Oak Ridge Reservation: Health Needs Assessment Work Group

Health Needs Assessment Work Group

March 13, 2002 - Meeting Minutes

Attendance

ORRHES Members: Kowetha Davidson, Bob Eklund, Karen Galloway, James Lewis, Susan Kaplan, Donna Mosby, Brenda Vowell, TN Department of Health

Public members: Peggy Adkins, T.L. Dishman (phone), L.F. Raby

ATSDR Staff:

Jack Hanley (phone), Bill Murray

The meeting was called to order at 6:05 p.m.

James Lewis apologized for not having a formal agenda for the meeting. He said the clinic issue is the primary topic of discussion for the meeting - whether an environmental clinic can be set up in Oak Ridge, what government agency would support such a clinic, and, if other communities have such a clinic, how did the community get it. Further, he said there are two key topics or agenda items for discussion. The first is the March 11, 2002, email that was sent to Donna Mosby but he did not receive a copy. The email went from Dr. Robert Jackson, Health Resources and Services Administration (HRSA), to Kowetha Davidson. There will be an update on that issue. (Copies were handed out to the attendees.) Dr. Jackson gave a talk on HRSA activities regarding the clinics the agency sets up and other activities at the ORRHES meeting on December 4, 2001.

James Lewis said there was a list of five questions raised after his talk and Dr. Jackson is sending the response to the Oak Ridge Field Office at Kowetha Davidson’s request. He asked the WG members to review the email.

Susan Kaplan said that it appears that Dr. Jackson is saying if he is paid he will answer the questions. She said that Dr. Jackson states “the HRSA budget is expected to include a small appropriation for support services for citizens who worked in the uranium mining industry and/or were involved in the testing of atomic weapons.”

James Lewis thinks this is funding for clinics for these people. There was discussion about what he meant by this statement in his email. He said we need to look at Dr. Jackson’s responses to the questions and determine if they meet our needs.

James Lewis asked about the questions submitted to Dr. Jackson of HRSA and his response to them. He asked Jack Hanley to read the questions sent to Dr. Jackson.

Jack Hanley stated that there were five questions sent to Dr. Jackson for response (copies were handed out):

1. Can HRSA provide an environmental clinic?
2. What criteria does HRSA use for determining if an area can be designated as a medically underserved area (MUA)?
3. What clinics have been established by HRSA because medical care was not independent of factors or influences in a community?
4. Would he send a copy of the HRSA needs assessment?
5. Is the Hanford clinic a HRSA clinic?

Peggy Adkins asked where Dr. Jackson is located.

Jack Hanley said he works in HRSA’s regional office in Atlanta. He continued that Dr. Jackson will be sending the MUA criteria (#2) and the needs assessment (#4).

James Lewis said the questions were pulled together was because the minutes of the December 2001, were not explicit enough to meet the subcommittee’s needs. A follow-up was needed to clarify these issues and Kowetha Davidson sent a letter requesting the information. But there is nothing to look at until his response is received.

There was discussion about the MUA criteria and the fact that there could be exceptions to them and there were legislative remedies also where the criteria were not met.

Susan Kaplan brought up the Hanford [Hanford Environmental Health Foundation (HEHF)] Clinic which is a worker clinic set up independently of the operating contractor. Mr. L.F. Raby has been involved with the Hanford clinic. She expressed concern that there are not enough people in Oak Ridge to justify a clinic here. We could team up with Mr. Raby’s effort to get the worker clinic out of the operating contractor. Mr. Raby has filed legislation to get the contractor out of the loop in providing medical care to DOE workers. She mentioned that the Hanford clinic is set up for DOE workers and that she believes it provides services for the worker’s family.

James Lewis said there will be a presentation on the DOE medical and exposure surveillance program for former workers at the next ORRHES meeting (March 26, 2002) for the workers at K-25 and the construction workers..

Kowetha Davidson stated that the health services for current workers are provided by the contractor’s medical department. She discussed in some detail about physical examinations that are done on a routine basis for workers and some additional medical exams for all workers, including office workers. The clinic will also refer you to your personal physician if needed.

Susan Kaplan said the main issue is who runs the clinic. Is the clinic under management control?

James Lewis asked about the characteristics of the HEHF clinic. Is it on site? Who funds the clinic? Who controls it?

Donna Mosby commented that we need to find out more about the HEHF.

Jack Hanley asked who funds the HEHF clinic.

Bill Murray said that said that the HEHF clinic is funded by DOE.

Peggy Adkins said that people are not tested for heavy metals at DOE clinics and it is not part of a routine check-up. She continued that heavy metal screening should be included to plot the right course.

L.F. Raby said that there is a problem here in Oak Ridge and elsewhere in the DOE complex. The doctor works for the contractor and his first obligation is to protect the contractor liability wise. The worker is way down the line in terms of priorities. He talked about his wife’s medical problem. She was never informed of her hematologic problem until it was too late. He said her blood counts were decreasing for eight and she was given no warning.

Kowetha Davidson said that after your tests are done you are supposed to go back and discuss the results with the doctor. They will inform you of abnormal results.

Bob Eklund stated that, in line with what Peggy Adkins said, is that in addition to clinics for routine medical tests, they ought to trying to attract researchers who could look at relationships between exposures and the results of the medical tests or diseases.

Peggy Adkins said doing better at the clinics now than they did historically. We are still dealing with problems that people had historically with exposures.

Kowetha Davidson said that the follow-up discussions with the doctor originated within the last five years.

L.F. Raby met with Leah Dever, manager, DOE Oak Ridge Office, to urge her to send a directive to the doctors to inform the patient about the results of all lab tests and the doctor and the patient have to sign off on that. He said she did that.

Susan Kaplan is concerned that there are not enough people in Oak Ridge to justify a clinic then we ought to tie-in with the workers and piggy-back with the workers.

James Lewis said we have captured the concern about what Peggy Adkins said about heavy metal exposures. The question about exposures to heavy metals will be presented to the speakers at the March ORRHES meeting. He reiterated that there are two issues:

1. What does the HEHF clinic do and is it a DOE-sponsored effort?
2. What is the difference between medical screening, medical clinics, and medical monitoring? These terms need to be defined. He referred to the medical screening that is being done at the Paper, Allied-Industrial, Chemical and Energy (PACE) workers union hall. They do not do treatment. What does the clinic do? Is it done by DOE?

Peggy Adkins said they need treatment.

Bob Eklund said the clinic doesn’t have to be in one building. It can be a concept that is already in place.

James Lewis asked who is responsible for treatment for illnesses? DOE is probably not responsible for treatment.

Brenda Vowell said these are the 330 clinics that are set up for medically underserved communities and there are several in the area. HRSA has set them up in several near-by communities, Wartburg and Jellico, TN and Franklin, KY.

Susan Kaplan said that Dr. Jackson didn’t mention them when he spoke here.

James Lewis asked again about medically underserved areas.

Brenda Vowell said that they are in medically underserved communities and they all are primary care centers.

James Lewis said the question is do we know about any clinic anywhere in the country that can handle non-occupational exposures that can handle that.

Peggy Adkins asked about Veterans’ hospitals and aren’t they government-funded? So that’s one option. So what if there hasn’t been any in the past. What if we’re innovative enough to say we’re going to do something differently. We have a problem that we’re going to take care of in an innovative way.

Susan Kaplan said that Dr. Jackson said there were action that could be taken in a legislative manner. It may not be easy but there are alternatives.

Peggy Adkins is going to meet with the Tennessee Congressional delegation on another issue and she will bring this issue up.

James Lewis said there are two issues to examine:
1. How to set up a clinic under the HRSA criteria but we don’t have that information now so we can’t pursue it.
2. The medical monitoring being done under the PACE program. He has looked into that program and has prepared a presentation on it. Part of their program is a needs assessment and that is what he has focused on. That is the second item on the agenda.

Donna Mosby asked again about the HEHF. Is that issue still under discussion.

James Lewis replied that Jack Hanley had addressed that issue.

Jack Hanley said that he would present this issue to the DOE speaker for the medical surveillance program and have that person clarify how the HEHF clinic is funded and whether it provides medical services only for the worker or for the worker’s family also.

T.L. Dishman said if the Hanford clinic is under the control of the contractor, the families will not trust it.

Jack Hanley clarified that ATSDR can set up a clinic only when an exposure has been identified and that a medical screening program will be done only as it relates to the exposure. At Libby, Montana, ATSDR screened 6000 people for asbestos-related disease since there was an exposure and some were referred to their family doctor. At Oak Ridge, the Watts Bar exposure investigation identified people exposed to PCBs and mercury. The residents were tested for these chemicals. The screening is exposure-specific and only done for those people who were potentially exposed.

Susan Kaplan said the screening is done only for a finite period of time.

James Lewis brought up the DOE medical and exposure surveillance program (referred to as DOE Former Workers Program [FWP]). He said his interpretation was that there are two phases in the FWP. The 1st phase is controlled by DOE. Phase One included six worker groups at four sites (Hanford, Rocky Flats, Nevada Test Site and ORR), including the OR gaseous diffusion plant and the construction workers. The gaseous diffusion workers are covered under the PACE program.

In response to a question whether Hanford workers are covered under the FWP, only the construction workers are covered.
Kowetha Davidson described the services that are available to Hanford workers through HEHF from the brochure that came with the videotape. The HEHF provides services to all workers and is not under the FWP.

Jack Hanley said the HEHF is similar to the medical program available to UT-Battelle workers at the worksite that Kowetha Davidson had described earlier.

Kowetha Davidson agreed and said the only difference is that HEHF is off-site and is strictly for workers and does not relate to the community.

Donna Mosby asked Jack Hanley to follow up on HEHF and have them present to the ORRHES.

Susan Kaplan suggested that the funding from HRSA could be combined with the funding for the occupational clinic to support an environmental clinic for the community that is not under the thumb of the production contractor.

Kowetha Davidson said even in the FWP, the worker is referred to their family doctor.

James Lewis said the two issues that continually arise are the process issues and the trust issue. We can never get through the process issues without bringing in the trust issue. He prefers to look at the process first and then go back and examine the trust issue.

Peggy Adkins wants to think bigger and envisions a Mayo Clinic where people from all over the world can come for diagnosis and treatment of environmental toxins by specialists for all over the world.

James Lewis is not disagreeing but wants to move on to what is going on at PACE.

Bob Eklund wants to make one additional point. The Tennessee Valley Authority (TVA) is involved here also. Not only are there historical exposures from their plants but also present exposures whereas DOE exposures are past exposures. TVA should pay for part of this clinic too. Rather than buy (pollution) credits, they should put emission controls on their plants.

James Lewis talked about pollution controls being needed worldwide and pollution being spread worldwide. But now he wants to focus on the needs assessment for the FWP and compare the PACE process with the ATSDR process for the public health assessment (PHA). The comparison is set out in the Table below:

Program Comparison	ATSDR	PACE
Congressional mandate	CERCLA, Superfund	1993 National Defense Authorization Act
Responsible agency	ATSDR	DOE
Types of assessments	Public Health Assessment/ Community Needs Assessment	Needs Assessment
Methods	Public Health Assessment/ Community Needs Assessment	Needs Assessment
Data Sources	ChemRisk	ChemRisk
Stakeholders	Residents (Outside fence)	Workers (Inside Fence)
Conclusions	??	??

James Lewis emphasized the similarities between the two programs. The PACE program needs assessment included both an exposure assessment and a medical needs assessment. Both programs used ChemRisk as a data source. The Phase I was used as a means of making the recommendations for medical surveillance needed. There are logical steps and phases that you go through. Then you evaluate the results to identify the medical tests or monitoring or education so that you can target the specific exposures. The key here is we should be taking information from HRSA or wherever you can and looking at it and boiling it down as it relates to this and make your call. If we go ahead and start pursuing that, I did not say we should not research how they did it, but I think these questions we’re lining up are the types of things we should ask. To me, the key point is we should wait until we get through this effort, look at what our findings are, define what the area of interest is depending on what the findings are, and then pursue it from there. Are there questions? This is just a thumbnail sketch of what I was able to extract from this.

Susan Kaplan commented that when all of this is done sequentially, it can take a long time, especially if legislation action is needed. So there’s no reason why we can’t look at what obstacles there are to a clinic to formulate a strategy or even decide if we want to tackle that. We have to understand what the obstacles are and how to get around them. If we wait for epi studies, I mean epi studies are never going to get done.

James Lewis said there are no epi studies in this. He thinks that they did their Phase I in a year. They went through their Phase I very quickly and they looked at it and made decisions. We’re working at something that’s a lot bigger and need a lot more information. But the point is where we are on this is - we’re collecting the data. This is his personal opinion. Can you ask for something if you don’t have data. If go request something from somebody, somebody will say well give me some indication. He thinks you have to have some supportive information and data. He feels we need to look where we are, how does this work, look at what has gone maybe on at other sites and has anything triggered anything that is associated with this. In addition to this, as he was looking at this - the whole thing about beryllium, for instance, which is something he thinks there’s a program they’ve got in place that they’re do things on, supposedly assisting people. He thinks we should look at all the various programs, some where they set up clinics and look at what they’re doing, how they found that, and then try to determine what we’d like to do.

Kowetha Davidson said one of the first things you have to do is lay out a rationale. If you don’t have a rationale, then you don’t know what the obstacles are. You have to have some vision as to where you’re going. If you don’t have this vision of the road you want to go. You have to identify some concepts. HRSA already has criteria and you have to look at that. That will give you a starting point. If you don’t have a starting point it will be like a shot in the dark. If you have something in place you can modify it but you need a place to start.

Bob Eklund agrees.

Kowetha Davidson continued saying that right now you don’t have that but you have to focus on something, start with an objective approach and look at this from an objective point of view.

Bob Eklund said that even if it ends up being a legislative matter, the other options must be elucidated. For example, if HRSA can’t do it, that would have to be known before following through on other avenues.

Donna Mosby said the other thing about following this process would help us determine if we need to think outside the box. We need to know what the shape of our box is before we can get innovative and get outside the box.

James Lewis said that our perception of being innovative means that you have found that the same thing is going on someplace else. So we should follow this process and look at all the various programs that are out there. Determine what logic was used to get that program put in place. You need a process and logic pattern and figure what’s going on.

Jack Hanley interjected that he is looking at all these different options that are out there and quickly summarized them. With ATSDR, we focus on exposure and we respond to that exposure. HRSA provides clinics; primary care clinics are their main focus. They may support environmental clinics but we don’t know and we’ll have to get the answer to that. It is based solely on need and they serve underserved areas. Remember what Paul Seligman (former Deputy Assistant Secretary of the DOE Office of Environment, Safety and Health) said last January. He clearly stated that if we come up with information that they can take to Congress, like they did for beryllium and berylliosis or the compensation program. To expand the beryllium program across the DOE complex, they got the sources, contaminants, exposure pathways, the ill workers, and they put that all together and showed it to Congress and Congress responded. So you have to get something concrete they can take to Congress and ask for. That was his message. Henry Falk’s (Assistant Administrator of ATSDR) message at that time was that if we find exposures, we will work with everybody and do everything we can to address those exposures. That’s the way I see these different programs.

Susan Kaplan said not to forget how that NHANES (National Health and Nutrition Examination Survey) program can potentially fit into that. The program could be expanded.

Kowetha Davidson said that has been an ongoing program for many years.

Jack Hanley added that it is a research program.

Kowetha Davidson said they are doing medical tests for a specific purpose and as a research program you can’t shift in the middle of it. They are looking to establish baseline values nationwide that can be used to compare for abnormalities.

Susan Kaplan said that they have to be testing for the proper things to compare to. If they’re not testing for nickel, we won’t have a baseline comparison to know what’s abnormal.

Kowetha Davidson said just because NHANES isn’t testing for nickel doesn’t mean you can’t get baseline values for nickel.

Jack Hanley said metals are mostly of interest for occupational settings and the information is readily available from NIOSH.

Brenda Vowell asked Jack Hanley if he knew if HRSA uses the MAPP (Mobilizing for Action through Planning and Partnerships) approach for their assessment

Jack Hanley doesn’t know. It will be interesting to see if they do. When we get the materials from Dr. Jackson. He said he is sending the instructions for health center applicants’ assessment of need.

Brenda Vowell said if they do, I know all of our health councils (in the counties) are preparing to do the MAPP approach soon. They will start by evaluating the past and then using the MAPP process to go forward.

Question - what is the MAPP process?

Brenda Vowell said the MAPP process is Mobilizing for Action through Planning and Partnerships. It is a community-wide strategic planning process. And it will have the support of HRSA.

Jack Hanley said and each county health...

Brenda Vowell said each county health council...

Jack Hanley reiterated the health councils are doing this...

Brenda Vowell said the councils will first evaluate what they’ve done and then use MAPP to go forward.

Jack Hanley said a lot of them have conducted in the past what is called a needs assessment.

Brenda Vowell said that’s all been done and now they’re moving on to the MAPP. They’re in the process of doing their evaluations right now.

James Lewis puts the worker at ground zero. Our exposures differ from the workers’ exposures. He is very interested in hearing about the worker programs - what they have found in a program that has been in place. He wants to hear about the results of the medical surveillance. This is what they will present at the ORRHES meeting.

Kowetha Davidson asked why he mentioned 9/11.

James Lewis clarified that the similarity is that the people they are focusing on are those exposed at ground zero.

Peggy Adkins said there are a couple of other dimensions that will complicate matters but she hopes they will be considered. One is the time frame. The workers and residents who lived nearby in the 50s and 60's had different exposures than now and will have different symptoms now. Also, the geography, the flow of water, the underground aquifer, all those things may have an effect. The two dimensions, geography and time, will complicate this and shouldn’t be overlooked. There may be people who lived in different locations and the well water was of different composition.

James Lewis asked if that was examined in the dose reconstruction.

Jack Hanley said it wasn’t but that ATSDR will look at that difference in pathways. We will look at ground water.

T.L. Dishman said there was over half the world’s supply of mercury at Y-12. So many were exposed and some have symptoms. Please try to get it included along with beryllium for health tests. People have no faith in the contractors’ doctors; they think it’s a stacked deck. And he is one of those people. If we can get this outside of the contractors’ hands, we’ll already be a step ahead. If you have a program the people don’t have much faith in, you don’t have much hope.

Jack Hanley encouraged Mr. Dishman to come to the subcommittee meeting on March 26. He described the program.

James Lewis said all these programs are referred to as pilot programs. The results will dictate what happens. The beryllium program is not a pilot program.

Bob Eklund asked if he said all existing programs.

James Lewis replied all of the DOE FWP were pilot programs but the beryllium program is not a pilot.

Jack Hanley said the beryllium program was initiated and in 1999 it was expanded to the other sites.

James Lewis said the jury is out on the other programs.

Bill Murray described the pilot program is similar to a clinical trial, where a medical test is studied to determine if it effective in diagnosing a given disease. The example used was breast cancer. Mammography was not always recommended as a method of diagnosing breast cancer until the studies showed it was an effective method of detecting that disease.

L.F. Raby said a pilot is a way of dragging things out for a long period of time until all the patients die before you determine anything.

James Lewis said that is what the programs are described as.

L.F. Raby talked about the program to monitor DOE workers exposed to hazardous and radioactive substances. said the legislation for the DOE FWP was passed in 1993. Congress
directed DOE to reach an agreement with the Department of Health and Human Services and get it set up within 180 days. He talked to the medical director last week and it hasn’t been done yet.

James Lewis said he went to the website and looked it over. The answers to a lot of questions can be found here.

L.F. Raby said Congress gave them 180 days from October 22 or 23 in 1992. This is 2002 and they’ve not done it yet.

James Lewis said something is in place. We need to read the material ahead so we know what questions to ask.

Jack Hanley said the legislation is on that website too.

Discussion about the 180 day startup time.

Donna Mosby said we have to follow this process that has been laid out for us. Discussion muddled.

James Lewis said various components have to come together. One component is HRSA. This is one component. There is the needs assessment component. At some point in time, we have to lay them all out and looked at. Each group seems to have a programmatic step they go through. There are weaknesses to both; things that can be challenged. I think they need to be looked at by someone with expertise in the area.

Kowetha Davidson is confused about what he means about the process being done by another workgroup. What Work Groups are involved.

Someone commented that each workgroup has a specific role.

James Lewis said all of these workgroups have overlapping things. He talked about the linkage among all the workgroups. And how it relates to the subcommittee

Kowetha Davidson asked how all this relates to the clinic. She has trouble understanding the connection.

James Lewis replied that if you wait until the end, when you get there you’ve got more questions than you know what to do with. But if you follow through with the appropriate expertise to raise the questions as you go along, when you get to the end there are only a few questions with the recommendations.

Bob Eklund remarked in terms of being prepared, it would be helpful if Kowetha Davidson shared Dr. Jackson’s response with the whole subcommittee.

Kowetha Davidson said the information will be disseminated.

Jack Hanley remarked that the website shows the whole law and will clarify the 180 day period.

Donna Mosby said the issue of the delay in implementation is not the Work Group’s issue.

L.F. Raby said people should understand that DOE is not interested in the health if the workers. In November 2001, a group of senior managers recommended that 440.18, the directive for occupational medicine for all DOE, be deleted and not replaced. They said it was contrary and redundant to contractors’ programs and programs established by other agencies.

Peggy Adkins asked what action had been taken.

L.F. Raby said none had been taken yet but it was a recommendation from an Assistant Secretary to delete it.

James Lewis said we should write it up and make sure it is presented to the DOE representative.

Peggy Adkins brought up a point to make sure she was interpreting the meeting the same way as the others. She has written it up as a motion, but will not submit it as a motion. It seems that this group has agreed to aggressively pursue basic information, necessary to create a diagnostic, treatment, research, and public education center or clinic related to environmental toxins, particularly identified in DOE or TVA releases from 1944 to present. Is that what we’re about?

James Lewis said we are aggressively looking at coming to conclusions.

Susan Kaplan said we need to establish exposure pathways first.

Bob Eklund emphasized that we need to look at HRSA’s options.

Donna Mosby said we must look at all options.

James Lewis said to look at the ideal - consider the vision and mission. We have to determine what’s measurable. First we have to identify the problem.

Kowetha Davidson said the HRSA criteria must be met. Look at the whole box first.

Donna Mosby remarked that we can do fact finding.

There was discussion about getting the information from Dr. Jackson or any federal agency.

James Lewis summarized the action items:

• ATSDR will follow up on HEHF - operation, funding budget, etc.
• ask DOE rep about the status of the agreement.

Peggy Adkins said we need to broaden our scope. Look at the VA, UT hospital (teaching and research)

James Lewis adjourned the meeting at 8:20 p.m.