2

Opening Session

This chapter provides a summary of the opening remarks and presentations that framed the workshop. Presentations discussed the growing use of hydraulic fracturing to extract natural gas from shale rock, and the health and other related concerns raised by community members. The Centers for Disease Control and Prevention (CDC) programs that support the assessment of community concerns and that provide monitoring of potential adverse health impacts are briefly described. Health impact assessment (HIA) is discussed as a potential systematic process (based on data, analysis, and input from stakeholders) to determine the potential effects that a proposed project may have on the health of a population. HIA is used to inform decision making and create opportunities for planning and management of the potential negative impact of a project.

OPENING REMARKS

Harvey V. Fineberg, M.D.
President, Institute of Medicine

Harvey V. Fineberg opened the workshop by explaining that the Institute of Medicine (IOM) is the health arm of the National Academy of Sciences. The National Academy of Sciences, together with the National Academy of Engineering, the National Research Council, and the IOM constitute the National Academies. The IOM, he noted, like its sister academies, is an honorific association. It was chartered in 1970, but its mission is to serve as an advisor to the nation, to government, to the citizens, and to interested parties on matters related to health. The mission of the IOM is to provide unbiased, evidence-based, and authoritative information and recommendations related to health and science policy, to policy makers, to health professionals, to interested groups, to businesses, and to the citizens at large. The IOM also serves as a convener of thought leaders and experts on matters of science and



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2 Opening Session This chapter provides a summary of the opening remarks and presentations that framed the workshop. Presentations discussed the growing use of hydraulic fracturing to extract natural gas from shale rock, and the health and other related concerns raised by community members. The Centers for Disease Control and Prevention (CDC) programs that support the assessment of community concerns and that provide monitoring of potential adverse health impacts are briefly described. Health impact assessment (HIA) is discussed as a potential systematic process (based on data, analysis, and input from stakeholders) to determine the potential effects that a proposed project may have on the health of a population. HIA is used to inform decision making and create opportunities for planning and management of the potential negative impact of a project. OPENING REMARKS Harvey V. Fineberg, M.D. President, Institute of Medicine Harvey V. Fineberg opened the workshop by explaining that the Institute of Medicine (IOM) is the health arm of the National Academy of Sciences. The National Academy of Sciences, together with the National Academy of Engineering, the National Research Council, and the IOM constitute the National Academies. The IOM, he noted, like its sister academies, is an honorific association. It was chartered in 1970, but its mission is to serve as an advisor to the nation, to government, to the citizens, and to interested parties on matters related to health. The mission of the IOM is to provide unbiased, evidence-based, and author- itative information and recommendations related to health and science policy, to policy makers, to health professionals, to interested groups, to businesses, and to the citizens at large. The IOM also serves as a convener of thought leaders and experts on matters of science and 5

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6 HEALTH IMPACT ASSESSMENT OF SHALE GAS EXTRACTION policy—these occasions are intended as regular opportunities to have a dialogue on important health challenges. Dr. Fineberg further noted that the IOM uses roundtables as an opportunity for all interested parties (i.e., government, industry, inter- ested groups, and representatives of citizens at large) to gather periodically to engage in free exchange. The Roundtable on Environ- mental Health Sciences, Research, and Medicine, the sponsor of the workshop, has adopted and emphasized a theme of health-in-all policy. That approach, he noted, recognizes that many aspects of decision making and choice in society, whether it is about housing, education, our trans- portation system, or certainly about our environment, all have potential and documented impacts on human health. Thus, the Roundtable is interested not only in learning about the sources of these influences on health, but also in exploring options and opportunities to improve health through improved policies in all of these areas. The workshop, he stated, brings together many eminent scientists, physicians, public health experts, and representatives from government agencies at federal and state levels, from nongovernment organizations, from the business sector, and from interest groups representing the interests of the citizens to exchange ideas and to inform on a very challenging problem—hydraulic fracturing as a means of extraction of natural gas. It is a challenging question that has many dimensions to be illuminated in order to understand more clearly what is at stake and what can be done. INTRODUCING THE WORKSHOP THEME Lynn R. Goldman, M.D. Vice Chair, Roundtable on Environmental Health Sciences, Research, and Medicine Dean, George Washington University School of Public Health and Health Services Lynn R. Goldman began her remarks by highlighting that when first convened in 1998 the Roundtable adopted a broad view of environmental health—one that includes the natural, built, and social environments and considers how changes in the environment can impact human health (IOM, 2006). The roundtable has used a life-cycle approach that includes both upstream and downstream drivers to understand health impacts. For example, for a product on the market there may be health implications during production, use, and disposal that need to be taken into account. Because environmental protection is also health protection, the Round- table has been drawn toward a number of issues, including energy.

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OPENING SESSION 7 Dr. Goldman noted that energy is today a predominant theme in national policy discussions. There are debates about drilling along the Gulf Coast, building the Keystone Pipeline, and opportunities for U.S. energy independence. She stated that over the next few years and decades, the United States and many other countries will be making important decisions about where to invest resources for ensuring that energy needs are being met. These decisions will not be easy to make; there is no clear path forward and trade-offs will need to be made. She emphasized that policy decisions often focus on energy needs, environmental impact, or economic considerations. In many of these decisions, the health community is not at the table. She stated that health impacts of energy alternatives are important and need to be evaluated and discussed early in the decision-making processes. When health impacts are considered late in the process after decisions have been made, then needed adjustments to protect health too often are difficult and expensive. When considered in a timely matter, health decisions do not have to be at odds with economic growth, but can serve as a partner in ensuring an energy future. During the planning of the workshop the planning committee recognized that the discussion on shale gas extraction and energy production in general is part of a much larger and more complex picture of a major societal transformation of how we generate and use energy for the power grid and for transportation. As the country begins to think about ensuring sustainable energy, there will be a need to continue these discussions in order to have a more complete view. Members of the Roundtable have heard concerns and anecdotal reports of possible health problems related to shale gas extraction from communities and have read some of the preliminary research in this area. The Roundtable will not be making any conclusions or recommend- ations, but rather this workshop gathers experts in the field to better understand the state of the science as it exists in April 2012. Dr. Goldman emphasized that comments made by individuals, including members of the Roundtable, should not be interpreted as positions of the Roundtable, the IOM, or its sponsors. FRAMING THE WORKSHOP Christopher J. Portier, Ph.D. Director of the National Center for Environmental Health and Agency for Toxic Substances and Disease Registry Centers for Disease Control and Prevention Christopher J. Portier began his presentation by noting that improved methods for recovering natural gas from large reserves in the United

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8 HEALTH IMPACT ASSESSMENT OF SHALE GAS EXTRACTION States have emerged in recent years. The expansion of natural gas extraction has led to new jobs and improved economies in states and communities across the country. If lessons from past experiences can be drawn, over time these improved economies will lead to improved public health in these communities. But improved economies can also introduce new public health concerns. He noted that some reports to the Agency for Toxic Substance and Disease Registry (ATSDR) have raised concerns about the potential for adverse health effects on individuals and communities involved in hydraulic fracturing. Dr. Portier stated that most notable among these concerns are: the potential for chemical contamination of drinking water wells from hydraulic fracturing fluids, the mobilization of naturally occurring metals and salts, the potential for emission of volatile organics into the air, the potential for explosive hazards from buildup of methane in drinking water wells, increased traffic leading to reductions in road safety, the potential for stress to the medical and emergency response systems and infrastructure in communities, and changes in the overall quality of life that could adversely affect human health. He emphasized that although the CDC and ATSDR are not regulatory agencies, they serve a critical role in protecting environmental public health in this nation by protecting the nation from immediate public health threats 24 hours a day and through the development of programs that prevent disease. Prevention not only saves lives but it can save money through reducing or eliminating health care costs and losses in productivity, he stated. Dr. Portier proceeded to outline programs that address community concerns related to shale gas extraction under the National Center for Environmental Health (NCEH) and ATSDR at the CDC. ATSDR works in communities, evaluating the potential for environmental exposures that can negatively affect human health. The agency has received calls from community members, community organizations, media, and local and state governments. These callers have raised a number of health concerns related to shale gas extraction, including nausea, respiratory issues, and irritating odors. Further, individuals living near drilling sites have also expressed concern about potential long-term health effects. The agency is working to address these community concerns. NCEH also addresses community concerns through its Environmental Public Health Tracking Network and the National Biomonitoring Program. The Environmental Public Health Tracking Network1 tracks both exposures and disease incidence and prevalence at the county level to understand trends in the environment–disease linkage and to collect evidence on the effectiveness of interventions. The National Biomonitoring Program2 has the capability to measure more than 450 chemicals and nutrition indicators in human tissues and urine to understand the 1 See http://ephtracking.cdc.gov/showHome.action (accessed May 30, 2013). 2 See http://www.cdc.gov/biomonitoring (accessed May 30, 2013).

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OPENING SESSION 9 magnitude of exposures at the individual level (CDC, 2012). Additionally, ATSDR and NCEH are supporting other scientific efforts by providing public health and toxicological expertise to the U.S. Environmental Protection Agency’s (EPA’s) National Hydraulic Fracturing Study.3 Dr. Portier then proceeded to describe the focus of the workshop. He noted that the intersection of health and hydraulic fracturing is a rapidly evolving issue. Currently, 16 states have begun or are contemplating shale production, which underscores the importance of this topic for many individuals across the United States. He said that the objective of the workshop is, through scientific discussion, to shed light on whether shale gas extraction poses potential public health challenges and the extent of the concerns for the nation. Dr. Portier further commented that on January 13, 2012, the White House released a report of the administration’s support for economic investments, including support for natural gas development (White House, 2012). He also noted that President Obama has stated that America will develop this resource without putting the health and safety of our citizens at risk (Executive Order 13605, 2012). Public health professionals recognize that health is positively linked to job growth and economic development. However, public health officials are also committed to ensuring that economic development progresses responsibly and in a way that addresses the health and safety concerns of Americans. Thus, the steps taken now to identify health threats can be used to improve shale gas extraction techniques, allowing all to continue to advance the economic and security goals of this nation while protecting health and preventing disease. HEALTH IMPACT ASSESSMENT FOR SHALE GAS EXTRACTION Aaron Wernham, M.D., M.S. Project Director, Health Impact Project Pew Charitable Trusts Aaron Wernham began his presentation by noting that the use of HIA is relatively new in the United States and has been growing in use over the past 10–12 years as a mechanism to conduct health-oriented planning and decision making. HIA has been used primarily in natural resource development, and only recently has there been interest in applying principles to other areas of decision making such as hydraulic fracturing. 3 See http://www2.epa.gov/hfstudy (accessed May 30, 2013).

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10 HEALTH IMPACT ASSESSMENT OF SHALE GAS EXTRACTION Dr. Wernham explained that HIA is a systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects. (NRC, 2011) HIA is not a health risk assessment. HIA is a management tool to assess complex societal decisions that may have health implications and options for managing the health effects. It is not meant to just identify risks, and its purpose is not to determine if a proposal or policy is a good idea or not. HIA  informs decision making on a specific proposed action (legislation, new regulation, permit, growth plan, and so forth);  identifies a broad range of potential risks and benefits of the proposal;  emphasizes interagency collaboration;  solicits input from stakeholders (regulators, industry, community, and so forth); and  offers recommendations to address data gaps, establish a monitoring framework, maximize benefits, and minimize any risks. HIA is primarily qualitative in nature and does not make quantitative comparisons across choices. The focus is to identify the different ways, both direct and indirect, that health may be affected. Further, HIA is more than just an analytic tool; it is an opportunity for dialogue. During the development of an HIA, the process provides an opportunity for stakeholders to have a reasoned discussion about what they view are the risks and how to manage them (NRC, 2011). There are six steps to develop HIAs: 1. Screening. Decide whether HIA should be done; consider if it will add information and can be done within the time line. 2. Scoping. Develop the framework for the HIA; identify the most important health effects and affected populations to assess with the available evidence. 3. Assessment. Analyze the baseline conditions or characteristics of the population and predict potential effects. 4. Recommendations. Develop health-based recommendations, a feasible plan for implementing them, and indicators for monitoring. 5. Reporting. Develop a report, disseminate the results to decision makers, the public, and other stakeholders.

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OPENING SESSION 11 6. Monitoring and Evaluation of the HIA Process. Determine whether it added value to the decision-making process; evaluate the outcomes of implementing HIA recommendations. (NRC, 2011) Although HIA is a growing field in the United States, the international community, including the World Bank and the International Finance Corporation (IFC), routinely uses this tool. HIA in international practice has been driven by natural resource development, the oil and gas sector, and the mining sector. The IFC, which establishes lending standards for most large development loans worldwide, the International Council on Mining and Metals, and the International Council on Oil and Gas Producers have issued guidance and standards on HIA (ICMM, 2010). According to Dr. Wernham, industries recognize HIA as a good business practice; HIA provides an opportunity to lower business costs, protect workers and the community, and proactively manage risk. HIAs are often part of an industry’s corporate social responsibility plan. HIAs in the United States HIAs are occurring across the United States and a few are being developed to address energy and natural resource development decisions (Health Impact Project, 2011):  biomass (California, Massachusetts, Oregon, Virginia),  oil and gas leasing (Arkansas),  mining (Arkansas),  shale gas development (Colorado), and  wind energy (Oregon). According to Dr. Wernham, what is unique about the energy and natural resource sectors is that often these projects are polarizing and political as they focus on issues of jobs, national security, and environ- mental concerns. There is a mix of environmental health and socioeconomic risks and benefits. Some people in the community are concerned about protecting their communities against environmental risks, whereas other individuals are interested in the economic benefit. Governments also have both an economic interest and an interest in protecting people. Finally, industry has invested years and resources in exploration and planning. Thus, it can be a challenging environment in which to conduct HIAs, he said. HIA encompasses the breadth of health and it is crucial that HIA include areas other than pollutants. The common subset of influences on health that may be included in HIAs are air quality, water quality, noise, subsistence and agricultural uses, demographic changes and influx of workers, traffic patterns, revenues, and employment and income.

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12 HEALTH IMPACT ASSESSMENT OF SHALE GAS EXTRACTION Common questions raised about HIA are: What is the value added of HIA? How does HIA add to what is covered in health risk assessment or an environmental impact statement (EIS)? Dr. Wernham explained that in an EIS or environmental permitting, for example, there are criteria hazardous air pollutants (HAPs) regulated by the EPA; an evaluation is conducted to determine what the specific project will add to the airshed with respect to HAPs (EPA, 2013). HIA provides additional information; it will capture the prevalence of relevant diseases, affected populations, and the populations’ relationship to emission sources. Other potential information could be modeling of the emissions to determine which communities may be affected and local concerns from the communities. Understanding local concerns of perceived contamination can be important for understanding changes in behavior that may have health implications. For example, concerns about perceived contamination of air and water in areas reliant on local subsistence farming and hunting may result in individuals’ reducing their consumption of wild foods. This change in behavior can have nutrition and health implications. Dr. Wernham emphasized that HIA is primarily a qualitative assessment, but some analyses can be quantitative. Assessments that look at air and water quality can often be similar to risk assessments, but HIA goes further by finding ways to address local concerns and data gaps. When assessing noise, for example, HIA offers mitigation measures such as sound walls, housing modifications, changes in truck routes, and hours of operations. Traffic is also given a more robust assessment in HIA than in an EIS or health risk assessment. HIA will include the baseline injury rates, identification of the most dangerous intersections or dangerous roads in the community at baseline, and locations of high-risk groups (e.g., school crossings). As part of the process, traffic flow is used to predict potential hotspots. Figure 2-1 shows an increase in traffic injuries in relation to the oil and gas boom in Sublette County, Wyoming. With good planning and management, there are opportunities to prevent these increases in injuries. Similarly, when assessing demographic change such as the influx of nonresident workers into an area, HIA can provide information on the strain in local services, changes in violence and crime, and changes in the spread of infectious diseases. The IFC has issued guidance documents for managing influx, and the literature supports the need to pay close attention to the management of influx. One of the important contributing factors for the spread of multidrug-resistant tuberculosis in Africa is mining. Partnerships between the mining corporation’s occupational health program and the public health infrastructure in the community, for example, could be leveraged to ensure that people have access to directly observed therapy for the treatment of tuberculosis both onsite and in the community (Stuckler et al., 2011).

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OPENING SESSION 13 FIGURE 2-1 Increase in vehicle-related accidents in relation to oil and gas boom in Sublette County, Wyoming. SOURCE: Ecosystem Research Group, 2007. Reprinted with permission from the Ecosystem Research Group. According to Dr. Wernham, although this type of outcome may not occur in the United States, it raises the point that sometimes the most important health risks are not the ones that are obvious. In North America, there has been one reported example of a transmitted illness in relation to a resource boom. In Fort McMurray, Canada, a significant spike in local syphilis rates was said to be associated with the oil sands boom (Richardson, 2012). The health department did not plan for this health concern. Working with the companies, prevention strategies could have been developed to forestall and manage the problem instead of having to react after the problem had occurred. Further, there are economic revenues and costs that need to be considered when managing risks and maximizing the potential benefits. Cities and states may find opportunities to improve health by leveraging revenues coming into the community to plan for the costs related to increased education, water and sanitation, public safety, clinics and hospitals, and emergency medical services. The North Slope of Alaska community provides a good example of planning for revenue capture to fund community services in a rural area. The community worked with the oil and gas industry to determine the costs associated with basic water and sanitation needs, staffing schools, police, and emergency medical services (State of Alaska HIA Program, 2011). Planning for revenue capture allowed the community to develop from a village with no running water and primitive waste removal to a community with a water and sanitation system that could run year round, a system that costs millions of dollars. Through efficient early planning

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14 HEALTH IMPACT ASSESSMENT OF SHALE GAS EXTRACTION with industry, the community was able to plan for the impact of growth associated with natural resource development in the area. In closing, Dr. Wernham identified a number of issues and challenges associated with HIA of unconventional shale gas operations. He noted that there is a need to engage polarized stakeholders by supporting productive conversation and building common ground among industry; community groups; local, state, and federal governments; and others. He also noted that there are important data gaps, especially in small towns where the amount and type of emissions and discharges and baseline disease prevalence data are often unavailable. HIA is a way to identify these gaps and build a plan to collect the information. Finally, there are often no clear decision points or a comprehensive planning process where HIA would be more helpful. The permitting process is being done one well at a time and not as part of a comprehensive planning process. Dr. Wernham noted that there is not a federal EIS and that many states have not undertaken a comprehensive review prior to permitting. DISCUSSION Dr. Portier began the discussion by asking Dr. Wernham for a rough estimate of the resources needed to conduct HIA for shale gas extraction, for example, the time, effort, and human and financial resources required. Dr. Wernham stated that it depended on the scale of the HIA. When designing the HIA, consideration is given to the available resources and time frame available. If the HIA is required in 3 months, an effort is made to give some useful input within this time frame. If a comprehensive HIA is needed, for example, to assist a state developing a new regulatory framework, such as the State of New York, a year is a good estimate. With respect to staff, one person to manage the HIA and a few consultants may be reasonable. HIAs have been conducted for under $100,000, but up to $300,000 may be reasonable to bring together all the right stakeholders. Carlos Santos-Burgoa from the Pan American Health Organization asked Dr. Wernham to comment on HIA and equity issues and the time horizon used in HIA. Dr. Wernham responded that although he did not emphasize equity in his remarks, HIA certainly does emphasize health disparities or health equity issues. It is emphasized in practice as part of the identification of vulnerable populations. This would include identifying individuals who are vulnerable because of a preexisting health issue, disparity such as low income or ethnic minority status, or earlier exposure to other sources of pollutants. With respect to the time horizon, Dr. Wernham stated that it will depend on the extent that the data allow. Often the time horizon attempts to consider the time span needed for a chronic disease to develop, for example, noncommunicable diseases such as obesity and diabetes or other risks that could take place over 20 to 30

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OPENING SESSION 15 years. The need to consider multigenerational risks and HIAs has been raised. Dr. Wernham also addressed a number of questions from the audience; one question focused on the possibility of a federally sponsored EIS on hydraulic fracturing. Dr. Wernham responded that what is most important is the value added by the HIA and the deliberative process opportunity it provides. Through the process, critical stakeholders are convened to discuss a proposed action or possible scenarios for action prior to decision making. Another commenter asked Dr. Wernham whether there were true data gaps or if what appeared to be data gaps were in fact a lack of data sharing among the health and environmental communities and industry. Dr. Wernham stated that collaboration among these sectors is valuable; such collaboration is facilitated by having stakeholders involved in the HIA process and dialogue. Through the process, data are shared, data gaps are identified, and data collection activities can be organized. He also noted that in some cases data gaps do exist. REFERENCES CDC (Centers for Disease Control and Prevention). 2012. National Biomonitoring Program: About the program. http://www.cdc.gov/bio monitoring/about.html (accessed May 30, 2013). Ecosystem Research Group. 2007. Sublette County socioeconomic impact study: Draft report. http://www.sublettewyo.com/DocumentCenter/Home/ View/363 (accessed May 30, 2013). EPA (U.S. Environmental Protection Agency). 2013. Air permits: Definitions of selected permitting terms. http://www.epa.gov/region9/air/permit/defn.html (accessed May 30, 2013). Executive Order 13605. 2012. Supporting safe and responsible development of unconventional domestic natural gas resources. http://www.gpo.gov/fdsys/ pkg/FR-2012-04-17/pdf/2012-9473.pdf (accessed May 30, 2013). Health Impact Project. 2011. Health Impact Project: Advancing smarter policies for healthier communities. http://www.healthimpactproject.org (accessed May 30, 2013). ICMM (International Council on Mining and Metals). 2010. Good practice guidance on health impact assessment. http://www.icmm.com/library/hia (accessed May 30, 2013). IOM (Institute of Medicine). 2006. Rebuilding the unity of health and the environment in rural America. Washington, DC: The National Academies Press.

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16 HEALTH IMPACT ASSESSMENT OF SHALE GAS EXTRACTION NRC (National Research Council). 2011. Improving health in the United States: The role of health impact assessment. Washington, DC: The National Academies Press. Richardson, A. 2012. Oilsands workers at high risk for STI: Report. http://www.fortmcmurraytoday.com/2012/01/30/oilsands-workers-high-risk- for-stis-report (accessed May 30, 2013). State of Alaska HIA Program, Department of Health and Social Services. 2011. Health impact assessment: Point Thomson Project. http://www.epi.alaska. gov/hia/PointThomsonCompletedHIA.pdf (accessed May 30, 2013). Stuckler, D., S. Basu, M. McKee, and M. Lurie. 2011. Mining and risk of tuberculosis in sub-Saharan Africa. American Journal of Public Health 101(3):524–530. White House. 2012. Investing in America: Building an economy that lasts. http://www.whitehouse.gov/sites/default/files/investing_in_america_report_ final.pdf (accessed May 30, 2013).