San Joaquin (Fresno, Bakersfield, Modesto, Stockton)

If you have further questions, let me know.

Sincerely yours,

Werner G. Siem

Werner A. Siems

Director of Public Affairs

Senator MUSKIE. May I invite our other witnesses to join us at the witness table: Mr. Larry Moss, of the Sierra Club; Mr. John J. Sheehan of the American Lung Association; and Dr. Bertram Carnow of the University of Illinois School of Public Health, representing the Clean Air Coalition.

Mr. Moss. We would like to follow the order of Dr. Carnow first and then Mr. Sheehan and then myself.

STATEMENT OF BERTRAM W. CARNOW, M.D., ON BEHALF OF THE NATIONAL CLEAN AIR COALITION AND THE AMERICAN PUBLIC HEALTH ASSOCIATION

Dr. CARNOW. My name is Bertram W. Carnow, M.D., of Chicago. While I ame speaking today on behalf of the National Clean Air Coalition and the American Public Health Association, I hold a number of other affiliations and positions which may interest the subcommittee.

I am professor and director of occupational and environmental medicine at the University of Illinois School of Public Health and also hold a professorship at the University of Illinois Lincoln School of Medicine, Department of Preventive Medicine and Community Health.

I serve as director of the Environmental Health Research Center of the State of Illinois Institute of Environmental Quality and am environmental consultant to the Governor of Illinois.

Additionally, I am chairman of the American Public Health Association Energy Task Force which will shortly publish a major study entitled, "Health and Safety Effects of Energy Systems" and chairman of the National Academy of Sciences Panel on Sulfur Dioxide which will shortly report formally to this subcommittee.

At the local level, I have been medical director of the Chicago Lung Association since 1967, a chest consultant at the Union Health Services since 1957 and attending physician and chest consultant at the Michael Reese and University of Illinois Hospitals.

I am a fellow in the American Public Health Association, a fellow in the Royal Society of Health, a fellow in American College of Chest Physicians, and a member of numerous medical and scientific organizations.

The National Clean Air Coalition and the American Public Health Association have asked me to represent them here today to provide some comments on the Clean Air Act from a physician's viewpoint.

I will share with you some of my concerns based on 15 years of observing and treating humans suffering from the effects of air pollutants and 10 years of epidemiologic study of air pollution's impact on health.

My concerns about the impact of air pollutants on health must be seen as part of a total concern for public health in view of what is occuring in regard to the diseases afllicating Americans, particularly cardiovascular diseases, bronchitis and emphysema and lung cancer.

The major killer, cardiovascular disease, particularly coronary artery disease, now kills 60 percent of all Americans. It is more than 1 million each year.

Bronchitis and emphysema disable millions and are reponsible as a primary and secondary cause for some 100,000 deaths each year. Lung cancer has increased to the point where it kills more American males than all other cancers combined. These are all noninfectious diseases, have multiple causes, insidious onset and very long incubation period.

What is most frustrating to clinicians is that when they appear they are irreversible, in a majority of cases, and very little can be done for those who suffer from them.

With lung cancer the salvage rate is somewhere between 5 percent and 10 percent in the best medical hands. I note this in relation to air pollution because studies carried out by our group at the University of Illinois, by the Federal EPA, and by others strongly suggest that air polution is an important factor in all of these diseases.

In view of the nature of the onset and irreversibility of these diseases, it becomes critical to define the major causative agents in order to practice primary prevention. And this represents one of my major concerns in regard to air pollutants.

A few comments about health effects assessment and its use as a basis for standards setting are now in order. Air pollution standards, like other health standards, reflect social, economic and political decisions.

Too often, however, standards are viewed as levels which protect the health of all people. This, of course, is just not true. The environment is essentially hostile, and humans, as biological organisms with varying degrees of resistance and adaptive capacity, are in a continuous struggle with it.

Any factor in the environment which increases its hostility or anything lowering the resistance of humans decreases adaptability. When one views the health effects of air pollutants on humans in the context of this struggle, it becomes obvious that in a heterogeneous population of 200 million people with varying ability to adapt, for example those with genetic defects, asthma, allergies, heart disease, and lung disease, there can be no well defined threshold or safe level.

Our studies and those of others strongly indicate that at every level of air pollution, someone's health is affected adversely, and someone may die.

Human adaptive capacity is limited by many factors in addition to those noted, including developmental defects, personal habits, physical and mental stress and living conditions.

The latter includes poor housing, medical care and nutrition. All of these are environmental stressors which tend to diminish adaptive capacity of humans. A detailed listing of these factors is attached as appendix 1. (See p. 525.)

Many of the diseases and factors that I list have never been tested out, but these are areas where one might expect that serious concern should be manifested.

Those populations at high risk because of limited ability to adapt have not been well defined, and the pollution levels at which various groups may be endangered have not, in most cases been adequately quantitated.

While some, like cardiacs and asthmatics, are well known, others like this with sickle cell anemia or alpha, antitrypsin deficiency, a genetic effect in the blood, are just now being recognized.

It is therefore critical to consider both the numbers and kinds of people at high risk at different pollution levels and the pollution levels themselves, if we are to make decisions in regard to the impact of environmental stresses on human health.

Two other important and related questions which have not been. adequately dealt with and must be answered relate to the concept of total body burden and synergism.

While most of the standards have been based upon epidemiologic data, in some cases, serious consideration has been given to setting standards based on data obtained in studies of normal populations exposed to single pollutants.

A lot of these studies are put forward as reasons why we might consider these standards too high. I should add that studies, for example, which examine healthy, young, normal, well-rested medical students and such a study was done looking at carbon monoxide, which found no effect at relatively high levels-cannot in any way be extrapolated to a 63-year-old man with arteriosclerosis, who has not eaten for 8 hours, who is fatigued after a day's work, has smoked a pack of cigarettes, and going home on an expressway.

These are totally different organisms. One cannot say that a safe level was represented by ones which affect the youngest, healthiest and strongest people in our population.

Drawing such conclusions from these data can be hazardous, since, in life, humans are exposed to many sources of the same pollutants. For example, carbon monoxide may enter the blood stream via cigarette smoke, automobile exhaust, industrial, and energy sources.

Lead is another case in point. As an automobile pollutant, it may be inhaled from the air and ingested with street dirt. In addition, many other potential sources exist such as ingestion from toothpaste tubes, leaded paint, cheap pottery, and so on.

It is critical to understand that it doesn't matter what the source; the total burden faced by the body represents the environmental

stress.

Additionally, multiple pollutants such as sulfur dioxide, nitrogen dioxide, ozone, and cigarette smoke, to name a few, all impact on a single target organ, the lung.

Thus, consideration of standards based on a single source of a single pollutant may not adequately safeguard human health. This is particularly true when one considers that 70 million Americans smoke significant numbers of cigarettes, and are therefore at high risk when exposed to these pollutants.

Another important point to keep in mind when considering the safety of standards relates to the concept of synergism, that is, two materials which have a greater than additive effect when acting together.

In regard to lungs, for example, sulfur dioxide and ozone have been found to act synergistically, affecting the lungs much more ad

versely when both are present than when they are presented singly in equivalent amounts.

In relation to the severe problem imposed by the growing rates of lung cancer deaths, synergistic effects should also be of considerable concern. Studies which we have carried out suggest that for every microgram of benzopyrene, a carcinogen present in the air, and used in this case as a marker since other carcinogens are also present, per thousand cubic meter of air, there appears to be a 5-percent increase in lung cancer deaths.

It is our estimate that a 60-percent reduction in urban air pollution might result in a 20-percent reduction in lung cancer. The carcinogenic effect of asbestos and cigarettes and radioactive materials and cigarettes are well known.

It would also appear that air pollutants and cigarettes may act synergistically, causing this dread disease. For these reasons, pure physiological studies should not become institutionalized as a clean air standard; such standards will not likely protect the health of our heterogeneous population of 200 million people exposed to multiple environmental insults.

The Clean Air Act, of course, recognizes the principles of synergism, of multiple sources, and the need for considering total body burden. Federal standards most often do not.

Congress should strive to assure that these principles are continually recognized. Moreover, Congress should foster the viewpoint that clean air standards are the minimum protective measures for public health.

Rather than a standard-by-standard appraisal of the existing EPA regulations, it might be more useful to direct the subcommittee's attention to four significant health hazards which have not been considered in the current standards.

These include respirable particulates-those less than 5 microns in size-airborne carcinogens, of which there are many from stationary and mobile sources, many carcinogens, toxic metals, and derivatives. of sulfur dioxide, namely acid sulfates and sulfuric acid aerosols.

Ambient air quality standards do not exist for any of these materials despite the fact that there is strong scientific evidence that they jeopardize human health.

The air pollution-lung cancer study noted above and studies examining the SO2 sulfates, and acid aerosols, moreover, find correlation between variations of levels of these pollutions and mortality and morbidity rates.

I recognize that the analytical and monitoring equipment is not fully developed. However, in some areas, particulate sizing and monitoring of many airborne carcinogens such as benzopyrene and trace metals can and should be measured and should be so that better quantitative assessment of their health impact can be made, even though it appears that development of standards are some years away.

Since they are recognized at least qualitatively as hazardous materials, strict control of fuel sources and combustion methods must be