that local health departments can use to enforce lead problems in households and around homes.

The Federal Government could be of assistance in several ways. One is that the support for basic research in several areas, including a less painful and more efficient technique for screening children for lead exposure. Currently the best method is to draw blood by venipuncture, and physicians do not like to inflict pain on children by doing screening tests. It has been a very difficult thing to sell. Second, we need a more cost-effective technique for removing paint from housing, without further damaging children, workers, and the surrounding environment. And we also need nationwide reporting of lead poisoning to the U.S. Centers for Disease Control. Another area of concern is that children at risk for environmental exposure have inadequate access to health care. And this is something that we have encountered in the State Health Department, with our epidemiological studies of both childhood cancer and lead poisoning.

Anecdotally, before we went into McFarland, we heard from parents and health professionals that children with cancer in McFarland would have had a better prognosis if their cancers had been diagnosed and treated earlier. In our studies of McFarland children, we found that average household incomes were below $15,000 per year. And 46 percent of the families had no health insurance, not even Medicaid. And 20 percent had Medicaid coverage. And the physicians who do practice there do not accept Medicaid. So poor families must travel long distances for care, or pay out-of-pocket. In fact, we found that many people in McFarland who have Medicaid do pay out-of-pocket for care.

Although urban areas have more physicians per capita, we found similar problems in the childhood lead studies. For example, 41 percent of the families in the neighborhoods we studied in Los Angeles were without any kind of health care insurance.

Inadequate access to health care for children has increased over time. And no easy solutions have emerged. Federal leadership needs to find innovative ways to assure that all families have access to care.

The last area that we are addressing is inadequate training of physicians. In both our lead reporting system and our conversations with physicians who are treating cases of childhood lead, and also in investigating cancer clusters, we found that physicians have inadequate knowledge of problems such as lead, pesticide poisoning, and air pollution. And they don't know how to identify and report possible environmental health problems. In partnership with Children's Hospital and the Agency for Toxic Substances and Disease Registry (ATSCR), we have been working to develop a curriculum to train physicians in pediatric environmental health. The course will be given for the first time this week, and we are hoping that it will become a model for training all physicians who will take care of children.

Thank you again for the opportunity to testify. Our State has already taken several steps to address the effects of environmental exposure on children. But much more needs to be done. All research in this area is hindered by inadequate levels of funding, and by lack of appropriate priority-setting.

Our children are an investment in the future. We must take the necessary steps to ensure their health and well-being, and thus to ensure our competitiveness as a nation. We urge you to take a close look at the problem, and to develop Federal policies that will enhance our ability to prevent harmful environmental exposures to children.

[Prepared statement of Lynn R. Goldman follows:]

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.

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. It 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.

We have not been able to interview cases about individual exposures So our findings must be interpreted with caution.

What have we learned from McFarland?

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. despite that many investigations will reach blind alleys.

And

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