Testimony on behalf of International Trauma Anesthesia and Critical Care Society
on the EPA's Particulate Matter and Ozone Rulemaking
before the Committee on Environment and Public Works
Subcommittee on Clean Air, Wetlands, Private Property and Nuclear Safety
April 29, 1997
by Christopher M. Grande, MD, MPH

Good morning. My name is Dr. Christopher Grande. I am a practicing physician from Baltimore, Maryland. I am a board-certified anesthesiologist and intensive care specialist in trauma injury. I have authored and edited numerous medical books and have had about 30 articles published in professional journals.

I am also Executive Director of the International Trauma Anesthesiology and Critical Care Society or "ITACCS" for short. ITACCS is a 10-year old professional association of more than 1,000 trauma specialists and emergency room physicians, nurses, and related professionals.

I also hold a masters degree in public health from the Johns Hopkins University School of Public Health.

I'd like to thank the committee and Chairman Inhofe for inviting me to provide ITACCS' views on the proposed ozone and particulate matter standards.

Before I specifically address the standards, though, I'd first like to give the committee some important background information.

Everyday I'm in the hospital emergency room , I see patients and problems vying for critical resources. From acute asthma patients to traumatic injuries. These are all competing public health priorities. All competing for limited available public health resources.

The focus of ITACCS is traumatic injury, often accidental in nature such as that caused by motor vehicle, on-the-job, or household accidents.

Injury is the leading caused of death for those under the age of 45. And it is the fourth leading cause of death overall in the United States. About 150,000 deaths every year.

Trauma cuts across all of society. The injured person is not someone else. The injured patient is you, your child, your spouse, your parent.

The average age of injury victims is 20. Death from injury is the leading cause of years-of-life-lost in the U.S. -- more than twice the number of years of life lost as the next leading cause, cancer, and three times that of heart disease.

According to 1990 statistics from the Centers for Disease Control and Prevention, traumatic injury was responsible for approximately 3.7 million years of potential life lost. In contrast, cancer was responsible for 1.8 million years of potential life lost. Heart disease was responsible for 1.3 million years of potential life lost.

What does this tell us? The National Academy of Sciences concluded in 1985 that trauma was the "number one" public health problem in the U.S. This situation remains unchanged today. How is this relevant to the debate over the ozone and particulate matter standards?

It can be simply put in three words, "public health priorities."

The fact is that society has limited resources that it can spend on public health. As such, responsible public policy dictates that such resources be spent so as to achieve the "biggest bang for the buck."

ITACCS is not convinced, and neither should the public be, that the proposed ozone and particulate matter standards are a smart way to spend our limited resources.

But I want to make it clear that we are not singling out only the proposed ozone and particulate matter air quality standards. The proposed standards are merely the latest example in what we see as a disturbing trend of the last two decades where scarce public health resources are diverted from more clearly demonstrated beneficial uses.

The unintended consequence of this diversion might be a decrease in the overall effectiveness and efficiency of public health care delivery.

As the makers of our laws and the ultimate allocators of our public health resources, Congress should take the lead in rationally allocating our limited resources.

But how would Congress know what is a priority and what is not?

The process behind the proposed ozone and particulate matter air quality standards has not been helpful.

First, the proposed rules do not provide a ranking or comparison between the estimated health effects attributed to ozone and PM and those of other public health needs.

One of the health endpoints associated with the proposed rules is asthma. No doubt asthma is a serious issue and public health resources should be directed at asthma. But a recent study published in the February 1997 American Journal of Respiratory and Critical Care Medicine a journal of the American Lung Association helps place air pollution-induced asthma in perspective.

In this study, which employs a study design that has been characterized as the most reliable on the potential health effects of ambient ozone -- i.e., the study model of children attending asthma camp -- air pollution was associated with a 40 percent increase in asthma exacerbation in children. It sounds bad, but what does this really mean? Assuming for sake of argument that the authors' conclusion is reasonable, this increase in asthma exacerbation equates to one extra use of an inhaler among one in seven severe asthmatics on the worst pollution day. However, close scrutiny of this study reveals that many confounding risk factors for asthma exacerbation were not considered by the study authors. These risk factors include changes in temperature, atmospheric pressure, anxiety, physical exertion, allergens, dust, and fumes.

Moreover, this study is inconsistent with the general observation that while asthma has increased over the last 15 or so years, air pollution has decreased. There appears to be no generally accepted explanation for this phenomenon.

Therefore, this study does not satisfactorily link ambient ozone with asthma exacerbation.

Before we commit our scarce resources wouldn't it be useful to know exactly where this very uncertain health effect ranks among other real public health priorities?

If asthma qualifies as a public health concern, appropriate levels of funding should be targeted at programs that have been proven to be effective, but not fully implemented. Such programs include appropriate research, public and patient education, increased compliance with asthma medication schedules, intelligent avoidance of triggering factors, etc.

Just last week, President Clinton issued an Executive order requiring federal agencies to pay more attention to environmental health and safety risks that disproportionately affect children. While it is easy to agree with the intent of the Executive order, it is not clear that air pollution disproportionately affects children. What is clear is that traumatic injury disproportionately affects children, and it has been clearly identified as the leading cause of death in children.

Second, the proposed rules do not provide an accurate estimate of what their associated opportunity costs are.

For example, if a community is forced to spend its resources implementing the ozone and particulate matter air quality standards, what other public health needs will the community sacrifice? A new trauma center? Training for its paramedics? A new ambulance?

Filling these other public health needs can produce results that cut across many public health problems. For example, ambulances and trauma centers benefit everyone from asthmatics to heart attack and trauma victims.

It would seem to be good public policy to develop and rely on an analysis of opportunity costs.

Third, the true uncertainties associated with the proposed ozone and particulate matter air quality standards have not been fully presented. For example, it has been estimated and widely reported that chronic exposure to fine particulate matter causes 20,000 deaths per year. In fact this estimate appears to be based on very uncertain epidemiology.

It was acknowledged recently by EPA and reported in major newspapers such as The Washington Post that the simple error of using an arithmetic "mean" instead of an arithmetic "median" reduced the estimated mortality from fine particulate matter by 5,000 deaths.

It could very well be that chronic exposure to fine particulate matter, in fact, causes no deaths. On this point, it is greatly troubling that the data underlying this estimate has yet to be made publicly available. Given that major confounding factors for mortality appear to be omitted from the analyses - factors like lack of exercise, poor diet, and prior health history - weak epidemiologic associations could easily vanish with more thorough analysis.

In stark contrast to what has been hypothesized about particulate matter and mortality, we know that about 150,000 people die every year from injury. These are real deaths, not those calculated through debatable assumptions and statistics.

One year ago the television show Dateline NBC featured the story of Robert Meier. In April 1995, Mr. Meier was driving through rural Oklahoma heading home for Easter. Just before 4:00 that Saturday afternoon, Meier's van careened off the highway, slamming through a guardrail. His van rolled over five times before plummeting into a ravine. Within a few minutes rescue personnel were at the scene.

The ambulance took Mr. Meier to Shawnee Regional Hospital. But the doctor on duty determined that Mr. Meier had serious internal injuries and needed to be transferred to another hospital better equipped to treat them. But as Mr. Meier bled profusely from a ruptured aorta, no hospital in the area would accept him because critical resources were not available.

It was not until half past midnight, eight hours after his accident, that a surgeon was found to operate on Mr. Meier. This delay cost Mr. Meier his life.

Mr. Meier was fully covered by health insurance. He had done his part. But because of a lack of crucial resources, the system failed.

Stories like this one are common. But they should not be, nor do they have to be. Proven solutions are possible now, but must compete for attention and funding.

More than 25 studies indicate that between 20,000 and 25,000 Americans who die each year from injury could be saved if regional trauma systems were in place across the nation ensuring prompt access to a qualified trauma center. In 1973, Congress enacted the Emergency Medical Services System Act to help states improve their trauma systems. But lack of federal support made this an unfunded mandate that states could not afford to implement on their own. And as a result, significant deficiencies exist in trauma systems across the country like the one that resulted in Mr. Meier's death.

But how would Congress know this when currently there is no mechanism to identify, compare, and prioritize public health needs. The ozone and particulate matter proposals in their present formats are prime examples of this defect in how we do public health in America.

I understand that a bill was introduced in the last Congress which would have required the comparative ranking of health risks. This would be helpful for prioritizing our public health needs. I urge that Congress continue along this track.

Stimulated by this latest raid on our scarce public health resources,. ITACCS is establishing a new forum to facilitate public debate on the allocation of public health resources. The mission of the National Forum for Public Health Priorities will be to provide policymakers with information necessary to prioritize public health needs.

Those who wish to commit the public's limited resources should be required to justify such proposed commitments against all other competing needs. And, as a major allocator of public health resources, Congress must ensure that the public health is not short-changed by unproductive expenditures.

Thank you for your attention. I will be happy to answer any questions you may have.