5
Evaluating the Department of Health and Human Services Dissemination and Communication Efforts

INTRODUCTION

The committee’s charge included evaluating the Department of Health and Human Services’ (HHS’s) efforts to disseminate the research findings emerging from projects it undertook under its Memorandum of Understanding (MOU) with the Department of Energy (DOE) to affected workers and communities. For the purposes of this report and consistent with its statement of task, the committee drew a distinction between dissemination and communication in the programs of HHS and DOE in pursuit of each objective. This distinction is grounded both in formal definition and in practice. Dissemination is a one-way process—to send information out widely, to publicize or broadcast information. This term was used specifically in the charge to the committee. However, the committee judged that to truly evaluate public understanding of health effects, as described in the MOU, it also had to look closely at the communication efforts of HHS agencies. Communication implies a two-way process—an interchange of knowledge, thoughts, and opinions or—as one dictionary puts it—communication is a back-and-forth process (Webster’s Third New International Dictionary 2003).

In keeping with its charge, the committee’s findings and recommendations are directed primarily at HHS activities. As noted earlier, the committee functioned under the public policy decision, reflected in the MOU, that to facilitate public understanding and acceptance of scientific findings related to health effects of hazardous exposures, responsibilities for operations and monitoring should be separated between two federal agencies, with DOE administering the nation’s nuclear activities and HHS monitoring, measuring, disseminating, and communicating information about worker and community health and safety is-



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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services 5 Evaluating the Department of Health and Human Services Dissemination and Communication Efforts INTRODUCTION The committee’s charge included evaluating the Department of Health and Human Services’ (HHS’s) efforts to disseminate the research findings emerging from projects it undertook under its Memorandum of Understanding (MOU) with the Department of Energy (DOE) to affected workers and communities. For the purposes of this report and consistent with its statement of task, the committee drew a distinction between dissemination and communication in the programs of HHS and DOE in pursuit of each objective. This distinction is grounded both in formal definition and in practice. Dissemination is a one-way process—to send information out widely, to publicize or broadcast information. This term was used specifically in the charge to the committee. However, the committee judged that to truly evaluate public understanding of health effects, as described in the MOU, it also had to look closely at the communication efforts of HHS agencies. Communication implies a two-way process—an interchange of knowledge, thoughts, and opinions or—as one dictionary puts it—communication is a back-and-forth process (Webster’s Third New International Dictionary 2003). In keeping with its charge, the committee’s findings and recommendations are directed primarily at HHS activities. As noted earlier, the committee functioned under the public policy decision, reflected in the MOU, that to facilitate public understanding and acceptance of scientific findings related to health effects of hazardous exposures, responsibilities for operations and monitoring should be separated between two federal agencies, with DOE administering the nation’s nuclear activities and HHS monitoring, measuring, disseminating, and communicating information about worker and community health and safety is-

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services sues. In describing the events shaping the MOU, this report necessarily addresses previous concerns expressed about DOE’s management of these facilities and its actions in communicating the safety and health effects of radiation releases. This report however is not an assessment of DOE’s activities. The committee’s approach to this evaluation was shaped by a number of considerations, particularly the multiple and diverse ways in which individuals and communities process scientific information related to complex, often adversarial, scientific and technological issues. COMMUNICATING ABOUT RADIATION RISKS Communicating effectively about risks such as radiation health effects at DOE facilities to workers and concerned citizens is difficult for a number of reasons. First is the level of public fear about radiation from these sites. Although there is no uniform and consistent perception of radiation risk, research on the general public’s attitudes in the United States, Sweden, and Canada has shown that “public perception and acceptance is determined by the context in which radiation is used” (Slovic 2000). This means that although most people do not fear medical or dental X-rays because of the positive health value of these technologies, they do fear the radiation associated with nuclear weapons, nuclear power, and nuclear waste. Research using risk perception analysis in which different factors reflect how lay persons evaluate health and environmental risks on a number of characteristics has found that nuclear power and nuclear waste were rated as extreme in two dimensions: “dreaded” and “unknown” risks (Slovic 1987). Dreaded risks are catastrophic, deadly, and uncontrollable. Unknown risks are poorly understood, are unknown to those exposed, and have delayed effects. “Validation of these psychometric studies occurred when survey respondents were asked for word associations to a high-level radioactive waste repository. The resulting images were overwhelmingly negative, dominated by thoughts of death, destruction, pain, suffering and environmental damage” (Slovic et al. 1991). Another finding from this research is that in every context of use, with the exception of nuclear weapons, public perceptions of radiation risk differ from the assessments of the majority of technical experts. In most instances, members of the public see far greater risks associated with a radiation technology than do experts (Slovic 2000). This disconnect between what the public and experts see as risks may lead experts to make little effort to understand what drives public fears and to dismiss these fears as trivial or “irrational.” A consequence of this disconnect is that communication efforts are frequently one-sided or unidirectional, reflecting the perspective of experts who want to communicate specific messages to the public rather than the view of what the public wants to know. The second reason why communicating about radiation risks at DOE facilities is difficult is the complex documented history of secrecy at these sites (PSR

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services 1992; Ackland 2002; Schneider 1988; NRC 1990). There is a history of hidden intentional and unintentional radiation releases potentially exposing both workers and citizens, producing serious public concerns about the motives and performance of DOE and its contractors and resulting in a loss of public trust and confidence in federal agency operations of these facilities. This loss of trust and confidence undermines acceptance since public confidence in information and in how well managers understand and control hazards and how trustworthy they are in fulfilling their protective duties is needed (Flynn et al. 2001). Again, the events leading to having three HHS agencies replace DOE as the performer of research on health effects and becoming the lead agencies in conducting research and communicating research findings and operations at DOE facilities were attempts to restore public confidence and trust in the operations of the federal government. However, restoring or even establishing public trust is not easy. Trust in risk management assessments is difficult to achieve and maintain. It is usually created slowly but can be destroyed very quickly even by a single mistake. Once trust is lost, it may take a long time—if ever—to rebuild to its former state. “The fact that trust is easier to destroy than to create reflects certain fundamental mechanisms of human psychology that Slovic called the ‘asymmetry principle’” (Slovic 1993). According to this principle, when it comes to winning trust, the playing field is tilted toward distrust for several reasons. “First, negative (trust-destroying) events are more visible or noticeable than positive (trust-building) events. Negative events often take the form of specific, well-defined incidents such as accidents, lies, discoveries or errors or other mismanagement. Positive events, while sometimes visible, more often are fuzzy or indistinct. Second, negative events have much greater weight on people’s opinions than do positive events. Finally, sources of bad news tend to be seen as more credible than sources of good news by both people and the mass media” (Slovic 1993, cited in Kunreuther and Slovic 2001, p. 342). A third reason why communicating about radiation risks at DOE sites is difficult is the complexity of the technical language and concepts. Radiation terms are foreign to most lay people and even seem contradictory at times (Friedman 1981; Friedman et al. 1987). In addition, when discussing possible radiation health effects, adding to the mix of rems, rads, and alpha or beta particles in radiation terminology is the language of epidemiology with its discussions of cohorts, case-control studies, and statistical power. Even well-intended glossaries often cannot help effectively translate this complex information or help lay people comprehend the concepts involved. More often than not, more can be accomplished in conveying such highly complex information in face-to-face situations where members of the public have the opportunity to ask questions about things they do not understand. This, however, can be a time-consuming and costly task and requires a special set of communication skills as well as specialized technical knowledge (NRC 1989).

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services Special Risk Communication Challenges for Federal Agencies There are challenges beyond radiation risk and language that also have to be considered when trying to evaluate HHS dissemination and communication programs for DOE facilities. A fundamental conundrum for federal science agencies dealing with environmental risk controversies is that scientific and technical information alone seldom serves to resolve issues. The best-intentioned and most effectively considered and implemented communications programs encounter at least two major hurdles. First, environmental controversies are typically amalgams of scientific, political, economic, sociological, and ethical considerations. Second, provision of the “best” possible scientific and medical information may serve to lessen disagreement or forge consensus about “technical” aspects of the issue, but even if these goals are achieved, other dimensions of the issue may remain (Johnson 1999, as cited in Tuler et al. 2005). More immediately germane to the challenges confronted by HHS agencies and DOE in organizing communication programs is that members of a community can have varying preferences about how they want such programs to be conducted and different criteria for determining the effectiveness or success of such programs. For example, a study of the attitudes and preferences of stakeholders living in the environs of Lawrence Livermore National Laboratory in Livermore, California, discerned five different and, in some cases, competing perspectives (Tuler et al. 2005): Evidence-driven process with good communication to the lay public. “This perspective describes a process that is about making recommendations based on a good understanding of the evidence about the nature of the problem and to effectively communicate with the community. In this perspective, the definition of the right problem should be locally determined.” Efficiency and focus in a science-driven process. This perspective emphasizes “addressing the key problem in an efficient and well-run process…. The quality of information is important to those holding this perspective. The best available science should be used for analysis. Data must be evaluated to assess their quality for making public health determinations. Thus, it is important to identify weaknesses and gaps. At the same time, there was no support for exploring uncertainties in the data; doing so can lead the process astray.” Meeting the needs of the community through accessibility and information sharing. This perspective places the concerns and needs of local people at the center while the needs and wishes of the responsible agencies are peripheral. It emphasizes generating and sharing information with the community. It places the highest value on tapping the knowledge of the community, ensuring that participants have equal access to information and that uncertainties are acknowledged and explored. Ensuring accountability with broad involvement. “Those holding this per-

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services spective are interested in addressing and solving problems in a manner that ensures agency accountability and allows full involvement of the community. There is an underlying distrust of the motivations of the responsible agencies (e.g., DOE, ATSDR [Agency for Toxic Substances and Disease Registry]) to redress public health risks that have arisen as a result of contamination released from the Laboratory” (italics added for emphasis). Searching for the truth by thoroughly examining the evidence. This perspective emphasizes broad and informed discussion of the issue. “Information must be validated and it must be fully available for public discussion and consideration…. Those holding this perspective are interested in the truth of the matter.” In effect, these perspectives point to stakeholder proclivities to employ different subjective frames of reference in responding to closed-ended scales of client satisfaction, thus reducing the value of conventional measures of program effectiveness. As noted by Tuler et al. (2005): “The core of our argument is that while generalized guidance about best practices can be useful, it can also be inadequate (and perhaps misleading) for a particular situation. Decisions about, for example, what risks to consider, how to compare and frame risks, and what are credible channels and sources of communication must be made in a process that meets social expectations about what is an appropriate process for the situation. The effectiveness of the risk communication effort may rest, in part, on meeting social preferences for how the process of planning and decision-making is designed.” General Risk Communication Guidelines As described above, each site and different stakeholders involved at that site have their own ideas, preferences, needs, and problems regarding the risks present or anticipated. Developing an environmental or health risk communication program to meet all of these needs is a complex process that requires considerable levels of commitment, time, money, and personnel on the part of government agencies. However, federal agencies do not enter this difficult territory without some general guidelines derived from a more than 30-year history of research and practice in the field of risk communication. According to leading risk communication researchers, good risk communication is “communication intended to supply laypeople with the information they need to make informed independent judgments about risks to health, safety and the environment” (Morgan et al. 2002). As described in a National Research Council (NRC 1989) report that addressed the challenges of risk communication: “Risk messages should closely reflect the perspectives, technical capacity, and concerns of the target audience. A message should: (1) emphasize information relevant to any practical actions that individuals can take; (2) be couched in clear

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services and plain language; (3) respect the audience and its concerns; and (4) seek to inform the recipient, unless conditions clearly warrant the use of influencing techniques.” Effective communication should focus on the issues that recipients most need to understand. Which issues need to be understood should be determined by both the communicator and the recipient. Risk researchers caution that if a communication omits critical information, it leaves the recipients worse off because it could make them believe that the information they have is complete. If it presents irrelevant information, it wastes recipients’ time and diverts their attention from more important tasks (Morgan et al. 2002). Effective risk communication also requires authoritative and trustworthy sources. If communicators are perceived as having a vested interest, then recipients could doubt the truth of the information communicated. This lack of trust makes the communication process far more complex, spreading confusion and suspicion and thereby eroding relationships. Finally, for a risk communication effort to succeed, the developers of the communication program must ensure that their messages are being understood as intended. Failing to evaluate whether risk messages have been understood or whether a risk program has been effective is a major problem because everyone involved in the process could be miscommunicating or talking past each other and yet no one knows it. When a message is not understood, the recipients, rather than the message, may be blamed for the communication failure. However, if “technical experts view the public as obtuse, ignorant, or hysterical, the public will pick up on the disrespect, further complicating the communication process” (Morgan et al. 2002). Lack of evaluation wastes both communicators’ and recipients’ valuable time as well as the resources spent in developing and providing the risk communication efforts. No matter how good a risk communication program looks to its designers, it will be discounted if it is only a one-way dissemination system in which information is given to workers and citizens with no room for their opinions. Using, at the minimum, a two-way risk decision-making process that includes both citizens’ and workers’ concerns has been increasingly recommended and implemented. For example, in its final report, the Presidential/Congressional Commission on Risk Assessment and Risk Management (1997) concluded that a good risk management decision emerges from a process that elicits the views of those affected by the decision, so that differing technical assessments, public values, knowledge, and perceptions are considered. The Presidential/Congressional Commission on Risk Assessment and Risk Management (1997) referred to those affected by a risk or a risk management decision as stakeholders, stating: “Stakeholders bring to the table important information, knowledge, expertise, and insights for crafting workable solutions. Stakeholders are more likely to accept and implement a risk management decision they have participated in shaping. Stakeholder collaboration is particularly important for risk management

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services because there are many conflicting interpretations about the nature and significance of risks. Collaboration provides opportunities to bridge gaps in understanding, language, values, and perceptions. It facilitates an exchange of information and ideas that is essential for enabling all parties to make informed decisions about reducing risks” (Presidential/Congressional Commission on Risk Assessment and Risk Management 1997). An important guideline from an NRC (1989) report also bears directly on the committee’s review of HHS’s communications activities: “Risk communication is successful only to the extent that it raises the level of understanding of relevant issues or actions and satisfies those involved that they are adequately informed within the limits of available knowledge.” All of the guidelines mentioned for effective risk communication in this introduction, taking into consideration the considerable challenges involved, were used to evaluate HHS dissemination and communication efforts to workers and citizens. COMMITTEE’S APPROACH TO EVALUATING THE HHS EFFORTS To evaluate HHS’s dissemination and communication efforts under the MOU, the committee reviewed information provided by HHS agencies to the affected communities in terms of relevance, accuracy, accessibility, timeliness, comprehensibility, and credibility. For its evaluation, the committee reviewed a sample of written, electronic, and oral communications of the HHS health study findings and other outreach efforts at three sites: Hanford, Oak Ridge, and Los Alamos. These site-specific reviews are described in detail in Annexes 5A, 5B, and 5C, respectively. Beyond looking at specific efforts, the committee also contacted selected members of the Hanford Advisory Board and others in that region to get their input about the impact of the dissemination and communications efforts on this community. It also solicited information from social scientists who had studied some of the government-public interactions at DOE sites and sought the views of former members of several site-specific committees as well as other knowledgeable individuals. In addition, the committee ran searches in the Lexis-Nexis academic database to identify key public and worker issues that appeared in newspapers at each of the three sites and whether these had been addressed by HHS risk communication efforts. It also searched the Lexis database specifically to see whether information disseminated by the National Institute for Occupational Safety and Health (NIOSH) to workers and the public about various studies had reached a wider audience through newspaper coverage. Finally, to ensure that it had as complete a picture as possible, the committee reviewed NIOSH media coverage in a large collection of articles in the evidence package presented by the agency.

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services AGENCY COMMUNICATION EFFORTS The three HHS agencies involved in this study had a number of dissemination and communication responsibilities. NIOSH, through its Office of Occupational Energy Research Program (OERP) and its Health-Related Energy Research Branch (HERB), was responsible for communicating its study findings to workers, the public, Native American tribes, the scientific community, and other stakeholders. The National Center for Environmental Health (NCEH) provided information about its studies to workers and the public primarily through its contractors. Several NCEH contractors, including the Technical Steering Committee for the Hanford Environmental Dose Reconstruction (HEDR) and the Fred Hutchinson Cancer Center for the Hanford Thyroid Disease Study (HTDS), undertook considerable public communication efforts. Of the three HHS agencies, the ATSDR is the most heavily involved in conducting communication, outreach, and education efforts for the general public in the communities surrounding DOE facilities. As part of its broad congressional mandate to evaluate public health concerns related to exposures at hazardous waste sites, ATSDR developed and provided information, education, and training concerning hazardous substances to affected communities across the country, including but not limited to DOE facilities. National Institute for Occupational Safety and Health NIOSH is responsible for conducting epidemiological studies of workers at DOE facilities and for communicating the findings to workers and their representatives and to the community at large. The OERP has a number of communication goals related to effectively informing workers, scientists, and the public about its work. These goals include the following (NIOSH 2005): “Develop better mechanisms for generating research hypotheses by expanding the involvement of partners and actively seeking their input.” “Conduct research in an open environment with attention to clear and accurate education of workers and the public.” “Provide information that enhances the understanding of risks associated with radiation-induced health effects.” “Solicit and consider worker interests and the public’s concerns.” “Provide relevant occupational exposure and health outcome information for public health research and policy.” NIOSH communication activities include establishing communication plans and channels for the various sites, providing simultaneous communication to management and labor representatives, distributing one-page Brief Reports of Findings, making final technical reports available, and interacting directly with

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services workers. NIOSH conducted a needs assessment of what workers wanted to see in summaries of research findings, including simplified definitions of technical terms, other language-level issues, and increased availability of information (Ahrenholz 2001). According to NIOSH, the main mechanisms for OERP and HERB communication efforts include the following (NIOSH 2005): Regular research meetings. These meetings allow researchers (primarily those funded extramurally) to have an opportunity to communicate about their research. Periodic conference calls and on-site meetings with affected workers to discuss study status and results. Slide shows and other presentations are given at these meetings for workers, providing an update on findings of studies that had been completed, the studies that are currently under way, and occasionally reminding viewers about the MOU, its various governmental links, and the responsibilities of NIOSH under the MOU (NIOSH 2006b). NIOSH made presentations to both the Hanford and the Oak Ridge Health Effects Subcommittees, including slide shows and other briefing materials (NIOSH 2006b). Brief Reports of Findings issued to workers through the mail, electronically, and on-site. These one- or two-page summaries are discussed in more detail below. Public meetings. Occasionally, NIOSH has convened a public meeting such as the one about its epidemiological research program conducted under the MOU in Washington, DC, on October 27, 2005 (NIOSH 2006a). It also has a plan to provide study results to individual workers but has not used it. The 1988 NIOSH Worker Notification Procedures Manual details how these results are to be reported; however, NIOSH has stated that “to date, researchers have not had a study finding that necessitated formal individual worker notification” (NIOSH 2005). NIOSH Brief Reports of Findings NIOSH places significant emphasis on the use of short reports of study findings to communicate about research and activities to workers and the general public. These reports have various titles, including “Brief Reports of Findings,” “Announcement of Findings,” or “Summary of Findings.” The Brief Reports typically have included information on the type of study conducted, its purpose, a description of the study population, the study methodology, the main study findings and conclusions, limitations of the study, a glossary of terms, and information about how to obtain a copy of the full study and to reach a contact person for addressing questions (NIOSH 2005). According to NIOSH (NIOSH 2005), these reports were prepared after extensive consultation with workers and management at DOE facilities. The report summaries were converted to a conven-

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services tional file format (portable document file or pdf) so that they could easily be placed in site newsletters, on bulletin boards, and on web sites. They were also distributed directly to individual workers or to worker representatives as an e-mail attachment. While NIOSH did not require extramural researchers to engage in communications activities, information about a number of their studies was disseminated through these reports. NIOSH frequently provided the same information to various DOE facilities with these reports, using different “editions,” such as the Hanford or Oak Ridge edition. This was particularly true if the study was one that involved multiple sites. It also occasionally issued NIOSH-HERB updates, which related information about two or three main studies that were being conducted at a particular site and also included very brief descriptions of other studies going on at the site. Several updates were evaluated for Hanford, Oak Ridge, and Los Alamos: these usually contained the same basic information for all sites but were tailored to highlight information from the viewpoint of a particular site. When a study was completed under the OERP, study findings were reported to workers, DOE Headquarters, site managers, and site contractor management. Initially, study results were communicated to workers and worker representatives simultaneously. However, because of concerns expressed by DOE, the procedure was changed and findings were communicated to DOE Headquarters three days before the communication to workers and site management. All of this resulted in a complex communication and clearance procedure, which is diagrammed in Figures 5-1 and 5-2 (see NIOSH 2005). Agency Communication Evaluation NIOSH states that these reports have been used to “successfully communicate the findings of approximately thirty internal and external studies to some 300,000 current and former DOE workers” (NIOSH 2005). The basis for this assessment that findings have been “successfully” communicated, however, is not documented in NIOSH reports. It appears to relate to estimates of the number of individuals “reached” by NIOSH activities, rather than to any systematic study or assessment from target audiences about the relevance, quality, and timeliness of the information. NIOSH reports also a lack of evidence about whether or how the information was used or the degree to which this information produced increased agreement within the affected community about any specific scientific or technical aspect of the subject matter under study. According to NIOSH, there were no external evaluations of its outreach program. Instead, there were internal evaluations by its communications team, which consisted of the assistant branch chief, a health communication specialist, and one or more service fellows. Scientific and technical staff and others at NIOSH with health communications expertise assisted as needed. NIOSH states that “the success of the OERP communication strategies was evaluated periodi-

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services FIGURE 5-1 Phase I: NIOSH’s Study Communication Planning. SOURCE: NIOSH (2005).

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services as being “misleading, technically deficient and inappropriate” (Rogers 2005b). Another issue discussed in the local press was ATSDR’s report on health risks associated with exposure to low-level radiation, which was disputed by the ORRLOC group as being “deeply distressed” over conclusions drawn in a study for ATSDR by investigators from Massachusetts-based Clark University (Rogers 2005c). The decision by the U.S. Senate Appropriations Subcommittee on Energy and Water Appropriations to eliminate ATSDR’s budget for activities at DOE facilities for FY 2006 brought forth further debate about the value of these activities in the local press (Rogers 2005d). ORRLOC advisory committee member Al Brooks, in a letter to local government representatives, called the decision “a serious reduction” that would leave Oak Ridge without assurance that its city is a safe place to live and work, a position supported by the advisory committee as a whole. On the other side, Janet Michel, Coalition for a Healthy Environment secretary, stated that “ATSDR has squandered far too much money on endless meetings of the ORRHES—a group the agency manipulates to its own benefit and whose recommendations they are free to ignore. I have found that ATSDR’s PHAs are leaving much to be desired. ATSDR scientists are not following their own guidance documents on cancer risk for radiation exposure” (Michel 2005). Independent of HHS health communication activities, DOE itself established mechanisms to provide the community with information regarding operations in Oak Ridge. Initially, there was a DOE Public Reading Room and a DOE Information Resource Center. In 2003, these were combined into the DOE Oak Ridge Office Information Center “One Stop Shop,” which is staffed by a contractor to DOE and serves as an information resource to the community. This center does not contain health information on employees and advises that such concerns be investigated through the Department of Labor’s Energy Employees Compensation Resource Center. ANNEX 5C THE LOS ALAMOS COMMUNITY The Los Alamos Laboratory (LANL), or Project Y, came into existence in early 1943 for a single purpose: to design and build an atomic bomb (see also Chapter 3). Sited in northern New Mexico and owned by DOE, LANL has been managed by the University of California since 1943, when the laboratory was born as part of the Manhattan Project. During subsequent years, the mission of the 28,000-acre site changed and expanded to include thermonuclear weapons design, high-explosives and ordnance development and testing, weapons safety, nuclear reactor research, waste disposal or incineration, chemistry, criticality experimentation, tritium handling, biophysics, and radiobiology.21 Its current 21 Los Alamos Historical Document Retrieval and Assessment Project. 2006. Available at http://www.lahdra.org/.

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services research efforts focus on national security, environmental quality, and energy resources (ATSDR 2005c). The LANL workforce in 2003 was estimated to include 7,500 University of California employees and over 3,000 contractors (ATSDR 2005c). LANL is now managed by a consortium of University of California system and three private companies. Nuclear weapons production at the LANL site left an environmental legacy, including contamination of the air, water, and soil through releases of radioactive materials and chemicals during production (ATSDR 2005c). The releases occurred through a variety of activities including “direct discharge of liquid wastes to canyons, burial of solid wastes, direct release of air emissions to the atmosphere, and accidental spills” (ATSDR 2005c). Significant quantities of plutonium, uranium, and a wide variety of other toxic substances were processed and released to the environment in quantities that are not well known. The contamination of the site was of particular concern to workers and the surrounding community. ATSDR noted that citizens living near the site expressed concern about elevated cancer rates possibly linked to exposures at the site; other non-cancer health issues related to potential exposures including thyroid disease, allergies, asthma, and congenital anomalies; tribal exposures; and potential contamination of food and drinking water (ATSDR 2005c). NIOSH, NCEH, and ATSDR have worked in different capacities to examine the effects of these releases at the site on human health, particularly among former and current workers and in surrounding communities. Agency Communication Efforts An assessment of HHS communication activities at LANL is provided below. NIOSH As discussed previously, NIOSH produced one-page Brief Reports of Findings to communicate study results to workers and the community. Two multisite studies involved LANL. These were the study on ”Mortality Among Female Nuclear Weapons Workers” by Gregg S. Wilkinson (Wilkinson 2000), and “The Impact of Downsizing and Reorganization on Employee Health and Well-Being at the DOE LANL Facility” by Lewis D. Pepper (Pepper 2000). NCEH In 1999, NCEH initiated the Los Alamos Historical Document Retrieval and Assessment Project to systematically review and evaluate documents related to site operations for information about releases of contaminants from 1943 to the present (Shonka et al. 2006). The LAHDRA project team was established to investigate materials used throughout LANL’s history of operations to identify

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services and prioritize releases in terms of their apparent relative importance from the standpoint of potential off-site health effects. Based on the project’s findings, NCEH will work with stakeholders to determine if more detailed assessments of past releases are warranted. Should additional investigations be warranted, they might be in the form of screening-level evaluations, or they could progress to detailed dose reconstruction for the releases of highest priority.22 In January 2006, an interim report of the LAHDRA Project V4 was updated and is available on the project’s web site.23 (See Chapter 4 for more information about the document retrieval project at LANL.) According to the LAHDRA project, its “comprehensive study of LANL records is providing useful information to CDC [NCEH] and others who are interested in LANL releases and potential public health effects. Possessing the security clearances and ‘need to know’ associated with this study, the project will bring about public release of relevant documents that, until now, have been kept from public view simply because no one had authorization to locate them and request that they be reviewed for public release.” Documents declassified and released from LANL that the project team considers to contain useful information regarding off-site releases are available to the public at the University of New Mexico and at various libraries. These documents are summarized in a searchable database, which also will be available in the reading rooms.24 The LAHDRA web site notes that public outreach has been an important part of the project, including ongoing solicitation of public input and active outreach efforts in public education. The goal of the public outreach program is to present a complete and accurate picture of past operations and releases. The project’s Web page and public meetings solicit the public’s participation and input. The public is informed about the project’s purpose, methods, and progress through publication and distribution of newsletters and fact sheets. The project’s responsiveness to the public’s input about and awareness of project activities is continuously evaluated and will be summarized at conclusion of the project. The LAHDRA project team hosted 13 public meetings from 1999 to 2005 and members have given additional presentations to organizations, communities, tribes, and pueblos throughout northern New Mexico.25 ATSDR ATSDR has conducted a number of communication and outreach activities at Los Alamos. These include PHAs and educational efforts geared toward edu- 22 See http://www.lahdra.org/. Last accessed August 2006. 23 See http://www.lahdra.org/. Last accessed August 2006. 24 See http://www.lahdra.org/. Last accessed August 2006. 25 See http://www.lahdra.org/outreach/outreach.htm. Last accessed August 2006.

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services cating the surrounding community as well as health professionals about potentially relevant exposures at the site. Public Health Assessments In 2005, ATSDR released a PHA for LANL for public comment. The PHA evaluated monitoring data from the site from 1980 to 2001 to assess possible exposures to chemical contaminants and radionuclides in a variety of environmental media. In preparing the document, ATSDR “collected relevant health data, environmental data, and community health concerns from the Environmental Protection Agency, state and local health and environmental agencies, the community, and potentially responsible parties, where appropriate.” According to ATSDR, the document represents the agency’s best efforts, based on currently available information, to fulfill the statutory criteria set out in CERCLA section 104 (i)(6) within a limited time frame. To assess community health concerns for the PHA, in 1994, Boston University conducted a survey to identify the public health concerns of the community surrounding LANL under an ATSDR grant. Initially, surveys were mailed to 71 citizens and organizations on an NCEH contact list. Follow-up telephone interviews were conducted and additional community concerns were collected more informally. Distinct communities within the areas surrounding LANL were identified, each with unique concerns about LANL’s operations. Among the community concerns expressed were the following: Elevated cancer rates; Non-cancer health impacts, including thyroid disease, allergies, genetic effects or reproductive outcomes, asthma at pueblos, and rheumatism; Health impacts of LANL releases on tribal nations including questions based on exposures through unique tribal practices, such as the use of surface water from streams for ceremonies and irrigation, as well as impacts on sacred areas; and Long-term health impacts of earlier accidental releases. The PHA evaluation concluded that “no harmful exposures are occurring or are expected to occur in the future because of chemical or radioactive contamination detected in groundwater, surface soil, surface water and sediment, air or biota” (ATSDR 2005b). More information about the scientific aspects of this PHA can be found in Chapter 3. As mentioned previously, the PHAs are released to the public for a 45-day public comment period, after which the agency typically addresses these comments in a revised PHA (see discussion of Oak Ridge PHA and Hanford PHA). The committee reviewed the PHA for LANL that was released for public comment on April 26, 2005.

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services Educational Efforts to Health Care Providers and the Community ATSDR conducted a number of health education programs in the communities surrounding LANL. The agency partnered with the Association of Occupational and Environmental Clinics and the University of New Mexico through a cooperative agreement to develop and implement health education materials and promotional activities related to community and health professional environmental education for communities living near Los Alamos (ATSDR 2006b). It was also involved in funding educational projects through the National Alliance for Hispanic Health (NAHH) “to increase knowledge about Hispanic children’s exposure to hazardous substances” (ATSDR 2006b). Through this funding, the National Hispanic Environmental Health Education Network was developed to “increase knowledge about Hispanic children’s exposure to toxic substances among health and human service professionals within the Alliance’s network and to build the capacity of community-based organizations to develop and implement culturally proficient environmental education programs for Hispanic families” (ATSDR 2006b). Fact sheets, developed in English and Spanish and posted on the NAHH web site, have been developed on a variety of environmental health issues including smoking and radon exposure. ATSDR notes that the NAHH also worked closely with Youth Development, Inc. in developing community education programs related to potential exposures to contaminants of concern at LANL. This included developing three environmental health modules and training nearly 90 people in 2003. Stakeholder Input: Citizens Advisory Board The Northern New Mexico Citizens’ Advisory Board (NNMCAB) is the site-specific community advisory group chartered under FACA in 1997 to provide citizen input to the DOE on issues of environmental remediation and cleanup, waste management, monitoring and surveillance, and long-term stewardship at LANL. For Los Alamos, ATSDR also has been working through this DOE site-specific advisory board. According to its web site, the NNMCAB is “dedicated to increasing public involvement, awareness and education relating to environmental remediation and management activities at LANL.” It strives to ensure that decisions about LANL include informed advice from the community, and it openly solicits public participation in all deliberations. The NNMCAB committee’s goal is to make it easier for members of the public to make their voices heard by DOE decision makers, emphasizing the continuing need for intensive public information and involvement efforts by LANL and DOE.26 The NNMCAB stresses that such public information and involvement events 26 See http://www.nnmcab.org/. Last accessed August 2006.

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services should be well organized and well managed so that the information presented is comprehensible to the intended audience and the public has ample opportunity to interact with the presenters. According to its Community Involvement Committee (CIC), which existed through 2005, the public requires understandable and usable information about environmental remediation and waste management at LANL.27 In 2005 the CIC made two major recommendations to DOE approved by the parent board to improve public interaction and comprehension of the information. The first was a series of recommendations for meetings aimed primarily at conveying information to the public (Recommendation 2005-4), and the second noted that the executive summaries of some specific DOE reports on environmental surveillance at Los Alamos “did not adequately summarize the key points and conclusions in a way that would be understandable to the general public” (July 27, Recommendation 2002-05). Although both of these recommendations are for DOE because this body advises that agency, many of its comments also could be applied to efforts reviewed by this committee for HHS agencies at other DOE sites. In 2006, the duties of the CIC were transferred to the NNMCAB staff to be more effective and to help incorporate communication concerns into the efforts of two technical subcommittees of this group (L. Novak, NNMCAB, Santa Fe, NM, personal communication, July 27, 2006). Media Coverage of HHS Activities at the Los Alamos Site The committee conducted a limited search of news articles related to HHS activities at Los Alamos between 1990 and 2006. Many articles discussed the Energy Employees Occupational Illness Compensation Program, but as mentioned previously, this program is not included under the MOU and is not discussed here. Other activities covered by the news media included the difficulty that researchers had in obtaining data from the LANL for use in health studies; ATSDR’s PHA; and LAHDRA. NIOSH An early article in the Santa Fe New Mexican in 1996 described difficulties encountered by NIOSH in obtaining data from LANL for use in health studies. It noted that “Los Alamos National Laboratory has dragged its feet in making information available to outside researchers studying cancer rates in federal DOE workers, federal and academic health researchers say.” According to the article, 27 NNMCAB Recommendation to DOE No. 2005-04, “Improvements to DOE/LANL Public Meetings,” 2005. Available at http://www.nnmcab.org/recommendations/recommendation-2005-04.pdr.

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services “the researchers said that in the cases where they have been able to get their hands on records, the information has been spotty and difficult to interpret” (Easthouse 1996). Another article in 2004 showed that the situation had not changed very much. It discussed NIOSH’s difficulty in obtaining data to estimate exposure for compensation claims: “The National Institute for Occupational Safety and Health says it is having a hard time getting data on the amount of radiation to which Cold War-era nuclear weapons plant workers may have been exposed” (Zuckerbrod 2004). NCEH The LAHDRA project was also the subject of many articles. Some issues discussed included the release of an interim report that provided information about the status of the LAHDRA project, difficulties in obtaining needed records from the laboratory, and the delay in completing the project. One article noted, “Begun in 1999, the project is taking much longer than anticipated” (Rankin 2004). Another noted that “work on the project has at times been slowed down because the CDC and the lab have disagreed over access to various documents. The CDC at one point threatened to terminate work altogether after the current $4.2 million contract ran its course this year” (Associated Press 2004). ATSDR A few articles in 2005 discussed the release of the PHA for the site. One article discussed the findings of the PHA and provided details about how the public could submit comments. One article noted criticisms of the PHA: “At least one LANL environmental watchdog group, however, isn’t buying the conclusions and is concerned the study’s authors didn’t seek input from any sources beyond LANL and the federal Department of Energy” (Rankin 2005). REFERENCES Ackland, L. 2002. Making a Real Killing: Rocky Flats and the Nuclear West. Albuquerque, NM: University of New Mexico Press. Ahlstrom, D. 2005. Low level radiation dose poses higher cancer risk. Irish Times, June 29, pp. 3. Ahrenholz, S. 2001. Overview of Current NIOSH/HERB Occupational Research & Worker Outreach Efforts at Hanford. NIOSH’s Response to the National Academies’ Request 12/9/05, Supporting Documents, CD ROM-2. Presentation to the Committee to Review the Worker and Public Health Activities Program Washington, DC, January 25. Associated Press. 1998. Study finds no link between DOE workers, children’s disease. Associated Press, October 16. Associated Press. 2000. Study finds increased radiation exposure boosts risk of blood cancer. Associated Press, April 10.

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services Associated Press. 2004. CDC looking at pollution caused by nuclear work at Los Alamos. Associated Press, April 3. ATSDR (Agency for Toxic Substances and Disease Registry). 1997a. Hanford Public Health Assessment—Initial Release 200 Area. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. ATSDR (Agency for Toxic Substances Disease Registry). 1997b. Public Health Assessment for Hanford—300 Area. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. ATSDR (Agency for Toxic Substances and Disease Registry). 1997c. Hanford Medical Monitoring Program: Background Consideration Document and ATSDR Decision. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. ATSDR (Agency for Toxic Substances and Disease Registry). 2000. Hanford Infant Mortality & Fetal Death Analysis 1940-1952. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. ATSDR (Agency for Toxic Substances and Disease Registry). 2004a. A Guide for Physicians. Thyroid Evaluation of Patients Who Are Concerned About Hanford Iodine-131 Releases [on-line]. Available: http://www.atsdr.cdc.gov/hanford/docs/guide_for_physicians_brochure.pdf [accessed August 16, 2006]. ATSDR (Agency for Toxic Substances and Disease Registry). 2004b. Toxicological Profile for Americium. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. ATSDR (Agency for Toxic Substances and Disease Registry). 2004c. Public Health Assessment for Oak Ridge Reservation, Oak Ridge, Anderson Country, Tennessee, EPA Facility ID: TN1890090003. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. ATSDR (Agency for Toxic Substances and Disease Registry). 2005a. Educational Materials Clearinghouse. Educational Materials about Hanford, Radioactive Iodine and Related Topics [on-line]. Available: http://www.atsdr.cdc.gov/hanford/educational/ [accessed August 16, 2006]. ATSDR (Agency for Toxic Substances and Disease Registry). 2005b. Using Public Relations Strategies to Prompt Populations at Risk to Seek Health Information: The Hanford Community Health Project (draft journal article). Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. ATSDR (Agency for Toxic Substances and Disease Registry). 2005c. Public Health Assessment for Los Alamos. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. ATSDR (Agency for Toxic Substances and Disease Registry). 2006a. Statement of Mission [on-line]. Available: http://www.atsdr.cdc.gov/mission.html [accessed August 16, 2006]. ATSDR (Agency for Toxic Substances and Disease Registry). 2006b. NCEH/ATSDR Response to Committee Questions. The Committee to Review the Worker and Public Health Activities Program, Worker and Public Health Committee’s Public Access File. No. 40, Atlanta, GA, February 19. ATSDR (Agency for Toxic Substances and Disease Registry). 2006c. Hanford Community Health Project. Request for Medical Evaluation for Past Exposure’s to Iodine-131 (Physician’s pamphlet) [on-line]. Available: http://www.atsdr.cdc.gov/hanford/docs/physic1.pdf [accessed August 16, 2006]. ATSDR (Agency for Toxic Substances and Disease Registry). 2006d. Results of the Hanford Community Health Project Survey [on-line]. Available: http://www.atsdr.cdc.gov/hanford/docs/survrlt.pdf [accessed August 16, 2006].

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services ATSDR/NCEH (Agency for Toxic Substances and Disease Registry/National Center for Environmental Health). 2006. ATSDR and NCEH responses to the NRC committee questions. The Committee to Review the Worker and Public Health Activities Program, July 24, 2006, Atlanta, GA. Beierle, T.C., and J. Cayford. 2002. Democracy in Practice: Public Participation in Environmental Decisions. Washington, DC: Resources for the Future. Boseley, S. 2005. Workers in N-plants risk cancer. The Guardian (London), June 29, pp. 7. Business & News Desks. 1999. Public comment sought on proposed public health activities at energy department sites. Business & News Desks/Energy & Health Writers, June 4. Cary, A. 2005a. Hanford project continues. Tri-City Herald (Richland, WA), February 1. Cary, A. 2005b. Federal agency completes study of radiation at Hanford Nuclear Reservation. Tri-City Herald (Richland, WA), January 17. COSMOS. 2001a. Final Report for the Evaluation of the Health Effects Subcommittee Advisory Process, Vol. 1. Report submitted by COSMOS to Centers for Disease Control and Prevention. Contract No. 282-98-0027. Atlanta, GA: Centers for Disease Control and Prevention. COSMOS. 2001b. Final Report for the Evaluation of the Health Effects Subcommittee Advisory Process, Vol. 2. Report submitted by COSMOS to Centers for Disease Control and Prevention. Contract No. 282-98-0027. Atlanta, GA: Centers for Disease Control and Prevention. Dworkin, A. 2005. Hanford health project seeks former “downwinders,” officials want to educate those who lived near the nuclear site decades ago about possible health risks. Science, March 23, p. A17. Easthouse, K. 1996. LANL slow responding to health studies, cancer researchers say problems with lab worse than most. Santa Fe New Mexican, April 28, p. A-1. Flynn, J., E. Peters, C.K. Mertz, and P. Slovic. 2001. Risk, media and stigma at Rocky Flats. Pp. 309-327 in Risk, Media and Stigma, Flynn, J., P. Slovic, and H. Kunrether, eds. London: Earthscan Publications. Friedman, S.M. 1981. Blueprint for breakdown: Three Mile Island and the media before the accident. J Commun 31:116-128. Friedman, S.M. 2001. Risk communication, the Hanford Thyroid Disease Study and draft reports. Risk: Health Safety & Environment Spring:91-105. Friedman, S.M., C.M. Gorney, and B.P. Egolf. 1987. Reporting on radiation: a content analysis of Chernobyl coverage. J Commun 37(3):58-78. Geranios, N.K. 2005. Doctors also need to focus on mental health of downwinders. Associated Press, August 18. Hebert, H.J. 2000. Study examines mortality rates of women in nuclear weapons plants. Associated Press, June 29. IOM (Institute of Medicine). 1999. Exposure of the American People to IODINE-131 from Nevada Nuclear-Bomb Tests. Review of the National Cancer Institute Report and Public Health Implications. Washington, DC: National Academy Press. Johnson, B. 1999. Ethical issues in risk communication: continuing the discussion. Risk Anal 19:335-348. Kelley, M., P. Sutton, R. Gould, T. Pritikin, and M. Ferrucci. 2004. Letter to Mark Evans, Environmental Geologist, ATSDR, August 11, 2004 [letter]. Submitted to the Committee to Review the Worker and Public Health Activities Program, June 24, 2006. Kunreuther, H., and P. Slovic. 2001. Coping with stigma: challenges and opportunities. Pp. 331-352 in Risk, Media and Stigma, Flynn, J., P. Slovic, and H. Kunrether, eds. London: Earthscan Publications. Long, C. 2003. Study finds Rocky Flats workers have increased risk. Associated Press, April 18. Mangano, J.J. 1994. Cancer mortality near Oak Ridge, Tennessee. Int J Health Serv 24:521. Michel, J. 2005. Oak Ridger, July 18. “ATSDR Rife with Problems.”

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services Moore, L. 2004. Letter from Leroy Moore, Ph.D., Rocky Mountain Peace and Justice Center, and others to ATSDR, October 20, 2004. Submitted to the Committee to Review the Worker and Public Health Activities Program, June 24, 2006. Morgan, M.G., B. Fischhoff, A. Bostrom, and C.J. Atman. 2002. Introduction. Pp. 1-16 in Risk Communication, A Mental Models Approach. Cambridge, UK: Cambridge University Press. Morson, B. 2003. Plutonium might be deadlier than thought: lung cancer danger occurs even at “safe” levels, study says. Rocky Mountain News, April 18, p. 12A. NCEH (National Center for Environmental Health). 2005. Project Profiles: Hanford [on-line]. Available: http://www.cdc.gov/nceh/radiation/brochure/profile_hanford.htm [accessed August 16, 2006]. NCEH (National Center for Environmental Health). 2006a. Radiation Studies [on-line]. Available: http://www.cdc.gov/nceh/radiation/default.htm [accessed August 16, 2006]. NCEH (National Center for Environmental Health). 2006b. NCEH/ATSDR Response to Committee Questions. The Committee to Review the Worker and Public Health Activities Program, Atlanta, GA, February 19. NCEH (National Center for Environmental Health). 2006c. Response to NRC committee’s questions. The Committee to Review the Worker and Public Health Activities Program, May 23, 2006, Atlanta, GA. NCEH/ATSDR (National Center for Environmental Health/Agency for Toxic Substances and Disease Registry). 2006. Response to Committee Questions. The Committee to Review the Worker and Public Health Activities Program, Atlanta, GA, February 19. Nicholson, K. 2003. Some cancer rates at flats above average; fatal doses tied to single incidents. Denver Post, April 18, p. B-01. Niles, K. 1996. Reconstructing Hanford’s Past Releases of Radioactive Materials: The History of the Technical Steering Panel 1988-1995. Hanford Environmental Dose Reconstruction (HEDR) Project Technical Steering Panel. Olympia, WA: Washington State Department of Health. NIOSH (National Institute for Occupational Safety and Health). 2005. Evidence for the National Academies’ Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services, Cincinatti, OH [on-line]. Available: http://www.cdc.gov/niosh/nas/oerp/pdfs/OERP-NAS.pdf [accessed August 16, 2006]. NIOSH (National Institute for Occupational Safety and Health). 2006a. Verbatim Transcript, Public Communication, NIOSH’s Response to the National Academies’ Request 12/9/05, Supporting Documents, CD ROM-2. Atlanta, GA: Centers for Disease Control and Prevention. NIOSH (National Institute for Occupational Safety and Health). 2006b. NIOSH’s Response to the National Academies’ Request 12/9/05, Supporting Documents, CD ROM-2. Atlanta, GA: Centers for Disease Control and Prevention. NIOSH (National Institute for Occupational Safety and Health). 2006c. Response by Schubauer-Berigan to NAS committee’s questions. Atlanta, GA: Centers for Disease Control and Prevention. NRC (National Research Council). 1989. Improving Risk Communication. Washington, DC: National Academy Press. NRC (National Research Council). 1990. Providing Access to Epidemiological Data. Washington, DC: National Academy Press. NRC (National Research Council). 2000. Review of the Hanford Thyroid Disease Study Draft Final Report. Washington, DC: National Academy Press. O’Neil, K. 2004. INEEL health, safety report released; study of workers at the INEEL finds higher risk of some cancers. Idaho Falls Post Register, October 28, p. B1. ORHASP (Oak Ridge Health Agreement Steering Panel). 1999. Releases of Contaminants from Oak Ridge Facilities and Risks to Public Health, Final Report of the Oak Ridge Health Agreement Steering Panel. Nashville, TN: Tennessee Department of Health.

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Review of the Worker and Public Health Activities Program Administered by the Department of Energy and the Department of Health and Human Services ORNL (Oak Ridge National Laboratory). ORNL Review. 2002. Chapter 1. 25(3 and 4). Oak Ridge, TN: Oak Ridge National Laboratory. Parkin, R.T., L. Ragain, T. Guidotti, and G. Paranzino. 2003. Assessing the Health Education Needs of Residents in the Area of Oak Ridge Reservation, Tennessee. Final report. Washington, DC: Association of Occupational and Environmental Clinics. Paulson, T. 2000. Hanford study finds high risk in low radiation; exposed workers died of cancer. Seattle Post-Intelligencer, April 11, p. A1. Pepper, L. 2000. The health effects of downsizing in the nuclear industry: findings at the Los Alamos National Laboratory. Boston, MA: Boston University School of Public Health. Available from NIOSH/HERB, Cincinnati, OH; 135 pp. Presidential/Congressional Commission on Risk Assessment and Risk Management. 1997. Final Report, Volume 1. Framework for Environmental Health Risk Management. Washington, DC. PSR (Physicians for Social Responsibility). 1992. Dead Reckoning. Washington, DC. Rankin, A. 2004. Lab problems not affecting CDC project. Albuquerque Journal, July 28. Rankin, A. 2005. No contamination woes at LANL, report says. Albuquerque Journal, June 25, p. E2. Rogers, E. 2005a. Oak Ridger, May 16. “ATSDR Defends Health Check.” Rogers E. 2005b. Oak Ridger, June 15. “SENES President Claims PHA is ‘Misleading’.” Rogers, E. 2005c. Oak Ridger, July 21. “ATSDR Discusses Clark University Study.” Rogers, E. 2005d. Oak Ridger, July 18. “ATSDR Budget Reduction Debate.” Schneider, K. 1988. How secrecy on atomic weapons helped breed a policy of disregard. New York Times, November 13, p. E7. Schumacher, E. 1999. Many Hanford “downwinders” losing faith—those on Hanford dosage-study panel seek elusive radiation figures. Seattle Times, February 10, p. B2. Seattle Post-Intelligencer. 2000. Hanford study finds high risk in low radiation; exposed workers died of cancer. April 11, p. A1. Shonka, J., S. Flack, R. Burns, J. Budenbaum, J. O’Brien, K. Robinson, J. Knutsen, and D. Shonka. 2006. Interim report of the Los Alamos Historic Document Retrieval and Assessment (LAHDRA) Project. Version 4. Atlanta, GA: Centers for Disease Control and Prevention. Slovic, P. 1987. Perception of risk. Science 236:280-285. Slovic, P. 1993. Perceived risk, trust, and democracy. Risk Anal 13:675-682. Slovic, P. 2000. Perception of risk from radiation. Pp. 264-274 in The Perception of Risk. London: Earthscan Publications. Slovic, P., J. Flynn, and M. Layman. 1991. Perceived risk, trust and the politics of nuclear waste. Science 254:1603-1607. Steele, K.D. 2000. Hanford health network to close; information service a victim of budget cuts at DOE. Spokane Spokesman Review, March 23. Tuler, S., T. Webler, and R. Finson. 2005. Competing perspectives on public involvement: planning for risk characterization and risk communication about radiological contamination from a national laboratory. Health Risk & Society 7:247-266. Webster’s Third New International Dictionary. 2003. Springfield, MA: Merriam-Webster Incorporated. Wilkinson, G.S., N. Trieff, and R. Graham. 2000. Final Report: Study of Mortality Among Female Nuclear Weapons Workers. Buffalo, NY: State University of New York at Buffalo. Zuckerbrod, N. 2004. Government having problems getting data on weapons plant workers’ exposure to radiation. Associated Press, May 13.