ORRHES Meeting Minutes
December 3-4, 2001

Table of Contents

December 4, 2001

Presentation and Discussion: Community Health Centers: Needs and Strategy
Public Comment
Presentation and Discussion: State of Tennessee Screening Process for Past Exposure
Public Comment
Unfinished Business: Update on Subcommittee Nominations and Update on ORRHES Website
New Business/Issues/Concerns: Work Group Recommendations and Future Meeting Dates
Public Comment
Identification of Action Item Assignments/Closing Comments
Evaluation Consensus - Building Process

Day 2: Opening Comments

At 8:19 AM on Tuesday, December 4, 2001, Dr. Davidson welcomed the group to the second day of the Oak Ridge Reservation Health Effects Subcommittee meeting. The Subcommittee did a "roll call," and there was a quorum present.

Presentation and Discussion:
Community Health Centers: Needs and Strategy

Dr. Robert Jackson
Associate Director for Primary Care
Southeastern Regional Field Office
Health Resources Services Administration (HRSA)

Dr. Jackson addressed the group on the topic of Community Health Centers, explaining that HRSA is the arm of HHS that is concerned with personal care, access to care, and disparities between and among population groups. The agency provides leadership for ambulatory care, primary care, and other special healthcare needs around the country. HRSA is leading the Health Centers Presidential Initiative and covers all 50 states and the territories.

For the first time in a long time, significant new resources are being devoted to community health centers and related organizations. There is not yet a budget for the fiscal year. Given the times, reductions in the number of new clinics and in the amount of money available are possible. To date, about 10.5 million people receive care from HRSA's various enterprises. There are well over 3000 access points. Instead of general primary care, some clinics have begun to address management of specific issues, such as diabetes, high blood pressure, and trying to improve pregnancy outcomes.

The National Health Services Corps is the clinical work force of HRSA. They offer scholarships and professional training through a popular program called loan repayment. Through prior agreement, clinicians work in under-served areas and in addition to compensation, receive a certain amount of dollars to retire their education-related loans. HRSA is also responsible for Title V of the Social Security Act, which makes dollars available to states to improve pregnancy and the general health status of infants and toddlers. HRSA also operates the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act.

The southeast is one of the fastest-growing areas in the discovery and confirmation of new infections. CDC is the main organization for developing prevention programs, but when prevention is no longer possible, HRSA ensures that service and availability is at a proper level of quality in the community. A growing program at HRSA is in rural health, where outreach grants in states and communities support primary care clinics. Each state has an Office of Rural Health, and this program will likely continue to grow due to the difficulty of maintaining healthcare services in rural areas when the population is so migratory and more health professionals prefer to live in urbanized areas. There is no shortage of clinicians. The distribution of those physicians and other clinicians, however, is an issue. HRSA's programs provide scholarships for people entering clinical training and loan repayment for people who are completing their training. The production of health professionals and clinicians lies within states as states take responsibilities through various universities, colleges, and professional schools. HRSA works with states regarding how many clinicians are needed, where they need to be, and what incentives need to be developed to influence how they locate themselves.

Because of increasing attention to healthcare quality, the National Data Bank of Practitioners is the authoritative database of clinicians in the country who have been involved in malpractice difficulties and credentialing. HRSA is also responsible for organ procurement, transplantation, and vaccine injury. The many programs of HRSA work together to provide supportive services in states. HRSA is working with ATSDR to assess whether situations at Oak Ridge require HRSA's particular attention and resources. Understanding the Oak Ridge situation will require a great deal of discussion and understanding what HRSA can and cannot do because of their legislative mandates. Dr. Jackson noted that he had researched the Oak Ridge situation and did not have a "ready-made answer" regarding the possibility of HRSA's involvement there.

Discussion Summary:

• Ms. Kaplan observed HRSA's special initiative areas include women's programs. Women are disproportionately affected by Iodine-131 exposures. Also, rural areas are disproportionately affected by the placement of hazardous facilities because of their low population density. It is important to understand that traditional healthcare services are not working in the Oak Ridge area, where residents have been saying for some time that they are not well-treated by their healthcare providers.
• Dr. Jackson said that nothing in HRSA's legislation speaks to environmentally or occupationally challenged or damaged individuals. There is a piece under the Department of Energy that includes a very specific, industry-related, limited entitlement. He asked about the status of the needs assessment for the Oak Ridge area. HRSA is concerned with the number of people in need and their particular needs, including the clinical and technical expertise needed. The HRSA programs for women are driven by pregnancy, not by the woman's overall needs. He could not find legislation that would authorize ongoing clinical oversight of people who have been in communities and environments that raise questions of risk and potential damage. Dr. Davidson replied that the Health Education Needs Assessment is being conducted. It encompasses not only Oak Ridge, but the areas around it. The study is projected to be completed in May 2002.
• Dr. Jackson said that the number of people in need makes a great deal of difference. All pieces of legislation are specific about who has eligibility to receive services, and over what length of time. There is a Worker Health Protection Program under the Department of Energy in several communities, including Oak Ridge, with a specific list of benefits. He noted that in 1982, HRSA administered the Black Lung Program at a clinic for coal miners in Oak Ridge. This program ended in 1986 and there was no successful effort to retain the program. There is no law requiring retention of records from 1986, so it was not possible to say why the clinic closed, but Dr. Jackson surmised that the reason concerned the declining number of people who make their living from working in coal mines.

Mr. Lewis then offered a series of questions to Dr. Jackson from concerned citizens:

What kinds of health clinics does HRSA usually establish to meet community needs?

Dr. Jackson answered that HRSA usually provides generalized, primary care services; that is, a clinic is intended to meet the needs of anyone who visits it. Their interest is in the primary healthcare "safety net." In order to provide clinics to respond to specific needs in Oak Ridge, those needs must be expressed by a needs assessment. Mr. Lewis noted that the Subcommittee's efforts have not yet defined those needs. Dr. Jackson understood, and was therefore hesitant to provide details about what HRSA can do.

What kind of medical clinics can HRSA establish to meet the expressed Oak Ridge needs?

Dr. Jackson responded that HRSA is legally authorized to do general primary care, not specific programs for people with particular needs such as environmental damage or occupational medicine. They are, however, open to the possibility. He said that the only occupational group for which HRSA specifically provides funding is migrant farm workers.

If HRSA cannot meet the Oak Ridge needs, what other avenues are open to the community to obtain the desired clinic or clinical services?

Dr. Jackson said that the Department of Energy's program is very focused, and does not include families. Traditionally, the government has been reluctant to take on the obligations of family members in addressing an issue that is perceived to be occupationally-related, wherein workers are at risk, not families.

Could diagnosis, treatment, and research be facilitated by a cooperative agreement between some Oak Ridge or Knoxville health entity and existing, appropriate clinics? Can HRSA mediate such agreements?

Dr. Jackson felt that HRSA's responsibility was to mediate discussions that might be helpful. He was obliged to be alert to funding needs. HRSA can help the community make beneficial alliances, but devoting money requires "jumping hurdles related to legislation." These pieces of legislation are very detailed and specific. He believed that they should address the following question aggressively: Is there a need for generalized primary care in the Oak Ridge area? The foundation of most available money is in general primary care. It is widely perceived that Oak Ridge is not a medically needy area. Measures will determine whether communities are eligible or competitive for grant dollars. The Bush administration has been vocal about its wish to expand personal health services at the community level, so the discussions should increase in intensity.

If the needs assessment suggests a need, and a response is desired by the community, then HRSA can assist in convening a meeting with the parties that can facilitate the process, said Dr. Jackson. It is possible to create a clinic that is a "satellite" of another eastern Tennessee clinic. This process is less competitive and more flexible than other programs. The Oak Ridge community needs to meet the medically under-served designation for HRSA to be able to act.

The general discussion then continued:

• Ms. McNally noted that there is no federal legislation to investigate and protect communities such as Oak Ridge and Hanford that have been contaminated by problems from activities during the Manhattan Project. With more political activism, this area could become a focus in the future. She asked whether this movement could come as a result of the state of Tennessee becoming more active. Dr. Jackson replied that such a movement would be ideal. In this era, activity is moving to different levels of the government. He has been impressed by local community initiatives and innovations, which are politically viable.
• Ms. Sonnenburg emphasized that their ongoing assessment is for health education needs, not healthcare needs. This study was arranged before the Subcommittee formed. The community of Oak Ridge is well-educated. HRSA works to assure access to comprehensive, quality healthcare to all, and a group of people do not have comprehensive, quality healthcare available to them. She pointed out that workers are tested via a program in which a van comes to town for testing. If a the workers are deemed to need healthcare, then they are sent to out-of-town hospitals.
• Mr. Pardue recalled that the first step toward a clinic is to identify a need. Assuming that the Subcommittee recommends a clinic and HRSA is able to mediate or assist in that project, he asked whether the Subcommittee could interact directly with HRSA, or if they had to work through ATSDR. Dr. Jackson replied that ATSDR, HRSA, and whatever other agency might be identified to assist would join in the dialogue. He assured the group that they could rely on HRSA to be responsive.
• Mr. Hill commented that the Employees Medical Screening Program in Oak Ridge is not available to all employees. It is only available through the Pace Union through the AFL-CIO building. It is not available to the workers at the ORNL, at Y-12, or to the guards. When workers are sent to out-of-town hospitals, as Ms. Sonnenburg had mentioned, that work is diagnostic and treatment is not provided.
• Mr. Hill recalled learning at an earlier meeting that Hanford had a medical monitoring program that provided periodic medical evaluations. Dr. Jackson was not sure about the clinic situation at Hanford. The phenomenon of providing a diagnostic exam and then referring to the primary source of care has been the pattern for years. There are many people who do not qualify for Medicare or Medicaid and who also are not insured. Community health centers and those primary programs assure people that they get what they need, but it is hard to reach all of those people.
• Mr. Malmquist reflected on the numbers of people needed to qualify for a program. In Roane County, they had hoped for a veterans' clinic, but the Veterans Administration would not operate a clinic unless there were at least 3500 active cases in the service area. He asked if HRSA had such a specific number requirement. Dr. Jackson answered that the programs managed by HRSA assume at least 2500 people. In addition to people who have the issues and concerns that they had been discussing, they should consider the number of people in the Oak Ridge area who are likely to use a clinic because they are uninsured or because it is more convenient. A clinic's existence does not guarantee that people will use it. HRSA tries to buy into communities that have energy and organization to sustain the clinics.
• Dr. Davidson commented that Oak Ridge is an "oasis" within the area of interest. The outlying areas do not resemble Oak Ridge. She wondered about the proximity of a rural community to a town or city that would be considered under-served. Dr. Jackson replied that the criterion for unacceptable availability is 20 miles or 30 minutes of driving time. The residents of the nearby county are crucial to whether the area should receive a satellite clinic of an ongoing enterprise. There is a greater likelihood of building a patient load quickly in this option. It would be preferable to have the clinic next to the hospital, but there are many issues to be resolved. For instance, is the area inhospitable to the clinic because of the number of physicians' offices nearby? Also, the closer the clinic is located to groups of physicians, the more difficult it is to prove a need for additional resources.
• Mr. Johnson wondered about HRSA's receptiveness to working in collaboration or partnerships with grassroots communities, initiatives, and healthcare providers. He also asked how sustainability and self-sufficiency relate to attracting a clinic to the Oak Ridge area. Dr. Jackson said that HRSA has become very interested in partnerships. They encourage partnership development not just because of resources, but also because of validity in the community. He said that on the average, their clinics get approximately 45 percent of their annual revenue from a grant and 55 percent from patient fees, reimbursements, write-offs, et cetera. Factors such as the number of people who bring insurance and local support from laboratories and hospitals also contribute.
• Dr. Creasia asked whether Anderson County, in the Oak Ridge area, is medically under-served. Dr. Jackson replied that there is a primary care community health center grant in this part of state which includes part of Anderson County as its service area. That group might be one to consult in the process of seeking a clinic.
• Dr. Akin asked whether HRSA's legislation distinguishes between clinical services and medical monitoring facilities or capabilities. Dr. Jackson answered that the HRSA legislation calls for services. Monitoring is included as a form of service.
• Dr. Akin clarified that "clinic" typically includes a broad category of services for many medical needs. "Monitoring" implies more focused efforts; that is, monitoring for a specific reason such as exposure or another condition in the community. Around hazardous waste facilities, "medical monitoring" indicated a focused service for people who feel that they have been exposed. Dr. Jackson felt that the terms should not be distinguished. In offering primary care to populations, these services blend together. "Monitoring" to him applies to clinical outliers. They should focus on services, which include monitoring people with occupational or environmental history.
• Mr. Washington commented that Oak Ridge has been described by Margaret Mead as "an island of plenty surrounded by a sea of poverty." If a clinic must be located in a medically under-served area, then it probably could not be located in Oak Ridge. The surrounding communities may represent a better choice. One of the justifications for a clinic could be related to blood pressure, which could be related to occupations in this area such as heavy metals affecting kidney functions over long periods of time. There are several dialysis clinics in the area, and so a combination of these factors might lend to the possibility of a clinic. Oak Ridge is not so much under-served as residents do not have confidence that the medical community is aware of, or well-trained in, occupational illnesses that related to the diseases associated with facilities in Oak Ridge. Another possibility is HRSA's responsibility for organ procurement and transplantation. Their effort should center on a real needs assessment of a geographical area. Black lung disease still occurs in the area as well.
• Ms. Kaplan called the group's attention to the efforts of a local activist. His wife worked at ORNL and passed away, and he has become involved in issues regarding a clinic at the facility. Legislation is being introduced into the state that would force the plants' clinics to be operated independently. This effort might be a good partner.
• Mr. Lewis said that some community members have identified Oak Ridge as a "company town." There is also a feeling that physicians are "on the take." The perception is that a clinic would be independent of the current healthcare provider structure. He wondered if similar situations have been used as the basis for establishing a HRSA clinic. Dr. Jackson said that HRSA clinics allow for a certain autonomy and independence because community-based organizations are not beholden to public agencies or to private interests. He offered to provide examples of similar efforts after some research and clearance.
• Mr. Pardue suspected that a large problem with establishing a clinic is cost. A clinic for this area would be large and include a great deal of expensive equipment. He wondered about an approach that would use the Methodist Medical Center equipment and facilities so that there would not be duplication. There are concerns about physicians employed by Methodist Medical Center, but independently-funded, public health service doctors could see patients and perhaps conduct research. The community has good research facilities, and grants could come from a government agency or from the Department of Energy at ORNL. Dr. Jackson felt that an approach that utilizes and perhaps augments existing resources was logical and rational. The problem is not with the model, but in its implementation, as HRSA does not have the legislative authority to purchase the high-tech equipment that might be involved. HRSA has experience with using the resources of an existing facility, but they do not advocate for that approach because of the many problems with the process. It is difficult to be independent when working in another group's facility.
• Dr. Pereira asked whether HRSA requires a specific format for its needs assessment. Dr. Jackson said that HRSA has certain needs assessment issues that have to be addressed and he said that he would provide them to the Subcommittee.

Public Comment

• Ms. Cheryl Smith asked about the clinic in the Hanford area. Dr. Jackson replied that to the best of his knowledge, that clinic is not a HRSA-funded operation. He would follow up to make sure.
• Ms. Janice Stokes was concerned that discussion about a clinic was too focused. She asked the Subcommittee to consider a wider focus that would not only test for one or two contaminants in the body. Proper and thorough testing should be done, as a simple blood test will not identify all toxins and the "body burden." Many people will test below "permissible limits." A clinic must be operated independently and carefully and test properly. Her mother has tested positive for lead and arsenic at high levels, but they cannot get treatment for her. Toxicologists have recommended treatment, but the state is taking the licenses of the few doctors who will treat for metal poisoning.
• Ms. Gass mentioned a new test for PCBs in human tissue. She asked if HRSA has had experience with that test or with testing for heavy metals or cyanide in humans. Dr. Jackson was careful about making a generalization, as HRSA has 3000 clinic sites. He suspected that they had experience, but planned to investigate the issue. The question is interesting because of the primary care clinics that operate around various industrial plants on the eastern seaboard.
• Ms. Faye Martin observed that there is a high frustration level because of a lack of action. For several years, the community has wanted clinics. She suggested that they form a committee that will raise funds for a clinic. There are doctors all around that area, sick people, and buildings: what else do they need?
• Dr. Davidson wondered if such a group in Oak Ridge and the surrounding areas could partner with HRSA.
• Mr. LF Raby addressed the group about Tennessee Senate Bill 280. This bill requires the Department of Energy to operate the medical clinics at ORNL, Y-12, and K-25 with private contracts so that the medical clinics can be independent. The occupational medicine in Oak Ridge is nonexistent through DOE. There is no Medical Director for occupational medicine and they have no oversight in Oak Ridge. He is in meetings to gather support to get the bill passed. He offered to provide updates on the effort and gave his contact information: 865-435-1152.
• Ms. Gass also gave her contact information: 898-4263 linda99@mindspring.com
• Ms. Sonnenburg asked members of the public to comment on the necessity of an independent clinic and to share the experiences that have made them support an independent clinic.
• Mr. Raby said that his wife worked for DOE for 23 years and had her annual physicals at ORNL. The doctors did not pay attention to her blood work. Her cell lines decreased continually for ten years and she was never informed that she had a problem. He asked the Medical Director for a meeting, but was refused. The Medical Director would not discuss his wife's medical records: their primary interest was to protect the contractor, at that time, Lockheed Martin. If the clinics are operated independently, then this situation will not occur. DOE facilities operate in this manner in other locations, and have since 1965. There is legislation in Washington requiring them to do that.
• Ms. Stokes said that in the past month, two physicians have been called before the State Board of Medical Examiners because they have addressed the fact that heavy metals exist in bodies. The Tennessee State Department of Health is stopping physicians from treating patients with heavy metal poisoning. These actions are a travesty of justice and inhumane treatment. In 1993, Ms. Stokes went to a toxicologist who verified that the toxic level of nickel in her was moderate, which meant that if she did not eliminate the nickel from her body, she would eventually die. Within a year, that physician was no longer practicing in Tennessee. If the Subcommittee is interested in helping people, then they must stop any entity that is interfering with poisoned citizens' access to healthcare.
• Ms. Gass wondered if it would be appropriate to ask the Tennessee Department of Health liaison for the Subcommittee could bring information to the process. She had asked for the liaison roles to be clarified. Ms. Brenda Vowell offered to assess the situation, contacting people in charge of licensing at the State Board of Medical Examiners. She said she was not sure that the rest of the Subcommittee felt that it was appropriate to address requests for information directly to the liaison members. Occasionally, questions should be addressed to the Department of Energy, and the day before, a DOE representative had responded at the public microphone. The role of liaisons had never been properly clarified, but she appreciated that sidebar conversations had stopped. She hoped that there could be a process for addressing questions of DOE, particularly how the members of the Subcommittee and the public could interact with DOE representatives, one of whom was seated at a side table with the writer/editor.
• Dr. Davidson noted that Ms. Brenda Brooks of DOE had volunteered to gather information, which was appreciated. The liaisons communicate with their agencies about Subcommittee activities and can respond to specific requests, such as Dr. Akin's working with EPA's soil sampling work. The Subcommittee's recommendations go to ATSDR and CDC, not to other federal or state agencies, but ATSDR acts for the Subcommittee in requesting and obtaining information. Dr. Joseph of DOE was present at the meeting as a member of the public, and could sit anywhere in the room save at the table with the Subcommittee.
• Ms. Stokes said that she was almost sorry for bringing up the situation with doctors being called before the State Board of Medical Examiners. The last issue that she had brought to the Subcommittee was the Mangano study, which the Subcommittee "beat ... pretty bad." When the state intervenes with physicians who are trying to treat patients, the rationale is that the physicians are not toxicologists. She had challenged the state to replace those physicians, if they are not qualified, to replace them with physicians who are qualified. She hoped that those physicians would not be embarrassed because of her comments, as Dr. Mangano was. They are loving humans are trying to help people and who are being stopped for political reasons, and she did not want to see them "trashed" in the Subcommittee. Ms. Stokes said that the issue would be taken up be some person or some agency at the recommendation of the Subcommittee. The Subcommittee took on the Mangano paper as an academic exercise and spent a great deal of money on the effort. She would not provide the Subcommittee with the physicians' names because she was concerned that the Subcommittee would somehow discredit them, which would be "in poor taste." In the past, she said, the Subcommittee has accused her of having poor taste, being incompetent, and not being credible. If the physicians are "raked over the coals," then she would respond in the press.
• Dr. Davidson responded that the Subcommittee would not become involved in discussions of individual physicians and how they treat their patients. She apologized if the Subcommittee had caused problems for her or made statements to her. She could not recall making such statements. The activities of individual Subcommittee members outside the Subcommittee setting is not controlled by the Subcommittee.
• Ms. Stokes felt that since the Subcommittee members are paid by ATSDR, then there was control over them. Dr. Davidson replied that there was no control over members outside the meetings. Ms. Stokes responded that the Mangano report was discussed in Subcommittee meetings and in sanctioned settings. Any review of any paper will reveal missing details. They should not take a similar approach to the issue with the physicians. Instead, they should take the positive approach of trying to get trained toxicologists who can helate them and make them better rather than "defending [their] toxins."
• Mr. Lewis said that if the Subcommittee wants comments and support from DOE, then DOE ought to be at the table. That issue should be evaluated. He asked for clarification on disease and symptom prevalence studies, which are defined as: "A study designed to measure the occurrence of self-reported diseases that may, in some instances, be validated through medical records or physical examinations, if available, and to determine those adverse health conditions that may require further investigation because they are considered to have been reported at an excess rate. This study design can only be considered as hypothesis generation." They hear about self-reported diseases and linkages, and people want to pursue these linkages via clinics. This issue might relate to a clinic in Oak Ridge.
• Dr. Peipins said that the issues in these studies are related to study design. The crux of the matter is that a study that looks at symptoms and diseases must include how well they are characterized, case definitions, how they are well measured, and whether they can be equally measured in exposed and unexposed populations. A valid study requires identical measuring. A unified case definition is also required to count the diseases in the same way and to evaluate relative risk.
• Dr. Jackson said that this question related to the questions and concerns that he had tried to express. What real symptoms could be identified and differentiated, and what would it take to treat them? A needs assessment may not answer these questions, but the questions must be implied and acknowledged. In many cases, there is no experiential answer.

Presentation and Discussion:
State of Tennessee Screening Process for Past Exposure

Mr. Jack Hanley
CDC/ATSDR

Mr. Hanley recalled the January 18, 2001 meeting in Oak Ridge, at which Ms. Janice Stokes asked a question about clinics. At that time, the Deputy Assistant Secretary of DOE answered the clinic question from DOE's perspective. One of the key points in the transcript is that there has to be a strong case for the existence of sick workers in the community who were not being appropriately compensated. The needs assessment must be done. The Associate Administrator of ATSDR responded to the question as well, giving an example of an ATSDR medical monitoring program in Libby, Montana. At this site, there was long-term, documented asbestos exposure with outcomes seen in the community.

There are often questions about why the state and ATSDR focus on environmental data in their public health assessments. The PHA process is used to evaluate environmental data, community concerns, and health outcome data, with a focus on the environmental data. These data are used to identify people off-site who have been exposed to a specific contaminant or contaminants at a level of health concern. When the contaminant and its pathway are identified and a dose to the population is estimated, the likely health outcome can be determined. At that point, they make a recommendation and create a public health action plan. Follow-up occurs with many other agencies and may include medical monitoring, surveillance, health education, and advisories, if the situation is severe. Follow-up can also include exposure investigations and health studies. The criteria for these measures can be addressed as the PHA process is underway.

Mr. Hanley then the presented an overview of the screening process that ATSDR will use in the health assessment at Oak Ridge as well as how ATSDR will use the state of Tennessee's screening to focus their evaluation on the contaminants of concern. There are two screening processes taking place:

• Past exposure
• Current or recent-past data

Past exposure concentrates on the years 1940 - 1990. The state of Tennessee conducted two studies in this time. The contaminants that were deemed potential candidates for further evaluation would be put through the ATSDR screening process, which would be explained to the Subcommittee in a later presentation. Current or recent-past data includes data from 1990 - 2001, which is mostly electronic. The DOE information system here will be used and the information will be put through the ATSDR screening process.

The first study conducted by the state was a feasibility study. The findings from this study went into the dose reconstruction study. Other contaminants required further evaluation and screening, so they were taken through another screening. The purpose of this work was to help the state focus its resources on the most important contaminants. The feasibility study for dose reconstruction included many tasks, four of which focused on the screening of the contaminant. Task One was an extensive historical review of the operations and releases from all three facilities. Task Two incorporated an inventory of the vast amount of environmental data and contains abstracts. The state used this information to identify the operations that did not have the potential for releasing contaminants off-site. The study focused on the quantities used, the source, and how they were used. A qualitative evaluation was made. For instance, releases of volatile organics were small and not associated with possible off-site health effects. There is a great deal of Freon, but it has low toxicity. Acids and bases dilute quickly, so they were also eliminated as priorities.

Tasks Three and Four identified contaminants that were at a high priority for further study. The study included a quantitative evaluation which estimated, based on source data, quantities that could have gotten off-site and compared them within different media, across media, and to each other. The contaminants were then placed in a ranking order. The radiological contaminants were compared to each other, and Iodine was considered to have the highest hazard ranking. All contaminants then had dose reconstructions, except for protactinium 233, which had a low relative hazard ranking. Mr. Hanley shared the list of contaminants, including which ones were screened out and which were included in the dose reconstruction. For the highest-priority contaminants, sources, releases, the transport medium, and the basic pathway of exposure were identified.

After completing the feasibility study, the state was able to conduct dose reconstruction studies on iodine, mercury, PCBs, uranium, and White Oak Creek releases. A group of contaminants needed further study, so they were evaluated in another round of screening, including a qualitative evaluation, a threshold quality approach, and a quantitative, two-level screening evaluation. This list grew as the program extended and as certain contaminants became declassified.

The qualitative approach was used in the beginning to identify contaminants that likely posed an off-site health hazard. The screening also identified contaminants that were not likely to get off-site or to be at sufficient levels to cause a health hazard. The quantities of some contaminants were still classified, so the state used "reverse engineering" with the threshold inventory approach. They estimated the level that would cause a health hazard off-site and then how much would have to be released from the stacks to reach that level. Then, they estimated the inventory required to yield that amount. The result was an estimation of quantities needed on-site, and the quantities on-site were not at those levels.

The first level of the quantitative portion began with quantitatively and conservatively estimating the off-site individual with the highest exposure, using the maximum concentrations detected off-site and the upper parameters in other pathways such as fish consumption and length of exposure. Using this "worst-case scenario," they identified contaminants that were below a minimum level of health concern. Level two used slightly less conservative and more realistic parameters, but there was still conservatism built into the screening. Exposures for most people were overestimated in this phase, but underestimated for any individual, highest-exposed person. This process eliminated all but the following eight contaminants:

• Beryllium
• Chromium
• Copper
• Lithium
• Nickel
• Technetium
• Arsenic
• Lead

ATSDR will put those contaminants through their screening process. The previous work not only identified the contaminants of highest priority, but also the pathways. 80 to 90 percent of the exposures came from vegetables and fish. Milk and beef ingestion were a dominant pathway for one of the contaminants.

Discussion Summary:

• Mr. Lewis asked whether, since vegetables and fish are the dominant pathways, people who live downstream are at higher risk. Mr. Hanley replied that the risk depends on the facility. The state used reference populations for estimating and identifying contaminants. The models were conservatives. The technical reviewers for this study commented on the conversion factors of how much contaminant is absorbed by the vegetables or the fish. There are new, updated bio-transfer factors available from the EPA that should be used in the ATSDR process.
• Mr. Lewis reflected on the "reverse engineering" approach and the concept of secrecy regarding contaminants. He understood that there are ways, despite secrecy, to eliminate items, and the facilities have cooperated with these efforts. Mr. Hanley agreed, observing that ORHASP has worked to release as much information as possible to the public.
• Dr. Creasia asked whether the evaluation of toxicity considered peak exposures, such as when certain plants will burn inventory that has "outlived its life." These peak exposures are more severe than regular exposures. Mr. Hanley was not sure whether the study had taken peak exposures into consideration. The study used the maximum identified concentration of contaminants in the initial screening. Volatile organics were in small quantities at the plants, but it was feasible that they were released at once, resulting in these peak exposures. He offered to look into the issue.
• Dr. Creasia asked about the conservative estimates at the beginning of the screening. Later in the process, the estimates became more liberal or typical. Mr. Hanley agreed, adding that the study used the same, conservative bio-transfer factors in the screening, which were over-estimates.
• Mr. Washington felt that the screening process was wrong. Y-12 is a manufacturing plant. Millions of gallons of Benzine, Xylene, and Toluene were used there. He noted that fluoride gas does not remain fluorine for long; it converts to HF, which penetrates through the skin to the bone. Mr. Hanley replied that fluorine was added to the list of issues that ATSDR would investigate.
• Y-12 has been in place for more than 50 years, Mr. Washington continued, and the area around it is contaminated. T-Male, a classified product, was not included as a contaminant of concern, even though its TLV is in the PPB range. He had made the compound, and workers could not remain in the room for more than an hour because of its toxicity. When the bombs are torn down and the material is re-used, there is another exposure in the community as there are releases from the stacks. Savannah River has a project in which there is an uptake of mercury in some plants. During the transferation process, metal mercury is transpired onto the leaves of plants. In making metals, too, other elements are added that are released into the atmosphere. He encouraged ATSDR to look at the big picture, that Y-12 uses all of the naturally-occurring elements on the periodic chart, up to element 92, and all of those elements are then present in the air. The steam plant burns coal, he added. Mr. Hanley replied that arsenic is listed because of the coal facilities at K-25 and Y-12. Most of the classified contaminants are unique to making metals. Mr. Washington was not sure that anyone has a good idea of how many of these elements are used, and how they are used.
• Mr. Hanley commented that the form and manner of use of materials was considered as well as quantities to determine what elements might have an impact off-site. Mr. Washington added that the compounds can remain in the atmosphere or make other compounds as they react with UV light.
• Dr. Akin asked about DOE's approach toward chemicals that are classified and on which there is no information. Mr. Hanley understood that the state, contractors, and members of ORHASP could look at all of the data, classified and non-classified. By the end of the process, the names of all materials were declassified, but some of the quantities are still classified and some contaminants and the building in which they are used are not connected.
• Dr. Timothy Joseph clarified that this issue emerged often during the study process. DOE declassified the names of all compounds and elements in all facilities. The classification issue arose regarding the building and the process used. Several members of the ORHASP panel were Q-cleared to see the quantities and buildings with any compound.
• Dr. Akin asked whether Oak Ridge citizens found this point to be an issue. He observed that they had an opportunity to move this issue off of the table and to clarify the issue with the Oak Ridge citizenry.
• Mr. Washington said that three compounds were classified and not included on the list. Dr. Joseph assured him that there were no classified compounds.
• Dr. Davidson noted that the name of all compounds were not included on the provided sheet because the sheet was about the screening process, not about which compounds were classified and listed. Mr. Hanley confirmed the observation, using the example of cadmium, which is not on the list. Sampling may reveal that cadmium was released and exists in the environment. Based on the volume of historical data, certain compounds and elements were screened out.
• Dr. Akin said that the ATSDR process is the same process that EPA uses for its risk assessment at any Superfund site, whether federal or private. The Subcommittee needs to understand the process thoroughly, and he was sorry that some of the community members were not in attendance for the presentation, as the process should also be understood by the community. The process is open for criticism, should there be any. Site characterization and toxicity information could be questions, as are exposure pathways and data gaps, that the Subcommittee and the community should address at these opportunities so that they can make progress. Mr. Hanley added that the details of the process were reviewed in the PHA work group. Outstanding issues could be addressed there. In the end, the process leads to focusing on contaminants of the highest priority.
• Dr. Davidson commented that the PHA work group would continue to look at this issue. They can then bring any outstanding issues back to the Subcommittee.
• Mr. Manley offered a "facetious" comment, rescinding his offer of vegetables from his garden, from which he has been eating for 40 years.
• Mr. Lewis asked EPA to endorse the process that Mr. Hanley described. He hoped to avoid confusion or argument between agencies in the future.
• Dr. Akin confirmed that the screening process was included in guidance documents for both ATSDR and EPA. The sheet of specific contaminants would not be endorsed by EPA, but the process used to arrive at them was a common process used to define chemicals that need to be studied further. Many chemicals are found in the environment, so the environmental media must be analyzed to name contaminants that may lead to health problems. Every aspect of the process has limitations in knowledge, but science must use a framework to focus on those chemicals that require immediate action. The ATSDR PHA process will lead to a list of chemicals that are still a problem today. EPA will address the chemicals, as a Superfund site, by making decisions about remediation that may need to be done about chemicals that remain and may be causing harm. There are gaps and questions in the process, and the Subcommittee and community must focus on those questions and gaps. Mr. Hanley pointed out that the quantitative analysis portion of the process used to use an EPA reference dose for comparison and would use new EPA bio-transfer equations. There are many standard equations.
• Mr. Lewis reiterated that an endorsement of the process would help the community.
• Mr. Hanley asked whether EPA uses a qualitative judgement process in preliminary assessments. Dr. Akin replied that the science is not well-developed in that area, so there is often not clear information. For example, metals can be in different forms, which are related to their bio-availability. These issues are often not clear. Issues such as these and such as interactions must be addressed in a qualitative way, so that the judgement allows work to move ahead without the ideal, exact science.
• Dr. Davidson asked Dr. Akin to provide the Subcommittee with EPA's screening process to be compared to the ATSDR process. Dr. Akin replied that he would.
• Mr. Pardue said that in recent years, the question of whether all classified materials have been identified has been raised often in public meetings. It is a continuing issue in the community, as evidenced by the fact that not all Subcommittee members were aware that the materials had been declassified. He encouraged Dr. Joseph to make a public statement to this effect to eliminate the question.
• Mr. Pardue also commented that public acceptance of the screening process was key to the success of the PHA. He noted that their current audience was not representative of the public, so he suggested that they make an announcement in the Oak Ridger. Almost everyone in the community reads the newspaper, particularly the editorial and front pages. The "guest commentary" is an opportunity for ATSDR to publish this process and to solicit questions from the community. If the process is understood and known in advance, then there is less likely to be negative reaction after the fact. Dr. Davidson supported the idea, particularly because not all members of the public have access to the ATSDR website.
• Ms. Kaplan also encouraged a press release that addresses the changes that have been made in the Subcommittee's work. She knew of plans at the newspaper to publish an article about the Subcommittee's one-year anniversary. The changes that resulted from Subcommittee and public input are very important.
• Ms. Kaplan asked whether EPA was in charge of remediation decisions in the off-site communities as well as at Superfund sites. Dr. Akin said that EPA responsibilities are separate at public and federal sites. At private Superfund sites, the site is a moving definition that includes any area into which a site contaminant is released. Therefore, a neighborhood that is contaminated by a Superfund site becomes part of that site for EPA to assess risk and conduct clean-up, if needed. At federal sites such as Oak Ridge, DOE is the lead agency and EPA provides oversight.
• Mr. Hill approved of the idea of a news article and suggested that all community papers be included in such an effort, including the Roane County News. The release should include information about the next Subcommittee meeting as well.

Motion 6

Mr. Hill moved that the Subcommittee recommend that ATSDR create an article for local media on the screening process. It is further recommended that information from DOE, via Dr. Joseph, be included regarding information about declassified chemicals for the dose reconstruction. The motion received a second. After discussion, it was added that information about Subcommittee accomplishments and changes in Subcommittee process should also be released.

• Ms. Dalton said that ATSDR would do its best to coordinate its effort with DOE. The information might need to be presented in two articles rather than in one.
• Ms. Mosby felt that the articles should be released as soon as possible.

Dr. Davidson opened the meeting for public comment. As there were no immediate comments from the public, discussion among the Subcommittee for Motion 6 continued.

• Mr. Hanley asked whether the Subcommittee preferred an editorial article or a press release. Dr. Davidson and Ms. Mosby said that the suggestion was for a "your views" part of the newspaper, which is longer than a letter to the editor.
• Dr. Kuhaida asked what newspapers should be included. Mr. Hanley replied that ATSDR usually contacts the Oak Ridger, the Clinton Courier, and the Roane County News. They used to advertise in the Knoxville News-Sentinel, but now they send that paper press releases.
• Dr. Murray suggested that the motion include specifics about which newspapers should be included.
• Ms. Dalton said that the agency typically uses press releases, not paid advertising. They do buy space in the Oak Ridger, the Clinton Courier, and the Roane County News to announce Subcommittee meetings.
• Dr. Davidson did not think that a paid advertisement was part of the recommendation.
• Dr. Kuhaida reflected that there are three separate opportunities: one, sharing information about the screening process; two, changes in the Subcommittee that came as a result of input and evaluation of Subcommittee activities, which shows that the Subcommittee is active and responsive; and three, the issue of declassified contaminants, a significant issue in the community. He felt that these issues should be addressed separately because they are so important. Dr. Davidson repeated the three issues, and Ms. Mosby added that they should also include the Subcommittee accomplishments along with the changes. Dr. Davidson held the vote to allow for public comment.
• Dr. Peele commented that when he entered the ORHASP panel in 1994, a number of members of the panel felt that no report could ever be issued due to classification and the resultant lack of information. Other panel members felt that a partial report and a classified report could be issued. As time passed, policies in changed as there was a national opening of information. The contractors learned how to make valid screening estimates based on the limited amounts of data that were declassified. It is possible to make correct analyses without using classified information. The final report stated that none of the conclusions were hampered by classification of information. He offered examples of public comments on and criticisms of the screening process that had been heard over the years. The first complaints regarded pathways. ORHASP did not estimate exposures for pathways that did not exist, such as for a river that people did not use. There were also doubts expressed about the lack of knowledge about the quantities of contaminants that were released. Some people doubted the standard coefficients, which may change over time. The most significant complaint regarded the confluence of various contaminants, or the "multiple exposure problem." There is no coefficient for this phenomenon. It is not possible to assess the toxicity of all known compounds, never mind of their combinations. The most obviously-suspicious cases were exposures to PCBs and mercury, in which similar symptoms occurred elsewhere in the country. Dr. Peele felt that interactions in the body have not been studied and understood, but he also felt that they were not likely. An analogous situation is with interactions of medicines.
• Other doubts were expressed about whether the transport of materials was considered properly. In most cases, these factors were well-assessed. Another problem was as a result of poor monitoring where people lived, such as a lack of measurements of ground water. In some instances, especially 40 years ago, it was not known that these compounds were toxic, so it is understandable that these measurements did not take place. The panel was forced to create some complicated extrapolations due to this lack of monitoring data.

Dr. Davidson called for the Subcommittee to vote on Motion 6, however, discussion continued.

• Ms. Mosby wondered whether a Subcommittee member should write one of the articles, rather than ATSDR because of possible questions of credibility.
• Ms. Dalton encouraged the Subcommittee to spread its own message about its accomplishments. It is important for the community to hear about Subcommittee activities from its local members.
• Mr. Pardue felt that the statement on declassified materials should be made by DOE. While the PHA work group is contributing to the screening process, ATSDR should write the article on that subject, which can indicate that the process has been endorsed by the Subcommittee, if that is the case. He suggested that the chair of the Subcommittee should write about the Subcommittee's accomplishments and changes.
• Ms. Dalton mentioned that ATSDR has provided the Oak Ridger columnist with the Subcommittee changes. ATSDR can collaborate with the Communications and Outreach work group to ensure that all Subcommittee accomplishments are included.
• Mr. Hanley said that his next step was to put the screening process into writing for the PHA. He would keep his document concise and readable, then presenting it to the Subcommittee.
• Ms. Mosby felt that the articles should not be combined, but released in three separate efforts.

Motion 6

Mr. Hill moved that the Subcommittee recommend that ATSDR create an article for local media on the screening process. It is further recommended that information from DOE, via Dr. Joseph, be included regarding information about declassified chemicals for the dose reconstruction. The motion received a second. After continued discussion, it was added that information about Subcommittee accomplishments and changes in Subcommittee process should also be released. Dr. Davidson called for a vote on the motion. The motion carried with a vote of 13 in favor and none opposed.

Public Comment

Ms. Gass
Member of the Public

Ms. Gass reminded the group that the state of Tennessee spent $15 million on the dose reconstruction, and she has reviewed meeting minutes from this time. Some of the same discussions have been going on throughout the process that are going on now. She reflected on the pathways that Dr. Peele had addressed. The biggest difference between Hanford and Oak Ridge is rainfall, and one of the biggest exposure pathways at Hanford was irrigation using the Columbia River and the subsequent uptake into produce. Oak Ridge does not have that exposure, but rain has a more negative than a positive effect on exposure in East Tennessee, which should be remembered when comparing the two locations.

She recalled a lawsuit over medical monitoring in Hanford, and Hanford had public interest attorneys, which are not available in Oak Ridge. Another difference, which has been noted by other committees, is the existence of environmental organizations at the grassroots level in the West. In contrast, East Tennessee has never had an appreciable degree of environmental grassroots organizations. She referred to a draft of time-lines for the three facilities and asked Mr. Hanley when their final versions would be available. Mr. Hanley did not have a specific date, but said that they would be finalized as he makes progress on the screening and receives input from the work group.

Ms. Gass noted that the time-lines were all historical information. Mr. Hanley replied that the work was done as part of the Task Two feasibility study. Most of the sampling studies included on the time-lines came from the feasibility study. Ms. Gass said that the books were difficult to acquire. Mr. Hanley said that the feasibility study was on a CD-ROM, which is why the state was not printed them any longer, which was available in the library.

She observed that the information in the feasibility study anticipates that more work will be done during the ORHASP process. In some cases, due to time pressure, activities were not completed or followed-up. She said that the time-lines were mostly focused on releases. She wondered if person within ATSDR other than Mr. Hanley was working on verifying releases for the PHA. Mr. Hanley said that state studies were being used to examine historical releases. ATSDR evaluated the data to assess whether it could be used in the PHA, and concluded that the data could be used in the PHA.

Ms. Gass asked whether technical reviewers recommended using the data. Mr. Hanley answered that the reviewers provided input into the data. The conclusions were that there were limitations and weaknesses, which is the case with all studies. The reviewers helped ATSDR to identify those weaknesses and limitations so that the findings could be used appropriately. In response to a question from Ms. Gass, Mr. Hanley added that his responsibility was not to assess whether all releases are included.

Unfinished Business: Update on Subcommittee Nominations and Update on ORRHES Website

Ms. LaFreta Dalton
ATSDR/Designated Federal Official

Ms. Dalton gave the group an update on Subcommittee nominations. The nomination process can begin and will be followed by Subcommittee member selection and placement. She has been working with the ATSDR website to have the Subcommittee nomination information included on the ATSDR homepage and available for direct printing. The nomination process will begin when the ATSDR website committee approves the posting.

Packets will also be mailed to everyone on the mailing list, and copies will be placed in libraries and other public buildings, as well as at the Oak Ridge Field Office. She asked for more suggestions for locations for the information. A press release will go to local newspapers. ATSDR will work with the Communications and Outreach Work Group to advertise the nominations in additional ways. It is critical that Subcommittee take an active role in announcing the nominations to the community. She does not have firm dates for when the process would begin, but the nominations will be open for at least 30 days and perhaps longer because of the holidays.

Ms. Dalton also gave an update on the website. The Communications and Outreach Work Group would present recommendation on the site map and template. The next step in process is for the contractor to incorporate links. Content can always be added to the site. When the links are incorporated, the pilot-testing will begin. Two pilot tests are planned, and then ATSDR has to give final approval before the page is added to the ATSDR site.

Discussion Summary:

• Ms. Sonnenburg asked whether an effort would be made to replace Subcommittee members who had resigned, such as a doctor. Ms. Dalton replied that one Subcommittee place was reserved for a sick worker. For the other three positions, preference for a self-identified ill resident and consideration to replacing the doctor was suggested.
• Mr. Lewis commented on Subcommittee balance and representation. It might not be necessary to be sick or ill to represent the sick or ill, he noted. ATSDR had kept diversity in mind in its initial selection of Subcommittee members, and he hoped that ATSDR would consider filling slots based on the caliber of individuals that had been on the Subcommittee in the past. Ms. Dalton replied that ATSDR always hoped to have Subcommittee members of high caliber who represent the community at large. It does depend on who applies, and they also have the option of re-considering the pool of applicants that applied for the Subcommittee the first time. They are hoping to match the talent and expertise that the Subcommittee lost.
• Ms. Mosby asked about the length of the new members' terms. Ms. Dalton replied that the new members' term would expire at the same time as current members, in 2004. If an applicant does not come forward for the sick worker position, then the position will remain open until the end of the term.
• Mr. Hill asked for clarification on the term "sick worker." He assumed that the term was defined as a worker who believes that he or she has had a health impact from their employment. Ms. Dalton agreed, adding that the applicant can be a past or current worker who has an illness that is believed to be associated with the Reservation.
• Mr. Lewis wondered about the procedure if a current Subcommittee member self-identified as a sick worker. He said that there is a difference between a sick person who acts as a representative for a group of people and someone independent who fulfills that category. Ms. Dalton replied that such an issue would have to be discussed by the Subcommittee, as the Subcommittee stated that an ill worker representative would be needed. She said she understood that the consensus was to solicit an ill worker.
• Mr. Hill noted that all Subcommittee represent themselves only; therefore, a sick worker would not be representing all sick workers, but their viewpoints only. Ms. Dalton agreed.
• Ms. Mosby commented that a drawback associated with a Subcommittee member self-identifying as a sick worker would be criticism and the perception that they are trying to circumvent process.
• Mr. Lewis asked whether an individual who resigned from the Subcommittee could reapply for membership. Ms. Dalton replied in the affirmative.
• Dr. Davidson noted that the Subcommittee had been operating for a year with no members being specified as ill workers and that the process would not be expedited by such an identification now.
• Mr. Manley asked what constitutes sickness in a worker. For instance, welders have a tendency to lose their eyesight. Would this person be a sick worker? Ms. Dalton replied that the individual's view of him- or herself is the deciding factor.
• Mr. Washington clarified that a sick worker is a person who feels that he or she came into contact with some contaminants while working in a facility that affected his or her health. There are some illnesses that have not yet been characterized, but when a number of people who worked under the same conditions have the same symptoms but no disease is named, then each individual is responsible for deciding his or her status as an ill worker. He added that people will always represent their own interests, even if they are members of specific groups.
• Ms. Kaplan commented that welders have trouble with their eyesight, but they also breathe fumes that may include contaminants.

New Business/Issues/Concerns:
Work Group Recommendations and Future Meeting Dates

Dr. Davidson began by reviewing the recommended amendments in the Subcommittee bylaws. Several motions were raised.

Motion 7

It was moved and seconded that the following amendment be made to the Subcommittee bylaws: "The Work Groups shall include the Guidelines and Procedures Work Group, the Agenda Work Group, the Communications and Outreach Work Group, the Health Needs Assessment Work Group, and the Public Health Assessment Work Group." The motion passed unanimously.

Motion 8

It was moved and seconded that the following amendment be made to the Subcommittee bylaws: "A quorum at work group meetings shall consist of two Subcommittee present in person at the meeting." The motion passed unanimously.

Motion 9

It was moved and seconded that the following amendment be made to the Subcommittee bylaws: "Subcommittee members who are absent in person or by conference phone from three consecutive work group meetings and who do not provide advance notification of their absence to the work group chair shall have their name removed from the roster of the work group. The member may be reinstated after providing notification to the work group chair prior to the next work group meeting of their intention to join the work group." The motion with a vote of 11 in favor and 2 opposed.

The following discussion resulted as a result of Motion 9:

• Ms. Sonnenburg clarified that Subcommittee members can inform the chair why he or she is missing the meeting. Dr. Davidson agreed, saying that there may be legitimate reasons for missing meetings. Dr. Craig added that the three missed meetings without informing the chair have to be consecutive.
• Mr. Johnson commented that it might be difficult to get in touch with the work group chair, but Subcommittee members can call the field office to say that he or she will not be present. Dr. Davidson agreed and said that a person who would miss a meeting could also inform another work group member of his or her impending absence.
• Dr. Davidson then turned the discussion to the mission statement. Ms. Galloway had spoken to other members of the ad hoc committee and attempted to make adjustments in the mission, vision, goals, and objectives of the Subcommittee in accordance with the previous day's discussion. The committee members were not in agreement about the goals, but were ready to propose the mission and vision for ratification. Dr. Davidson suggested that the Subcommittee vote on the vision and mission statements and that the ad hoc committee reconvene to work on the goals and objectives.

Motion 10

Ms. Galloway moved that the following vision statement for the Subcommittee be adopted:

"To promote the health of potentially impacted residents in the 8-county region surrounding the Oak Ridge Reservation."

She further moved that the following mission statement for the Subcommittee be adopted:

"To provide ATSDR and CDC with advice regarding public health studies and activities relating to people who may have been exposed to radioactive and chemical emissions from the ORR."

The motion received a second, and discussion ensued.

Discussion related to this motion was as follows:

• Mr. Johnson wanted the 8 counties to be named in the mission statement. Ms. Galloway said that the ad hoc group had discussed having a watermark of the map of the affected area. Mr. Lewis wondered how the counties could be named, since portions of the counties are included in the affected area.
• Dr. Davidson supported maintaining general language in the mission statement. There is also ongoing discussion about the counties in the area.
• Ms. Mosby said that the vision is the ideal perception for the Subcommittee. The ideal would be for all residents in the surrounding area to have good health. She supported the original wording for the vision and mission.
• Mr. Johnson commented that in Knoxville, there are "9 counties, one vision." The counties should be included. Ms. Mosby suggested that the specifics be addressed in the goals.
• Dr. Davidson suggested only voting on the mission statement. Ms. Mosby felt that the vision and mission pieces should go together, as the goals and objectives go together.
• Dr. Davidson recalled a suggestion from the previous day's discussion, which was "to promote the health of all residents in the community affected by the Oak Ridge Reservation." There was general approval of this wording.
• Mr. Washington did not support that wording because the emissions from the facilities affect Kentucky and other areas, both due to airborne emission and by contaminating waterways downstream. Dr. Davidson felt that if their work helped the communities surrounding them, then other areas will benefit as well.
• Ms. McNally recommended the word "directly" so that the statement would address residents in the communities directly affected by the Oak Ridge Reservation. Naming the specific counties could be problematic in the future if other effects are found in other places.
• Dr. Akin observed that the discussion seemed to indicate that the original vision statement was their most appropriate choice, as each modifier used leads to a semantic debate.

Dr. Davidson called for a straw vote to determine the wording, and amended Motion 10 to reflect the consensus of the Subcommittee:

Motion 10 - Amended

The vision statement for the Subcommittee was amended as follows:

"To promote the health of all residents in the community surrounding the Oak Ridge Reservation."

The mission statement remained unchanged:

"To provide ATSDR and CDC with advice regarding public health studies and activities relating to people who may have been exposed to radioactive and chemical emissions from the ORR."

The motion carried with a vote of 12 in favor and 2 opposed.

The vision and mission statements were adopted, and the goals will go back to the ad hoc committee. The committee will also develop appropriate objectives and present both at the next meeting.

Mr. Pardue then offered three recommendations from the PHA work group.

Motion 11

Mr. Pardue moved that the Subcommittee approve a resolution from the PHA work group recommending that the Mangano paper not be used as a basis for the Oak Ridge Reservation Public Health Assessment. The motion received a second and passed with a vote of 10 in favor and 2 opposed. Discussion ensued.

Discussion of the motion was as follows:

• Mr. Pardue clarified that the Dr. Mangano's written response to the evaluation included new facts, but did not question the evaluation or its judgements. The new information should still be evaluated, but did not have any impact on the recommendation.
• Dr. Davidson further clarified that the recommendation only applies to the report that is in the open literature.

Motion 12

Mr. Pardue moved that the Subcommittee approve a letter to Dr. Koplan, administrator of ATSDR, which addresses the topic of sampling environmental media in the Oak Ridge area, requesting that ORRHES have input into the process and that the process be better developed and explained to the public. Dr. Davidson added that Dr. Elmer Akin would be added to the list of people who receive the letter. The motion received a second and carried with a vote of 13 in favor and 1 opposed.

Motion 13

Mr. Pardue moved that the PHA work group draft a letter to Dr. Henry Falk, assistant administrator of ATSDR, requesting provision of administrative support in the Oak Ridge Field Office to improve efficiency. There was a second. The motion passed unanimously.

The discussion was as follows:

• Dr. Pereira suggested that the letter go to Dr. Falk through Bob Williams, for protocol.
• Action Item: Mr. Lewis suggested that Dr. Lucy Peipins be thanked formally for her efforts in helping the Subcommittee learn more about epidemiology and assisting with the evaluation of the Mangano paper.

Motion 14

Mr. Lewis moved that Design Number Three be approved as the ORRHES homepage and site map. There was a second and the motion passed unanimously.

Mr. Lewis then introduced the second recommendation from the Communications and outreach Work Group, which addressed capturing current and historical concerns into a database. With this system, there will be a formal list of the issues that are being addressed. There can then be a link between those concerns or issues and the resultant resolutions or findings. The recommendation came to the work group from a non-Subcommittee member.

Motion 15

Mr. Lewis moved that an ATSDR employee read the Oak Ridge Health Assessment Steering Panel's meeting minutes and put concerns into the present format to capture the concerns for ORHASP. The definition of "format" refers to the comment sheet being used. This motion was amended following further discussion.

The following discussion was held regarding Motion 15:

• Dr. Davidson wondered whether all meeting minutes were expected to be reviewed, and wondered whether the feasibility of this activity should be assessed, since the volume of minutes was not specified. Mr. Lewis understood that there were a number of meeting minutes. He agreed about assessment of reviewing the minutes, adding that once the process begins, then the feasibility of gathering concerns from other sources can be assessed.
• Dr. Pereira suggested that in work group meetings, when a topic of concern is raised but not fully discussed as part of the agenda, it should be captured in a condensed, "parking lot" form. With this approach, there can be no interpretation issues.
• Mr. Lewis added that there should be a standard operating procedure to capture these concerns. The work groups should capture concerns, he agreed. The larger problem is with historical records. There is a history of issues in the community. They should be captured and addressed.
• Ms. Mosby recalled the request from the work group meeting. She had not supported it because she found it to be a tedious task that was too nebulous. The idea has merit, though, because the historical concerns need to be captured. She suggested looking at the feasibility of the project before making a recommendation about it: its size, where the records are located, and how it might be accomplished.
• Dr. Davidson commented that database development can continue, and noted that concerns in Subcommittee and work group meetings can be captured on an ongoing basis.

Motion 15 - Amended

Mr. Lewis amended his motion to read, the Subcommittee recommends that ATSDR move ahead with a database that captures community concerns and issues which has links to the resolutions that are associated with them. There was a second, and the motion passed with a vote of 13 in favor and 1 opposed.

General discussion continued:

• Action Item: The Subcommittee recommended that ATSDR look at the feasibility of reviewing ORHASP minutes to capture historical concerns of the Oak Ridge community.
• Ms. Mosby hoped that this action item would have closure at the next meeting.
• Mr. Lewis pointed out that the needs assessment would be another source for these community issues and concerns.
• Action Item: Mr. Lewis had another recommendation from the Communications and Outreach Work Group, but he suggested taking it back to the work group for further refinement and review it, in light of recent changes.
• Mr. Pardue commented that a FACA group just like the Subcommittee wrote a letter recommending a clinic to the Secretary of Energy four years ago. The letter was developed in a work group with broad representation from sick workers and residents as well as people who were not convinced that there were ill people. While he liked to see the idea of a clinic being strengthened, it would be remiss not to acknowledge the work of the other group and its letter, which he believed led to the establishment of this Subcommittee.
• The Subcommittee turned to a consideration of future meeting dates. They considered conflicts with other groups that meet in the area. They also noted the need for planning and preparation.

Motion 16

It was moved and seconded that the next ORRHES meeting be held in Oak Ridge on January 11^th after a straw vote was conducted to assess consensus. The motion passed unanimously.

The Subcommittee then tentatively marked meeting dates through June, 2002. They can revisit whether the format is working in the future, and the dates can be adjusted.

• February 11, 2002
• March 26, 2002
• May 6, 2002
• June 18, 2002

There was discussion about when new Subcommittee members would be selected. The hope was to have them selected by the March meeting. The approval process is lengthy enough that it was unlikely that they would be confirmed by then, pointed out Dr. Murray. They could, however, attend meetings as non-paid, non-voting members.

Ms. Dalton then introduced the ethics video, The Ethical Choice: Ethics for Special U.S. Government Employees.

Public Comment

Ms. Gass
Member of the Public

Ms. Gass showed the group a poster that is a draft of the time line. There is quite a bit of information on the poster, and it is an attempt to summarize historical information. Also, it should be noted which processes are well-defined and over. For example, the 13-year time period for Iodine-131, in the late 1940s and early 1950s, coincides with the large "baby boomer" birth cohort being exposed in early childhood. That process is clearly defined, and its end is clearly documented. The poster indicates that some processes are ongoing, or their end is not clearly defined. They should have as good an understanding as possible of historical data and of ongoing processes such as current releases, current processes, and work that is still ongoing. EPA is charged with reviewing ongoing and future concerns, but not historical data .

She observed a great deal of change in the past year. As recently as a few months ago, the thought of having a clinic in Oak Ridge was not even discussed. She believed that it was good for the Subcommittee to discuss a clinic openly. She is more optimistic and has some hope that things could be turned. It will take a great deal of effort to turn the momentum from its original direction. The "unofficial website" has been the source of formative information for the process. It has not been open and receptive to people coming forward with concerns. She recalled the day's discussion, which had included the point that if a person works in a place long enough, he or she will experience health-related problems. Nobody in Oak Ridge has an idea of how many people have been affected, she said. Some of the health concern are at a deep level.

Ms. Gass offered an example of a citizen who had told her about how her husband prematurely died of cancer. They had both been well-positioned in Union Carbide and her husband continued working into Martin Marietta. When he was dying, he did not want questions to be asked about the connection between exposure and his illness. Ms. Gass said that she had told this lady to be true to her husband's memory. If he did not want that connection made, then his widow had to honor that wish. This example illustrates that many people will not bring their concerns forward. In some cases, the people are dead or they or their heirs have given up. Ms. Gass did have hope, though, because discussion about a clinic would not have been possible six months ago, when "the c-word" was taboo. The process has been opened up and she has the hope that several people on the committee are open-minded and want to do the right thing for the community, getting to the truth of the matter. The question now is what to do at the end of the process, when the truth comes out. She hoped that they would not worry about legal implications and suppress information. She also had hope that people who need help would get help.

Discussion Summary:

• Dr. Davidson thanked Ms. Gass for her comments and assured her that "the c-word" would re-surface in Subcommittee and work group discussions.
• Mr. Lewis commented that it was helpful when people from the community take the time to review documents and to bring issues to the Subcommittee members' attention, challenging the Subcommittee. The efficiency of their overall operation should improve to get more information to the public in a structured way.

Identification of Action Item Assignments/Closing Comments

Dr. Kowetha Davidson, Chair
Oak Ridge Reservation Health Effects Subcommittee (ORRHES)

Dr. Davidson led the group in a final discussion. She reviewed the list of action items for the Subcommittee, reading them into the record. A complete list of these items, with the motions posed and voted upon included, is attached to this summary document. She reminded the Subcommittee that work group meetings should be scheduled through the field office.

Discussion Summary:

• Ms. Sonnenburg, the chair of the Agenda Work Group, suggested that their next meeting be on Thursday, January 3^rd, at 4:00 pm.
• Mr. Pardue, chair of the PHA work group, proposed that the next meeting would be Monday, December 10^th, at the Oak Ridge Field Office at 5:30 pm. Major topics for the agenda included the upcoming visit from an ATSDR representative regarding current screening for contaminants.
• Dr. Murray ensured that everyone had received copies of the draft minutes from the last work group meeting of November 5^th. He offered to send the minutes to any new work group members and confirmed that his phone number was 865-220-0295.
• Dr. Davidson reminded Subcommittee members that additional members are needed for the Communications and Outreach Work Group and that they should sign up for the Guidelines and Procedures Work Group, even though that group did not have a task.
• Dr. Tim Joseph addressed the group. He had first seen the list of missing interviews and requested documents the previous day. Thanks to Steve Wylie at Y-12 and good record-keeping on the part of Senes, he was able to obtain the interviews, which he provided to the Subcommittee chair. They were not the interviews that Dr. Joseph had thought they were; they are interviews that were conducted in Oak Ridge by Senes during their modeling. The interviews are public information. He was also able to get an additional interview.
• Ms. Gass said that she had already asked Senes for the over 150 interviews, and Senes did not have them. Dr. Joseph said that he could try to get other interviews. Dr. Davidson said that copies of the interviews would be made available to Ms. Gass and that the originals would be kept in the Oak Ridge Field Office.
• Ms. Mosby suggested that the Needs Assessment Work Group meet on Monday, December 17^th at 6:00 pm. The field office would not be available on that day, so an alternate location would be chosen and the meeting would be coordinated through the field office.
• Dr. Joseph noted that work groups needing space to meet could consider doing so at the guard houses, which have been renovated and are open for the public's use, free of charge.
• Mr. Washington reviewed a statement of his from the September 11^th meeting, in which an EPA presentation resulted in his approval of having an EPA representative on the Subcommittee. Consequently, he made the following motion:

Motion 17

Mr. Washington moved that the Subcommittee recommend to ATSDR that a DOE liaison be included as a member of the Subcommittee. Mr. Lewis seconded the motion. After discussion, the motion was withdrawn.

The discussion continued:

• Mr. Hill offered a difference of opinion. The Subcommittee has to weigh the pros and cons that come with inviting DOE to participate in the Subcommittee. If there is a benefit to the community and the Subcommittee, then they should vote. A large population of the community have concerns about DOE being on the Subcommittee. There are even concerns that DOE is funding the Subcommittee, thereby making it biased. He did not feel that the Subcommittee is biased, but the perception of the Subcommittee in the community is crucial. DOE has separated itself from the Subcommittee, which he felt has been beneficial. He would support any Subcommittee decision, but did not feel that the Subcommittee has lost flow of information without having a DOE representative at the table, especially given the good information provided by Dr. Joseph.
• Dr. Craig agreed that Dr. Joseph had done an outstanding job of providing the Subcommittee with information, and that DOE participation was a matter of perception. For the Subcommittee to maintain its credibility and have its results viewed as independent and worthwhile, it must remain separate from DOE. He did not believe that it was in the best interests of DOE to participate on the Subcommittee and urged DOE not to come to the Subcommittee. Ms. Kaplan agreed and pointed out that no other Subcommittee includes a DOE representative.
• Ms. Sonnenburg felt that the topic should be discussed at the next meeting, as it is such an important topic that was not on the agenda. She hesitated to vote on the topic without prior notice. She offered a counter-motion:

Motion 17A

Ms. Sonnenburg moved that the topic be moved to the next meeting. The motion received a second and was amended after discussion.

Discussion continued:

• Dr. Davidson suggested that if discussion on the topic is postponed, then an ad hoc group should examine it and bring a report to the full Subcommittee at the next meeting. Ms. Mosby felt that if the topic is tabled, then more information on it should be gathered before the next meeting. Dr. Davidson noted that the Subcommittee seemed to feel that the topic needed more time for consideration and discussion.
• Mr. Washington, as the maker of the first motion, offered his rationale for having DOE representation on the Subcommittee. All other entities, such as EPA and TDEC, have liaisons at the table. He had initially not supported their participation because of community perception. As much as these entities are part of efforts in Oak Ridge, then they should be at the table, and the Subcommittee can hold them accountable to provide information to help them make decisions. EPA representation on the table resulted in benefit to the Subcommittee at the September 11^th, when a high-level official addressed them.
• Mr. Lewis said that if a smaller group meets to consider this topic, then the proceedings should be documented so that their logic can be documented and clear action can be specified. He also noted that this issue should be resolved before new Subcommittee members are selected.
• Dr. Davidson recommended that the topic should be discussed fully with time in the agenda at the next Subcommittee meeting. The full Subcommittee should participate in discussion on this topic, not just a sub-group. Dr. Creasia agreed.
• Dr. Craig pointed out that Dr. Joseph can get information for the Subcommittee, as proven by his acquisition of the interviews, without the Subcommittee having to suffer any negative perceptions from the community by having a DOE representative serve as a liaison on the committee.

Motion 17A - Amended

Ms. Sonnenburg amended Motion 17 to read that the topic be reviewed by the Communications and Outreach Work Group and then brought to the full Subcommittee for discussion at the next meeting. The motion was withdrawn after discussion.

Discussion continued:

• Dr. Davidson strongly recommended that the topic be brought to the full Subcommittee for discussion in a specific time on the agenda.
• Ms. Mosby noted that bringing the issue to a work group would collect input from a wide variety of people. It would also provide a chance to articulate the pros and cons of having representation.
• Ms. Sonnenburg withdrew her amended motion, asking Ms. Mosby to restate it. Mr. Washington withdrew his original motion and offered a new motion.

Motion 18

Mr. Washington moved that the Communications and Outreach Work Group study the issues surrounding, and conduct a full discussion of, bringing a DOE liaison to the Subcommittee. Time on the next Subcommittee meeting agenda should be devoted to deliberating the Work Group's information and to full Subcommittee discussion of the issue. The motion received a second. The motion failed with a vote of 5 in favor and 6 opposed.

Discussion continued:

• Ms. Kaplan felt that sending the issue to a work group would be divisive. The work group is an uncontrolled, small group environment. There is a great deal of emotion involved in this issue, and she strongly encouraged that it be discussed fully in the more formal setting of the Subcommittee.
• Dr. Davidson requested that the Agenda Work Group put the issue on the agenda for the next Subcommittee meeting.
• Mr. Pardue wondered whether, since Dr. Joseph was working to get the documents requested, a letter from the PHA Work Group requesting the interviews was still necessary. Dr. Davidson decided that the letter-writing should be postponed to see what Dr. Joseph could produce.
• Dr. Joseph pointed out that the interviews are a small component of the list, which contains many other documents and items that are not DOE-owned. He would do his best to get as many of the items as possible, but they are not all his responsibility. Mr. Pardue said that they would write the letter and then see if it was necessary to send it.

Evaluation Consensus-Building Process

Mary Ann Downey
Consensus Building Presentation

Ms. Downey addressed the group regarding their work with the Consensus Building Process. She said she appreciated everyone's frustration and encouraged them all to take care of themselves. She provided them with a handout and said that Ms. Dalton would send them all a copy of the evaluation summary. In essence, she said, they "are doing it right." She would also provide the results of the individual evaluation of the Subcommittee.

She asked the group whether they felt that they were ready to begin working in small groups, bringing that information back to the Subcommittee. According to her evaluation, the group was at that point. They should work at both levels, gathering information and opinions in a work group setting and then bringing that "homework" to the full Subcommittee.

Mr. Lewis advocated for developing a process for evaluating things. Without these processes, a conclusion might not be possible on any issue. Ms. Downey agreed, and then addressed the concept of consensus. She works with troubled youth in Atlanta on consensus, and she keeps the ideas basic:

• Speak out
• Listen up
• Go for diversity
• Teamwork
• Pull together on a plan

She felt that the Subcommittee had consensus "right." She asked Dr. Craig to read a story about how geese operate in a collective and what humans can learn from these facts. Ms. Downey concluded by sharing motivations that she had found from walking a marathon. She ended the session by playing a folk song from coal miners in Kentucky.

With no further business posed, Ms. Dalton thanked the group for their participation. With that, the meeting was adjourned.

End of Summary Report

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