Environmental Health Transcript
July 8, 2004

Participants:
Terry Allan, Health Commissioner
Cuyahoga County Board of Health
Dr. Cynthia Bearer, Director of Medical Education
Mary Ann Swetland Center of Environmental Health
Case School of Medicine
Rainbow Babies & Children’s Hospital
Dr. Mark Feingold, Pediatrician
Metro Health Medical Center
Joe Frolik, Associate Editor
The Plain Dealer
Stuart Greenberg, Executive Director
Environmental Health Watch
Dr. C. William Keck, Associate Dean
Community Health Sciences, Northeastern Ohio Universities College of Medicine

MR. FROLIK: Thank you for joining us today for the third discussion in the Tomorrow's Promise series. Today we're taking about environmental health issues, especially as they impact children in urban settings here in Northeast Ohio.

I want to start by just asking, go around the table and ask each of you, what is it about urban environments, particularly in older industrial cities like in Cleveland, Akron and Youngstown, that seems to take such a health toll on young children.

Let's start with Terry Allan.

MR. ALLAN: Well, I think, from my perspective, sort of being born and raised here in Cleveland, I think about Cleveland as primarily having been an industrial town. So you think about the fact that the industry was driving the jobs, people were coming here to work, but with the industry come pollutants, inevitably. It's sort of the price of the progress at the time. And so we see things like a lead deposit, certainly from auto emissions, from heavier congestion from autos in a community like that. You start to see housing stock that over time was placed very close together and, also, is old, and in some of the poorer areas, is not well maintained, the deferred maintenance causing problems. Things along those lines are some of the issues that relate to living in an urban area and some of the problems we face.

MR. FROLIK: Okay. Mr. Greenberg.

MR. GREENBERG: I would just pick up on Terry's point about substandard housing. We have lots of housing in Cleveland that's not in good shape. I love the term "deferred maintenance," means no maintenance. So we have lots of houses that are very old, as well, so we have heavy lead painted houses, lots of deterioration. We have pest infestations, heating systems that are not well maintained, lots of moisture problems, gives rise to mold, so there are a whole range of indoor allergens and irritants and toxicants that are associated with substandard housing.

MR. FROLIK: Okay. Cynthia Bearer.

DR. BEARER: I guess I view children's health as a developmental trajectory over time and you look at interactive influences on those trajectories whether it's going to be a high flying good health outcome or a lower flying health outcome. And if you look at the influences, there are multiple, there are environmental health, but environmental health interacts with families, communities, the built environment, access to healthcare. All of that is influenced by the environment, the inner city. And hopefully, we can tease some of those things out and see how we can improve the overall environment of the inner city to help the child.

MR. FROLIK: Okay. Bill Keck.

DR. KECK: I think Cynthia's statement is a good one for me because it encompasses the whole range of problems that are associated with older housing in center cities, often built because of transportation problems. At the time it was built near industries, so there's more pollution there. And then we have got not only the physical environment but the social environment that's an ultimate, the ultimate result of run-down housing, lower social economic status, and so all that puts children at risk and families at risk from a whole variety, both physical and social issues.

MR. FROLIK: Okay. Mark Feingold.

DR. FEINGOLD: As a pediatrician, I see children and I see their families. Many of the families we see and treat come from the inner city. Cleveland is an old city. The housing is old. It has, as already been mentioned, the problems of lead paint, and these things begin to become vicious cycles. If you are living in an older community, that is not all together so bad, but when you add to that the burdens of lead paint and of indoor pollutants so that children have more asthma and when you add to that another pollutant that's not exactly physical, I would call it the pollution of violence, it becomes a web, a tangled web of problems beating on each other and making each worse.

MR. FROLIK: Okay. Let's -- all of you mentioned lead at some point. Mark, maybe start with us from a pediatrician standpoint, why is lead such a problem and why is it such a concern particularly for families that have children?

DR. FEINGOLD: Well, lead has been around for thousands of years. People have used lead in all kinds of applications. One of the virtues of lead is it's terribly stable. It just doesn't change. It doesn't go away. Once it's in the environment, once it's been brought up from within the earth to be put into substances like paint, for example, it stays there. It can't entirely be removed. It can be controlled. It's been known for many years that lead is a toxic chemical. It's toxic for adults as well as for children. My neighbor across the street some years ago had retired and spent a wonderful summer doing an excellent job of repainting his house. In the process, he used a torch to burn off the old paint. And he said to me one day, you know, I don't understand it but my foot is not working right. He had lead poisoning with a peripheral nerve injury from the lead.

In the young children, the problems aren't in peripheral nerves. They are in the central nerves, the brain. And it's been shown over and over again that a little lead can go a long way towards knocking off IQ points. And now we see the association with problems of behavior like attention deficit hyperactive disorder, ADHD, and with other behavior disorders so that you have a child who's growing up in an old house, who is exposed to lead from the disintegrating paint products, whose IQ drops a little bit, not terribly much, usually, but just a little bit, who has some behavior problems, can't pay attention, can't sit still, is a little ornery and oppositional when asked to do something, tends to say no instead of yes. This is the effect that we see in children.

And the really frightening part of it is that even though the U.S. has done a wonderful job of lowering the lead levels enormously over the last 30 years, since lead was removed from gasoline, we now are facing the fact that even very low levels of lead are injurious and what do you do about that. We used to say children were poisoned when they had a level of over 25. Now it's 10, and, really, it probably ought to be 2 or 3 or 4. So you have got a practical problem of eliminating the lead to an extent we have never thought possible.

MR. GREENBERG: I think lead also provides an example of the issue that was brought out about this cumulation of disadvantage, sort of the compounding of bad things that are going on. For example, a child who has poor nutrition is going to absorb more lead than a child who is exposed to the same amount of lead, ingests the same amount of lead but has better nutrition, so you have the compounding of these disadvantages. I think the other thing about lead, the notion that it's a couple of IQ points, so people say, what are you getting excited about, a few IQ points. But when you look at the population level, you know, there's a normal distribution of IQ.

If you have a high prevalence, lots of kids in the neighborhood that are losing a couple of IQ points, then that distribution shifts so that you have half. You know, at the level of prevalence that we have in this area, you have half the number of kids that perform at the superior level and then double the number of kids at the lower end, so it becomes a whole community problem rather than simply a burden on that family and that child.

MR. ALLAN: I think to pick up on what Stew is saying, one of the main things that I think is surprising to people outside of public health and in related fields is the -- is the sense of a lead problem in Greater Cleveland. I don't think people really understand it. Matt Carol, he's the Director of the Health Department at the City of Cleveland, spoke at a conference and showed lead levels that were dropping in Greater Cleveland. We still see 3,000 kids poisoned every year here in Cleveland. It's a huge environmental problem.

And Matt showed the slide of the dropping lead levels against the slide showing Cleveland's dropping -- Cleveland Indian's winning percentage dropping. Strangely enough, they were correlated and Matt's main point, this is another sad point, but we hope for the better there, but Matt's main point in all this was that people would be more likely to quote you the winning percentage of the Indians than they would on the problem of lead in Greater Cleveland, so we think an awareness piece is important. And I think discussions like this help people understand that, you know, we have one of the 10 largest lead problems in the whole country and we have to do something about it.

MR. FROLIK: How do we track that? How do we know who has lead poisoning or an elevated lead level? How do we come up with statistics?

MS. BEARER: To build on what Terry was saying, one of the problems with having a lower level of lead associated with an effect on IQ is that we, as pediatricians, cannot see the effects of lead on our patients, it has a subclinical effect, this dumbing down of the population. So in order to find which kids have been exposed, we actually need to draw a blood lead level and measure the lead in their bodies to know that they have been exposed.

Now, the problem with that approach is that lead, once it gets into your body, already causes the damage. So we're just diagnosing children who have already had exposure to lead, their brains have already been exposed to lead and that has already had an effect. What we really need to start looking at is the environment and finding the lead before it gets into our children's bodies.

DR. KECK: There is, I think, more and more happening that will push us in that direction. No one is comfortable using children as canaries, if you will, in the mind, which is essentially what we do. Those communities that are organized and can approach lead poisoning in a fairly complete fashion will, of course, use the child as the marker and then move quickly to assess the environment the child is in, determine the source of the lead which often is in these neighborhoods, old paint in a house or dirt around, around outside the house or near a busy intersection. But once you do that, then you can move in and you can remove lead from that environment. You can haul it off, you can help the child, but it would be much better, as Cynthia said, to have a more organized approach to really moving through those facility structures, environments that we know are relatively high risk for lead and to do the testing whether or not there happens to be a child living there at the moment that might be a particular risk.

DR. FEINGOLD: One thing that was pointed out last year in a citywide lead conference which attracted national attention is that there are, in every community, certain houses, and Terry, you know more about this than I do, I'm sure, but there are certain residential houses that have given birth, if I can use that expression, to generations, one after another. Different families have moved in and lived there and their children have left with lead poisoning. These are highly contaminated houses. They look like the house next door, but there's something different about those toxic houses. And some communities have chosen to identify those high risk dwellings and correct the problems there. Otherwise, the children come, the children go and the problem just is reborn with each change of occupancy.

MR. FROLIK: On that front, is there a reporting function. I mean, if you are a physician and you examine someone and they find, does that information get to, say, to the housing department or to the building inspectors?

MR. GREENBERG: That is one thing about lead is we have very good statistics. Ohio has a reporting -- that any lab that does a lead test has to report the results to the state health department, then it gets reported to the local health department. So we have very good statistics down to the address level so that we can locate those houses that have poisoned multiple kids over several years.

Just to put some numbers on it, the City of Cleveland has overall, the average incidence of new cases of lead poisoning is about one in six kids under the age of six. This is an enormous problems. And that's a tremendous achievement from what it had been. But we still have some neighborhoods where it's one in five, one in four, one in three kids that have elevated blood lead level by the current CDC definition, which everybody agrees is too high.

MR. ALLAN: I think the data helps a lot to sort of target activities. There are dollars in Greater Cleveland and surrounding communities -- I know Dr. Keck can speak to Akron dollars -- for dealing with lead hazards in homes, mostly of kids that have already been poisoned, so it's sort of after the fact which is a problem. But to get back to Dr. Feingold's comment about houses at which people have sort of coined as, phrased, hot houses, certainly if a home has lead problems where it's been poisoning many kids, it goes back to no maintenance, as Stew related. So those homes often are folks that are tied up in the courts because there's no maintenance for plumbing problems, electrical problems. There may be renters. There may be a quick turnover so that we have to find a way in enforcement.

And we are working through our Greater Cleveland Lead Advisory Counsel, which has been in place for a couple years, to really start to look at the whole universe of ways to impact a community, whether it's through programs to fix the homes, to deal with educating the building folks or increasing screening or doing some true primary prevention with, for instance, pregnant women, looking at the whole scope of things, because, as Stew and others related, they are all interrelated, these problems.

MR. FROLIK: Can you talk a little bit about -- I'm sorry, Dr. Keck.

DR. KECK: I was just going to suggest that we should not leave your audience with the feeling that this is only a problem in poor neighborhoods. We certainly have examples from middle class and well-to-do neighborhoods of lead poisoning, as well. It tends to come during rehabilitation efforts, when you are repainting the house and you are going to chip the old paint off is probably the most common example. So anyone living in a home constructed before the mid to late '70s, when they are going to do significant rehab that involves particularly paint, really should find out whether they have a lead issue involved and whether they need to involve folks who are specially trained and licensed to remove lead appropriately.

MR. GREENBERG: That really relates to the need for a two-prong strategy for lead. You need a very intensive approach that focuses on high risk neighborhoods, high risk houses, high risk pregnant women so that you can get to them before the child develops a body burden, really focusing intense efforts there. But you also need a strategy at a very high level that educates people about the potential for lead exposure in ordinary activities of painting your house or doing remodeling.

So what you need for prevention overall is to infuse sort of every housing decision with some awareness of lead safety. In other words, when a bank writes a mortgage, they should be thinking about what is the lead status of this house. When you are going to do renovations, where is the lead and what do we need to do to protect ourselves. So you need that very broad level and you need that very intensive level. And that's the way the health departments are focusing their efforts at this point.

DR. KECK: We're hinting at the good news about lead. There is a lot of bad news about lead. The good news is it's an environmental pollutant that we understand reasonably well. We're learning more all the time, but we really understand it fairly well. We know what to do about it, so we're not helpless in the face of this at all. There's plenty that can be done, it just needs to be done correctly.

And as a society, we have to make a choice about where we're going to put resources. And that's, of course, one of the issues that is related to this and other pollutants. But while it's a serious problem, we can address it. And individuals can keep themselves and their family relatively safe from this, even if living in a relatively high risk environment.

DR. FEINGOLD: An example of the right way, the wrong way, this isn't from my medical practice, it's just from walking around my neighborhood. Not so many years ago I saw a new trend in house renovation. Somebody wanted to improve the outside of their house. You bring in a company and they'd steam blast, sandblast the surface of the house to the bare wood. All of the old paint was now gone. Well, it wasn't gone anywhere. It was gone in all of the neighbors' gardens. You know, the kids were running around in it, and as I say, it stays there forever. That would take the house down to bare wood and you could stain it. It looked very nice.

It actually took not too many years before the health department said, wait a minute, and now that's no longer done, at least where I live. On the other hand, not more than two years ago we had our own home repainted. And for the first time, in talking with the painters, did I learn that all of the paint crews have their blood lead level checked because they are exposed, but, also, after power washing the house, they spend a whole day going around with a power vacuum picking up all -- as many of the loose chips of paint as they could. That's a whole different way of doing business, and I think a very good way.

We have patients, I certainly had patients whose source of lead poisoning are the paint chips next to the garage, you know, that have been brushed off or washed off and they are lying on the ground, and children put things in their mouth, so, you know, some of these things are no-brainers. There are some easy things you can do to reduce the hazard, or at least avoid making it worse than it is now.

MR. ALLAN: You know, track-off matts walking into a home do wonders. There was mentioned recently, the things your grandmother told you, wipe your boots, wipe your feet, wash your hands. So that's a public health -- people get sick of us telling them to wash your hands, but it does wonders. And what follows those are practical things that families can do right now to limit exposure to their children.

MS. BEARER: There was a very interesting study done in Yugoslavia, when it was still Yugoslavia, between, I think, the Christians and Muslims who lived in a lead smelter town, and the Muslim children had much lower lead levels than the Christian children did. And when they went in to study what the difference was, it was because when the Muslims go into their house, a cultural difference, they take their shoes off, so they weren't tracking in lead from the environment, whereas, the Christians didn't have that kind of cultural practice.

But the other comment I wanted to make on lead is that we know so much about it and we understand it so well because we have a biomarker for it. We can measure it in people's bodies, and that is what, I think, hinders us a lot from understanding some of the other environmental pollutants and their impact on children.

MR. FROLIK: Okay. I wanted to get back to Terry on the housing issue. There has been some money. I believe you told me you can do about 160 homes a year which, given the number of homes we're talking about in Cleveland, is not that many.

MR. ALLAN: We described that as sort of spitting in the lake. It's such a small number. We have a lot more to do.

MR. FROLIK: But there's a pilot program you are planning to do next year in conjunction with some other counties. Can you talk about that?

MR. ALLAN: Sure. It's actually, and Stew can chime in on this because he's an important partner. As we go forward, we realized that we have to get in -- primary prevention is certainly the key. We need to get in before the kids are poisoned. So the dollars to date mostly have been geared toward doing some education but, also, remediating homes of kids who are poisoned and certainly at high risk. And 160 homes in Greater Cleveland, we're talking about, you know, tens of thousands of units throughout Greater Cleveland that are hazards.

So what we're looking at, working with the County Commissioner through the early childhood initiative, working with Stew's group at Environmental Healthwatch, working with the City of Cleveland and the health department and the departments of development is to do a primary prevention project where we're reaching out to pregnant moms and, also, when the kids are born, trying to reach out in the first couple months of life to develop a low-cost intervention to try to make the home lead safe during the highest risk period, which is between 9 and 24 months. So that's when the carpet crawlers are out and hand to mouth business begins.

And in Cleveland, we know it's the windows. You open and close them. It's not so much the chips. It's the dust, it's, as the windows are opened and closed, you start getting powdering. It's friction points when doors are opened and closed. It's porches and it's exterior paint and soil around foundations. So we can begin to define the highest risk areas and develop a low-cost intervention to get in there early. And then blood lead, as Dr. Bearer related, will be the proof in the pudding whether we're making a strong impact. So that's our hope, to be able to reach many, many more families in the early childhood initiative through the county commissioners. It is our hope to do that.

MR. FROLIK: Cynthia, did you routinely, as part of a well child check, do you do the blood test? Is that the norm for kids these days? Should you be tracking that as you go along?

MS. BEARER: There's a history behind that. Again, because this is a subclinical effect, you really can't rely until somebody comes in with symptoms. So in the early '90s, the recommendation came out that standard of care would be universal screening, every child would have a blood lead level drawn around two years of age, and enormous lines of data were generated from this practice.

Now, because of limited resources in trying to target the most number of kids who need interventions, that has changed to targeted screening, and the targeted screening is based on where the child lives and the housing stock or if the child is getting Medicare. Medicare children all get screened. That's still universal, but only the census tracks. A certain proportion of older housing now are targeted for universal screening and other children are on a case by case basis.

MR. GREENBERG: One correction, Medicaid children should be screened. That's the requirement. And they represent 85 percent of the high risk, but I'm sure you know, the statistics are that, in fact, in the state, something on the order of only a third of Medicaid kids that should get that blood test actually get it. We're better in Cuyahoga County and Northeast Ohio in general, but still, less than half the kids that are in a doctor's office for well baby visits actually get a blood test in areas that are considered high risk for blood tests.

MR. ALLAN: The message is focusing resources. That's the key message so that we can have an impact.

MR. FROLIK: Mark.

DR. FEINGOLD: A comment about what both Terry said and Dr. Bearer said. At MetroHealth, we have been doing screening for a long time and we try to do it annually on the one and two year olds, but we have also been doing the three and four year old kids coming from the inner city. And what we have found, unfortunately, is that there are a significant number of children who are three or four who had normal tests at one and two and didn't develop the habit of eating lead, whatever they were doing, until somewhat later, so we're concerned, still, about the older preschool children, not just the younger.

The second thing is sort of a question. I think it's very nice to be able to approach a house and do what's practical because to really remove the lead from the $50,000 house might cost you $100,000. I don't know. It's a very expensive proposition. But you can reduce the lead strategically for a whole lot less money. That leaves the government with a problem that they know they're not doing a totally perfect job. Is that acceptable to you?

MR. ALLAN: I think the point is that the idea of doing complete abatement is sort of gone these days. It's just not cost effective. As you say, you can't spend 20,000 on a house at a market value of $20,000. That's not practical. But we can, and we do know from studies that HUD has done that Stew participated in on the first rounds of lead hazard control that various interventions, we can tell you the life of that intervention in terms of how long it will keep that house lead safe. And it's not lead free. It's lead safe. The terminology has changed. It's important to understand that.

Still, when you walk into a house that hasn't been maintained, it isn't just lead. It could be major water damage. It could be plumbing problems, electrical problems, and the idea of trying to combine resources with existing department development programs, community development corporations to do rehab, furnace repair, that you need to integrate the programs. There isn't enough money to just take care of all these hazards with lead and it isn't appropriate because it's fairly targeted. So the integration has to occur. But we still hope to move away from a 10 to $15,000 intervention. We hope to be able to spend $1,000 on a unit with the education and giving some tools to the family so that the difference can be made to keep blood leads low among these children.

MR. GREENBERG: That still is expensive and a small number of units that can be touched, and the new state law about lead is promoting an intervention that can be much broader, and that's what is called lead safe maintenance. And these are things that we think are protective of children and yet are not terribly burdensome on a landlord. And it's things like correcting nonintact paint, covering bare soil, doing a special cleaning annually, those kinds of things. And, in fact, if a landlord does it, they get a certain level of liability protection, or at least they get a rebuttal presumption.

DR. KECK: Do you have some sense of what the cost is for that kind of intervention on average?

MR. GREENBERG: I don't know for sure. I do know, for example, that the, when this was all being debated, that the apartment owners association around the state, that they endorsed it. They said this, what we want, is a standard of care for how to protect our tenants and this is something we can live with.

DR. KECK: You know, in a former life I was director of health at the City of Akron and we had the same kind of lead abatement program that Terry has described, and I know for doing something like 100 houses a year, Akron is much smaller than Cleveland, but still, it's a long way from what is really required, and the average cost was somewhere between 8 and $9,000 to do a fairly good --

MR. GREENBERG: That is an intervention. What I'm talking about is much, much cheaper.

DR. KECK: I assume it would be something around 1,000 or so. That is dust removal, dust wipedown, special vacuum cleaners that will hold lead dust without blowing it out the back into the rest of the house, covering bare soil.

MR. GREENBERG: Probably, as Terry mentioned, fixing the underlying problem that's giving rise to the paint failure, whether it's, you know, a plumbing leak or roof leak or something like that.

DR. FEINGOLD: I would like to bring in a pediatric point of view, and that is that children are sort of like water, you know. If you are in a tent and it's raining, the water will find the little hole. And children are like that, too. If there's any place that they can find something, they will.

So part of the solution, and this comes from my own practice, really, part of the solution, I think, has to be improvement in child care. Children left crawling around on the floor with just a TV to keep them company and the parents aren't really stimulating them, educating them, playing with them, talking with them, those children are going to get into this kind of lead mischief no matter what we do. I think that's part of the reason we see lead more commonly, lead poisoning more commonly in inner city families who are so distracted by all of the other challenges, where am I going to get a meal, where am I going to get money for the rent, I just lost my job, there's violence, there's drugs, there's alcohol. There's not a whole lot of energy left over sometimes to do these extra things like playing with your kids, talking with your kids, supervising your kids.

We see it in other venues, too. I sit on the Cuyahoga County Coroner's Child Death Review Committee. We have recognized it for quite awhile that a leading cause of child deaths is lack of adequate supervision. That's at a very gross level. This is a more day-to-day micro level, but I think a child living in the house across the street who gets more positive parenting has a lot lower risk even though the environment is the same.

MS. BEARER: I think that's a very understudied area when we talk about children's health, what are the impacts on families and parents in terms of how they intervene on their own children's health. So when we talk about environmental health, we talk about lead poisoning to the kids. This might be a transgenerational problem where you are seeing the effect, the primary effect on the parents that then have this major secondary effect on the children.

DR. FEINGOLD: Well, you know, it could be more knowledge and more attention to good nutrition. You can eat better or you can eat worse for, probably, the same amount of money. Sometimes it's more expensive to eat badly because a bag of potato chips is very costly and a bottle of pop is really expensive. Children who are poorly nourished, as Stew said, have a higher risk of absorbing lead at a faster rate. If they are deficient in iron, same thing. And not only that, but the deficiency in iron also reduces their brain potential and their IQ to a subtle degree. And like lead, it doesn't matter if you go back later and give them supplements or reverse the problem, the damage is done. So parents really have a fairly short window of opportunity to keep on the right track. It's hard to go back and make good.

MR. GREENBERG: Our organization does a lot of parent education about these kinds of things. And we try and put it in the context of a division of responsibility. There are certain things that are within the domain of the parent. There are, you know, it's things that are within their home, but the landlord, the building owner, also, is responsible for providing a house that is free of defects. And the government, the health department, the housing departments have an obligation to do enforcement. And the government has a responsibility to regulate pollutants of various kinds.

So I think you have to put parent responsibility within a context. We use the example in talking to parents about protecting their kids. We say we're not trying to motivate to you protect your kid. We're assuming you know that. And if there's broken glass on the floor, you clean that up and you don't say that's the landlord's responsibility because the window broke and they were supposed to do it. You clean it up right away and then you worry about the landlord. The problem with lead is it's invisible and most people haven't been taught to worry about it. So, you know, it's -- the parent has a domain, but you can't clean a house that is not cleanable. If the floors are rough and pitted, you can't clean it to the level that is protective. And so you have to look at all the levels of responsibility, I think.

MR. ALLAN: I think the overriding message here to give people a sense of what is everyone doing about this problem. Maybe I didn't know it was such a big problem. Well, nationally there's been a movement with all the federal agencies, CDC, the Centers for Disease Control, EPA, HUD, looking at developing a plan that is now in place to eliminate lead poisoning by 2010. Well, I'd say that's a tall order, but the ambition side of it is very good. And once that's done here in town -- and it's taken this Lead Advisory Counsel. We are now building a very strong and detailed plan on how we're going to go about significantly reducing rates using all the facets that everyone has described here, hitting it from all angles, not just personal responsibility but governmental responsibility. And I think that making sure that parents have the tools that they need to assure that their children don't get poisoned. And right now, I think, we're in the process of building that plan, and I think it has a rosy outlook for Greater Cleveland on that end.

It gets a little more mirky when we talk about lead, and I think Dr. Keck said and others have said that you can remove lead. But then there are other things when you start dealing with other environmental problems, that sometimes you remove them and they grow back or they come back, whether it's a roach problem or a mold on a wall, so that becomes a little more insidious and that involves a whole other set of problems that you have to deal with the complexities.

MR. FROLIK: Let's talk about another problem for a moment here. When we did the community meetings on this, a big issue that seemed to come up a lot was a concern about asthma. And this sense -- I think the doctors back me up on this -- there has really been a dramatic increase of childhood asthma in the last 20 years or so. What do we know about the causes of that and the relationship to environmental pollution or environmental irritants?

MS. BEARER: I think that the causes are multifactorial. We know that the environment does play a role in asthma because there's been a couple of very clear epidemics where asthma attacks were associated with an air pollutant being introduced into the environment. One of those was when ships were coming into Barcelona, Spain and they were pumping out, it was soy powder from the ships. They didn't have the proper control around the pumps, so all this dust was going in Barcelona and they would have these epidemics of asthma that finally somebody put together the ships when they would come in and off-load the soy. And as soon as they put a shield over the pump and stopped the dusts, the epidemics of asthma went away.

Another example was when the Olympic games were in Atlanta, Georgia and because they were worried about traffic congestion and everything in Downtown Atlanta, they diverted the traffic flow pattern. And when they did that, they had the summer Olympics and they put the traffic back the way it was and some smart somebody, probably from the CDC, went and looked at the records of asthma admissions to or presentations to the local emergency rooms in the hospitals that were affected by the traffic pattern and compared them to hospitals that weren't affected by the traffic pattern and found that the ones, when the traffic pattern was relieved, when the congestion was gone, the incidence of asthma dropped, and as soon as they allowed it back, it came right back. And the ones that weren't affected had no change in the incidence of asthma.

So we know that there are important environmental precipitants of asthma. And I think another very interesting study, and more on the protective side than the negative side because we tend to focus on the negative stuff but there's also positive stuff, have been the series of studies now that have shown that children develop the control over their immune system which is important in asthma and the development of asthma by being able to play in the dirt or have animals in the home, and this is something called the hygiene hypothesis, that there's a critical period of time when kids have to explore their environment and have their body know what's them and what's not them and develop the control over their immune response. And so it's been shown that children who grow up with pets in the household, and you have to have two. I don't know why it's not good enough to just have one.

DR. KECK: Is that child or pet?

MS. BEARER: Well, if they did it per child, that would be good, too. I don't know if it's the dog or the sib. But having the two dogs or two cats in the house lowered the incidence of asthma in those families.

MR. FROLIK: Interesting. The relationship between the asthma that you are talking about, the outside pollution, also people talk about inside air versus outside air. Again, what are sort of the inside air things that are problems for asthmatics? Stew, you work a lot with this.

MR. GREENBERG: There are a lot of indoor triggers that are either allergens, things that people are allergic to, or lung irritants. And what is it, about 80 percent of asthma is related to allergies, I think. So you have animal dander from cats and dogs, birds, you have dust mites, you have roaches. Turns out roaches are very potent and persistent and surprisingly pervasive asthma triggers. Rodent urine, mold, tobacco. That's probably the biggest worry. So the whole range of things in the home, and there's the hygiene hypothesis and there's also the couch potato hypothesis about asthma, that a lot of inner city kids are stuck in the house, exposed to these allergens and irritants, sitting on the couch watching TV, playing video games or other kinds of sedentary activities. They are not outside because of worries about safety and things like that, so you have that interaction of things.

And, in fact, there are some projects that are developing ways to promote kids walking to school and riding their bikes to school. Safe routes to school they call it. And that's part of encouraging outdoor activity as a way to combat a number of conditions.

DR. KECK: But, you know, that's interesting, this conversation seems to be winding back. It's so interconnected. I think that Dr. Feingold's comment about violence, well, why are kids inside? Because they are afraid to go outside because their parents think it's not safe. And it's interesting, you know, we want kids to ride their bikes anyway because we're seeing an explosion of obesity and overweight in America, the second leading cause of death, and Type II, early onset diabetes among children is a big issue in America, and certainly in Greater Cleveland and Northeast Ohio. And so that all these things appear in some way protective or in some ways to make us, perhaps, more susceptible depending on whether it's a good thing to do or not. Certainly exercise may be protective on a number of fronts.

MS. BEARER: I was just going to say that, again it gets into the positive aspects of the -- environmental health isn't all about toxins. There are these positive aspects that we don't really seem to dwell on, and I think they're very important. Like a positive aspect of the environment would be how many feet away is it from a playground for every kid who lives in the city? And that's something you can measure and actually see an improvement in. And, you know, the safe biking to school and things like that.

DR. FEINGOLD: I think it would be wrong just to focus on the responsibilities of our government. Government can be very important in formulating rules and regulations to address these problems. Likewise, manufacturing, it's important to have manufacturing, but they have to do that in a responsible manner. And in that regard, the lead manufacturers knew for many, many years that they had a dangerous product and did nothing about it.

But also, we have families and they have a certain part of the responsibility, and we have the healthcare system and we have a certain responsibility. Let me talk about the healthcare first. Over the last few years, we've learned a lot about how to manage asthma better. It's quite different than 20 years ago. We have also learned that education of the families of the patients is very helpful. Somebody who knows how to control their problem does a better job at it. They have less trips to the emergency room, for example. So physicians need to work on methods to communicate with the families and teach them what they need.

That sounds like an easy thing to do, but I'll tell you that things don't get translated from the scientific bench to the scientific journal into practice in a very fast manner. It's a very slow process, wouldn't you say? And at MetroHealth, we have been running a series of quality improvement efforts, they're small, with our resident trainees. In pediatrics, specifically, last year, our projects dealt with asthma. My team worked on developing methods for educating families about triggers to asthma. Another team worked on a project for training families how to recognize when their child was getting out of control and what steps to take to stabilize the boy or girl. It wasn't rocket science, and we were trying to model this for our 30 or 40 trainees so they could replicate this as they go out into practice themselves.

On the other hand, we do have the families and one thing for sure, families learn real quickly what we expect of them. So when I am interviewing, taking a history and I ask a mother, does anybody smoke in the home, many say, no, we don't have any smokers in the home, and I say, that's great. And then we have got people who say, yes, there are smokers and then they quickly add, but they go outside, because they know that's what I'd tell them to do and they don't want to be criticized and they anticipate.

Unfortunately, when I drive down West 25th Street in January, I see very few people standing out on the porch smoking, so I don't know where they are going. I think we're getting an answer that people know we want, so they kind of smooth this over a little bit. But I think physicians can do a better job. The same is true with the lead poisoning. Yes, some of us do check lead regularly. I know you do at Rainbow. I know we do at Metro. Across the state it doesn't get done nearly as often as it should.

MR. FROLIK: At the community meeting a couple nights ago at Olivett and Fairfax, one of the people in the audience talked about one of the difficulties as you are doing this sort of health education is how do you approach a parent and suggest that you are doing something that may be damaging or hurtful to your children? Nobody wants to hear that. How do you approach that as a doctor or a health educator.

MS. BEARER: Well, I'm actually a pediatrician, but I am a neonatologist at Rainbow Babies and Children's Hospital and I take care of the small, sick babies and babies with birth defects and one way I approach parents who may be smoking, and you can tell who they are because you can smell them, you don't really need to ask them, is you say, I have noticed that you may be smoking and I just want to warn you that for your fragile newborn baby, this may place an additional risk on your baby's health when you get the baby home.

But I think one of the barriers for other neonatologists asking that is they don't know what to do with the information or how to guide the parents from that point. They may point out that it's a risk factor, but if you can't give them anything to do about it, it's an awkward place to leave the parents. So we have developed referrals to the American Lung Association, the American Cancer Society. There are smoking cessation programs that are available, and I try to have my residents who are training to be pediatricians aware of where they can send families to be helped with smoking cessation when they ask those kind of questions.

I think the same thing is true, you know, you might suspect that a parent has been using alcohol when you see the baby or he baby has the features of fetal alcohol syndrome, but we're very reluctant to ask them because we don't know what to do with the information. And actually building on what Mark said, I think that in the practice of medicine now, we were split from public health at the turn of the last century, and I think in the practice of medicine now with more emphasis on prevention, that we're beginning to realize we really need the public health system and we need to be better partners with, if we're going to be not just medicine which I think of as intervention, you know, once you get sick, there's medicine. If we're actually going to be promoting health and our new definitions of health and our understanding of health, then we're going to have to increase the partnership with the public health people.

DR. KECK: Well, this is a very important issue, one in which this country is way behind many others in the world. What you have heard in terms of how asthma is handled and to some degree lead poisoning are good examples of what real managed care is, a phrase that is somewhat negatively associated with events in the United States. But we're not talking about managed finances, which managed care has really come to be, it's really a partnership between the community and the family and the patient and the care providers to help people understand how to manage the disease they have and to diminish the acute risks that go with it.

It's not uncommon for families who have children or adults with asthma who have learned to deal with this to learn how to interact with a nurse or a physician to deal with the first symptoms at home to minimize the likeliness those symptoms will begin but also when they do begin, to deal with them at home and diminish the need for a quick trip to the emergency room. So it's not uncommon in these families to see emergency room visits drop from eight or nine a year to one or two. It's exactly this kind of interrelationship that's part of this whole concept that is so important.

And I'm hoping that as this trend continues, because I anticipate that it will, that we will begin to do a much better job of including issues related to health when it comes to public policy making, public policy decision making. Too often it's really quite rare when decisions are made in city council, mayors' offices or anywhere for one of the questions to which we must have an answer before we proceed to be what's the impact on the health of the people living in the community at large or in part of the community that will be affected by this decision we're contemplating.

MR. FROLIK: It's sort of like development issues, where you are going to put a new highway, housing questions, obviously.

DR. KECK: There's hardly an issue related to managing communities where it's not related, and it's the design of housing units, what to do with older housing units, how to protect people living downtown or in neighborhoods next to the factories from whatever might be coming out of that factory, it's all of the violence, sex issues, the obesity, the exercise, all of this. It's all really related and it's only in a few select communities, I think, where planners have actually carefully thought about all of that and tried to design communities as examples that are health promoting. It would be in our own best interests to think about what to do with our existing communities that would enhance the health promotional elements associated with diminished health and health defects.

MR. FROLIK: What would you see in a healthy neighborhood, if you were to sit down and design a healthy neighborhood or configure one in terms of a redevelopment effort or rebirth, revitalization effort?

MR. ALLAN: I think this is really important to think about, first of all, who needs to be at the table in that design, and I think all of a sudden there are people that you normally wouldn't reach out to and you talk about community planners. They have the understanding and the need for Greenspace. Well, the Greenspace, some people might say it's just nice to have somewhere for the kids to play, but it has to do with exercise, physical activity out of the home environment that you may not have enough money to afford a fix to a level to reduce risk significantly to a number of environmental hazards.

So you have, I would think, a neighborhood at a very general level that is safe where kids feel and parents feel it's okay to get out and play so you have an exercise component, somewhere where the school is very close or in the neighborhood where that school is more than just an educational place for the children, but there are positive behavior messages, because what we do, smoking, what we eat, what we choose to do relative to exercising or not has nowadays more to do with whether we will be sick or we'll die at a younger age than just about anything out there. Changing that is just about the most difficult things, as well. So those are our challenges, so I would think an environment where the school becomes a center for learning, it's in the neighborhood where kids feel safe and, by the way, have some fresh fruits and vegetables up the street that the parents can choose to let the kids have.

MR. GREENBERG: Walkability is a key element for exercise and because it reduces pollution from vehicles, so you can have -- community design for health has sort of accumulation of advantages whereas the communities that we have been talking about earlier, there's this cumulation and compounding of disadvantages.

MS. BEARER: I think something called social capital also, this sense that people have when they live in a place like this that they're part of this community. They have their place of worship, the school is there. People interact in open spaces on the street. You know the names of your neighbors and other people in the community. I think it's a very hard thing to measure this concept of social capital, but I think that's what makes communities thrive.

MR. GREENBERG: There are lots of government decisions about transportation, highway financing and those kinds of things that push development one way or the other from, you know, walkable communities to this sprawl and all the added pollution that is related to it.

DR. KECK: To some degree, we're victims our own culture in this. In the United States, it's rare that we ask ourselves what we should be doing to create the healthiest population possible. There are other cultures that make that one of the primary questions they are trying to answer. When it come to health, we're primarily interested in how we're going to pay for things, so we're continually trying to find answers to how the money is going to flow. And in some segments of society, how to keep that flow as small as possible and with other, of course, how to increase it. That's one of the major conflicts we have these days.

But it may in some ways take a little bit of a culture shift to understand that we do have the capacity to influence health in ways that most people just don't consider as being health related yet we're really poor and sicker for not doing it.

MR. FROLIK: It occurred, again, some of the things coming from the community meetings, is people feeling that they can make a difference or the buy-in to it, and I'm struck how -- the controversy over E check.

You remember in Akron a few years ago there was a legislator who basically lost her seat because she was a proponent of E check.

DR. KECK: I remember it very well.

MR. FROLIK: You can talk about the research that Cynthia mentioned in Atlanta, the clear connection between auto emissions and health issues, yet, again, people don't even want to deal with it every year having their cars checked to see if they're high polluters.

MR. GREENBERG: My view on that, I rarely believe in conspiracy theories, maybe not so rare. I think E check was deliberately structured to be as cumbersome as possible to generate negative reaction toward regulation and to have people think not that I'm doing something to protect the health of my family and protect the environment and this is a good, positive thing to do and I am happy to do it, I think it was structured in a way to engender a sense of this is a stupid regulation, it's unnecessary, it's costly and it's inconvenient. And I think it was done at the time that we were having some major debates about regulation of air pollution.

And just to bring it back to asthma and indoor and outdoor, right around the time that the research came out pointing to roaches as a very potent asthma trigger, there were politicians in this state, Governor Voinovich, who said, well, now that we know that roaches cause asthma, we don't have to worry so much about air pollution. And Exxon -- what's Exxon now? Whatever they are, Mobil, on the New York Times ad page, they have advertorials and they had one that explicitly said that. It said, we know that indoor triggers cause asthma and so we don't have to worry about outdoor. They were confusing triggers that provoke asthma attacks with triggers that cause the development of asthma. That whole business, it was a deliberate misdirection.

So E check is a good thing. We should be happy to do it.

DR. FEINGOLD: This is a little off the target of asthma and lead poisoning, but it's on track if we are talking about environmental pollutions, and I will say again that I think violence is an environmental pollutant. An organization no less than the Center for Disease Control has recognized that rather recently. They have had programs for asthma and programs for lead a lot longer than they had programs investigating why it is we have this epidemic of violence between people.

I deal with children who have been abused at home, typically, and the literature, scientific literature, demonstrates an enormous downstream bad effect from childhood violence. If you grow up in a violent home, your chances of growing up as a person who has a drug problem, alcohol problem, mental health problem or what we call in adult medicine a positive review of systems, that is, everything hurts, your eyes don't work, your ears don't work, your toenails, they itch, everything is wrong with you and you're a very expensive customer because nothing makes you better, these are the kinds of effects that we see from early exposure to violence, just as we see bad effects from early exposure to lead. Frequently because of the dynamics, those things overlap each other, also.

I couldn't agree with you more, Dr. Keck, about managed care should be focusing on the health outcome and we focus on the dollar outcome, but even with that, the dollar outcome of early exposures to violence is enormous. It's a very expensive epidemic.

MR. FROLIK: What do you do when you have a patient? How do we intervene and how do we break that cycle of violence?

DR. FEINGOLD: Well, with children, we have, first of all, the Cuyahoga Department of Children and Family Services. It's a big organization. They have people who are very good at working with these situations, recognizing them, doing the leg work, getting the facts. When you have got a thousand case workers, and I think that's what they have, you know, some are going to be better than others, but I think the organization is really devoted towards identifying children who are being mistreated in a serious way and trying to step in and act in ways that protect those children.

In our newborn nursery and I'm sure in yours, when a problem is identified at the time of birth, actions may be taken right then. You just can't send a new baby, let alone a preemie baby, home with a mother who is using crack cocaine. That baby is not going to make it. And we have a lot of those coming up every day in Cleveland. Once the abuse occurs, there are some interventions that work besides changing the environment and protecting a child from ongoing exposures. There's a form of psychotherapy called cognitive behavioral therapy that is pretty straightforward and has been proven across the country to be effective.

Medicine is not proven to be effective, so the pharmacy industry won't come into this discussion, I don't think, but there is an effective one on one form of communication that can help get you off the dime. You know, I think as long as we have had lead, and that goes way back to the time of the Romans, we have had violence and violence goes way back before the Romans. We're a violent bunch, at least some of us are, and I'm not sure I have an answer to that. Maybe somebody else does.

DR. BEARER: I have another question and that is is media violence the same as witnessing violence, this virtual violence, in terms of the impact on the child?

DR. FEINGOLD: That has been studied a lot. The effects of negative television, growing up seeing thousands of murders and now how little I see, it looks like it's more and more awesome, more and more gruesome, more and more in your face. As much as that has been studied, I think the results are still kind of debatable. But when you talk about real violence that really happens to you personally where your mother and your father are fighting and there's a weapon involved and there's words being used that are downright threatening, that has a real serious effect. That's sort of like a child being in an earthquake or a car collision. It scares you to your core and it doesn't go away. There are some people who can handle that and there are some people who can't. The ones who can't are going to be more affected by it.

MR. ALLAN: I start to think about hearing about these conditions that we treat after the fact. You have got an asthmatic child, you have a child that's been exposed to violence or they've been harmed by a family member is that from a public health standpoint, we start to think about prevention. You can't prevent everyone of these occurrences, certainly, but the amount of money that is spent for treatment versus prevention is sort of obscene. I think there needs to be -- that's a big shift in medicine and public health working together so that the emphasis and the thrust is geared towards that prevention and that the dollars at the federal level through the states come back into programming. That prevention needs to happen, so you find yourself with lots of competing interests. But if we're talking about societal shifts in America, I think that's a big one.

MR. GREENBERG: You say it needs to happen and it's not happening. We can't have a discussion like this without saying that particularly in the last few years, the Bush administration, both in term of funding for particular programs, funding to states, funding to cities, those cuts, the cuts that are coming are going to be horrendous, have an impact on everything that we're talking about and the rollback in regulation of pollutants, and I just heard on the radio today, WCPN, about the release of the report on air pollutants and Ohio was number one. It was attributed to power plants, cold fire power plants.

We have ome of the dirtiest power plants in the country and that's because of lack of enforcement of regulations on requiring these plants to bring their air pollution control systems up to current standards, so that's a big piece of environmental health. It's the failure of the federal government to fulfill its responsibilities both for funding and for regulation.

MS. BEARER: One thing on top of all the programs and sources that we're talking about is our ability to measure the impact on children's health. And that has to do with how we evaluate them and assess their health, and I think there's a problem in that we don't have very good ways, we don't have very good measurements of health. We just don't. We haven't developed them. We can say they are growing well, but that doesn't give you the cognitive, and so I think there's this trend to define health in a different way right now and in how we actually evaluate our programs, you know, do they have an impact, and that's dependent on how we're measuring it.

Right now with HIPA and the Privacy Act, the way we collect data, it's usually not personal data, it's population data, so this interacting nature of how these multiple influences will affect any particular child we just don't have any handle on unless it's in a research study which is going to be a very small part of the population. And I think there's a major national study that is being recommended called the National Children's Study that will track I think they are proposing 100,000 children in a geographical distribution, and hopefully Cleveland will be one of them, to see how these multiple interacting influences actually impact on children's health. And then once we can identify the appropriate measures of that and the influences, then we can do it on a more local level.

But I think when you talk about policies and the air pollution, unless we have some way of measuring how that translates into health for kids in Cleveland and then how cleaning up those plants will change the health of the kids in Cleveland, it's hard to sell it to the, you know, different interests that are calling for the same amount of money that might go into that.

DR. FEINGOLD: There are small steps that you can take and there are big steps that you can take. Just to mention two small steps that to me seem reasonable, one is our County Board of Health is sponsoring a shaken baby prevention project. It's low tech. It involves three or four or five minutes of discussion, perhaps watching a videotape for parents of new babies so that they understand that it's really easy to permanently cripple a baby or kill a baby.

From a dollar and cents point, a child who is rendered blind or deaf, it's very expensive to take care of for the rest of his or her life. Another low, ground level approach, I understand the early intervention workers, and correct me if I'm wrong, Terry, but the people who make home visits to new mothers throughout the County are going to be checking for lead in the environment; is that correct?

MR. ALLAN: What we're trying to do as part of the prevention project is to look at some indicators that would be -- it would be easy to sort of add on because having had -- I have some young children and seeing someone come into the home, it's been turned upside down and so what we're trying do, from what Dr. Feingold is describing, is just have a few questions because there's a stack of paper and information that is heaped upon the mom at a pretty sensitive time with a new baby at home to try to make it practical so that at the end of a visit, are we able to glean the information that we want and this nurse, I think, has an immense responsibility as they go in, or a case worker, to try to orient that mom on many fronts and the father and perhaps the other children. So, yes, we hope to be able to glean the information we want from just a few questions that are sort of indicative of the situation relative to lead.

MR. FROLIK: Stew, your organization very early on got this idea of a healthy house and stuff. Can you talk about how, sort of what were the factors that led you to that particular sort of focus of attention and how is it -- do you think it's having an effect in terms of changing the way we build and maintain houses.

MR. GREENBERG: The way we got into it, we were working on lead and we went into homes that were multi-problem homes. There was mold in the house, moisture problems, pest infestation. We had a single intervention. We were focusing on lead, and the families in these homes had -- we were focusing on lead poisoning prevention, but the kids had asthma and they were exposed to pesticides and mold and these other things going on. So one of the -- we were able to piggyback onto an existing lead program at the Cleveland Department of Public Health an asthma intervention.

So we were going into the homes anyway to do lead. We were doing education with the parents. We were doing interventions, and we were able to, using the weatherization money that dealt with other aspects of the home, address moisture problems and combustion sources and some of these other things. And I think that makes a lot of sense, and we have seen these kinds of programs around the country where you look at the house as a system and you look at all of the elements that interact within the home and the behavior of the occupants, and it's certainly more cost effective to do it that way.

MR. ALLAN: I wanted to quickly talk about behavior. To me, that's really, I think, a big issue is it's difficult to change behavior. We look at tobacco use and there's lots of dollars that came down through the attorneys general settlements to the states to be used ostensibly for tobacco prevention programs. Many of them went off for use for technology, for budget holes, for highways and roads, but some of those dollars are coming through. But even the issue becomes very controversial about tobacco use in greater Cleveland. We saw the Cleaner Air Coalition here look at that issue. The concern is about our businesses will be affected if you take tobacco out of our restaurants.

Cincinnati, Columbus is taking this up as we speak in front of their city council. Toledo has addressed this and there was a supreme court issue at the state level. The state supreme court said health departments don't have the right to move an ordinance through to prevention tobacco smoking in restaurants, bars, bowing alleys, that sort of thing. So the sense is we're dealing with people feeling they're infringing on your rights, but here it's the leading cause of death in the United States. So what happened in that discussion is a fear that the data is dispensing with.

El Paso looked at sales pre and post in restaurants, bars and there was no difference at all. It was with the Center for Disease Control shepherding the study. It showed no difference before and after the ban. People feel Cleveland is a hard working, hard drinking, big eating town and we need to lose that mantel. Super sizing it, you know, find that place that has the buffet, the big sandwiches and have my cigarette and my Bud and this is the way it's going to be. I think we really need to look inside and re-invent some of that, and I think maybe -- which is a huge challenge, but we saw the resistance with the issue of tobacco in restaurants. It was right out there in front.

MR. GREENBERG: The key thing you said was there was evidence. We have very good evidence about the economic impact, assuming you want to match up economic impact and health. That's key, that we can base public health decisions on evidence. That's what you were saying. I love the development in medicine, evidence based medicine. Silly me, not being a physician, I thought that's what you were doing all along.

MS. BEARER: It was an art.

DR. KECK: Actually, it's been described as one of the three major jobs the Health Department has is to influence public policy making with science. But it's very difficult to do with emotionally charged issues, particularly when someone believes their economic box will be smaller. So it is a real skill for public health departments to try to figure out how to bring that science to bear. That's part of what I think I was trying to get at before with suggesting that as a culture, we really need to focus a little bit more on what the impact on health is of the decisions we've made, and you can only make reasonable decisions about that if you have reasonable science.

There's also, you might be interested to know, if you don't already, there's a growing movement to develop better public health based science. Much of the source of dollars for research in the United States is focused on the disease of the month. Obviously, it's how to diagnose or treat illness that gets most of our attention, but there is now a very organized movement to try to move a certain portion of that into research focused on the kinds of issues we're talking about here including or in addition adding the effectiveness of the interventions that we try. And much work is going on now to try to delineate what the science is behind the various decisions we have made to understand whether we have good science for that decision or not. Some cases we have good science. In some cases we find that we have little or no science, and in some cases, we probably have science that is a bit equivocal.

We're not sure, but it's in the latter two cases that we need to better define what we know from scratch that should become the public health research agenda, that should attract dollars, that should attract a combination effort between medicine and public health and actually should link practitioners back to an academic basis in both disciplines in some interesting ways.

MR. GREENBERG: Isn't there a tough question when you don't have the evidence or the evidence is mixed, which direction do you go? Are you all caution or --

DR. KECK: It's one of the worst decisions to face, how do you make a policy decision in the absence of incontrovertible evidence, and that's very hard. Probably the best you can do is get a group of people who are knowledgeable about this, who are rational about it and don't try to make that decision yourself but rather get the best advice you can and pick an approach that's least likely to be harmful, most likely to be helpful, evaluate it and see.

MR. GREENBERG: I think the history of environmental and health regulation in the country for the most part in weighing are we going to be able to prevent harm because the weight of the evidence turns out to be that it's a bad thing or are we going to prevent unnecessary regulation and we have mostly opted to say, let's prevent unnecessary regulation and then down the road when we have more evidence,