ORRHES Meeting Minutes
February 3, 2004
- Call to Order/Opening Remarks, Agenda Review, Approval of December Minutes, Introductions, and Correspondence
- Status of Action Items
- Project Management Status Update
- ATSDR's Response to Recommendations from the ORRHES Regarding the Needs Assessment Document
- Oak Ridge Reservation Communication & Health Education Plan: White Oak Creek PHA Initial Plan
- Public Comment Period
- Proposed Plan for Collecting Information about the ORR Community
- Health Education and Needs Assessment Work Group Report
- Initial Release of PHA on White Oak Creek Radionuclide Releases from the DOE ORR
- Public Comment Period
- Vote on the ORRHES Recommendation Submitted by the NAWG
- Public Health Assessment Work Group Report
- Communication and Outreach Work Group Report
- Action Items from the 2/03/04 ORRHES Meeting
- Guidelines and Procedures Work Group Report
Peggy Adkins, W. Donald Box, Herman Cember , Bob Craig, Kowetha Davidson (Chair), Karen Galloway, George Gartseff, Jeffrey Hill, Marilyn Horton-Palmer, David H. Johnson, James F. Lewis, Anthony Malinauskas, LC Manley, Donna Mosby, Charles Washington, Sr.
ORRHES Liaison Representatives:
Chudi Nwangwa (TDEC), Brenda Vowell (TDH).
Shuba Chandar (Fellow), Paul Charp, Burt Cooper, Melissa Fish (ORISE Fellow), Jack Hanley, Marilyn Horton, Michael Hatcher, Elizabeth Howze, Sandra Isaacs, Theresa NeSmith, Jerry Pereira, Susan Robinson, Lorine Spencer (ATSDR/ORRHES DFO), Terrie Sterling, William Taylor.
Gordon Blaylock, Deborah Kirkland, Lucille Johnson, Timothy Joseph, Anne Pickering, Teresa Robinson (Cambridge Communications), Lynne Smith, Janice Johnson Stokes.
Kowetha Davidson, Chair
Oak Ridge Reservation Health Effects Subcommittee (ORRHES)
Ms. Kowetha Davidson called the meeting to order and welcomed everyone to Kingston and to the Kingston Community Center. Following several housekeeping announcements, Ms. Davidson briefly reviewed the agenda and made several changes in the order of the day's events so that the Public Comment Period would take place as advertised and on time. She then opened the floor for discussion regarding the subcommittee's December meeting minutes.
- Mr. James Lewis indicated that the December meeting minutes seemed to be more of a verbatim-type transcript and he had heard some people say that such a structure was quite meaningful. He suggested that the Agency for Toxic Substances and Disease Registry (ATSDR) consider more of a verbatim style for the ORRHES meeting minutes, because such minutes had been quite worthwhile for the December discussion. Also, he had heard some say that the abbreviated or summary minutes felt somewhat sanitized because certain comments had been omitted. Mr. Lewis stated that the subcommittee should reconsider whether they would like to continue to have summary minutes or whether they would prefer to have verbatim minutes, which are similar to the Public Health Assessment Work Group (PHAWG) meeting minutes.
- Ms. Davidson pointed out that during an earlier meeting, the subcommittee voted that they wanted detailed summary reports as opposed to verbatim transcripts of the meetings.
- Mr. Lewis indicated the PHAWG had a similar discussion, but that after the work group had perused both products, they decided that they appreciated the verbatim style. He pointed out that the minutes did not have to be complete verbatim transcripts, but might include, for example, verbatim during critical or technical discussions that may have a major impact, such as discussions regarding White Oak Creek or Y-12. These key discussions are important and should be more detailed. He urged the subcommittee to think about this idea for the future.
- Mr. Jeffrey Hill asked Mr. Lewis if he was making a recommendation or a formal motion.
- Mr. Lewis said he thought it would be nice if the subcommittee followed up on the idea. Again, a verbatim would not be necessary for everything that the subcommittee discussed, but it would be important for critical or technical discussions, so that the subcommittee would have a stronger document upon which to support its position.
- Mr. Hill asked Mr. Lewis how the subcommittee might determine when they wanted a verbatim transcript versus a summary.
- Mr. Lewis responded that the subcommittee could follow the PHAWG's current process. When the work group approaches more difficult issues, such as highly technical presentations, those issues are flagged in advance, so that the writer/editor will capture the deliberations regarding issues that the public may have difficulty understanding. He stressed that he was not suggesting a verbatim for every miscellaneous issue that the subcommittee discusses, but when the group is dealing with issues as important as White Oak Creek or Y-12, he thought it was important to document the discussion at least to a level of detail similar to that in the PHAWG.
- Ms. Davidson asked the group how many people actually read through the minutes. A show of hands indicated that everyone reads the minutes. She suggested that the group think about this topic for later discussion. However, it was her opinion that if the group switched back and forth from a summary to a verbatim in the same document, it might cause difficulties for the writer/editor. She suggested that the group should make a decision as to what type of minutes, either verbatim or detailed summary, they would like and leave it at that.
Hearing no further discussion, Ms. Davidson asked for a motion to approve December's meeting minutes.
Mr. Bob Craig moved to approve the December minutes. Mr. Charles Washington seconded the motion. The motion carried.
Ms. Davidson then requested that all meeting attendees introduce themselves for the record [those who were present are delineated at the beginning of this document]. Following the introductions, Ms. Davidson asked the ORRHES members from Roane County if they would like to extend a welcome to the group.
- As a resident of Kingston, Mr. Tony Malinauskas welcomed everyone to Kingston.
- As residents of Roane County, Mr. Hill and Mr. Lewis welcomed everyone to Roane County.
Ms. Davidson then requested that Ms. Spencer review the status of the subcommittee's action items.
Ms. Lorine Spencer
Executive Secretary and Designated Federal Official (DFO)
Oak Ridge Reservation Health Effects Subcommittee (ORRHES)
Before briefing the group on the status of the subcommittee's action items, Ms. Lorine Spencer reminded subcommittee members to turn in their applications to reapply for ORRHES membership by the end of this meeting, if they had not yet done so.
Ms. Spencer then referred attendees to Tab #4 in their binders, to the Action Item list. She indicated that the list was color coded, with the gray items being completed action items, the yellow items being pending action items, and the blue being ongoing action items.
Ms. Spencer discussed the following current pending action items:
- The Division of Health Education and Promotion (DHEP) will return in the future to discuss the Phase II work of the Needs Assessment. Ms. Spencer pointed out that representatives of the DHEP were present during this meeting to discuss their continuing plans. This item was expected to become a "Continuing Action Item" soon.
- ATSDR, in collaboration with ORRHES, develop an issue-based, cross-referenced index of key issues, based on the various agendas from meetings, to be placed on the website. This task is something that ATSDR is currently undertaking. There is a plan and there is some expertise within the DHEP with whom ORRHES will be working. The plan is to examine the website and develop ideas to submit to the Communications and Outreach Work Group (COWG) or any of the other appropriate work groups for feedback.
- ATSDR was to clarify with Dr. Tim Joseph the suggestion to update the compendium of all health-related research studies at Oak Ridge. Mr. Jack Hanley was to discuss this issue with Dr. Joseph. Ms. Spencer indicated that this task had not yet been accomplished, but she planned to talk with Dr. Joseph about this action item before he left this meeting.
- Mr. Jerry Pereira was to distribute the Public Health Assessment (PHA) Guidance Manual to ORRHES after the document is approved for release. Ms. Spencer stated that this document was still awaiting approval by administration. As soon as the document was approved, it would be distributed to ORRHES members.
- Ms. Adkins asked if all five vacancies on the subcommittee would be filled.
- Ms. Spencer replied that she did not know at this time. Staff assembles the application packets, but they do not have any control over who is selected to serve on the subcommittee. Those packets are submitted to Dr. Gerberding's office. Dr. Gerberding is the Director of the Centers for Disease Control and Prevention (CDC) and ATSDR. The packet then goes to Washington to the Secretary of the Department of Health and Human Services (DHHS). At that level, it is unclear what happens to the packets, but the administration will let staff know who is and is not approved to be on the subcommittee. Certainly, ATSDR makes strong justifications for the people who are submitted, but the actual selection decision for membership to the subcommittee is made at a higher level.
- Mr. Lewis asked if Ms. Spencer was talking about the final decision to bless the ones that ATSDR has picked. He reminded Ms. Spencer that the subcommittee had some concerns with maintaining a diverse panel and asked if ATSDR would be able to make the final selections based on the identification of any weaknesses in some of the open positions, or if that would be left up to senior management.
- Ms. Spencer responded that ATSDR has recruited people as best they could to fill the subcommittee positions. For example, an application has been received from a physician, which was one of the subcommittee's concerns. Staff submits the applications received and makes strong justifications for approving the applicants submitted. They also make the decision about whom they send forward to Washington. She indicated that, at this point, all of the applications received looked as if they would qualify for committee membership, but stressed that the final decision is made at a higher level.
- Mr. Jerry Pereira added that he was quite concerned about some talk he was hearing about Washington's playing hardball with renewing people, and he was afraid that there was going to have to be some strong, hard decisions made by the agency, certainly above his level, with regard to ORRHES membership. They may ask for his recommendation or they may not, but depending on what they do regarding the sitting members here and how much time is left to complete this subcommittee's goals, he is quite concerned. He stated that he could not fathom attempting to bring a whole new set of people up to speed regarding the ground that the ORRHES has covered and considering what ground there was left to be covered. He was optimistic that they would get the membership through, but he has seen things happen in other subcommittees that did not look good.
Mr. Jerry Pereira
Agency for Toxic Substances and Disease Registry (ATSDR)
Mr. Pereira stated that nothing had changed tremendously since his last report regarding the contaminants. In terms of dates, it was his understanding from a reliable source that, by the next ORRHES meeting, the Iodine PHA would be on track. The groundwater issue also would be on track. Mr. Pereira indicated that the entire package of all PHAs due was still within the guidelines and total timeframe.
The main point Mr. Pereira said he wanted to raise related to the budget. He directed the subcommittee's attention to Dr. Mark Bashor's letter, on the bottom of page one, where a chart showed that ATSDR's budget from 1999 to 2003 has been steadily decreasing. As of January 22, 2004, the omnibus budget was passed. Within that budget are the funds for all of the Federal Advisory Committee Act (FACA) charters. Within those funds, there are some earmarked monies for NIOSH and for the University of Nevada, Las Vegas (UNLV), which will have to be used for specific items. Mr. Pereira said he believed that the amount was approximately $7.2 million to NIOSH and $4 million to UNLV. He indicated that ATSDR was anticipating an additional cut, but he did not know what kind of impact the cut would have on the agency or on the ORRHES.
Mr. Pereira assured those present that if he found out something was going to impact the ORRHES immediately, he would meet with the senior management of ATSDR and with Dr. Davidson. He said that if Dr. Davidson did not hear from him between this meeting and April, he would report again on this issue during the April meeting. If something did arise that he felt needed the immediate attention of the senior staff at ATSDR, the ORRHES Chair, and the Work Group Chairs, then he would convene a special meeting to discuss the issue.
- Mr. Washington suggested that the decreasing budget might be included as part of the justification for maintaining the core group of the ORRHES. The justification should include budget concerns, legacy knowledge, cohesiveness of the group, and the critical timeline for completing their report.
- Mr. Pereira responded that all of those items would be included in the justification of everyone who wishes to reapply. Even if they chose not to allow everybody to remain on the committee, there is a six-month grace period from the actual termination date, during which a person would still be allowed to keep their seat on the ORRHES, as long as that seat was not replaced. In other words, if someone was not approved to return to the ORRHES, ATSDR could keep the member on the subcommittee for another six months, in order to complete projects. That is the worst-case scenario. The best-case scenario is to have everyone approved by Washington.
- Mr. Lewis asked if there was a target date for when the issue-based, cross-referenced index of key issues project might be completed and when that index would be placed on the website.
- Ms. Spencer replied that they were hoping to have the index up by April 2004 for testing purposes. She and Ms. Susan Robinson have not had time to pull that project together, but that was next on her agenda following this meeting. Ms. Spencer said she did have some community members come into the office, use the website, and download the application for the ORRHES from the website. Most of them found it relatively simple to use. More usability testing is planned.
- Dr. Davidson asked what the timeline was for submitting the ORRHES membership applications to ATSDR, or if there was a deadline for submitting them to Washington.
- Ms. Spencer responded that they had to have the package to Committee Management no later than June 2004, at which time Committee Management would submit the packet to Washington.
- Mr. Donald Box asked if Ms. Spencer knew if anyone on the present committee was not planning to reapply.
- Ms. Spencer responded that everyone had been given until the end of this meeting. She said she had received almost everyone's applications, and she knew that some people probably had their applications with them to submit. Her understanding was that most of the members were reapplying.
- Dr. Davidson pointed out that the subcommittee's project plan outlines a great deal of work ahead in 2004. She stressed that it was important for everyone to remain focused on their specific tasks and not become too distracted by other things, because otherwise they would not be able to complete all of their tasks. Also, if there are budget cuts, then members will need to become more efficient, because they will still have to do the same amount of work with, perhaps, less money.
Hearing no further discussion, Dr. Davidson asked the group to welcome the ATSDR/DHEP staff members who would be presenting a response to the ORRHES's recommendations to ATSDR regarding the needs assessment document. She reminded the subcommittee that, following the presentation, the Needs Assessment Work Group (NAWG) would deliver its report, because they would be presenting a recommendation to the ORRHES. The subcommittee would not take a vote on that recommendation until after everyone had a chance to familiarize themselves with the topic and recommendation. The other work group reports were to be held until later in the meeting, after further presentations.
Dr. Terrie Sterling
Dr. Terrie Sterling directed the group's attention to both her slide presentation and the written handout provided on ATSDR's response to the ORRHES's recommendations regarding the needs assessment document. She requested that those who did not have the documents let staff know. She indicated that on May 31, 2003, the DHEP/ATSDR submitted a draft report entitled, "Assessing the Health Education Needs of Residents in the Area of Oak Ridge Reservation, TennesseeFinal Report, May 23, 2003." This report was prepared by the George Washington University Medical Center. Members of the ORRHES, as well as the broader Oak Ridge Reservation community and surrounding area, conducted a thorough and extensive review of this report and developed conclusions regarding the report. During the ORRHES meeting on August 26, 2003, the NAWG made three recommendations that were voted on and passed by the ORRHES. What follows is the ATSDR's response to each recommendation:
- The ORRHES recommended that the report should not be used as the basis for any future public health education program to be conducted in the Oak Ridge Reservation Region.
- The ORRHES recommended that future ATSDR/PHEP activities related to PHA be based upon the findings of the public health assessment program which should, with the advice of the ORRHES, ascertain the following:
- The degree to which releases of containments from the DOE sites contributed to regional public health problems.
- The degree to which there is a need for additional public health educational services.
- The degree to which the existing public health and medical services establishment can supply any substantive unmet public health education needs in both the rural and urban areas.
- The degree to which ATSDR might meet any additional needs by augmenting the current system by printed material or presentations by experts. Not to do this will very probably result in the duplication of much effort as well as be an affront to the existing health care system.
- The degree to which any necessary educational effort can avoid the onus of distrust that has cursed all previous efforts.
- The ORRHES recommended that ATSDR examine the project structural and management components, which enabled the report and project to reach this state without ATSDR overview and without subcommittee or working group review that could have remedied its shortcomings.
DHEP/ATSDR agrees with this recommendation. This report will not be used as a basis for any health education or health promotion effort. However, the agency reserves the option of using portions of the report that it considers to be methodologically sound and potentially helpful in understanding the ORR community. For example, some information gathered from the key resource interviews may be useful, such as the finding that most health officials, community leaders, and community members often find out about residents' health concerns through public meetings. Another example, despite concerns with the telephone survey, is the finding that heart disease was a key concern that individuals had for themselves. This may be an issue that warrants further explanation and, if important to the community, DHEP could assure the information is communicated to the appropriate health resources.
The DHEP/ATSDR agrees that any planned health education effort for the Oak Ridge Reservation (ORR) community should include activities related to the findings of the PHAs, whether or not it is determined that releases of contaminants from the DOE sites occurred at sufficient levels to cause health effects. DHEP intends to work with Division of Health Assessment and Consultation (DHAC) staff from the beginning of the PHA process, so that education and communication can be an ongoing process.
The DHEP/ATSDR approaches difficult public health problems through the application of various strategies, including community and professional education, communication, and building supportive environments. The DHEP/ATSDR will use information about the ORR community that is presented in the PHAs as well as from other sources for health education planning. Health education and promotion efforts may also address questions that are not directly related to the PHA, but which are of concern to community members. Strategies may focus on health care providers who often have no training in taking an exposure history or counseling patients about hazardous substances. Education strategies may need to be tailored so as to be appropriate for specific audiences and community settings.
Finally, the DHEP/ATSDR knows that trust forms the basis of any successful partnership. Throughout all activities and interactions with the NAWG, ORRHES, and the ORR community, the DHEP/ATSDR will conduct business with this principle in mind and will work to engage all participants, inviting and accepting community input and involvement in the agency's efforts to build trust as a foundation for all educational efforts.
The DHEP agrees with this recommendation and is currently reviewing its processes for managing and providing oversight to contractors and subcontractors. The DHEP has determined that subcontracting for a health education needs assessment (as was done with GWU) is not the most efficient or effective process for obtaining the desired product. The DHEP is unlikely to do so in the future unless clear operating procedures are in place and agreed to by the contractor, permitting a step-wise review and approval of the subcontractor's approach and work products.
In future health education and promotion efforts for the ORR community, DHEP will seek closer working relationships with, and involvement of, the NAWG and the ORRHES. DHEP will work with the NAWG to establish effective mechanisms for clear communication to allow for the health education and promotion needs of the ORR community to be identified and addressed.
- Dr. Cember asked for clarification regarding the recommendation not to subcontract needs assessments. He asked to whom DHEP might allocate the responsibility for health education needs assessments.
- Ms. Sterling responded that the recommendation was that the DHEP review its processes, structure, and how it manages and conducts oversight of contracts. In the future, when the agency contracts directly or subcontracts with an organization, they will need to ensure that there are: clear oversight, deliverables, and processes in place to ensure that the work is done properly.
- Mr. David Johnson asked how the DHEP planned to maintain the level of trust required to maintain a successful partnership with the community, and what mechanisms they plan to use.
- Ms. Sterling said she was not sure that she could personally cite a particular mechanism. The DHEP plans to: be onsite more often; to stay in communication with ORRHES members; to make sure there is a clear way for people to be involved; to offer involvement and input; to allow for, whenever possible, activities that would build the capacity of the communities or neighborhoods with which the agency works. The DHEP plans to plug into the network that exists in communities that are trusted, to see if they will be willing to work with the DHEP. Ms. Sterling said she thought it was a matter of trying to be open, honest, and being there to listen and to respond.
- Mr. Johnson asked what mechanism the DHEP would be using with regard to conflict resolution, because the agency would sometimes encounter territorial mindsets in some communities. Also, some personalities take a governmental agency coming into their communities quite personally. He wondered how the agency would attempt to address those types of concerns.
- Ms. Sterling responded that the DHEP hoped that the community members working with them would help with those situations. She thought that it was really important to have community members accompanying the DHEP in every stage of their work.
- Dr. Cember pointed out that a study was conducted in large communities, in Eastern Pennsylvania. With regard to questions dealing with health effects from radiation and radioactivity, 90% of the people polled said that their main trust would come from physicians, nurses, and so forth. The other 10% said that their main trust came from the clergy. Dr. Cember suggested that if there were going to be any outreach and educational events, primary targets should be the healthcare community and then the clergy. Then the education would filter down, hopefully, to the general population, since those are the people whom they trust the most.
- Mr. Lewis produced several overheads and asked if they could be projected on the screen. He asked if he could speak for a few moments on the subject of trust, indicating that he had developed different types of trust after having done some reading. Two of the types of trust discussed in the books he had read were trust in the federal government and social trust. Dr. Davidson asked if Mr. Lewis could wait until later to present his ideas because they did not directly tie in with the topic at hand. Mr. Lewis agreed to wait.
Mr. Jerry Pereira
After sharing a map of the ORR community and an overview of his presentation, Mr. Pereira indicated that the White Oak Creek PHA Initial Plan, a plan to connect the ORR community to resources through outreach, communication, and education, was comprised of three phases: Red Cover, Brown Cover, and Blue Cover. The Red Cover Phase is data validation, which will involve limited distribution. The Brown Cover is the phase in which the ATSDR will ask for public comment. The Blue Cover is the final report.
Mr. Pereira explained that the emphasis of the communication/education activities would change depending upon the phase of the PHA and the specific needs of the community as it applies to the findings and what ATSDR has learned in that PHA. ATSDR does not believe that one-size-fits-all, and materials that might be appropriate the White Oak Creek Health Assessment (e.g., in terms of distribution of information, health education products, flyers, fact sheets, and brochures) may be totally different than those needed for Y-12, mercury, or one of the other contaminants. The agency must keep this in mind when working with the ORRHES and its work groups. ATSDR plans to tailor the products to the specific needs of each community. The ORR Communications and Health Education Plan's overall goals are to:
- Increase participation by ORRHES members and interested individuals in providing input on the PHA;
- Collect and address the community's needs and concerns related to the PHA and their health;
- Assist the ORR community in understanding the findings of the PHAs; and
- Build capacity within the ORR community to respond to issues related to release of the PHAs.
Mr. Pereira pointed out that there were several critical key words to be found in these goals. The first phrase of importance is "increased participation." Many people are concerned about community participation, not among the ORRHES members, but among people in the community. It is critical that the plan stimulates the interests and desires of the ORR community so that they become aware of the issues, participate in the process, and give the ORRHES and the agency feedback. To date, for whatever reason, this has not been done well.
Many theories exist as to the reasons why community involvement in this process is lacking. One theory is that the ORR community has been so saturated with information about the DOE and their facilities, that they just want to live their lies. These factors must be considered, but the key word is "increase." What methods can be used to increase the community's participation?
Regarding the second goal, the key words are "collect and address the community's needs." ATSDR and the ORRHES must be good listeners in order to discover what the real impact is to the community and what the community wants to know. If the community is given information that it members either already know or do not care to know, they will not pay attention. Again, one size does not fit all.
The third goal is critical. The agency and the ORRHES must help community members to understand the findings of the PHA, so that they can take ownership of it and, hopefully, embrace it. This is a difficult task because the PHAs are extremely technical and include a great deal of scientific notation that the general public typically will not understand. Even ORRHES members have indicated that sometimes, when items come up for a vote, they do not always understand what is being discussed. The ATSDR must make a commitment to explain the PHAs better, so that the public will understand them clearly. Ideally, the agency would like for the community to have ownership in the PHAs, but to ensure that the public takes ownership, they must be a part of the process.
The last goal is also critical because the agency realizes that people need to be given the tools with which to make personal life decisions based on results found in the PHAs: Do I move? Do I stay? Do I change my patterns of living, eating, fishing, and so forth? People are going to be making their own choices based on their understanding of the PHAs. Even if a PHA indicates that there is no public health hazard, that message has to be communicated in a way that people understand and believe. These goals sound quite nice, but in reality all of them are extremely difficult to accomplish for many reasons. Mr. Pereira indicated that Dr. Elizabeth Howze would be explaining how the DHEP proposed to accomplish some of these goals.
- Dr. Malinauskas stated that one of the primary goals of a PHA is to produce a document that is approximately ten pages long, with, perhaps, one hundred pages of appendices attached. If the agency releases a document that is forty or fifty pages long, the community is not even going to attempt to read it, much less understand it. He thought that the group should strive for brevity and that the document should be written in a language that the community would understand. He suggested that the appendices should be left to the technical people.
- Mr. Pereira concurred with Mr. Malinauskas and indicated that he had seen, in the past, a larger document for the technical people and a briefer version that gives details and refers people to the appendices for more technical information. He indicated that ATSDR strives for that type of document by developing fact sheets that explain the implications of the PHAs for the public.
- Mr. Lewis said he thought that sometimes the agency had a tendency to focus on technical individuals, but the ORRHES is made up of lay people as well as technical experts. As these PHAs are developed for the various contaminants of concern, many of the subcommittee members follow these issues via the PHA and find that sometimes not enough work has been done at the subcommittee level to even communicate the issues in a ten-page brief to the members of the subcommittee, who are also lay people. One subcommittee member has suggested releasing some sort of brief on the PHA. Mr. Lewis thought that the group should follow up on those types of suggestions as to how the group might create documents clear and concise enough for the general public and subcommittee members.
- Dr. Craig explained that at the last PHAWG meeting, Ms. Melissa Fish prepared a draft of her executive summary for the PHA. The summary is four pages long, two of which are large pictures. It is quite well done and fits the description of the type of document being discussed.
- Dr. Malinauskas stated that his point was that the PHAWG, or even the ORRHES as a whole, ought to be reviewing a ten-page document and not a fifty-page document.
- Dr. Davidson said she believed that this problem was arising because the public and the subcommittee are now being included at the Red Cover level. In the past, the ORRHES and the public have not been included at that level, and documents such as fact sheets were released at the Brown Cover level, with the public comment version. The Red Cover version was originally designed for technical people, but the subcommittee is now being involved in that process to allow members to review that particular version. She reminded the group that the document had to include technical aspects, because it went to the agencies for data validation, and in order to have data validation, all of the technical aspects have to be included in the document. She asked the ORRHES if they wanted to include another step earlier in this process, which would increase the levels, or if they wanted to wait until the public comment level. Dr. Davidson thought that the subcommittee included plenty of experts on the various issues, and if everyone would work together, she thought that they would be able to find a way to express themselves so that everyone would understand all of the particular issues.
- Dr. Tim Joseph said he would be pleased to address this issue if the subcommittee requested that of him.
- Dr. Howze suggested that she be allowed to continue with her part of the presentation, which might answer many of the subcommittee members' questions.
- Dr. Craig pointed out that it was the PHAWG's responsibility to conduct a line-by-line review of the seventy-page document and the hard technical work, not the job of the ORRHES. Then, when the document comes back to the ORRHES for comments, it is up to each individual member to look at it and make comments from their diverse points of view. Certainly, anyone on the ORRHES is welcomed to become involved in the PHAWG, but they are not required to do so.
Dr. Elizabeth Howze
Dr. Libby Howze expressed her pleasure at being in Kingston, with the beautiful Clinch River right outside the door. She said that although the presentation she and Dr. Pereira were presenting during this meeting was being presented with a focus on White Oak Creek, the DHEP has developed a template for approaching the work in terms of communication and education, and the agency would welcome feedback at the end of the entire presentation on any of the processes presented. She also noted that what she was going to present might not have the level of specificity that the ORRHES might be looking for, but that was because of the current phase of the plan. Still, what is planned now is quite a workable outline and the details can be penciled in as additional data is obtained.
In Speaking of Health, 2002, the Institute of Medicine (IOM) stated that, "Effective communication is highly dependent upon the social and cultural milieu that shapes the individuals, families, and the communities that are the intended recipients." The DHEP agrees. Dr. Howze said that as she went through the rest of her presentation, she wanted the group to note how important the DHEP thinks it is to pay attention to different audiences in the eight counties included in the ORR community.
The audience groups and segments included in the plan include:
- ORRHES Members
- Interested Community Members
- Technical and non-technical
- Within specific PHA areaoutside of PHA area
- Interested groups
- Civic and environmental groups
- Government agencies
- Public health councils
- Elected officials
- Health Care Providers
- Hospitals, private practitioners
- Oak Ridge, Regional media
There may be other groups as well, but this is the initial list.
Dr. Howze illustrated the synergy that exists between the four general categories of communication and education: 1) Community Involvement and Outreach; 2) Community Assessment in the ORR area; 3) Communication: Awareness and Understanding, which includes whether people are even aware of what is going on in terms of a particular PHA. Or, if they are aware that it is going on, whether they understand the meaning of the results and what those results infer in terms of their actions or behavior; and 4) Health Education: Knowledge and Skills.
Dr. Howze reminded the attendees that Mr. Pereira had mentioned knowledge, skills, and what people might want to do differently as a result of a PHA. They could be thinking about that in terms of their own individual or family behavior, but they could also be thinking about it at the community level. One of the things that Dr. Howze noticed when reading the White Oak Creek PHA draft was that at some point in the past, a policy change had been made that requires anyone who is thinking about building a dock on the waterfront to obtain a permit because of the possibility of disrupting the sediment in the water.
Dr. Howze then further detailed the four areas. For example, community involvement and outreach activities are being conducted by Mr. Pereira and his group in the ORR community. Target audiences in this area include people such as the ORRHES members, interested community members, other interested groups, community officials, and the local media. Strategies utilized to identify the community concerns include a website that is accessible to everyone. This website has the level of detail that might be of particular interest to the ORRHES members and to interested community members. The group also sends out pre- and post-meeting mailings and press releases associated with the PHAs. They also arrange meetings such as the ORRHES meetings and other meetings. The website is: www.atsdr.cdc.gov/hac/oakridge.
The purpose of the community assessment process in which the ORRHES is engaged currently is to refocus the gathering of important information about the ORR community that the agency would utilize to develop communication and health education materials, activities, and programs. The data contain things such as:
- Basic demographics for the eight county area
- Community infrastructure (e.g., medical resources or churches)
- Community networks for health education and promotion (e.g., churches, network of health departments, cooperative extension service agents)
- What the community knows about environmental hazards (No good grasp of this)
- What the community believes about living in the ORR area (No good grasp of this)
- Where community members get their health and environmental health information (Some ideas about this)
- Communication channels preferred by the different groups (Not known, but may be, as in Eastern Pennsylvania, that people rely on their health care providers for information, but in many communities, the clergy are often persuasive sources of information)
Dr. Howze explained that as they were building their evidence base, they were taking a four-pronged approach. Step one is to review existing reports, step two is to conduct some focus groups, step three is to conduct a literature review, and step four is to talk with people who are leaders in different aspects of their communities.
At this point the agency knows that:
- Cancer, heart disease, and respiratory problems are common concerns
- Physicians are the most frequently cited source of health information
- Hospital-based programs may be favored
- Short, written materials are preferred
Some of these patterns are similar to general patterns found in many populations. In terms of physicians being trusted sources, other research suggests that trickle-down does not necessarily work. There has to be a push-up by educated patients. This is something that will need to be investigated. Some key questions that the communication and education plan needs to answer about the different audiences before appropriate strategies may be developed include:
- What are our audiences' interests, opinions, perceptions, and information needs regarding the release of the White Oak Creek PHA and other PHAs?
- What do they recommend we do to communicate the findings of the PHA, to include approaches, sources, channels, and materials?
- What health issues continue to concern the community related to the PHA and in general, such as perceived health issues? For example, Dr. Sterling mentioned that heart disease is a community concern. That is something that ATSDR would want to discuss with the health department and see if there are some ways to address this concern.
- Do the developed materials communicate to our audiences what we want to convey and what they want to know?
Dr. Howze indicated that the DHEP wanted to give the ORRHES a taste of what might be possible, depending on the results of the needs assessment, but there are some things that could be done with each audience with the ORRHES advisement. For example, the DHEP is going to continue to communicate the results of the PHA and develop mechanisms that are effective to do that. Information will be continually added to the website. The agency is going to continue to develop the brochure, "Do Radionuclides from White Oak Creek Affect the Health of People?" For example, one activity might be a short, portable, video presentation that could be taken to community meetings, which is something that the ORRHES has asked for, that discusses what it is like to conduct a PHA. This would be an activity for people who are living in the White Oak Creek area and would be presented in a way that would take the technical process reflected in the Red Cover and put it in a visual format that would walk people through some of the steps of a PHA that are of interest to them.
Dr. Howze shared strategies, activities, and materials for audiences that might be outside the PHA area. The group might want to work with the Oakridge Museum to develop an exhibit that explains risk assessment. This exhibit might have a mobile component that could be taken to locations like the Kingston Community Center as part of a public education effort to help explain PHA findings and how those findings were developed. For specific interested groups, the group might undertake several different projects. For example, they might want to assemble community leaders in one county or across the area and present a detailed briefing of the PHA results, so that the leaders obtain those results in advance and are in a better position to engage in discussions with community members about those results. A special, in-service educational opportunity could be provided for high school teachers in the ORR community, for which they could obtain in-service credit. They, too, are opinion leaders and hold the key to being able to educate students, parents, and other community members. Another idea would be an oral history project, where younger people in schools might interview people who have lived in the ORR community for decades, about what their experiences have been like.
With health care providers, the DHEP has thought about the possibility of conducting professional education and training with physicians, physician assistants, public health workers, and others, so that they would hear about and understand the findings of the different PHAs as they are released. This would be based on community needs. With the media, a number of different strategies might be useful. The media is in important source of information for everyone and can be a partner in communicating the results of PHAs. One of the thoughts the agency had was perhaps to develop some personal stories about ORRHES members or members of the community living in some of the different areas where the PHAs are being conducted, to convey the concerns and the passion that the ORRHES exhibits in the work that it does.
Dr. Howze stressed to the group that it was important to keep in mind that what eventually was accomplished would depend on available resources. Mr. Pereira already mentioned that the agency does not have a good sense thus far of what the resources might be in terms of funding, but resources do not include only funding. Resources also include working in partnership with the ORR community to assist the agency in areas such as completing the community assessment and gaining access into communities for real partnerships. Obviously, the plan is not finalized and the agency needs input from the ORRHES. Dr. Howze explained that although she had used White Oak Creek as an example during her presentation, a wider focus is planned beyond White Oak Creek.
- Ms. Adkins said she was thrilled with the agency's plan and appreciated the concern for the people in the community. However, she pointed out three areas of caution in terms of aspects to consider as the plan is refined:
- Part of the mistrust is that the community is wondering if all of the information been provided to the people who were working on the PHA. Have they been provided all of the information regarding where things were buried, where things drained, and where things blew? It was for this reason that she kept emphasizing a multi-layered map that shows the topography of the land, underground terrain, sinkholes, the locations where waste was buried, et cetera, so that the agency could locate the problem areas and could confidently tell community members that the issue has been addressed properly.
- Although nationwide, people may indicated trust in their medical professionals, based on her personal experience and from talking to approximately eighty people, the people in the Oak Ridge area do not trust the medical professionals. In the 1980s, Dr. William Reid found a correlation between an unusual incidence of kidney cancer in his patients and the metals that were being emitted from the plants in Oak Ridge. He was discredited, humiliated, and horrible things happened to him as a result of his findings. The medical community froze at that time. She said she and her friends tried to obtain medical help, but could not because doctors were afraid of dealing with anything related to metal exposures or problems from Oak Ridge. She actually has had physicians refuse to treat her and has had physicians withdraw from treating her after they found out her various exposures, because they did not want to be labeled a quack like Dr. Reid. This is a major hurdle for the local citizens, and one which the agency may not be aware.
- It is important to include information on what to do if someone is suspicious that they have been exposed to something. Ms. Adkins said that a woman who planned to attend this meeting has strontium-90 showing up in her laboratory results. Ms. Adkins did not know if the woman would be well enough to attend in the afternoon, during the public comment period. The ORRHES and ATDSR do not need to just say, "Well, there is no apparent problem," because even this [indicating the PHA document on the table] says that some people could have possibly been exposed to these contaminants, and these contaminants are showing up in their bodies. What should someone do if they suspect they have been exposed? What do they do to set their minds at rest? Ms. Adkins concluded that this was going to have to be an important part of the plan.
Ms. Adkins then pointed out that community members with cesium, strontium, and arsenic issues had arrived, but they could not wait until the public comment period. She asked if the agenda might be reworked to allow an additional but brief comment period between then and 4:30 p.m., and if it might be possible to have five minutes at this time. Dr. Davidson agreed to give the public an additional, brief, five-minute comment period. The original public comment period took place as scheduled, later in the meeting. Ms. Adkins introduced Mrs. Johnson Stokes and her daughter Janice.
Ms. Janice Stokes
Citizen, ORR Community
Ms. Johnson Stokes opened her presentation by thanking the ORRHES for making the change in their schedule and allowing her to speak. She indicated that it had been a long time since she had attended one of the ORRHES meetings, but this meeting in Kingston was close to her heart because this is her hometown and she still has family who live in Kingston.
Ms. Johnson Stokes said she was reviewing the draft PHA document that was sent to her, and she wanted to make a comment before the official comment period began so that the subcommittee could be thinking about her observations. It is quite vital that the ORRHES understands that the ORR citizens live in a valley between the Cumberland Mountains and the Smokey Mountains. One of the problems is that the agency is looking at one individual contaminant at a time, and the quantity of that contaminant being released into the air will almost always show up as no public health effect. What the agency is not looking at is the cumulative total of releases (air, water, soil) with regard to the amount of radiation and chemicals to which the people in this valley have been exposed, not just downstream but also downwind, and including farmers and others who have eaten local produce and who drank the milk. This was one of Ms. Johnson Stooke's major concerns as she conducted a preliminary review of this latest ATSDR PHA document. She asked that the ATSDR address this concern before the assessment continued, because she did not think that it was worth reviewing anything if this issue was not addressed.
Secondly, in Kingston, she said she had witnessed the following: Upon starting down Highway 58, on Kentucky Street and Ray Street in Kingston, she first noticed the sky darkening with seagulls flying over the water. She and a friend stopped to look closer at what was causing such a feeding frenzy. They stopped at the park, got out of the car, and walked near the river's edge, where they found a massive fish kill floating downstream. Concerned, she placed a call to the Tennessee Wildlife Resources Agency Office and reported the fish kill. The Tennessee Wildlife Resources Agency was unaware of this. Ms. Johnson Stokes and her friend followed the flow of the fish kill to the mouth of the Clinch River, where it empties into the Tennessee River. They then noticed that the fish appeared to be floating upstream of the Tennessee River, which is just around the bend, south and to the left. She and her friend proceeded to a location under the Highway 58 bridge, which is over the Tennessee River, and noticed that the fish were, indeed, floating upstream and past the city of Kingston Water intake. This is a serious concern, since anything that may have killed the fish, other than temperature change or rollover, could affect the humans who drink the water.
It was explained to her that a natural phenomenon occurs when the Tennessee Valley Authority (TVA) shuts off one dam up the Tennessee River and at Melton Hill on the Clinch River. When the TVA shuts off Fort Loudon Dam spilling, Melton Hill is still spilling. Although the water is flowing, it is actually sucked back upstream, probably into the ground caverns. This was scientifically explained to her as being a phenomenon that does occur, which can be observed when buoys float upstream on the Clinch River. This can also be seen on the Tennessee River side. She is aware that this phenomenon does occur and it is quite visible. However, fish kills happen in this area often, several times a year. In the past, fish kills occurred so often that in the morning, there was an associated odor. As a student of this issue for an extensive period of time, as far as Ms. Johnson Stokes was aware, during the strontium spill at K-25 in the 1980s, which shut down Kingston's water intake for only one day, Kingston's water intake has never been shut down for any kind of spill other than that one. Although a local problem, Ms. Johnson Stokes thought it was definitely a problem that the DOE should investigate.
- Dr. Davidson asked Ms. Janice Stokes to provide her comments to Mr. Bill Taylor at the Oak Ridge Field Office so that they could be included with the comments that the work group is submitting to ATSDR.
- Ms. Janice Stokes agreed to provide her documents to the ORRHES. She added that on the handwritten document she had in her possession, she had not written her comments regarding her review of the PHA.
- Dr. Davidson asked if her comments were related to White Oak Creek.
- Ms. Janice Stokes replied that they were related to White Oak Creek. The Clinch River carries White Oak Creek water into Kingston, and with over 200,000 curies being released from White Oak Creek from approximately 1944 to 1971, that is a lot of radiation. She wondered if anyone in the room knew how many counts per second one curie was.
- Dr. Cember responded that it was thirty-seven billion disintegrations per second.
- Ms. Janice Stokes stated that thirty-seven billion disintegrations per second times 200,000 is how much radiation has come into this river. Kingston certainly needs activist currently, and she considered the ORRHES members activists or they would not be here. She stated that she appreciated their activism.
- Dr. Davidson asked Ms. Janice Stokes again to make sure the ORRHES received her written comments.
- Ms. Janice Stokes indicated that she had a letter to the Tennessee Department of Health (TDH) about the water intake, which she could copy for Dr. Davidson, but noted that she had made her comments about that in her presentation, for the record.
- Dr. Craig asked for the ORRHES copy Ms. Janice Stokes' comments for the work group, because they were good points.
- Dr. Cember said he remembered reading in the PHA that the estimated doses were based on all of the nuclides, not just each one separately. He found the paragraph and read that the "estimated whole body dose is based on a minimum 50-year intake or less than 100 millirems." He believed that this was for intake from 1944 until 1991. "The maximum estimated dose after 55 years of intake is 230 millirems for all of the radioisotopes." He said he read directly from the document to point out that the isotopes were not considered individually as being trivial, but together they were considered and the doses were estimated on that basis.
- Ms. Janice Stokes asked if ChemRisk calculated that estimation.
- Dr. Cember indicated that he did not know. He was just reading from the Red Cover PHA.
- Dr. Paul Charp indicated that the past exposure assessments from the 1940s through 1991 were performed by the Specialists in Energy, Nuclear, and Environmental Sciences (SENES) of Oak Ridge, under a contract with ChemRisk.
- Ms. Janice Stokes asked if a PHA had been conducted prior to their estimation (e.g., Was all of this information known when they calculated their estimations?).
- Dr. Charp responded that ChemRisk and SENES based their estimations on all of the information they could glean from DOE reports, interviews with workers from the site, and a document review through all classified and unclassified information. Their report was released in 1996. The current PHA covers releases from 1990 through the present.
- Ms. Janice Stokes commented that Dr. Owen Hoffman participated in the ChemRisk study. Dr. Hoffman has developed a program that shows considerably more exposure than this estimation shows. His calculations are shown in a document that the ORRHES can obtain. It is also based upon his participation in the review. She recommended that the group listen to Dr. Hoffman and observe his calculations as well, so that the group would have more than just one source for those calculations.
- Dr. Charp explained that the sources the ATSDR used for the past doses were his calculations.
- Ms. Janice Stokes acknowledged this, but said she did not know what time ATSDR did their calculations. The calculations she was talking about were done after the ChemRisk study was closed.
- Dr. Charp asked if Dr. Hoffman was refuting his own calculations.
- Ms. Janice Stokes replied that she was not going to get into a scientific debate with anyone, but she asked Dr. Charp to contact SENES and have them present what they believed to be the correct dosages to the ORRHES. She thought that the committee would see a major difference between what the ATSDR is saying and what SENES says.
- Dr. Craig indicated that the ORRHES has Dr. Hoffman's comments, and all of his calculations will be available to the reviewers and will be incorporated in the PHA.
- Dr. Davidson pointed out that Dr. Hoffman has never been shy about giving the ORRHES his comments.
Dr. Terrie Sterling then presented the proposed plan for collecting information about the ORR community suggested timeline. Ms. Mosby noted that the NAWG's recommendation to the ORRHES would follow Dr. Sterling's presentation.
Dr. Terrie Sterling
Dr. Sterling pointed out that the plan the DHEP was presenting was more detailed and related to the fact that the DHEP feels strongly that additional information is needed from the ORR community and the surrounding area prior to developing appropriate public health education and promotion activities. The DHEP wants to collect information so that the agency may address adequately environmental health concerns, as well as to integrate findings from the PHAs as they are released. For purposes of this plan, "community" refers to an eight-county area, including Anderson, Blount, Knox, Loudon, Meigs, Morgan, Rhea, and Roane counties. The types of information that the DHEP plans to collect through various approaches include:
- Demographics for the eight county area
- Community infrastructure (e.g., medical resources)
- Existing community networks
- What the community knows about environmental hazards
- What the community believes about living in the ORR area
- Where community members get their health and environmental health information
- Which communications channels are most often used by different groups in the community
- Other information as appropriate
Dr. Sterling presented the proposed approaches for collecting the information, reminding everyone that Dr. Howze had already reviewed these four approaches which included:
- Reviewing existing documents and reports
- Conduct focus groups
- Review existing literature
- Key resource interviews
Dr. Sterling then went through tables that showed a step-by-step process, along with an estimated timeline of how long it might take to accomplish each of the activities.
The task of reviewing existing documents and reports involves the following steps:
- Gathering and identifying materials to review, such as the University of Tennessee report and reports on the public health status that are produced by the county public health departments;
- Designing a template for extracting the types of information that would help answer some of the data questions;
- Extracting and organizing the data;
- Drafting a summary report;
- Gathering feedback from the ORRHES and the NAWG on the report, given for editing; and
- Finalizing the summary report on the review of existing reports and documents.
Dr. Sterling indicated that the body of the tables she would be displaying showed the estimated weeks allotted for each of the activities. In the Review of Existing Reports Timeline, for the first two activities of identifying and gathering reports and designing the template for extracting and organizing the data, would occur simultaneously, but might not be completed at the same time. Overall, the review of existing reports is anticipated to take approximately eleven weeks. The DHEP also feels that it is quite important to conduct focus groups, with the ORRHES's assistance. This was a major step in the development of health education/health promotion materials that everyone felt would be quite useful. Therefore, the DHEP's intent is to contract with someone to assist them in conducting the focus groups as well as to invite the ORRHES's participation and identification of community members who might be willing either to participate in or be co-facilitators for these focus groups. Dr. Sterling pointed out that the steps in the focus group activity include:
- Preparation will be made for focus groups
- Focus group participants and focus group leaders will be identified and invited
- Focus group leaders will be trained
- Focus groups will be conducted
- Focus group data will be compiled and a report drafted for review
- Feedback will be obtained on the report
- Summary report will be finalized
Dr. Sterling acknowledged that this thirteen-week timeline was ambitious, but she believed it could be accomplished with the right kind of assistance and support. Another step in the development of the health education and promotion materials involves a literature. Steps in the literature review process include:
- Identify appropriate publications, including newspaper articles, journals, et cetera
- Design a template for abstracting and organizing concerns
- Extract and organize
- Draft summary report for review
- Obtain feedback on report for editing
- Finalize summary report as part of community assessment.
The final activity will be the Key Resource Interviews. The DHEP wants to be efficient about this step, and at this point, the belief is that the sector of the community that needs to be tapped into is the public health sector, which includes physicians, hospitals, and other health resources that exist in the ORR community. Dr. Sterling asked for the ORRHES's and other community members' assistance with identifying representatives with whom it would be appropriate to conduct interviews. Steps in the Key Resources Timeline include:
- Identify up to 9 representatives from the health care system and other community networks
- Use interview questions from other community assessments and tailor for the ORR community
- Interview representatives
- Compile results from interviews
- Write draft summary report
- Obtain feedback on report given for editing
- Finalize summary report
Dr. Sterling estimated that it would take approximately 13 weeks to complete all of these tasks, with assistance from the ORRHES and NAWG members. Many of the activities will overlap, with some occurring simultaneously and others pending. Dr. Sterling pointed out that week one was the same week on all of the tables. A timeframe has not been scheduled yet for the project. The information that the DHEP hopes to gather from all of these activities include:
- Clarify and map health concerns and resources
- Target health education and health promotion efforts
- Find out what and how information needs to be delivered
- Discover what else is occurring in the community
- Encourage collaboration and avoid duplication
Ms. Donna Mosby
Health Education and Need Assessment Work Group (NAWG)
Ms. Mosby pointed out that she planned to present the Health Education and Need Assessment Work Group (NAWG) Report in the form of a recommendation. She indicated that the Co-Chairs are Mr. Lewis and herself and that the NAWG meeting was held on Monday, February 2, 2004. Ms. Mosby said that everyone was aware that gaps were left behind after the George Washington University study. Therefore, the NAWG's recommendation was that ORRHES recommend ATSDR adopt the Proposed Plan for Collecting Information about the ORR Community Suggested Timeline that is outlined as a process to fill the gapes that were left behind after the George Washington University study. This will be an opportunity for ORRHES members to sign up and participate themselves and/or identify individuals in the community who might be willing to help carry out the plan. Ms. Mosby clarified that this recommendation was being brought forth from the NAWG, for the ORRHES to pass on to ATSDR. She asked if there were any questions or comments from those who were not a part of the NAWG.
- Mr. Lewis pointed out that during the previous evening's presentation, he heard some discussion about the utilization of the Savannah River Site (SRS) report as it relates to focus groups. The way that the SRS conducted their focus groups was examined. The work group also read another document from Fallon. The Fallon's focus group process was different than the SRS's process. The Fallon focus groups also were conducted under the umbrella of the ATSDR. Their plan appeared to bring together clergy and all of the people together to set up a focus group to address the issue, versus the model that was used at the SRS. He did not know which planning stage the DHEP was in, but he thought it might be beneficial to consider this different approach to focus groups. He asked the ATSDR to consider the different types of styles and let the ORRHES know what they thought of them.
- Dr. Sterling thanked Mr. Lewis for his comments, indicating his was the kind of feedback that the agency was seeking. She said one thing they might do is use the focus group guides, which are essentially the questions that were developed to do the focus groups at SRS as a beginning, and then tailor those to the ORR community. However, his suggestion took the process a bit further, and the agency certainly would be willing to consider those suggestions. ATSDR was involved in the Fallon focus groups.
- Mr. Lewis said he thought the ATSDR did a pretty good job with those focus groups. He then asked whether the Phase I/Phase II process was being continued in this process, with what was found in the community assessment determining what would occur in Phase II.
- Dr. Sterling explained that there are many new players in this process and the Phase I/Phase II process was discarded. However, the DHEP acknowledged that they did need more information about the ORR community and the surrounding area in order to help plan the types of health education/health promotion activities would be the most appropriate for the different communities in conjunction with the PHAs. She said that a "Phase II" has actually already begun with activities such as some of the work that Dr. Howze presented with White Oak Creek, work on the website, and the briefs to the lay people. These activities have begun in conjunction with Dr. Pereira and his group, but the information base still needs to be supplemented with more evidence.