PREPARED STATEMENT OF LYNN R. GOLDMAN, M.D., M.P.H., CHIEF OF THE ENVIRONMENTAL EPIDEMIOLOGY AND TOXICOLOGY BRANCH OF THE CALIFORNIA DEPARTMENT OF HEALTH SERVICES, EMERYVILLE, CA

Good morning Mr. Chairman. I am Lynn R. Goldman, M.D., state of California Environmental Epidemiologist and Chief of the California Department of Health Services' Environmental Epidemiology and Toxicology Branch. I am responsible for California's Childhood Lead Poisoning Program and for the epidemiological investigations that have been carried out by California in response to childhood cancer outbreaks in the Central Valley of this state. In addition, I am a board certified Pediatrician with training in public health and epidemiology and have published extensively in the area of environmental health.

The California Department of Health Services serves all of the public health needs of the state of which environmental health needs of children have been an important priority. In these remarks, I will address four issues which are of concern for our Department: (1) childhood cancer outbreaks in several small towns in the state; (2) childhood lead poisoning problems in inner city areas in the state; (3) lack of adequate health care access for children affected by these problems; and (4) lack of adequate training in environmental health for physicians caring for these same children. These problems do not have easy solutions and are not amenable to state-by-state approaches. Rather they point to the need on the Federal level for increased attention to environmental hazards for children.

I am certain that the Committee, in preparing for these hearings, has already learned much about the childhood cancer problem in McFarland, California. The committee may not be aware of similar childhood cancer excesses identified in several other small towns in California (Rosamond, Montecito, and Earlimart). Since the McFarland problem is better known, I will briefly describe it to you but only for use as a case study. The other cases are of equal importance but have been of less interest to the general public.

Back in 1984, the California Department of Health Servces was notified about the occurrence of childhood cancers in the small town of McFarland. At that point six cases had been identified but by the end of 1985 three additional cases were found (for a total of ten cases) and an investigation was begun. We continued to monitor the occurrence of cases of cancer in the area. Three more cases occurred

between 1986 and the present, for a total of 13 confirmed cases. (A "confirmed" cases is defined as a malignant tumor occurring in a child under the age of nine and living in the town at the time of diagnosis.) Since 1984, the cancer rate has been about three times the expected rate.

All cases

Since the investigation began in 1984, much progress has been made. were interviewed to look for factors more common in cases compared to controls. The interviews focused on diet, pesticides, and other environmental exposures. The only common factor was residence in McFarland. An extensive environmental investigation was carried out to look for evidence of cancer causing agents like pesticides applied in the area. The investigations examined drinking water, soils, and even electromagnetic and microwave exposures from home wiring and nearby transmitters. Through these environmental investigations, we have been

able to alleviate some of the community concerns about the quality of the environment. In addition, we have begun a study of childhood cancer incidence

rates in a larger four county region around McFarland.

It

So far, these investigations have produced the following findings. First, we have been unable to date to determine the cause of the cancers in McFarland. is likely that the occurrence was through a combination of exposures at lower dose that cannot be determined epidemiologically (but which may have occurred in this community by chance), through past exposures no longer present in the community, or that we do not have the tools to identify the carcinogen in the community. The region wide investigation has concluded that the overall rate of cancer in surrounding counties is not unusual and that there is no evidence that farming areas as a whole have increased rates of childhood cancer. More detailed examination of the data is proceeding to look at rates in smaller areas, SO additional findings are anticipated for that part of the investigation.

Very little is known about the causes of the types of cancers found in McFarland, or in the other communities I mentioned earlier. Therefore, it was necessary to conduct a very comprehensive and wide-searching investigation. It is very difficult to conduct epidemiological investigations of small numbers of cases with poorly defined exposures. Questions raised by McFarland need to be addressed by larger studies of childhood cancer.

Cancer studies are not a very powerful way to examine risks of pesticide exposure. More precise tools are needed to measure exposures and to detect more subtle evidence of damage that leads to cancer. These tools need to be applicable to population based epidemiological studies. This means that development of tools must be taken beyond the laboratory bench and into the real world. This kind of research requires support from the Federal government, utilizing university resources.

We have also learned that there is a large gap between community perceptions of what science can do and the reality of scientific limitations. For example, back in the 1950's the Japanese began to notice an increase in mental retardation and cerebral palsy among children in a small town called Minimata. It took 15 years

for scientists to prove that the methyl mercury that contaminated the harbor and its fish caused the congenital defects in these children.

One step that California has taken is to establish comprehensive statewide cancer reporting and monitoring to facilitate identifying and investigating problems like McFarland, In addition, to avoid the initial delays that occurred with McFarland, we have written a protocol for conducting the initial phases of an investigation, and have trained California's local health departments. However, scientific investigation will still require time and intensive labor. And despite that many investigations will reach blind alleys.

Again, the federal government can be of assistance, particularly for setting priorities for use of our limited epidemiologic resources. Training more scientists in the field of environmental epidemiology (especially exposure assessment) and development of better investigatory tools would also help the

process of conducting these investigations.

It is important for the National Cancer Institute to continue to fund studies that will increase our understanding of the causes of cancer, particularly childhood cancer. These studies would enhance our ability to assess clusters.

I would now like to turn my attention to a pediatric problem that is well understood, preventable, and has yet to be adequately addressed on a national level. The Committee is probably also well aware of the problem of childhood lead poisoning. Generally good public health policy sets exposure limits for toxic substances well below the Lowest Observed Adverse Effect Level (or lowest dose at which health effects occur). Based on recent studies, the Agency for Toxic Substances and Disease Registry (ATSDR) estimated that lead is neurotoxic to children at levels as low as 10-15 ug/dl (micrograms per deciliter) well below levels once thought safe. It is estimated that 400,000 children in the U. S. are born with blood lead at these levels each year and that between three and four million American children now have blood lead levels at or above this range. What is not usually appreciated is the nationwide scope of the problem; lead is present at potentially toxic levels in the West as well as in the East. For several years California had no program to address the problem of lead poisoning. In 1986, we established an innovative program to conduct studies to estimate the magnitude of the problem statewide. In neighborhoods in East Oakland and in Los Angeles County (Wilmington and Compton), we found that around 19% of children between ages of one and six had blood lead levels above 15. Both areas had homes with extremely high levels of lead in paint and Oakland had very high levels of lead in soil. Lead is the only toxic substance to which we knowingly allow our children to be exposed above the Lowest Observed Adverse Effect Level. There is no evidence for a level that is safe for lead and no margin of safety for current levels. What is the cost to society because of IQ

loss to hundreds of thousands of children?

Childhood lead poisoning can be completely eradicated. But to do so will require much more attention to primary prevention, that is, to removing lead from the environment of children. The phase-out of lead from gasoline and house paint was

A comprehensive program
California has already

a start, but many other unnecessary uses of lead exist. to address the problem of lead paint on houses is needed. moved forward with a program to study methods for removing lead from home environments. In addition, we have begun to develop regulations for dealing with lead in household paint and soil. California developed one of the first lead poisoning reporting programs whereby cases of childhood and occupational lead poisoning must be reported to the Department of Health Services.

One is that the painful and more

The federal government could be of assistance in several ways. support for basic research in several areas, including a less efficient technique for screening children for lead exposure. Second, we need a more cost effective techniques for removing paint from housing without further damaging children, workers, and the surrounding environment. Nationwide reporting of lead poisoning cases to the Center for Disease Control would help states put our problems into better perspective. And there needs to be a long range plan to rehabilitate old, lead contaminated housing stock.

Another area of concern is that children at risk have inadequate access to health care. Both rural neighborhoods like McFarland and the urban neighborhoods where we studied lead exposures exemplify this problem. Our studies have shown that in areas where the environment is of most concern, parents are least able to obtain routine medical care for their children. Both parents and health professionals thought there would have been fewer deaths if the McFarland cancer had been diagnosed earlier. Average household incomes in McFarland are below $15,000 per year. In McFarland, 46% of the families had no health insurance, and only 20% had Medicaid coverage. And the physicians who practice there do not accept Medical (the state medicaid program). So poor families must travel long distances for care or pay out of pocket. Even parents in McFarland with private medical insurance reported that they must pay out of pocket beyond what they afford for their children's health care. Although urban areas have more physicians per capita, similar problems were found in the childhood lead studies. For example, 41% of families in our Los Angeles Lead Survey were without health insurance coverage. Inadequate access to health care for children has increased