June 10, 2014 Advisory Panel Meeting Summary:
Environmental Health Tracking & Biomonitoring
1:00–4:00 p.m, American Lung Association
Advisory Panel: Alan Bender, David De Groote, Melanie Ferris, Jill Heins Nesvold, Steven
Pedersen, Gregory Pratt, Cathy Villas-Horns, Lisa Yost
MDH staff: Jeanne Ayers, Joanne Bartkus, Betsy Edhlund, Jim Kelly, Jean Johnson, Aggie
Leitheiser, MaryJeanne Levitt, Mary Manning, Pat McCann, Paul Moyer, Jessica Nelson,
Christina Rosebush, Chuck Stroebel, Janis Taramelli
MAD consultant: Kris Van Amber
Others: Charlene Muzyka and Mika Hyden, Minneapolis Health Department; Ned Brooks,
Minnesota Pollution Control Agency
Welcome and introductions
Lisa Yost, filling in for chair Patricia McGovern, welcomed the attendees and invited the panel
members and audience to introduce themselves. Newly appointed Advisory Panel member
Steven Pedersen introduced himself as the Senate appointee on the panel.
Aggie Leitheiser and Jeanne Ayers introduced the Minneapolis Health Department guests,
Charlene Muzyka and Mika Hyden, part of the Minneapolis Health and Family Support Progam.
Both are working with the Healthy Communities Transformation Initiative (HCTI) funded
through HUD’s Office of Healthy Homes and Lead Hazard Control.
Sustaining Minnesota Biomonitoring: Workgroup Progress Report
Kristin Van Amber, Senior Management Consultant, Management Analysis Division, Minnesota
Management & Budget, reported on the Sustaining MN Biomonitoring Workgroup meetings.
The background material can be found on pages 5-12 of the June 10, 2014 Advisory Panel
Meeting book.
Discussion: The following questions were posed to the panel:
• What advice would you give the workgroup as they set out to develop an action plan?
• Are there other sources of funding not listed here that they should consider?
Steven Pedersen questioned whether the Department of Health received a certain percentage
of the Clean Water Legacy funding that could be used. Jean responded that no Legacy funds are
used for biomonitoring. He added that foundations were a way to get short term funding.
Assistant Commissioner Aggie Leitheiser noted that she did not see any reference to the MDH
general fund money in the plan. Al Bender stated that in order to take a long-term approach,
legislators will have be to educated about the importance of this work and the necessity of
these projects. He believed we would not be able to get outside funds without legislative
backing.
Aggie Leitheiser added that it is always good for any program to have multiple funding sources,
as much of the money the Department of Health receives is given out in grants. Jill Heins added
that multiple funders make you more sustainable for two to three year chunks, but most
government entities are not eligible to apply for foundation funding. She added that state
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funding is the most sustainable. Steven Pedersen offered to use his position as a Senate
appointee of the panel to give a presentation to the Senate.
Greg Pratt felt that stronger messaging on why it is good to put money toward the program is
needed—the successes. Al Bender added that we have six years of success stories; we need to
pick the ones that everyone can identify with in order to move this forward. Jill Heins noted
that some of this is urgent and that we need to plan less and do more, especially in the
communications area.
Steven Pedersen wondered if we had worked with the Inter Agency Research Group, the
executive branch, assistant commissioner-level group that discusses priorities that cut across all
agencies.
Melanie Ferris added that partners are important, and it may be more appropriate for us to
partner with healthy equity and community organizations who have concerns around certain
chemicals in an area. She added, then we are back to proposing a project rather than
sustainable funding.
Kris Van Amber noted that the next two years were critical to making connections and
educating people. The next step was planning the actions around this goal: the who, when, and
resources necessary to get a strategy in place.
MN FEET Protocol Review
Dr. Jessica Nelson reviewed progress on planning for MN Family Environmental Exposure
Tracking (MN FEET). Background material can be found on pages 13-17 of the June 10, 2014 AP
Book.
As a new development, Jessica presented the following two options for project design:
Option 1, which the Panel has heard about before and is summarized in Figure 1 of the AP
Book, would recruit participants through staff from 3 Metro clinics. Enrollment would be open
to all women, but there would be target numbers for certain groups. We pared back what we
would ask clinic staff to do based on feedback from them; the current plan would have them
ask eligible women for consent to test the leftover newborn bloodspot and receive a follow-up
phone call from MDH. A trained interviewer would call the woman, administer the survey, and
ask for additional consent to collect and test cord blood and urine samples. All three samples
would be collected at the hospital around the time of birth, the cord and urine samples by
hospital staff and the bloodspots as part of the MDH Newborn Screening Program.
A variation on this design, Option 2, has emerged as staff have had more meetings with clinics.
In this approach, participants would be recruited primarily by phone. We would contract with
two larger clinic systems to identify potentially eligible patients. Because women would be
selected from the larger clinic system’s patient list, women from certain clinics, racial/ethnic
backgrounds, and stages of pregnancy could be randomly chosen. Women would receive a
letter from the clinic saying they will be called, and then trained researchers from the clinic
system would conduct calls in the appropriate language. The caller would introduce the project,
ask for consent for all aspects of the project, and, if a woman consents, conduct the phone
survey. Specimen collection would be the same as in Option 1.
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Jessica noted that, while we are pursuing both options, it looks like Option 2 is more feasible.
Jeanne Ayers was surprised to learn of cord blood collection and storage routinely being done
in hospitals. Lisa Yost questioned whether it was de-identified. Jean explained it is for
diagnostic/health care purposes only, so not de-identified in the hospital. David DeGroote
asked whether we would need to get consent to use cord blood. Jessica said yes. Al Bender
thought it would be difficult to get consent in writing, and Jessica added that biomonitoring
projects have conducted consents over the phone in the past, but that, of course, the IRB would
have to approve.
Jill Heins questioned the timeline to recruit 500 participants. She had concerns based on her
past experiences. The clinics go in with the best intention and foresee no problems, but it does
not happen this way. If the clinics are using an electronic medical record (EMR), they do not
have race/ethnicity information and there is no way for a clinic to identify patients in their third
trimester. She hoped one of the options would work, but they have not had success with
recruiting people through clinics. Jill offered to share everything they have learned about what
did not work.
Jeanne Ayers thought some clinics did collect race/ethnicity data, but there was no
standardized format for collecting or reporting the data. Jessica responded that they are
working with the Health Partners Institute for Education and Research and West Side
Community Health Services, both of whom were very encouraging about Option 2. There are
certainly more details to work out, but, based on information shared so far, both clinic systems
do collect race/ethnicity data and can identify a woman’s stage of pregnancy.
Jeanne Ayers wondered if, in Option 2, we would have to pay the contractors. Jessica
responded that the MN FEET budget includes contracts with clinics, but those conversations
have just begun.
Jessica also presented the data analysis plan, with five main goals.
1. The first is to characterize exposure to mercury for all three sample types, and to
compare to results from MDH and other studies.
2. The second is to assess whether ethnic/racial disparities in exposure exist.
3. The third purpose is to investigate sources of mercury exposure using survey responses
and speciation.
4. The fourth is to extend our examination of whether newborn bloodspots are a good way
to assess newborn mercury exposure by comparing bloodspot v. cord blood v. maternal
urine results.
5. The fifth is to measure and perform similar analyses as above for lead and cadmium in
cord blood.
Jessica explained that we are primarily considering disparities by race/ethnicity, but will also
look at socioeconomic status. The question is, given our sample size, which racial/ethnic groups
can we consider? We want to design our study so that we have confidence we will be able to
detect a disparity if it exists. Two options under consideration are: 150 each of Somali, Hmong,
Latina, and white women; or, 200 each of Somali, Hmong, and white women. There could be
other options as well. To address this question, Jessica presented sample size calculations
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which show, for different-sized groups, the statistically significant difference in mean mercury
concentrations that MN FEET could detect (below). Jessica showed these for different standard
deviations to give a sense for the range; we don’t know what this will be in our population. For
some perspective, she also presented differences in means seen by race/ethnicity in other
studies (below). Jessica concluded that MN FEET probably will not be able to capture more
subtle differences, but should be able to detect larger ones.
Mean difference (µg/L) we could detect between groups (80% power)
TIDES bloodspot (GSD=1.8)
NHANES whole blood (GSD=2)
UT bloodspot (GSD=3.1)
n=150
0.6
0.65
0.97
n=200
0.5
0.57
0.85
n=300
0.4
0.47
0.72
Differences in other surveys
Blood mercury (µg/L)
NHANES 1999-2010, women 16-49
N
GM (CI)
95th %ile (CI)
Non-Hispanic White
4043
0.81 (0.76-0.87)
4.63 (4.11-5.2)
Non-Hispanic Black
2230
1.02 (0.94-1.1)
4.42 (3.8-5.15)
Mexican American
2589
0.68 (0.64-0.73)
2.87 (2.58-3.2)
Other Hispanic
751
0.98 (0.85-1.14)
4.32 (3.56-5.23)
Other Race
474
1.5 (1.3-1.74)
8.68 (6.55-11.51)
Non-Hispanic White
Non-Hispanic Black
Non-Hispanic Asian
Hispanic
NYC HANES 2004, all adults
529
2.83 (2.62-3.07) 10.85 (9.36-14.21)
390
2.61 (2.36-2.88) 9.26 (7.77-12.26)
231
4.11 (3.24-5.21) 19.19 (14.03-23.95)
630
2.27 (2.11-2.43)
8.46 (7.03-9.93)
Al Bender stated that this is a classic argument between sample size and budget. If you only
studied two groups, you would have a much greater chance of detecting a difference, because
you had a larger sample of both.
David DeGroote asked whether in past analysis we had looked at all of these racial categories:
Somali, African, Hmong, Latino? Is there any previous evidence that one or two of the groups
would be more likely to show disparities? Jessica responded that we are concerned about these
groups, as well as other groups, including African Americans, because there is evidence
anecdotally and from other studies that they may have higher exposures. But, we do not have
any information on their exposures in Minnesota.
Lisa Yost wondered whether NHANES looks at socioeconomic status and whether there is an
intersection there that could be helpful. Jill Heins asked whether participants self-identify their
race/ethnicity, and what will happen if they associate themselves with multiple races. Jessica
said that we still need to decide what to do in this case. There is new language being proposed
MDH-wide about how to ask about race/ethnicity. Al Bender suggested that you may also have
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an opportunity, in the post-data collection phase, to pool groups. He added that the reason to
do this would be because the joint confidence interval of the differences gets smaller.
Steven Pedersen wondered where cadmium fit in and whether you had considered expanding
the risk factors in the survey questions to diet. Jessica explained that the survey needs to be
relatively short, but added that we may have the space to add one or two key questions about
exposures to cadmium or lead. Steven Pedersen suggested adding a question about leafy
vegetables, which take up cadmium. Even if there is not a strong association, it would answer
the question of whether some groups have different dietary habits than others.
Greg Pratt mentioned herbal medicines because some of the Asian medicines contain metals.
Jessica replied that we are considering this question and have talked to a couple groups about
suggested wording. Greg Pratt did not have specific language in mind. Jean Ayers asked if use of
‘herbal/ traditional’ would work. Jessica thought different wording might apply to different
groups. She has seen ‘folk remedies’ used, but got feedback that this is not ideal. Jill Heins
suggested physician Naomi Duke as an expert source to consult for studying traditional
medicines in certain racial/ethnic groups. Jessica added that MDH/Environmental Health has
also worked on this issue.
Next, Jessica discussed the timeline, which has been extended for this project. The hope is to
establish clinic contracts and submit protocols to IRBs by the end of August. Recruitment would
begin in September and last for one year. Births would be staggered a few months later, and lab
analysis and individual results reporting would follow. Final data analysis and reporting should
happen by Dec. 2016. Alan Bender asked about contracts executed and whether the concept
and principals were established. Jessica responded that contracts were still being developed.
Melanie Ferris asked whether we know if use of skin-lightening creams is more frequent among
new immigrant or refugee women. She wondered whether length of time living in the U.S.
should be a screening question for eligibility. She added that with consent over the telephone
and in a follow-up mailing, it could be a challenge to be sure that the consent is really
understood. Jessica assured her that we have been working on this; the draft consent has been
shortened to one page, and will be included with a short description in plain language. We may
also mail a consent, but have not made a final decision about these procedures.
Jill Heins felt that at the clinic level, it is complicated to engage hospitals to get the blood draw.
Jessica responded that we will get the leftover bloodspot directly from the Newborn Screening
Program, but the cord blood and urine samples, which the Advisory panel has strongly advised
we include, can only be collected through hospitals. Which hospitals will depend on the clinics
we choose and where their babies are delivered; we know we can work with no more than two
hospitals. The hospitals we have spoken with have conducted these kinds of studies. In one
example, the clinic/hospital flagged the EMR of participants to indicate that a cord blood
needed to be collected. There are a lot of logistics to figure out.
Lisa Yost commented that one of the purposes is to better characterize the relationship
between bloodspots and body burden. This is separate from the disparity question. The
disparity question is very important and is an ultimate question, but it may be a lot harder to
answer. To answer the question about the relationship between bloodspots and body burden,
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you need numbers. If you can get that, then you can work on the second question. You still
need some level of permission to use the bloodspots, but it becomes much easier than trying to
get all three pieces in that triangle. Lisa suggested trying to go for numbers in that first round.
Melanie Ferris underlined the importance of getting feedback on how we report results at the
end of the study – this will be important for the community, as will partnering with the
clinics/hospitals or community groups.
Biomonitoring Updates
Dr. Paul Moyer, Environmental Manager of the Public Health Laboratory gave an update on the
MDH Public Health lab. Background material can be found on pages 18-22 of the June 10, 2014
Advisory Panel Meeting Book.
Dr. Moyer shared information on the water damage that occurred last winter, the expedited
recovery process completed in April, current Environmental Lab projects, and the CDC
Biomonitoring Application.
The lab has analyzed cord and maternal blood samples from the National Children’s Study. The
next priority is the Riverside blood spot analyses and The Infant Development and Environment
Study (TIDES Study) whole blood vs. blood spot methodology.
The lab also has the Great Lakes Restoration Initiative under way and the Fish are Important for
Superior Health (FISH) study on the horizon for the Environmental Health Division.
The CDC Biomonitoring Application process was described by Dr. Moyer as a three-fold effort of
the Minnesota Department of Health’s Public Health Lab, as well as the Chronic Disease and
Environmental Epidemiology, and Environmental Surveillance and Assessment sections. The
grant application was submitted in early May, and we should know the result by September 1st.
Christina Rosebush gave a brief update on the PFC3 project. Written updates on the following
mercury projects were also included in the panel’s book (all updates can be found on pages 2324 of the June 10, 2014 Advisory Panel Meeting Book):
•
Pregnancy and Newborns Exposure Study
•
NCS Newborn Mercury Biomarker Validation Supplemental Methodological Study and
•
Riverside Newborn Mercury Project
Panel members were invited to ask questions and comment on all updates.
Following the PFC3 update, Lisa Yost commented that the new residents who moved in after
2006 seem like a more difficult recruitment effort because they, presumably, would not have
any exposure to the contaminated water. She asked how they are being recruited and what
message is conveyed to them. Christina Rosebush described the recruitment packet, which
includes a fact sheet, a colorful flyer , a letter, consents and questionnaire. Lisa added that the
response rate was pretty good considering what you were up against. Christina replied that
recruitment involved three mailings, the third being a reminder postcard that seemed to be
effective. We also had phone numbers for about 60% of the residents on the water billing
records list and phone contact was very effective. Jean Johnson added that there is an
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incentive; a $25 gift card. Christina said it remains to be seen if we will reach our recruitment
target; right now we have about 60-65 new resident participants.
Steven Pedersen presumed that we were looking at post-2006 because we do not think we will
detect heightened exposures in new Oakdale residents. He asked if we will look at where
participants have lived to see if they may have come from an area that had heightened PFC
levels. Christina replied that we will to a limited extent—we do not have information on PFC
exposures in every area of Minnesota and certainly not outside of the state. We ask
participants about previous residences in Cottage Grove and Lake Elmo, which were included in
our original cohort populations. Steven Pedersen remarked that you could have skewed results.
Christina acknowledged that the results could reflect previous exposures.
MN Tracking report: The Economic Burden of the Environment on
Childhood Disease in Minnesota
After a brief refreshment break, Jean Johnson began the Tracking portion of the meeting with a
brief overview of the purpose, findings, and limitations of the report: The Economic Burden of
the Environment on Childhood Disease in Minnesota. Background materials can be found on
pages 25-35 of the June 10, 2014 Advisory Panel Meeting Book.
About a year ago, the CDC directed Tracking grantee states to focus more effort on projects
that demonstrate ways that Tracking data can be used to inform policy and public health action.
This report is one such data use demonstration project and is being done in collaboration with
five other states and the CDC. The project looks at costs for 2 specific child health outcomes
that are known to be causally associated with environmental risk factors: asthma exacerbations
and blood lead poisoning. We did consider other outcomes (childhood cancer costs and
neurodevelopmental disease costs). Although other states are going to be reporting costs for
these additional diseases, MDH decided to report on the two that we felt were more defensible
in terms of having an established environment-disease causal connection.
The report uses methods first published by Landrigan et al in 1992 and updated in 2011.
Landrigan derived a range of environmental attributable fractions, or EAFs, for several
childhood diseases by consulting with experts and using a Delphi process. For asthma the EAF
we used was 30% (range 10-35%), and for blood lead poisoning the EAF is 100%.
MDH also used definitions for “environmental” factors consistent with Landrigan’s paper, which
are defined as human-origin, non-biological factors, and specifically exclude naturally occurring
risks (such as radon, indoor mold, pests) as well as behavioral risks such as diet and smoking.
After describing report and the results, Jean invited MDH epidemiologists Dr. Stephanie Yendell
and Dr. Wendy Brunner to comment on how they see this report being used by their programs.
Dr. Wendy Brunner, Epidemiologist with the Asthma Program, said this report will be useful in
terms of demonstrating the environmental burden of asthma in Minnesota, in grant writing,
and in communicating with our partners. We also expect that the findings are going to be useful
to our partners at the MPCA. We often interact with them about questions about what is the
potential impact of this facility on my community in terms of asthma. We also think it might be
of particular interest to local public health agencies in the metro area as well as organizations
like Minnesota Environmental Initiative, whom we’ve collaborated with in the past.
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Dr. Stephanie Yendell, Epidemiologist with the Lead and Healthy Homes Program, reported that
in terms of blood lead, there’s a couple misconceptions about blood lead that this report helps
to address. One is that we’re “done with lead” in public health, because we’ve made great
strides in reducing the numbers in kids with exposure to lead. We want to show that although
we have had a great public health success in reducing exposure to lead, the costs remain very
large and it still does require monitoring and funding support. Also, this helps put a number on
some of the costs associated with very low levels of lead. We know through the literature that
there is no level of exposure to lead where we cannot detect health effects.
Mary Manning, MDH Chronic Disease Division Director, asked whether the California report
used the same definition for “environment”, looking at man-made pollution only or did
California have a broader definition. Jean answered that they are writing up their report now,
so we are not sure what they used. However, most states have adopted the same general
definition. California did review studies conducted in California and they calculated their own
California-specific EAFs for asthma and childhood cancers (different from Landrigan’s).
Jean noted that MDH will be adding another section for the report to discuss the policies and
actions currently being implemented to address these costs, but that the report will not
promote any particular policy initiative.
Discussion: The following questions were asked of the panel:
•
•
Given the limitations, what is the primary value of this report? How well does it serve its
intended purpose?
Should this report be updated or modified in the future to add other diseases or
conditions? If so, what changes are needed?
Gregory Pratt wondered if it was a correct interpretation to say that the asthma-related costs
were annualized, whereas the lead-based costs were lifetime costs, to which Jean agreed.
Gregory continued that to show those numbers side by side could be misleading, if you assume
a 70-year lifetime. It might be best to consider presenting this in an apples-to-apples
comparison of cost. Jean agreed, adding that each of those outcome costs is a little different in
how they were done.
Stephanie Yendell clarified that the lead costs were per birth cohort year, for all the kids born in
that particular year throughout their lifetime, and so for 2010, it wasn’t all the kids that were
under 6, it was the kids who turned six in 2010. Gregory Pratt noted that if the lead exposure
trend continues downward, costs will go down, to which Stephanie agreed
Jill Heins Nesvold commented that she thought it was very valuable. She added that she
approved of mentioning some program things that MDH is already doing in the report, but she
did not think there could be use of the asthma home visit example because it only impacts the
things that the EAF doesn’t take into account. So, no matter if there was an increase in asthma
home visits, the EAF (which is limited to outdoor pollutants) can’t be impacted.
Jill Heins Nesvold continued that she would be very interested in COPD in the future. Even
though it does not involve kids, and it is more the end of the life, it has more connection to
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environment than asthma does, and it’s more expensive. She offered to help in whatever way
that she could; she would be very interested in seeing the costs of COPD.
Alan Bender commented that this report caused him to think about this in much greater detail,
particularly relative to the issue of childhood cancer. He stated that he is starting to believe that
perhaps we should not be putting this out for any disease, because these are advocacy
statements. The purpose is to put issues in front of people and it implies their importance to
public health, when in fact, there’s a whole range of other attributable factors that are not
considered. It would be more honest to put out what the best estimates of the cost of the
various diseases are and then, put out the range of all statements of the EAF in the literature.
Childhood cancers are the most problematic. You have the one EAF (10%) from Landrigan, but
also there are statements from the National Cancer Institute, from the American Society of
Clinical Oncology, and from the American Cancer Society, which says we don’t know enough to
make these estimates about childhood cancer. Let people apply whatever EAF percentage they
want to support their own advocacy statement.
Alan Bender noted that there are some punitive exposures that may actually decrease the risk
of cancers. For example, pesticide application reduces the general costs of fresh fruits and
vegetables so that certain populations have more access to them. Overall, the population
attributable cumulative cancer risk for pesticides may be negative (preventative).
Jill Heins Nesvold added her agreement. We know that asthma rates started to go up in the US
with the advent of the Mickey Mouse show. It was the first after-school tv program; kids
started spending more time inside; they were more sedentary. Our housing stock also got
tighter and at that point we saw an explosion of asthma rates. So there’s really lack of
consensus in the expert community to the causal factor of asthma. One thinks that there is an
environmental component that might be causing it, but there’s an equal amount of data that
shows that there are environmental factors that are protective for children. For instance,
there’s a good amount of research showing that kids that grow up on farms rarely have asthma
because they have that kind of constant exposure, possibly some kind of protective factor. Jill
stated, “If we continue to spur the debate and continue to push the research agenda, I think
that’s wonderful.”
Jeanne Ayers commented that she didn’t think we should do anything that dampens
appropriate advocacy. When it came to the end of the report, where people would generally
put policy recommendations, we should be talking about the principles around the kinds of
recommendations that could be considered. It could be that based upon this understanding of
the costs, rudimentary or flawed as it may be, we should be continuing to explore both more
understanding of the risks and any actions that could decrease the environmental exposure
because we’re going to need them both.
Gregory Pratt noted that to him, the problem with isolating one factor, is that many of the
environmental stressors are auto-correlated. If people are more likely to be exposed to one risk
factor, they’re often more likely to be exposed to many others. There’s also evidence that it’s
the challenge of multiple stressors that reduces the ability to respond to a single stress. Some
studies have shown that the number one issue in terms of susceptibility to stress is poverty, so
that’s another part of the picture.
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Lisa Yost liked the idea of decoupling the economic costs from the factors which are uncertain
and variable. She felt that did a better job of allowing multiple diseases, because you don’t
know how they correlate and inter correlate, that just becomes incredibly complex. She
thought if you give people some kind of review of the range that has been identified, then they
could make their own decision. She added that not only the legislature, but the general public
also thinks about things in dollars. They may not be able to understand the whole report, but
they will definitely see the big numbers.
Alan Bender stated that one of the reasons he strongly recommended that childhood cancer be
excluded from this report was that, if you look at all the components of the analysis, the levels
of uncertainty for virtually all of them was so much higher than they were quantitatively
different. He used the example of childhood cancer and the unmeasurable impact on the family
of the child with cancer--what that means to their earning and their livelihood in terms of the
treatment and the follow up. Jill Heins Nesvold agreed that it would be a problem accounting
for all these factors; one being a lifetime cost and one being an annual cost.
Jeanne Ayers commented these diseases are multifactorial, so saying (in the report) that there
has to be multifactorial approaches; they have to be thought about together and we have data
to suggest that there are some areas that are amenable to intervention and others that need
further exploration.
Mary Manning added that the things that could be done, even though they were behavioral,
rather than environmental, had to be addressed. Jill Heins Nesvold agreed that home visiting,
the home assessment, and remediation was vital to asthma; they were 50% of the puzzle. But
that’s all been taken out of the Landrigan definition. Mary Manning agreed that acknowledging
the indoor environment is critical for addressing asthma.
Alan Bender added that our social resolve to deal with particular risks plays a big role in this, far
more than any of the uncertainty of the scientific relationships. So it’s a very complicated issue
when we get to speaking to advocacy and we just have to be cautious as to what we’re saying.
Jill Heins Nesvold commented that in light of the sustainability conversation at the beginning of
the meeting, the report contains so many excellent points and sound bites that it could be used
by your communications group on a daily basis. Jean replied that they had plans for breaking
the report down into infographics.
Melanie Ferris offered to pass the report onto her staff economist. She said she was curious, for
the blood lead poisoning, why some of the short-term cause, the direct treatment, and
assessments weren’t included. The challenge of these kind of calculations in general is that the
assumptions are not always clear. Decisions do have to be made around the quality of
evidence. So while it still is very difficult and there are limitations, being able to describe that
and present, in this complicated landscape, a conservative estimate based on our best
information. It’s important for the department to lead the way in showing how to sift through
these complicated issues.
Jeanne Ayers asked if there would be a section describing the assumptions that were used, or
conclusions. Melanie Ferris explained that just being able to be very explicit and transparent is
covering that, but to the general public, that may be a hard thing to be able to sift through.
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Stephanie Yendell clarified that one of the papers that we looked at had included direct costs
for lead. It was approximately 2 orders of magnitude smaller than the IQ loss. So it basically
ended up dropping out from rounding error. That was one of the reasons we didn’t include it.
Also there’s very few cases that ended up being hospitalized or treated. There are costs for
local public health to do education and to do the environmental assessments, but a lot of our
costs are in the surveillance, which isn’t directly related to how high the blood lead levels are.
Cathy Villas-Horns commented that it was very valuable to do this, even with all the
imperfections in coming up with the numbers. It was unusual in that we haven’t often tried to
quantify the ‘what if we don’t do something?’ In light of all the arguments against doing things,
this showed us what the cost, collectively, would be if we don’t do the things we’re doing in
prevention of these things and the cleanup. MDH could present the information with all the
precautions and It would still be very useful to have these numbers.
David DeGroote agreed, noting that too much of the time it has been all anecdotes heard in
public or in the legislature. This provided a cost, “warts and all”. Maybe keep some things
around how we had gotten there and some things we’ve done about what these problems are.
So that, whether it’s childhood cancer, or whether it’s asthma, COPD, there were real costs and
here was our best estimate, and if we don’t continue to do something about the problem, the
costs are still going to be there.
Steven Pedersen commented that what was missing was the question of what to do with this
information? It was his feeling that the legislature would ask, “what do you want us to do?” He
noted that this is a first step to a policy position, but legislators want to know what is this risk in
relation to and where is my money best spent for protecting children. Is there some place else?
If there is, well, talk to me about that. If there isn’t, then tell me what you want me to do.
Wendy Brunner asked to make a quick clarification just to make sure everybody is clear that for
asthma, this report is measuring the environmental cost related to exacerbation, so not
whether you have asthma or not because that science is not clear at all. There’s some evidence
that air pollution is associated with the development of asthma in the first place, but that’s not
consensus. There’s certainly consensus that air pollution, as referred to in the environmental
attributable fraction, is connected with outdoor air and with exacerbations.
Jean thanked everyone. Staff will take all comments into consideration and will complete the
report.
Environmental Justice in Minnesota: MPCA’s Approach
Ned Brooks, Environmental Justice Coordinator at the MPCA, gave an overview of a new
Environmental Justice Initiative at the MPCA. The background materials for this topic are found
on pages 36-40 of the June 10, 2014 Advisory Panel Meeting Book.
Ned welcomed the opportunity to present an overview of what the MPCA is doing and, more
importantly, stimulate thoughts and discussion among panel members about how the EHTB
program can work with the PCA and how we can support each other.
First, Ned provided background and definitions about what the MPCA means by
“environmental justice.” Ned mentioned the Dayton Administration’s focus on reducing
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disparities across all state government’s programs and outcomes; that it’s closely related to the
health disparity work of the health department. Ned added that there’s a more organized local
and national environmental justice movement, and the PCA Commissioner is also very
passionate about the issue, so we are working very hard to do a much better job than we have
before.
There are the two pillars of environmental justice: fair treatment and meaningful involvement.
Fair treatment is about exposure to pollutions. PCA’s mission is to protect and improve the
environment, but also to enhance human health. When PCA talks about environmental justice,
it’s mostly about the health component—to make sure there is not disproportionate exposure
to harmful pollutants. Multiple exposures on top of overburdened people is another part of
environmental justice, as well as the lack of voice and political clout in the process—that’s
another tenet of environmental justice’s meaningful involvement. PCA strives to make sure that
all Minnesotans have an opportunity to be involved in decisions that are going to affect them.
Ned explained that they had recently included environmental justice as a goal in the PCA
strategic plan for the first time (one of 15 goals). The initial focus has been to analyze how
MPCA’s program activities may have an effect on reducing disproportionate impacts and
provide opportunities to more meaningfully involve Minnesotans.
MPCA is also working to develop external relationships with communities. Many times there
will be a contentious issue, and that’s the first time people meet MPCA staff, when they’re
angry, and that’s not a great place to start. Building relationships, identifying various members
of the community, particularly those that represent lower income and minority groups, and
also working to coordinate among state government, because many of us are struggling with
the same issues, is key.
Ned continued that the MPCA is developing a framework with a goal of having something
similar to EPA’s Environmental Justice Action Plan for 2014. There’s five areas listed:
stakeholder engagement; outreach around specific actions, such as permitting actions; talking
about ways to characterize, identify which communities are considered more overburdened or
are a potential concern for environmental justice. Ned shared examples of how the
components of the framework are being developed.
And to transition towards the thinking of the Environmental Health Tracking, he talked about
how they’re trying to measure effectiveness. Tracking and monitoring levels of pollution in
environmental justice areas would be especially helpful, and an opportunity for linking further
with EHT.
Ned hoped he’d stimulated some thinking on the panel’s part on how the Health Tracking
program and PCA could work together.
Discussion: The following questions were asked of the panel:
•
•
How can the MN Tracking program best support the MPCA’s work?
What data would be beneficial for informing the screening process and the evaluation of
outcomes that is planned?
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Jeanne Ayers wondered if Ned had thoughts about what data would be beneficial from the
Health Department that would facilitate the kind of more robust community decision making
that he was envisioning? Ned replied that some help, in particular in asthma, with what the
best measure is. There is a controversy as to whether it is about hospitalizations or emergency
room visits; that sort of thing. What health outcomes can they measure that are due to
exposures and how can they track those over time? To the extent that there is data available to
correlate environmental exposures to health outcomes that could be parsed out by the census
tract or areas like that, that would be most useful. Jill Heins Nesvold responded that asthma
hospitalizations was the better measure. Emergency room visits for asthma were too volatile
and were based on Medicaid coverage in the State of Minnesota, so when there’s more
generous coverage policies for individuals on Medicaid, asthma emergency department visits
go down and when it tightens up, emergency department visits go up because that’s their
primary care at that time, so it’s too volatile, so you are right on track with hospitalizations. Jill
continued that If you are looking for other data sources, if you are going to select asthma
hospitalizations, you need to look at COPD hospitalizations as well. Certainly without a doubt
the environment relates to COPD exacerbations.
Ned mentioned a joint initiative to work with the Health Department to identify ways where we
could have an influence in reducing air pollution related issues, and respiratory disease in
environmental justice areas. It included health impact assessment and report on the health of
twin citians related to air pollution.
Shannon Lotthammer, MPCA Director of Environmental Analysis & Outcomes, introduced
herself, after arriving late from another meeting. She noted that the Health Tracking Program is
already supporting the PCA’s work by providing the kind of information that Ned discussed.
Shannon noted that MPCA is striving to engage communities in conversations in advance of
permitting decisions. She shared a specific example of how MPCA is using health outcome data
to help communicate with permittees about the need for greater community engagement and
to look for opportunities to reduce impacts on vulnerable communities that go beyond meeting
standards and permitting requirements. So having this kind of information really helps PCA, and
that’s also a two way street. As PCA gets further into this and identifies needs or opportunities,
having the partnership with the Department of Health and having this group here will allow PCA
to bring ideas forward. The more data can be shared, the better informed policy decisions will
be made to move forward to achieve those health outcomes that we are all trying to move
towards.
Jeanne Ayers commented that she really appreciated the approach of the MPCA; the
recognition that it was not just whatever is happening in the community, but it was the level of
vulnerability of the community. There are particular communities which you are addressing
that are more vulnerable, which would suggest that we should actually have more supports and
protective approaches in those communities versus the kind of clustering of hazards that
sometimes does happen in those communities. This is consistent with what we’re trying to lift
up with the MDH health equity report. She really appreciated this pilot that we’re going to learn
together.
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Tracking Updates
The following tracking updates were provided in report form on pages 41-45 of the June 10,
2014 Advisory Panel Meeting Book. Panel members were invited to ask questions or comment
on the following updates:
•
•
•
•
•
CDC Renewal Application
Portal Updates
New HIA Toolkit
Health and Climate Video
Urban Air and Health Project
New Business
There was no new business.
Audience Questions
Visitor Charlene Muzyka, Minneapolis Health Department commented on the last discussion
about presenting data together in a user-friendly format that has overlays and rankings of
smaller geographic areas—that is what the Healthy Communities Transformation Initiative is
trying to do for Minneapolis. We are one of 4 pilot cities in the country. We want this tool to be
piloted by different organizations and people in Minneapolis within the next year. We hope to
get feedback on how it’s used to have these types of conversations and to effect different
policy decisions. Charlene added that the website is not up yet, but, at a later date, she would
be happy to present to this group, if interested. The pilot group will upload the data.
Jeanne Ayers added that there was a steering committee that spent a lot of time looking for
indicators that were commonly available.
Adjournment
Lisa Yost adjourned the meeting at 4:00 p.m. The next Advisory Panel meeting will be held on
October 14, 2014, from 1:00–4:00 p.m. at the American Lung Association in Minnesota.
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