcome data bases to examine the availability of information on 
diseases that may be linked to the environment. Three are particularly 
worth noting:
     The National Hospital Discharge Survey (NHDS) conducted 
since 1965 is a continuous survey based on a sampling of patient 
medical records discharged from hospitals. The survey collects 
demographic information, admission and discharge dates, diagnoses and 
procedures performed.
     The National Ambulatory Medical Care Survey (NAMCS) and 
the National Hospital Ambulatory Medical Care Survey (NHAMCS) are 
national surveys designed to provide information on the types and uses 
of outpatient health care services for office-based physicians, 
emergency rooms and hospital outpatient centers, respectively. This 
allows us to measure the number of doctor visits pertaining to specific 
health concerns that may be environmentally-related, such as asthma.
     The National Health Interview Survey (NHIS) is a 
multistage sample designed to represent the civilian, non-
institutionalized population in the United States. The survey is 
conducted by the CDC's National Center for Health Statistics (NCHS). It 
has been conducted continuously since 1957. Due to budget reductions, 
the survey was redesigned in 1997 to track a much more limited set of 
health problems.
    These data bases are not designed to describe either State and 
local communities or environmentally-related health outcomes, but they 
provide warning signals or ``big picture'' level information on the 
prevalence and trends of health outcomes in need of closer study. For 
instance, the NHIS data show the 10-year national trend in rising rates 
of asthma and clearly established it as an epidemic chronic disease. 
From 1986-1995, the surveys of about 5,000 people annually found that 
endocrine and metabolic disorders increased by 22 percent, while 
neurological and respiratory disease increased by 20 percent.
    However, the role of the environment in these health outcomes 
remains unknown. Without an adequate tracking process, such links are 
difficult to clarify. This type of snapshot data does not provide the 
full panoramic view needed by health professionals to identify 
clusters, uncover risks or guide the prevention programs that make 
people healthier.
            a look at state and local capacity for tracking
    The Commission interviewed environmental health leaders from public 
health agencies in the 50 States and a sample of local health 
departments as part of its examination of State and local public health 
capacity for environmental health tracking. While some States and 
localities have well-developed programs, others have virtually no 
capacity for environmental health tracking. Overall, the survey found 
that the State and local infrastructure for environmental health 
tracking has been neglected; with the result that today many have 
outmoded equipment and information systems, and lack technical and 
laboratory support. As a result, fundamental information about 
community health status and environmental exposures is not available.
    In a Commission survey of State health officials, it was found that 
while over three quarters of State health departments track blood lead 
levels, biomonitoring for other substances, including hazardous 
pesticides, is very limited. Only about 25 percent said their 
departments can measure human exposure to environmental contaminants by 
monitoring the air in a person's breathing zone, an important 
investigative capability in responding to a health threat. Most of the 
chronic diseases and health problems that the Commission identified as 
priorities are not being tracked.
    Even for health problems that most States do track--cancer, 
infectious disease and birth defects--tracking efforts have significant 
problems. For instance, an earlier Pew Commission report found that 
while 33 States have birth defect registries, the majority was 
inadequate in terms of generally recognized standards for an effective 
tracking program. Another Commission study found similar gaps in State 
efforts.
    Finally, information that is tracked according to current standards 
is often not usable for intervention, policy, and scientific purposes. 
First, State data sets commonly lack enough samples from more refined 
geographic areas to make it possible to characterize health hazards, 
exposures and outcomes at the local level. In addition, the 
Commission's survey found that many departments lack the staffing, 
expertise, or technology to analyze and in some cases even to access 
existing data sets relevant to local environmental health. Rather, 
local health practitioners find themselves focusing on enforcement and 
reacting to complaints. Another concern is the absence of national 
standards to ensure consistent data collection.
    State and local public health agencies are the foundation of the 
nation's health tracking capacity. The first requirement for an 
effective, integrated network is strong State and territorial public 
health organizations with linkages to strong local health agencies, as 
well as Federal agencies, healthcare providers, State environmental 
agencies and communities. While the States and localities may have the 
will, this vision of a Nationwide Health Tracking Network will only 
come together with the support, guidance and leadership of the Federal 
Government.

                           THE TIME IS RIGHT

    Advances in hazard identification, exposure assessment health 
outcome data collection and information technology provide 
unprecedented opportunities for advancing tracking and improving our 
understanding of the environment and health.
    Despite the challenges, there are unprecedented opportunities to 
strengthen the national infrastructure for environmental health 
information, expand public access to this important information and 
protect the privacy of individuals. New technologies in biomonitoring 
have the potential to transform the nation's capacity to track 
exposures to pollutants and understand their impacts on health. 
Advances in communication and information technology have expanded 
opportunities for public access and given us new tools to analyze, map 
and disseminate health data. New technology also can improve safeguards 
to protect the confidentiality of identifiable personal health 
information. We have better tools than ever before to meet the public 
health missions of protecting Americans' health and privacy.
    New initiatives at CDC and EPA have the potential to address 
tracking needs, including information technology development and State 
and local capacity-building, along with exposure measurement, 
interagency coordination and public access to health information. 
Opportunities exist, but we need to do more to advance the science and 
support for inclusion of environmental health components.
    The integration of public health information and tracking systems 
is listed as a top priority of the CDC. Spurred by concerns about 
bioterrorism, a Health Alert Network is being developed to improve 
tracking and information sharing on key infectious diseases and 
priority chemical and poison agents that may be used in terrorist 
attacks. In addition, there are several other data systems being 
developed by CDC and EPA that could be building blocks in a national 
tracking network. However, national vision and leadership to bring this 
all together on behalf of environmental health issues will be required 
if any of these current initiatives are to become building blocks for a 
national environmental health tracking network.
    Environmental health tracking will give us an unprecedented 
opportunity to ensure our environmental policies are successfully 
reducing exposures in our communities and safeguarding public health.
    Reduction of risks from hazards in the environment and people's 
exposures and the improvement of public health are fundamental goals of 
environmental regulations. At present, tracking activities are focused 
primarily on hazard identification for regulatory permitting and 
enforcement. Improved capacity to measure peoples' exposures to hazards 
and track health outcomes will strengthen the scientific basis for 
these important policy decisions. In addition, environmental health 
tracking will give practitioners and policymakers better indicators of 
progress, and assure that benefits of healthier communities continue 
well into the future.
    The public increasingly wants and demands more credible 
environmental health information so that they can make independent and 
fully informed decisions. The Internet explosion has further fueled 
this desire.
    Recent public opinion research confirms that Americans want to have 
access to national, State and community level health data. In fact, 
they are incredulous when informed that health tracking information is 
not readily available. The Internet now allows the public quick and 
highly accessible information on most facets of their lives. There is a 
widespread belief that health tracking information should be and needs 
to be available to the public. With growing concerns about environment 
and health, this public demand should help support the Network.
    Recently, a group of environmental health leaders held a summit co-
sponsored by the Pew Environmental Health Commission, the Association 
of State and Territorial Health Officials, the National Association of 
County and City Health Officials, and the Public Health Foundation at 
which they strongly endorsed the Commission's efforts to strengthen 
environmental health tracking.
    Summit participants endorsed a tiered approach to national 
environmental health tracking that is consistent with the Commission's 
five-tier recommendation. It includes: national tracking for high-
priority outcomes and exposures; a sentinel network to identify acute 
and emerging hazards; a coordinated network of pilot regional, State 
and local tracking programs; and aggressive research efforts to guide 
and evaluate tracking.

               WHY WE NEED A HEALTH TRACKING NETWORK NOW

    Earlier this year, a scientific breakthrough was announced that has 
incredible potential to help us understand the links between people, 
their environment and behaviors, genetic inheritance and health.
    As researchers begin to apply this new genetic knowledge to the 
study of disease, we will have more information than ever before to use 
in revealing the connections between environmental exposures, people's 
behaviors and genetic predisposition to health problems. But only if we 
have the basic information about what is going on in our communities--
the hazards, the exposures and health problems that Americans are 
experiencing.
    The ``building blocks'' of knowledge provided by the Nationwide 
Health Tracking Network will enable scientists to answer many of the 
troubling questions we are asking today about what is making us sick. 
The Network will provide the basis for communities, health officials, 
businesses and policymakers to take action for making this Nation 
healthier. The result will be new prevention strategies aimed at 
reducing and preventing many of the chronic diseases and disabling 
conditions that afflict millions of Americans.
    The Commission is calling upon our national leaders to take the 
steps outlined in this report, and with a minimal investment, 
revitalize our nation's public health defenses to meet the challenges 
of this new century. It is time to close America's environmental health 
gap.
                                 ______
                                 
       THE PEW COMMISSION PRINCIPLES FOR PROTECTING PRIVACY AND 
       CONFIDENTIALITY AND OUR ENVIRONMENTAL HEALTH RIGHT-TO-KNOW

    Without a dynamic information collection and analysis network, 
public health agencies would be ineffective in protecting health. The 
Commission recognizes the substantial benefits that accrue from 
personally identifiable health information and provides these 
principles to assist agencies in addressing privacy and confidentiality 
concerns associated with collection and use of this information in 
environmental health investigations.
    The Commission is aware of the sensitivity of individually 
identifiable health information and is committed to protecting the 
privacy of such information and to preventing genetic and other 
sensitive health information from being used to discriminate against 
individuals. The Commission believes that the values of public health 
activities and privacy must be reasonably balanced.
    The Commission also is aware of the need to increase public 
confidence in our nation's public health system by making 
nonidentifiable health information and trends widely available and 
providing access to the analyses of collected data. This also will 
serve to better inform communities about the value of public health 
data.
    The Commission believes that adherence to the following principles 
will enable public health agencies to honor their traditional 
commitment to the confidentiality of individually identifiable health 
records without significantly hampering execution of their obligations 
to the public health:
     Recognize that it is largely possible to balance the 
protection of individually identifiable health information and the 
acquisition, storage and use of that information for environmental 
health purposes;
     Protect individuals' privacy by ensuring the 
confidentiality of identifiable health information;
     Disclose only as much information as is necessary for the 
purpose in cases where the public health requires disclosure of 
identifiable information;
     Require that entities to which identifiable information 
has been disclosed take the same measures to ensure confidentiality 
that are taken by the disclosing agency;
     Utilize the best available organizational and 
technological means to preserve confidentiality of information 
(includes such measures as limiting access, staff training, agreements 
and penalties as well as updating of security measures);
     Provide individuals the opportunity to review, copy and 
request correction of identifiable health information.

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