Gerald Mueller and members of the Libby Community Advisory Group (CAG) introduced themselves. A list of the members and visitors in attendance is attached below as Appendix 1.
The CAG agreed to the following agenda for this meeting:
Dr. Spence stated that his purpose in attending and making a presentation to this meeting is to address questions from the December CAG meeting that Craig French passed along to him. He said that his role and focus in Libby is to insure that quality medical screening occurs in Libby and to report to the community important developments related to the screening. Because he is not a CAG member, Dr. Spence attends CAG meetings only when he has information to report. If people need to reach him, they can call his office number at (406)444-1286 or the Montana Asbestos Screening and Surveillance Activity (MASSA) Program in Libby at (406)293-5060. His Helena office number has voice mail and may direct the caller to a cell phone number if he is out of his office. Dr. Spence said that he was out of the office from the day before Thanksgiving until December 15, first at a conference and then on vacation, but he did return telephone calls. He can also be reached via email at firstname.lastname@example.org.
Dr. Spence's Qualifications - Some months ago Governor Martz received a letter questioning Dr. Spence's qualifications to direct the MASSA Program. Dr. Spence explained that he has been a licensed medical doctor with 35 years of clinical experience. He has over 20 years teaching at two US Medical Schools. He also has a Masters Degree in Public Health and has over 30 years of experience working in public health. He has been a medical and/or public health consultant for the Center for Disease Control, National Institute of Health, World Health Organization, and USAID. Finally, he has over 30 years of experience in grant writing and management.
MASSA Screening - To date, over 600 individual people have been screened through the MASSA Program, and over 900 people have been scheduled for screening. The rate of referrals to personal physicians for diagnosis and treatment from the MASSA screening has been 20%, a rate higher than the 18% referrals resulting from the ATSDR screening in Libby. The MASSA rate is higher because the screening to date has focused on former W.R. Grace workers. Former workers over 45 years of age and other Libby residents also over 45 make up the highest risk group for asbestos-related disease. The number of people screened through the MASSA Program is projected to increase this year.
Actuarial Study - The actuarial study is being directed out of the Governor's office by Jean Branscum. Funding for the study comes through the US Department of Health and Human Services and was obtained by Senator Conrad Burns. The money flows to Libby through Dr. Spence's state budget. Ms. Branscum, who formally worked in the Montana Department of Labor and Industry (DLI), obtained a DLI actuary to conduct the study. Ms. Branscum conducts periodic conference calls concerning the study, and anyone wishing to do so may participate in them. The study data abstraction form was developed via the conference calls with the participation of Rick Palagi. A report from the study is planned for mid-April 2004. At the last CAG meeting, Dr. Black mentioned a letter he had written to Dr. Spence on behalf of the CARD Clinic Board of Directors setting forth concerns about the actuarial study. Dr. Spence read his reply to Dr. Black's letter, which is attached below as Appendix 2.
Mesothelioma in Montana - Data on the incidence of mesothelioma come from the tumor registry and death certificates. This data may be an undercount of actual cases because of a failure to report or a lag time in reporting and because the cause of death listed on a certificate may not be mesothelioma even if the deceased had the disease. Dr. Spence passed out a map showing the location and number of the reported mesothelioma cases in Montana from 1979 through 2001. The map is attached below as Appendix 3. Higher incidence of the disease follows railroad lines, railroad terminals and highways. The high incidence of mesothelioma cases in Great Falls may be associated with Zonolite processing facilities formerly located there. We are aware of six cases of mesothelioma in Montana in 2003. Dr. Spence stated that he will encourage people in Libby to reach out to other Montana communities experiencing high rates of ARD such as Great Falls .
Asbestos Contaminated Mines in Montana - Dr. Spence also passed out a map showing the locations of vermiculite and talc with and without asbestos contamination. See Appendix 4. On Appendix 4, vermiculite mines with asbestos contamination are shown in yellow, vermiculite mines without asbestos contamination are shown in green, and talc mines without asbestos contamination are shown in blue.
CAG Member Question - Is the incidence of mesothelioma associated with chrysotile of amphibole forms of asbestos?
Answer - We don't know.
CAG Member Question - You said that we had six mesothelioma cases reported in 2003. How many cases did we have in 2002?
Answer - We don't know yet. We just closed the books for 2002 data at the end of 2003. There is a one year lag in reporting and analysis.
CAG Member Question - Do we know the locations of the 2003 cases?
Answer - We don't know yet.
Answer by Dr. Black - We have had four cases in the Libby area over the last two years.
CAG Member Question - In his 1979 study, Irving Selikoff looked at data for 17,800 workers exposed to asbestos. He found extra pulmonary cancers that would not show up with a smaller number of cohort data. Have you looked at Dr. Selikoff's study as a part of the actuarial analysis?
Answer - No, we have not. We have examined data from people screened and treated resulting from Libby exposures. We are doing so because we believe that the exposure to tremolite asbestos will result in different disease rates than other asbestos forms. We will look at the study if you email a reference.
CAG Member Question - Have you followed up on those referred as a result of the MASSA screening to determine if those referred have been diagnosed?
Answer - We have not yet done so, but we hope to look at clinical data kept at the CARD Clinic to see how many referred get a diagnosis and treatment for ARD. It is typical after disease screening that some people are afraid to get a diagnosis.
Audience Member Comment - People here are not getting diagnosis because they don't have medical insurance or the money to do so.
Response by LeRoy Thom - The Asbestos Related Health Care Program (ARHCP) provides gap coverage which will pay for the doctor's office visit and testing for a diagnosis for all people qualified for the W.R. Grace medical program. All 800 plus people qualified for this program received a letter explaining the gap coverage.
Audience Member Question - Where do you apply to receive ARHCP funding for a diagnosis?
Answer by Pat Cohan - Application forms are available at the CARD Clinic, St. John's Lutheran Hospital , and the Community Health Center .
Answer by Carol Holoboff - The MASSA office will also provide the application form.
Audience Member Question - My kids were screened and no sign of disease was found. Who can be rescreened under the MASSA Program?
Answer - People who have had a negative screen, i.e. no sign of lung abnormalities, can be rescreened periodically. The frequency of the rescreening depends on age and worker/non-worker status. People with ARD cannot be rescreened.
Audience Member Comment - Don't forget that primary medical care is available at the Community Health Center at no or reduced cost depending on income.
Jim Christiansen introduced Peggy Churchill, a Superfund project manager, who will be working at times in Libby. He also said that he received today a copy of the EPA Inspector General's report on Superfund funding shortfalls. The report is available at the EPA Information Center . While Mr. Christiansen has not yet read the entire report, it is apparently critical of the current funding situation.
Wendy Thomi showed the video of the cleanup process. Its purpose is to show Libby residents and business owners what a residential or business cleanup will entail. Community members including those appearing in the video reviewed a draft of the video and in some cases suggested changes to it. Minor changes may still be made in it. The fact sheet that will accompany the video is not completed.
CAG Member Comment - The video says that using a HEPA vacuum to cleanup up reintroduced contamination is safe. It would not be totally safe .
Response - Using the HEPA vacuum would be the safest response.
Audience Member Question - Could the video be made available at video rental stores?
Answer - We will check with the video stores. It will be available at the library and the EPA Information Center .
Audience Member Question - Can you give a copy to homeowners before the pre-design meeting?
Answer - I cannot make 2,000 copies, but we will think more about how to make viewing possible for homeowners.
Audience Member Question - Could it be shown on our local TV information channel?
Answer - We will make it available to the local channel.
CAG Member Comment - The video is a very positive development, even for people not undergoing cleanup. It helps the community understand what will be happening.
Audience Member Question - Last fall an EPA contractor visited my home and took pictures. When will cleanup happen?
Answer - I am not sure when cleanup of your home is scheduled. To date we have screened about 4,000 residences and conducted 500 pre-design meetings with residents and completed 200 cleanups. Completing the screening and pre-design meetings helps us both to plan for using our resources most efficiently and to conduct better cleanups. As we complete more of the preliminary steps, the longer the lag until cleanup may occur. It may years before some cleanups occur.
Gayla Benefield read the final version of the letter which the school district had revised to shorten it to one page. A copy of the final letter is attached below as Appendix 5. Kirby Maki stated that the letter was shortened but its content was not changed. Basically, the letter states that we want the community cleaned up sooner rather than later. The school district sent out with students for their parents and to school staff about 1,500 copies of the letter yesterday and today.
CAG Member Question - The letter mentioned a $5 million annual shortfall. This shortfall was just this year, correct?
Answer by Jim Christiansen - We asked initially for $20 million for this year's cleanup. EPA reduced the $20 million to $17 million and allotted $2 million of these funds for expenditure last year, leaving only $15 million for this year. Next year, the budgeted amount is $17 million.
Mike Giesey reported that today is the last day to provide comments on the draft of the community resolution on this same topic. A final version of the resolution will be prepared next week and a plan will be developed to obtain signatures on it. The resolution will be presented to EPA Administrator Leavitt when he visits later this winter.
Audience Member Question - When will the resolution be available? The school board meets only once per month. This month we will meet on the 21 st .
Answer by Mike Giesey - We should have the final version available early next week.
Audience Member Comment - As we go door-to-door seeking signatures on the resolution, we should also ask people to write personal letters.
CAG Member Response - Personal letters are very important, even if they are only one sentence. We will make a big push to get resolution signatures and personal letters about 10 days prior to the Administrator's visit. We will try to get interviews about our effort in our local television, radio and print media.
CAG Member Question - When is the Administrator expected to come to Libby?
Answer by Jim Christiansen - We have requested that he come in late February or early March.
CAG Member Comment - It is important to tie the cleanup to economic development.
Response by Jim Christiansen - Engaging the business community about the cleanup is important. We are bringing money into Libby. As the cleanup winds down, we can also discuss ways to fund redevelopment.
Gerald Mueller read the letter which Clinton Maynard had drafted at the CAG's request and which was previously circulated with the summary of the November 13, 2003 CAG meeting. The letter asks Montana Attorney General Mike McGrath to review CDC Administrator Gerberding's refusal to declare a public health emergency and to determine if the Superfund law provides for health care for people subject to asbestos-related disease. Mr. Maynard stated that if the legal interpretation in Administrator Gerberding's letter is correct, then the CAG should work with Montana 's Congressional delegation to amend CERCLA to provide long-term medical care to people in Libby with asbestos-related disease.
CAG Member Question - The letter mentions that copies of past correspondence will be enclosed. What correspondence, past CAG letters?
Answer by Clinton Maynard - Yes, past CAG letters related to the declaration of the public health emergency including the May 2, 2003 letter to HHS Secretary Tommy Thompson and Ms. Gerberding's reply will be included.
CAG Action - The CAG agreed unanimously to send the letter to Attorney General McGrath. Clinton Maynard was directed to prepare a final version of the letter and email it to Mr. Mueller so that he can print the letter on CAG letterhead and prepare a signature page. Signatures on the letter will be solicited at the February CAG meeting.
Clinton Maynard asked that the CAG discuss this document at this meeting. Wendy Thomi stated that the purpose of the fact sheet is to describe the precautions that anyone can take if they come in contact with vermiculite inside or outside their home. The fact sheet advises people to avoid contact with vermiculite. However, after the cleanups are completed, people will occasionally encounter small amounts of vermiculite. Copies of the fact sheet were mailed to all postal patrons in the Libby area, some 5,000 addresses. Mr. Maynard stated that while the fact sheet contains well-stated warnings and precautions, it also includes statements to help people feel comfortable living around the contaminated vermiculite. He believes these statements may be accurate for chrysotile asbestos, but they are not supported by science for amphibole asbestos which will continue to be dangerous. This fact sheet was sent first to people in the Libby area, but it will also probably be used nationwide. We should discuss this fact sheet with the EPA toxicologist and the entire community. Mr. Maynard asked that a second asbestos conference be held in Libby this summer to discuss the fact sheet.
Comment by Jim Christiansen - We prepared this fact sheet to provide guidance to people awaiting cleanup. We waited before publishing it until EPA had issued nationwide guidance on vermiculite. The content of the fact sheet was discussed with Aubrey Miller, Chris Weis, Paul Peronard, and me. We have attempted to strike a balance between asking people to avoid contact with the vermiculite and telling them that they need not stop living their lives. Some contact will be inevitable, and the fact sheet explains what to do in the event of such contact. Aubrey Miller will be in Libby in the latter part of January, and people can discuss the fact sheet with him then.
Comment by Mike Giesey - We will have a second conference on asbestos-related disease here. Some twelve doctors will be returning to participate. We remain confident that Libby will get a research center established here.
CAG Member Question - Will this conference be open to the public?
Answer by Mike Giesey - No, it will not be open to the general public. The conference participants do not have sufficient time to open the meeting.
CAG Member Question - Could we be notified at least ten days prior to the EPA Administrator's visit?
Answer by Jim Christiansen - We will try, but you may know of it before I do.
CAG Member Question - Can we agree to hold a special CAG meeting the Thursday prior to the Administrator's visit to prepare for it?
CAG Action - The CAG agreed to convene a special meeting the Thursday prior to the EPA Administrator's visit.
The next regular CAG meeting is scheduled for 7:00 to 9:00 p.m. on Thursday, February 12, 2004 in the Ponderosa Room of Libby City Hall. The agenda will include collecting signatures on the final letter to Attorney General Mike McGrath discussed at this meeting.
CAG Member & Guest Attendance List
January 8, 2003
Technical Advisory Group
EPA Project Manager
Gary D. Swenson
David F. Latham
The Montanian Newspaper
CARD/Lincoln County Health Officer
Area Asbestos Research Group
Former Grace Employee
Dr. Michael Spence
Montana Chief Medical Officer
EPA Project Manager
DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES
HEALTH POLICY & SERVICES DIVISION
GAIL GRAY, Ed.D.
COGSWELL BLDG., 1400 BROADWAY
P.O. Box 202951
HELENA , MONTANA 59620-2951
16 December 2003
Brad Black MD
308 Louisiana Avenue
Libby , Montana 59923
I want to thank you for your letter of December 3, 2003 when you expressed your concerns that tile Governor's actuarial analysis of the healthcare costs for patients from Libby with Asbestos Related Disease (ARD) may result in an underestimate of the total health care costs for these individuals. I couldn't agree with you more. You may recall that at the first meeting that Ms Jean Branscum held in Libby at the St John's Lutheran Hospital that both you and I expressed this concern, as did Dr. Fred Tai from the Libby Cooperative Health Center . It is my firm opinion that this actuarial analysis, that will evaluate only Libby patients that have been exposed to Libby Tremolite asbestos, is only the first step in what will have to be an ongoing process with continued reapproximations of the costs every two to three years. You may recall that I also indicated this at our first meeting. Actuarial analyses will most likely have to continue for the next few decades based on the number of new patients that continue to be added to pool, as the technology in caring for these patients' changes and as the sources of health care coverage for the patients change. This actuarial analysis is a working document that will never really be finalized but will have to continue forward much like is clone for other conditions such as acute myocardial infarctions, strokes and other severe medical conditions. I think that we will find that the health care costs incurred for caring for a patient with ARD in 2003 are substantially different in 2008, just like the health care costs for a patient with an acute myocardial infarction in l998 is far different from those incurred in 2003.
I as you, also believe, as I stated at the last conference call in November, which I am sure Pat Cohan and/or Rick Palagi informed you of, that we definitely need to obtain data if possible from the patients with ARD that have been cared for by Dr. Alan Whitehouse. There is no doubt that he has a wealth of experience in caring or these individuals and has data on a patient population that should make a significant contribution. We on the conference call were told by Pat Cohan that Dr. Whitehouse had concerns, as rightfully any practicing physician should have, as to how a review of his records for the actuarial analysis might disrupt his office practice. In view of this, the group on the Novemher conference call, including Jean Branscum, Rick PaJagi. Jim Buck, Pat Cohan, Dan Strasbaugh, Rebecca Manna and myself, decided it would be host to first start the actuarial analysis in Libby in order to get a better understanding of what all was involved before requesting access to Dr. Whitehouse * s records. We want to be absolutely sure that we provide Dr. Whitehouse with an accurate representation of what is involved as well as have the record review process operating as smoothly as possible to minimize any disruptions to his practice.
In regard to your comment number 4 I think that you are absolutely correct in that previous actuarial analyses were based on experience with chrysotile asbestos. That is one of the major reasons for conducting this analysis on patients with Libby Tremolite ARD. It would be remiss of us to utilize healthcare cost data on chrysotile asbestosis, a condition which we believe is quite different from what is seen in the Libby population. We need to make our estimates based on the patients that we care for.
As I stated in our telephone conversation today I look forward to meeting with you and Dr. Whitehouse and discussing these issues. I feel that these discussions will be very productive. I am also looking forward to the research meeting in late January, which I definitely plan to attend.
Michael R. Spence, MD, MPH
Chief Medical Officer
Cc: Jean Branscum
ALL MESOTHELIOMA CASES FOR MONTANA RESIDENTS
ASSOCIATION WITH CITIES & RAILROADS
TUMOR REGISTRY AND DEATH CERTIFICATE CASES
1979-2001 (N=172, with 7 Missing City Information)
MINES IN MONTANA
The Citizen's Advisory Group of Libby , Montana
Dear Citizen's of Libby:
The Citizen's Advisory Group of Libby (CAG) would like to inform you of the recent developments in the EPA asbestos clean-up plan for South Lincoln County . Originally, the Environmental Protection Agency (EPA) estimated our community asbestos clean-up would proceed at a pace of up to 250 properties per year. At this rate, the community would have a clean bill of health within three to five years. The local EPA project manager had set a South Lincoln County Clean-Up budget of $20 million per year to complete this goal.
Recently, National EPA officials have cut Libby's project-operating budget by $5 million per year. This action will extend the South Lincoln County clean-up project to ten/twelve years rather than the originally estimated three/five years. Therefore, only 130 properties per year will be addressed, not the 250 properties per year that were initially set forth in the EPA's clean-up plan.
The Citizen's Advisory Group of Libby (CAG) would like to enlist your assistance in a letter writing campaign. We would like to send thousands of letters to the EPA that express the concerns of the community regarding the EPA down-shifting the priory of our community. To ensure your letters reach the highest Environmental Protection Agency authority, the CAG intends to personally hand every letter to the current EPA director, Governor Leavitt. The CAG will set up a drop basket at Timberline Auto Center for you and all of your family to deposit your letters in. We are asking for our community to unite and voice their concerns about the EPA's current budget reductions. Please deliver your letter to Timberline Auto as soon as possible. If you have any questions, please call Gordon Sullivan at 293-3768.
Citizen's Advisory Group of Libby
Photos courtesy of Dudley Dana, Dana Gallery