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Testimony on Asbestos Exposure by Henry Falk, M.D.
Assistant Administrator
Agency for Toxic Substances and Disease Registry
U.S. Department of Health and Human Services

Before the Senate Environment and Public Works Committee
Field Hearing in Libby, Montana
February 16, 2000

Good day, I am Dr. Henry Falk, Assistant Administrator of the Agency for Toxic Substances and Disease Registry (ATSDR), a public health agency within the U.S. Department of Health and Human Services (DHHS). Accompanying me is Dr. Jeffrey Lybarger, Director of the Division of Health Studies at ATSDR. ATSDR appreciates the opportunity to evaluate to the public health issues in the Libby, Montana, area in response to concerns expressed by key elected officials such as you, community members and former mine workers. ATSDR, with the support of other federal, state and local organizations, will carry out the activities to meet the public health needs of the community in Libby, Montana.

Dr. Lybarger and I, along with ATSDR and DHHS staff, share your concerns about the health issues being raised in Libby, and share your desire to develop immediate and long-term steps to address those issues. Among the activities ATSDR will pursue in Libby are providing advice and guidance on environmental sampling; reviewing medical and vital records for residents already diagnosed with asbestos-related disease; developing protocols for medical testing which will begin later this spring; developing and distributing health care provider and community education materials; and providing relevant training to health care professionals who may need to provide services to residents and workers in the Libby area.

ATSDR's mandated activities and expertise enables provision of these public health activities in the Libby area. ATSDR was created by Congress in 1980 under the Comprehensive Environmental Response, Compensation, and Liability Act as amended (CERCLA), or what is more commonly known as Superfund legislation. CERCLA mandates of ATSDR a broad, national program of Superfund site health assessments, health investigations, surveillance and registries, applied research, emergency response, health education, and toxicological database development. Broadly speaking, ATSDR's responsibilities under Superfund, the Resource Conservation and Recovery Act (RCRA), and other federal statutes are to assess the effects of toxic substances on community populations and to recommend interventions to protect public health where they are needed. This may include medical screening and epidemiologic investigations of health effects of community populations exposed to hazardous substances. We also conduct investigations to measure human exposure to toxic substances released from waste sites or other sources of release. Our work is conducted in close collaboration with the U.S. Environmental Protection Agency (EPA), state health departments, local health agencies, and affected communities.

ATSDR administers public health activities through: state partnerships; public health assessment and consultation activities; exposure investigations; health studies and registry activities; development of toxicological profiles and attendant research; emergency response; health education and health promotion; and community involvement. In general, ATSDR organizes its site-related activities by developing Public Health Response Plans. A Public Health Response Plan identifies appropriate public heath activities, designates who is responsible for the conduct of the activities, and provides an estimated time line for accomplishing those activities in the community. All stakeholders, including officials and the affected community, provide input throughout the Response Plan process.

Libby-area asbestos description and background:

From 1920 - 1990 a vermiculite mine and two refining facilities were located in the Libby area. Natural vermiculite ore and its products can be contaminated with asbestos. The vermiculite ore mined at Libby has been shown to be contaminated with asbestos, and the degree of contamination is under investigation.

Reported health concerns: In the past, asbestos-contaminated dust may have been spread in the course of operations of the facilities through emissions from the refining process, via disposal operations, through product shipping and use, and on miners' clothing. Studies published by the National Institute for Occupational Safety and Health (NIOSH) at the Centers for Disease Control and Prevention (CDC) in the mid 1980s documented asbestos exposure and related health effects, including respiratory and lung ailments, in workers at the Libby vermiculite facilities. Truck drivers, railroad workers, forestry service workers, and others who provided services and support to the mining operations may have been exposed to asbestos-contaminated dust during their daily work activities. ATSDR will consider other ways that residents in the area might have been exposed to asbestos including children playing with vermiculite, recreational activities near the mine, insulation in homes, or other activities and situations reported by the community.

ATSDR's primary objectives for public health activities in Libby, MT, are to: identify the people at health risk from exposures to asbestos, evaluate the association between exposures to asbestos and health effects in the community, conduct an epidemiologic investigation to assess the full scope of health effects in the past and present, and to intervene to eliminate exposures and prevent further adverse health effects in the community.

Health effects associated with asbestos: A significant potential health concern with vermiculite is the degree to which it may be contaminated with asbestos. Vermiculite alone can cause irritation to the respiratory system (nose and throat), but it does not represent the threat to health that it does when in combination with asbestos.

The amount and duration of exposure to asbestos determine the risk for adverse health effects. Breathing high levels of asbestos may cause several severe adverse health effects. Asbestosis is a serious disease that results in a slow build up of scar-like tissue within the lungs. People with asbestosis have shortness of breath, often along with a cough and sometimes heart enlargement. Less severe, but important in assessing exposure to asbestos are changes in the lining of the lung which are quite common in workers heavily exposed to asbestos. When exposure to asbestos causes scarring to the lining of the chest wall surrounding the lungs, these areas are called pleural plaques. They are often not associated with symptoms, but they do indicate that asbestos exposure has occurred and that the person can be at risk of other, more serious, asbestos related conditions.

Exposure to asbestos has been related to two types of cancer. The first is lung cancer. Studies of workers exposed to asbestos have demonstrated higher rates of lung cancer; interactions between cigarette smoke and asbestos increase the chances of getting lung cancer. The second type of cancer, which is highly associated with asbestos exposure is mesothelioma. This cancer is extremely severe, and is more common in workers, although it has also been reported in non-workers with apparently limited exposures. Smoking plays no role in risk for mesothelioma. Studies of workers suggest that breathing asbestos can also increase the chances of getting cancer in other parts of the body, although less frequently.

ATSDR involvement

Since October 1999, ATSDR and DHHS Region VIII staff in Denver, CO, have consulted with EPA and county health officials on environmental sampling of mining waste and interpretation of the environmental data with respect to potential health effects.

ATSDR has worked with the Libby community and local, State and other Federal officials to identify key elements of a Public Health Response Plan to address the public health needs of the community.

ATSDR initiated site activities with a site visit from January 18 to January 21, 2000, in Libby, MT. The site visit by ATSDR and DHHS regional staff allowed the review of current public health environmental actions; gathering of environmental data, health data and community concerns; and meetings with relevant parties to formulate an action plan. ATSDR staff met with officials of EPA, the Montana Department of Public Health and Human Services (MDPHHS), the Lincoln County Commissioners and Department of Health, St. John's Lutheran Hospital, and a key local physician who has seen and diagnosed individuals with asbestos-related illnesses. During this visit, ATSDR and the State and local health officials initiated discussions to address the public health needs of the community.

During a follow-up site visit February 2-9, 2000, DHHS regional and ATSDR staff worked with State and local health officials to outline future public health activities in a Public Health Response Plan. Key elements of the overall Public Health Response Plan for Libby, MT, are to:

  1. provide input and advice on environmental sampling being done by EPA to better understand patterns of exposure;

  2. collect and analyze medical and epidemiologic data to better characterize the nature and extent of asbestos-related disease in the community (this would involve review of medical, pathology, and vital records data for residents of the Libby area who have already been diagnosed with asbestos-related disease);

  3. coordinate medical testing for people in the community who have had past exposures to asbestos in order to identify people with asbestos related conditions so they can be referred for medical care; and

  4. provide a public health education program to assist residents and health care providers in obtaining full and up-to-date information on asbestos-related risks and diseases.

Medical testing and referral: Medical testing to identify the extent of the site-related adverse health effects is a key component of the Libby Public Health Response Plan. Planning to provide medical testing to persons who lived or worked in Libby during the time of highest exposure is ongoing. The medical testing will provide screening services and advice on diagnosis and long-term care needs, where appropriate, for people who were exposed to asbestos; estimate the prevalence of asbestos-related conditions in people who might have been exposed; and assist the local health department and local physicians to estimate the magnitude of asbestos-related illnesses that must be addressed by local physicians. Under this plan, people who lived near the site, worked with vermiculite, lived in a household with a vermiculite worker, or had some other activity which allowed them to have frequent contact with the vermiculite in the Libby area, could be identified and included in the medical testing plan. People who meet the designated criteria will be scheduled for a chest x-ray and will be asked to complete a detailed questionnaire. The x-rays would be reviewed by expert radiologists and the results will be provided back to the participants. People with abnormalities associated with asbestos would be notified, counseled and offered additional lung function tests and radiographic procedures, along with referral to their physician. People who do not have a physician would be referred through a system coordinated by the local health department. We currently estimate that as many as 3,000 people would meet the criteria for testing and desire to be tested.

A written project plan, as described above, is currently being formulated and is planned to be submitted for independent review by a panel of physicians and health scientists with expertise in asbestos-related diseases. We anticipate this review will occur by the end of February 2000. We hope to begin medical testing within two to three months. The Health Resources and Services Administration (HRSA) has already committed $80,000 toward the medical testing program.

Health education, communication and community involvement: ATSDR's health education and promotion program encompasses the overall goals of educating individuals, communities, and health-care providers about the health effects of hazardous substances in the environment; working with affected communities to develop and promote public health strategies to mitigate the health impact of hazardous substances; and disseminating environmental health education materials, training, and information.

To date, local public health professionals (physicians and nurses) have been contacted to enable ATSDR to better understand local health-related concerns; community involvement specialists in the various represented organizations (including EPA, ATSDR, and the state health department) have begun developing strategies for clear, effective message delivery; and contact lists are being developed to ensure that affected and interested parties in the Libby area receive information that is disseminated. Further, ATSDR is working with EPA to discuss mechanisms, such as a community-based group, to obtain regular and consistent community input to the development and implementation of the Public Health Response Plan.

A key part of ATSDR's health promotion program is education and training for health care providers and other health professionals, to facilitate access to environmental medical services, and to establish the connection between environmental public health practice and long-term health care. An integrated health care provider education plan is being developed that will target primary care physicians as well as community health nurses, x-ray technicians, respiratory therapists, and other health-related professionals who interact with people who may have been affected by Libby-area contamination.

ATSDR staff are currently working with local partners to plan a community meeting in Libby. The idea is to create an environment for individuals to talk directly with scientific, environmental and health experts at "information kiosks" about their health-related questions and concerns. The public availability session is expected to be held within in the next month and before the medical testing activities begin.

I would like to reiterate that ATSDR shares your concerns about the situation in Libby ­ both the environmental contamination and the health concerns. I am confident that the expertise of the ATSDR staff and its partners, working through the integrated Public Health Response Plan, can address both short- and long-term public health needs of the community.

ATSDR continues to provide input and advice on environmental sampling; is reviewing medical and vital records for residents already diagnosed with asbestos-related disease; is developing protocols for medical testing to commence later this spring; and developing health care provider and community education materials for use in this response. Each of these activities are in collaboration with other federal, state, and local agencies. Our efforts will result in an integrated program to address the health concerns of prior and current residents of Libby and the surrounding areas. The community's concerns about the environment and its impact on their health can be addressed only if we continue to work in the collaborative manner that staff of the federal, state, and local agencies involved in this response have already begun.

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