Eli Adashi, MD: Hello. I am Eli Adashi, professor of medical science at Brown University and host of Medscape One on One. Joining me today is Dr. John Howard, an occupational physician, a lawyer, and the Director of NIOSH -- the National Institute for Occupational Safety and Health. Our topic: Understanding the Potential Impact of the Gulf Oil Spill on Our Nation's Health.
Welcome Dr. Howard, it's wonderful to have you with us.
Dr. Howard: Thank you very much for having me here on your program.
Dr. Adashi: Can you briefly describe to our audience the role of NIOSH in this and in related disasters?
Dr. Howard: Well, the National Institute for Occupational Safety and Health, or NIOSH as most folks call us, is basically an institute which was established by the Occupational Safety and Health Act of 1970.
Dr. Adashi: I see.
Dr. Howard: Similarly in that same act, the Occupational Safety and Health Administration, or OSHA, was established.
Our role within the act is to do the research and to make recommendations to OSHA and to employers and workers about how to protect themselves. Our recommendations are used by OSHA to create regulations or standards. Our research then has that outcome [to assist OSHA], which is the one that we think is most important, although our research is used by all sorts of folks. We give grants to academic centers. We have 17 education and research centers in academic medical centers throughout the United States, so we fund researchers in various universities throughout the United States. We have 7 agricultural health and safety centers that are often located in academic medical centers or in medical schools throughout the United States that do work exclusively in agricultural safety and health. We offer, as the National Institutes of Health [NIH] does; extramural grants. So we support -- like NIH supports -- the research that is necessary to move occupational safety and health knowledge into the future.
Now, the other part of the question is, what is our role in terms of these large events, which often people call disasters or spills depending on what they are. Our role there -- part of our institute has a wonderful group of folks that go out as front-line evaluators during a disaster to assess what issues are going to impact the workers, the response workers who are responding to that disaster. Now, there are professional responders, such as firefighters, police, and other emergency responders, but also if the event is big enough, as we saw in the Gulf of Mexico, tens of thousands of others who aren't professional responders come into the area to do clean up, reconstruction, recovery, you name it. So our folks go out and look at the hazards that those responders are facing in order for us to provide guidance to employers. OSHA uses our guidance, too, to protect responders during their response activities.
Dr. Adashi: Would it be fair to say that you are, in a sense, the core scientific organization of this nation when it comes to occupational and other forms of health safety?
Dr. Howard: I think that's a fair statement because there's only one Occupational Safety and Health Act on the federal level, and we are the designated institute to generate new knowledge in the field of occupational safety and health, but I always try to point out that it's not just [those of] us who work in the Institute. Our partners in medical centers and universities throughout the United States are our true partners in generating that knowledge.
Dr. Adashi: Of course, but in part through your support?
Dr. Howard: Yes.
Dr. Adashi: Well, turning now to the recent event, many of our viewers probably would be interested to know why is crude or weathered oil, or for that matter some of the ingredients, hazardous to one's health?
Dr. Howard: Well, you know this question is very complex and one point I want to make to anybody listening, whether they be a physician, nurse, or any kind of healthcare provider, is that there are about 3 million gallons of oil per year that leak into waterways in the United States.
Dr. Adashi: One way or the other.
Dr. Howard: One way or the other. A tanker spill, a leak out of a tanker that is going into harbor, or this massive type of spill that we've encountered in the Gulf of Mexico, which is really an outlier.
Dr. Adashi: And how many magnitudes or orders magnitudes difference are we talking about between the background level and the recent acute spill?
Dr. Howard: The recent event in the Gulf of Mexico really is a tremendous outlier. The only thing close enough in the United States that would compare is when the Exxon Valdez tanker ran aground. Otherwise, a lot of the leaks or spills of crude oil or refined products [that occur are] because we have tankers that carry refined petroleum products. They can also leak, but the point is that if you're a physician anywhere in the United States -- you don't have to be a physician in the Gulf -- to say, "Oh well that wouldn't concern me." No, you may see individuals who are professional responders or voluntary responders, or had been recruited for a particular event --
Dr. Adashi: In the context of smaller --
Dr. Howard: Exactly -- you may see them as patients, so don't just focus on the Gulf of Mexico because it's certainly the biggest event, but you can see patients who have been exposed as responders or members of the community.
Dr. Adashi: Why or how, to just go back to the original question --
Dr. Howard: Right, which I jumped over so --
Dr. Adashi: Right. I mean what is it about oil that is potentially dangerous?
Dr. Howard: Well, you know crude oil, the best way that I understand it -- and that is my test of whether I can explain it well -- it's a mixture of a lot of different chemicals. Some of those chemicals are volatile, meaning they have very low boiling points, and the minute they hit the atmosphere they become gaseous, okay? Now, some of those things like benzene, toluene, naphthalene; those are quite toxic. Benzene, for instance, is a carcinogen. It produces -- with enough exposure over a long enough period of time -- leukemia. Those volatiles then are a serious issue in crude oil exposure, but because they vaporize and often disappear and are diluted in the atmosphere -- unless you are right over a crude oil spill -- what you encounter and what we encountered in the Gulf of Mexico is crude that's been weathered by evaporation of the volatiles mixing around in the wave action that occurs. Those volatiles are gone, and then what's left is often this tarry, asphalt looking thing -- the tar patty that we saw on TV. We can see sometimes slicks on the surface of water or we see accumulated oil or "moussey." It is called mousse -- like hair mousse -- or it's a thicker kind of gelatinous material, and in those cases, usually the volatiles are gone.
When you look at those weathered crude products you are talking about long chain carbon chemicals. They are acute skin irritants, and they also can be associated -- the aromatic cyclical versions of those had been associated -- also with cancer.
In terms of the acute exposure, we look for skin irritation because you can develop rashes from contact with crude oil. If you're exposed to the volatiles, they can cause nausea, headache. It's like an acute intoxication. Toluene, xylene, for instance, are types of short carbon chains, volatiles that can be found in crude, and they produce a type of intoxication. The acute effects that are primarily neurological, gastrointestinal, some respiratory irritation, throat irritation, respiratory cough, and then the longer [carbon chains] tend to be more cancer producing. That's what we're most concerned about with those who have had long-term exposure -- oil workers who work in the industry, for instance, as opposed to a responder who has a short-term exposure.
Dr. Adashi: Thus far, to the extent that you can summarize, what kind of acute symptoms have been observed and what numbers of individuals potentially have been affected?
Dr. Howard: When we looked at this Gulf of Mexico spill, one of the things that we wanted to do was to collect as much information as we could about acute health effects that were being seen in communities that surround the Gulf area. So at the CDC [Centers for Disease Control and Prevention] we started collecting information from the 5 Gulf states and their state health departments that we're monitoring. For instance, are we seeing more asthma? Are physicians reporting more asthma, because we know that respiratory effects -- nose irritation, throat irritation, tightness in the chest -- could be signs of asthma. We then looked at gastrointestinal complaints -- nausea, vomiting, headaches, intoxication. So we began surveying the state health departments to get a handle on what they were seeing in the community, or what individual physicians may be reporting, but we also then looked at the safety and health logs that the employers who were contractors for these responders were reporting.
What we saw during the Gulf response is a lot of heat-related stress issues. It's very hot in the Gulf, even in April or May when this Gulf response started. We were in the 90s, and the heat index is exceeding 100. We saw a lot folks dehydrated. We saw folks who hadn't been screened before they became a responder, and this is a point that I would make to practicing physicians, too. If they have any patient that they see who says, "I want to be a responder, I want to go down there and help," or "I am a responder and I am helping," well, if they have uncontrolled hypertension and they're going out in a heat stress situation, that's not good. I think it's important for us as part of our work to tell physicians that preplacement evaluation is an extremely important step in ensuring the health of a responder, because we don't want to send people out who have unstable medical conditions.
So, heat stress was number one. The other things that we saw were lacerations because they are handling a lot of equipment that could cut, rashes, and then dehydration. You are out there, people are getting headachy, and you're not sure what's going on. A lot of reports of headache, dehydration, and most of the time that people had to go get first aid or advanced medical care was [because of] heat or dehydration.
Dr. Adashi: Now you mentioned very briefly potential chronic effects like myeloproliferative disorders in response to benzene, I believe. What is the state of the knowledge -- to the extent that there is a repository of information -- on the long-term consequences of this and related disasters? Granted, this is way too early for this particular situation, but what do we know and how can we extrapolate with some certainty to the future?
Dr. Howard: This is really an excellent question, and I wish I had all of the information that we require to be able to answer your question fully and tell the audience more than what I know right now.
If you look at the world's literature on oil spills -- whether it be a tanker spill, tanker running aground, or in this case, a well having a gusher for months on end -- there is precious little in the way of data on chronic effects. Most of the world's literature focuses on acute effects. What are the acute effects on a responder population or the nearby community? They tend to be the types of things that we just talked about. There are a few studies that have gone as far as 6 months later, and they've said that some of those folks still have some respiratory complaints. Others don't, but we don't have good studies of longer-term health effects in the [population of] responders to a spill.
There are studies of petroleum workers who spend their life in the petroleum industry. That's a different thing -- but in the response area, no. People always ask me, "Well, didn't they study the Exxon Valdez responders?", and the answer is "No." And then the next question is, "Why not?"
Well, these are very interesting situations, and there are more than just health issues at stake. As we're seeing now and will continue to see with the Gulf, there will be an attempt to find out what happened, who's to blame -- the attachments of blame -- so all of our friends in the legal world come into play, and those kinds of things sometimes [make it] difficult for a health study to get accomplished during that time. I am happy to report that this time in the Gulf of Mexico the National Institutes for Health is working on a longer-term health study, meaning following these individuals over time, 5 to 20 years, to see the kind of longer-term health effects on this responder population. And I'm happy to report that other parts of the federal government are looking at the community, because one of the issues has been the significant mental health stress that the community has had. As you know, this is an area that's had multiple traumas from the mental health standpoint.
Dr. Adashi: From what we have been led to believe or have read, the NIH dedicated 10 million dollars for the research, and a question, I believe, was what was contributed by BP [British Petroleum] to this end. I seem to recall that BP is going to dedicate something on the order of 500 million dollars toward this and similar ends. Can you tell us a little bit about how we as a nation plan to use these resources, and how your agency plans to go about documenting long-term consequences, which you pointed out so well have not been studied before.
Dr. Howard: Well, I think that is an important issue, and I think we now have the right set of policies in place. In other words, people are actively saying that we need to follow workers and community over time. We cannot leave this situation. We need to fill in these gaps in the medical literature about longer-term health effects. We've talked about the NIH study, and that may go 5 to 20 years, funded both by NIHand jointly by BP, and also from the recovery and restoration funds, which are going to be made available by Navy Secretary Mabus, who President Obama has tasked with looking at what kind of funds we need for recovery and restoration of the Gulf. In addition, as you pointed out, BP has established a Gulf research institute, which has an advisory committee of prominent physicians and scholars, and [BP] has made the commitment of 500 million dollars for researchers who want to look at aspects of the longer-term health effects on responders or on the community. So those types of studies I think are planned now. When we look back at 1989 at the Exxon Valdez event, none of that was going on, so I think right now we are dedicated to looking at this issue, not only for the responders who participated, but, as you know in medical science, often the greatest benefits of some of these longer-term studies accrue to responders of the future.
Dr. Adashi: It sounds indeed like a substantial investment in the future. If I may turn now to dispersants -- in a similar fashion to what we were trying to address with the oil -- what is known about the health hazards associated with dispersants. Why are they, if they are, hazardous to your health?
Dr. Howard: Well, first of all, I think we have to understand most of the literature on toxicity of dispersants are [studies of] the biological organisms that happen to inhabit the sea, whether they be birds or mammals or fish. I think we have more information there than we do on the human side.
When you look at why dispersants are being used, there is a lot of literature on this. The National Academy of Sciences did a report in 1989 and another report in 2005. The major reasons for using dispersants are to decrease the impact on the shoreline if oil is broken up, to decrease the impact on birds and mammals, and also to increase the biodegradation of the oil so that it is able to be eaten by -- in the case of the Gulf of Mexico -- bacteria that actually feed on hydrocarbons. So that's the purpose of it. For us at NIOSH, we cautioned about aerial spraying of dispersants, because there are workers underneath those airplanes, and we said, "Is there some way that we can avoid that?" So BP switched to applying the dispersant in the column of crude oil that was coming up from the Macondo well, [which was a] subsurface application.
Right now when you look at dispersants; they are essentially another or a mixture of more hydrocarbons, so we can't get away from a hydrocarbon society. Some ingredients [in manufactured dispersants] are proprietary, so it's hard for everybody to know what's in them. Now, the Environment Protection Agency and the CDC have gotten knowledge about what's in them. We've looked at toxicity, and some dispersants have a higher concentration of worrisome chemicals. There are hemolytic agents in some of those surfactants, because essentially they're mixtures of surfactants. Sometimes people will refer to them as [being] like dish detergents -- they break up oily things, but some have a high concentration. One particular [chemical], butoxyethenol, can be a hemolytic agent. The issue is dispersants being used in this kind of volume, you know, we are talking about almost a million pounds now. This is the largest use of dispersants. This is going to be on the health agenda and the public policy agenda for a long time. [First], what are the long-term effects of people exposed to dispersants, and, [second], is this the way we are going to handle oil spills from now on? Are we going to apply dispersants in this kind of volume? So the dispersant issue may not be totally settled at the present time, but clearly, I think it will remain on our health agenda and on the public policy agenda when it comes to taking care of an oil spill.
Dr. Adashi: It might be fair to say that our knowledge base for dispersants is still nascent and that many of the funds that are being invested will presumably address dispersants as well as other elements.
Dr. Howard: Yes. In fact at NIOSH we're doing some animal toxicity studies looking at dispersants, which we've obtained from the Nalco Corporation, who was the exclusive contractor to BP. They were kind enough to give us a sample of the dispersants that they use. We also got unadulterated crude from the Macondo well that is not contaminated with a dispersant, and we're now doing acute animal toxicity studies looking at dispersants, looking at crude oil, looking at a combination of both, because there could be a synergistic effect of the dispersant and the crude. So, we're looking at that from animal toxicity studies. We hope to continue that work, and as you pointed out, then looking at what the effects are in exposed populations. I think we have a lot to learn from dispersants, and I think it's important to learn that, because if we're going to use them in this volume for the next spill, then it's important that we have this information available.
Dr. Adashi: It sounds like you are well underway with many of these efforts. Our audience probably would be also very interested in finding out what types of surveillance is currently being employed on multiple fronts, especially those related to human health, and for how long do we plan to maintain this? Is this a commitment we have made to ourselves for the next decade say, or beyond? What should we be thinking about?
Dr. Howard: Well, I think the answer to that is 2 part. One, is that we utilize the existing surveillance systems that are in place, that every state has, and the 5 Gulf states, which have quite a few different surveillance systems. We also then use new ones. For instance, BP contracted with poison control centers. We then collected the calls that they were getting to see whether or not we saw any blips in certain things. There were a lot of people calling, saying that [they were] having a lot of respiratory problems. We then looked at that data in relationship to the third arm of that data, which was what people were saying within medical institutions, either urgent care clinics or other types of institutions. What are they saying? Are they reporting anything new and different? So that was active surveillance that we were doing.
And now we're looking at the longer term. One of the things that was just funded is a behavior health survey that [the CDC does] routinely. We're now adding some questions to that related to the spill. This is a longitudinal survey that goes on regularly, so we can leave those [added] questions in for the 5 Gulf states for the next 10 years in order to be able to trace what some of those issues may be As you know , behavioral health issues tend sometimes to show up a little later, then tend to be extinguished much later, and as we know with multiple hurricanes several years ago -- Katrina being the biggest one -- and the spill, the Gulf community, Mississippi and Alabama, has undergone multiple traumas.
Dr. Adashi: Before closing, another question that I suspect most of our audience would want to know, especially the healthcare providers, has to do with the safety of the food that derives from the Gulf, especially seafood. What can you share with us on the safety of that seafood or the lack thereof?
Dr. Howard: Well, first of all I would say that the primary responsibility for assessing the safety of seafood comes from the National Oceanic and Atmospheric Administration, NOAA. They're the ones who declared certain areas of the Gulf as no fishing. They're the ones who made the decision to open up certain areas [along with] the Food and Drug Administration, which is part of the Department of Health and Human Services. Those 2 agencies have the primary responsibility.
The FDA obviously tests food and, as we've all seen on TV, they use 2 different types of testing. One is testing by smelling the seafood products. They have trained individuals who can tell seafood apparently by olfactory sensation. The other is by actual chemical testing. There were areas that were closed to fishing, and they've reopened. Now, as we saw President Obama in his visits and the first family going down and eating seafood, and most recently we saw the Commissioner of the FDA, Margaret Hamburg, and the White House executive chef go to an event in New Orleans, in which they learned how to cook Gulf seafood in many different ways. So certainly the seafood that Americans have in their stores and on their dinner plate is safe, and in fact, I personally want to volunteer to eat any Gulf seafood that I can get my hands on.
Dr. Adashi: That's very reassuring. In closing, it is hurricane season. There's no way of ruling out another one. Hopefully, that's not the case, but if that were to transpire, in what way would it affect the situation in the Gulf, especially again the issue of human health?
Dr. Howard: Well, I think right now, you know today when we're recording this show, we expect within 48 hours for Admiral Allen to announce the well is dead. The bottom kill process is going on now, so we don't expect any new oil from that well.
The issue, though, about the oil that went into the Gulf is still -- as you've read in the newspaper and we've all seen -- that it may be alive, because we now have a very prominent university that has looked at the bottom of the Gulf and has seen layers of oil. So, with regard to your question -- and I'm no expert in this area but I've listened to the NOAA experts, I've listened to the Weather Channel -- is whether or not a large hurricane coming into the Gulf with that kind of power and wave action might be able to bring up some of the sediment from the bottom of the Gulf and bring more of that crude onto the shoreline into the Louisiana marshes. I think that's an open question. We certainly hope that doesn't happen, but I know some of the commentators on the weather side are asking those kinds of questions.
Dr. Adashi: Well I want to thank you very much for a very informative discussion and I know that the healthcare providers who tune into these conversations are very much reassured by having a healthcare professional at the helm.
Dr. Howard: Thank you very much.
Dr. Adashi: On this note, sincere thanks to Dr. John Howard and to you our viewers for joining Medscape One on One.