Speaker: Rob McConnell, USC

Presentation (PDF) by Rob McConnell, M.D., Associate Professor, University of Southern  California Presentation in Word

Jeanette Swafford, Director of Health  Initiatives, Collaborative on Health and the Environment, co-coordinator  of the Asthma and  the Environment Discussion Group: I’d like to welcome everyone  to the first call of Asthma and the Environment Discussion Group.  On today’s call, we’ll begin with a summary of who’s  on the line, and then mute lines and go to a presentation by Dr.  Rob McConnell of the Keck School of Medicine at the University  of Southern California. Then we’ll have a twenty minute question  and answer period. Finally, we’ll take twenty minutes to  discuss the direction of the group, which is unusual, but will  be important on this call. Dr. McConnell’s presentation for  the call is posted online, at http://www.healthandenvironment.org/wg_asthma_news/247.  A participant list is also posted. There are three coordinators  of this group, and my two co-conspirators are Polly Hoppin at the University of Massachusetts, Lowell, and Ani Gupta of the Center  for Environmental Health in Oakland, California.

Ani Gupta, Center for Environmental  Health: I coordinate the Community  Health Program here, so I work with Community-based organizations,  building bridges between the science that people need and peoples  campaigns and struggles for health on the ground. To me, the timescale  for asthma outcomes is do-able, in the neighborhood of several  years, and hopeful in a field when there are lag times of thirty  years or more between chemical exposures and health outcomes. We’ve  received seventy RSVP’s for this call—not time for  roll call. We have ten registered nurses; clusters of people in  Massachusetts, the Bay Area, the Detroit metropolitan area, and  Seattle; we have members of the American Lung Association in several  states; a dozen academic scientists; we have community-based organizations  in South Bronx, Detroit, and Oakland; Public Health Agencies in  several cities and states; Environmental Organizations in Minneapolis,  Boston; and independent researchers in several states. We will  send out, with call notes, the participant list, with full contact  information in a couple of weeks.

Jeanette Swafford: A little bit of background on this group: in  2003, we had a partnership call on asthma, which was followed by  a call in November of 2004, called True Grit: Particulate Matter  and Health. After the November call on particulates, Polly Hoppin  of University of Massachusetts, Lowell, came forward and agreed  to co-lead a group focused on asthma and the environment, in answer  to widespread interest in follow-up from the call.

Polly Hoppin, U. Mass Lowell: I’m thrilled with the mix of  people on the call. There are also a number of people interested  in the discussion group, but who were unable to make the call.  I’ve been working on asthma for a number of years, in government,  non-government, and now in the academic realm through U. Mass,  Lowell. It’s exciting to bring together people from multiple disciplines, focused on health and the environment. I’m affiliated  with the Lowell Center for Sustainable Production, and I’m  working with asthma as an important part of health and the environment.

 We’re looking forward to creating a discussion series with  regular presentations from cutting-edge work, both on science and  policy sides, and building toward collaborative work, bringing together people from different backgrounds and perspectives to  understand the science better and to chart a course for moving  forward. The science on asthma and the environment is rapidly evolving,  as is the information on environmental interventions. It’s  an exciting time to explore how new knowledge can open opportunities  for solutions.

 Rob McConnell is an associate professor in dept of preventative  med at USC. His training is in medicine and epidemiology, he has  worked with the Centers for Disease Control and the World Health  Organization, in non-profits and now in academia. His focus area  is air pollution and childhood respiratory health, especially asthma.  He is the PI on several important studies many of you have seen  in the news in past year regarding links between outdoor air pollution  and respiratory effects.

Rob McConnell: Thanks, Polly.  It’s my pleasure to be here,  and doing this. On the speaker phone with me is Andrea Hricko,  who is head of the outreach core here. I hope everyone has access  to the PowerPoint presentation. I’ll be following it closely  in the ten minutes that I have allotted. I’d like to focus  on the results from the children’s health study, but also  lots of topics related to air pollution and asthma. The asthma  epidemic has been increasing in the last thirty years, especially  among children in the developed world, perhaps leveling off in  the last few years. Most importantly, the cause of epidemic is  unknown, but we know a lot about triggers. Perhaps triggers are  involved in causing the disease. Listed triggers: outdoor air pollution, indoor air pollution, allergens, second-hand tobacco smoke, early  and later life infections, obesity, dietary factors, second-hand  smoke, ozone and air particulates. I have listed health effects  that a number of studies have linked with these particulates. At  least until recently, the common wisdom on air pollution and asthma  has been that it exacerbates asthma, but recently, we see that  air pollution may actually cause asthma. There are implications  for the burdens of the disease and the costs associated with them.

 Los Angeles is our laboratory, and has some of the worst air pollution  in the US as a region. The Los Angeles air basin’s air pollution  is caused by traffic, and there is regional, wide-spread pollution:  smog blankets large parts of the basin, primarily from auto emissions.  Local pollution has different effects near major roads. We have  been doing this study for more than ten years now.

 We’ve done a longitudinal study of 6,000 children, by now  12,000 children in 12 communities, since 1983 (??). First assessed  effects on lung-function and growth, then other symptoms and health  conditions related to air pollution exposure. There is also a school  absence monitoring program, that we won’t talk about too  much on this call. We analyzed asthma clusters inside the air basin  and outside of it.

 You’ll see on the slide a picture of the twelve communities  involved in the study. There is a cluster of communities inside  the air basin, and then communities with different mixes of pollutants  outside of the air basin. We set up a monitoring station in each  community.

 There are two primary pollutants, ozone, and a series of other  pollutants that are fairly highly correlated among the different  communities. PM 2.5 has a heavy concentration up against mountains  in Riverside and Mira Loma, and to a lesser degree as you spread  out to give the contrast we’re interested in.

 Air pollution makes asthma worse. As an example, the red dots are  the rates of bronchitis in children in communities that have asthma.  Bronchitis rates are tied to children with asthma in communities  with high concentrations of particulate matter. There is a larger  effect of pollutants on bronchitis in children who are playing  team sports, a marker for outdoor activity in polluted communities,  and a source of exposure. Children with asthma are a group that  is uniquely susceptible to air pollution. We also found higher  rates of bronchitis among children who play team sports, which  is a marker of outdoor exposure to air pollutants.

 We looked at role of exercise in polluted versus clean communities.  Dividing the communities into two groups, we can see that in high  ozone sites, children have 3x the risk of developing asthma over  the course of the follow-up of this study, compared to children  in low-ozone sites. In sites with low-ozone counts, there is no  effect of playing team sports on asthma rates. This was controversial  when it came out three years ago, but a number of toxicological  studies have shown through a monkey model of asthma developed at  UC that air pollutants can cause a disease that looks a lot like  asthma.

 Let’s shift gears. Up until now, we’ve studied regional  pollutants and the broad spread of smog. Now we’ve switched  to local pollutants, again traffic-related pollutants, fresh vehicular  exhaust that you might see near a busy roadway. The community we  studied is Nottingham—a large group of children were evaluated  with respect to asthma and the distance of their homes to a main  road. We saw a dramatic increase in asthma rates at 30m to a main  road. These results are similar to children’s health study,  and correspond well to data from colleagues at UCLA that show dramatic  increases in total particle numbers and other kinds of pollution  at a distance of 50-75m from 405 freeway, as well as increased  asthma rates. In Riverside, we geo-coded children in our study,  overlaid homes and major street arteries, and estimated exposures  at the homes. A study forthcoming from the journal “Epidemiology” shows  that NO2 measured at the homes corresponds to inner quartile range  a doubling of rates of lifetime asthma and corresponds to the model  developed by our UCLA colleagues.

 How does NO2 correspond to asthma prevalence? Similarly to freeways.  It’s not clear what role air pollution is playing in the  epidemic of asthma—often it’s said that air pollution  couldn’t have an effect on the epidemic, because regional  pollutants such as ozone, NO2, etc. have decreased in the last  ten years, but PM 10 and 2.5, localized pollutants from fresh traffic  exhaust, have been increasing in specific areas over time.

 I’ll close with some challenges to policy makers. The current  standards clearly aren’t adequate to protect children with  asthma from the exacerbation of the problem. They don’t protect children who already have asthma. Also, there is increasing evidence  that children are at-risk for developing asthma as a result of  exposure to pollutants. Local traffic exhaust hasn’t been well-addressed by local regulators.


Question and Answer Period:

David Schonbrunn, Transportation Solutions  Defense and Education Fund: We are party to a challenge to federal highway administration  for the highway in Las Vegas, and this is seen as a national test-case  for whether this kind of epidemiological information is going to  be considered in widening of highways.

 Andrea Hricko, University of Southern California: I was under the  impression that they had lost case in Vegas?

David: It’s currently before  the 9th circuit court of appeals. It may be a way in, in terms  of a way of goosing the regulatory  system.

John Balbus, Environmental Defense: The EPA regulations on fine  particulates, pm 2.5 and below, are open for comment for one more  day. If you want to weigh in, be in touch after the call. Here  is my question for Rob: on the study, we see model pollution from  freeways and non-freeways. There is an association with pollution  from freeways, but not from non-freeways. Why is that?

Rob McConnell: Jim Gardner is  the first author on that study. It’s  not clear why we see this effect from freeways. See effect clearly  with simple distance to freeways. The most likely explanation is  that the distance to a freeway in Southern California is an indicator  of exposure to traffic, not only from the freeway, but also from  feeder roads and arterioles that are very busy as well. People  in those areas get exposure both from the freeway and the busy  roads that feed into it. That’s a better indicator to overall  exposure to traffic than non-freeway exposure from all the other  roads in the community, where traffic is not nearly as well-measured.  We get all of our traffic data from CalTrans, which does a very  good job of measuring automobile and vehicular traffic on the busiest  roads, but not on the other roads. Also, there could be something  about emissions from freeways that are different from those of  local roads.

Jack Fox, Citizens Protecting our Rural  Environment: We are experiencing  a situation anticipating the siting of asphalt and cement batch  plants. Can you discuss the relationship of asthma to both of those  facilities?

 Rob McConnell: not aware of literature relating asthma to cement  and asphalt plants. Asphalt plant will have volatile and reactive  combustion products that would exacerbate asthma.

Terry Greene, JSI Center for Environmental  Health Studies: To respond  to the last caller—contact Alternatives for Community and  the Environment, also known as ACE, in Boston, http://www.ace-ej.org/.  Phone number is 617-442-3343; they gathered research on asphalt plants

 Rob McConnell: In addition, there’s a very good community  group in SD called the Environmental Health Coalition that does  great work on air pollution.

Andrea Hricko: Also NIOSH has several documents on and asphalt  and emissions. One, on occupational exposures to asphalt is available  at: http://www.cdc.gov/niosh/pdfs/01-110.pdf. The NIOSH homepage  is: http://www.cdc.gov/niosh/homepage.html, and a search of the website yields several reports of March 25, 1998, that give descriptions  of specific pollutants from an asphalt facility.

Bill: Mentioned multiple studies that showed air pollution as a  cause of asthma. Post some studies on the CHE website.

Rob McConnell: Some of those studies are cited, the toxicological  ones. There is a whole series of European studies that have looked  at the relationship between asthma and wheeze near busy roadways.

Andrea Hricko, USC: Sierra Club  has a recent report with a lot of the literature about living or going to school near a busy road  or freeway. There are citations, and a several paragraph abstract  of each one. One extensive report is called “Highway Health  Hazards,” http://www.sierraclub.org/sprawl/report04_highwayhealth/report.pdf.

Carolyn Wysocki, Ecological Health Organization,  Inc., CT: There’s  a lot of discussion about substituting diesel fuel with biodiesel  fuel. Does anyone have an opinion about whether we’re creating  a new problem by making the replacement?

Sylvia Swan, Tri-County Watchdogs: Calling  from the Frazier Park, California area. We’re dealing with major industrial factories—they  are not licensed as incinerators. One of them is a major national  corporate organization, Texas industries. The facilities have switched  over to using diesel fuel. They are licensed to burn 4 million  gallons of diesel annually, and in a rural community, so there  is virtually no response because the agencies are so far away.  After the switch to biodiesel, the Air pollution Control Board  has not been able to determine what they’re using as a biodiesel  source. It could be anything (vegetable oil, animal fat, oil or  fuel saturated grounds for reclamation). So this is a critical  issue and it’s happening nationally.

Andrea Hricko, USC: The City of Santa Monica just switched some  of its equipment to Biodiesel: http://santa-monica.org/epd/news/Biodiesel_Press_Release_3_21_05.htm.  It had a town meeting recently, and one scientist was asked the  same question. If you’re burning biodiesel, you’ll  be coming up with particulate matter that needs to be studied and  that cannot be assumed to be safe. We can look up some references  for you (contact Andrea at 323-442-3077, ahricko@usc.org.

Rob McConnell, USC: There is a fair amount of toxicological study  relating to diesel and allergens. Diesel is known to be a bad actor,  but there has not been enough toxicological or human study to make  assessment of biodiesel or the new diesel engines that trap the  larger particles. New engines have reduced the emissions standards  have reduced the total particulate mass, but the number of particles  that are toxic, or toxic particle concentrations, may be increasing.  This issue requires some careful investigations before we jump  on some changes in policy that might create another problem.

John Balbus, Environmental Defense: We  haven’t really done  studies on the epidemiological aspects of biodiesel. But I should  point out that biodiesel does reduce greenhouse gases, and total  particulates, but increases the NOx, so in places with high ozone,  this may not be good. There are some environmental benefits.

Andrea Hricko, USC: We don’t  want a solution that creates another problem, like asking companies  to jump to MTBE.

Barbara Wilkie, Environmental Health  Network: EHN—Berkeley  trash and recycling uses biodiesel, www.ecologycenter.org.

 Note from Barbara: for those wanting to learn more about biodiesel,  the site I had recommended is: Ecology Center, Berkeley California  and two of their pages to start with:
http://www.ecologycenter.org/erc/fact_sheets/biodiesel.bbc.html
http://www.ecologycenter.org/erc/fact_sheets/biodiesel.html

 Rob McConnell, USC: I’d like to make a comment on John’s comment regarding the benefits of diesel. It’s clear that some vehicles run better on diesel, like big trucks. Arguments that diesel reduces the emissions of greenhouse gases were widely promoted as a reason to switch the automobile fleet over to diesel. It has been successful in Europe, and has been a big part of the switch to biodiesel. There are unknown hazards to that sort of a policy. The question should be: could we have more fuel efficient cars period, rather than tinkering with the type of fuel.

Sylvia Swan, Tri-County Watchdogs: With regard to the facility in my community—it is considered an aggregate because it is also an incinerator. Natural Gas and biodiesel are both burned, so the sulfur content of emissions could be very high. We’re coming up for Title V permitting, April 21st. Western Europe managed to reduce the sulphur content to a large degree, but it’s not so in this case, because of the different combination of fuels.

 John Balbus, Environmental Defense: Just to clarify, my question was not about diesel versus gasoline, but about a biodiesel blend vs. 100% diesel.

Michael Lerner, Commonweal: Rob, what are your thoughts for a working group of the Collaborative on asthma? What are the shared scientific and policy interests that might best shape the future dialogue and collaboration of this working group. Where do you see the opportunities for science dissemination, science development, and policy that might help us to shape the direction of a large group of people from grassroots activists to senior academics?

 Rob McConnell, USC: As I’m new to this discussion, I may not be the most appropriate person to answer your question. There are good opportunities now to engage some policy-related issues around air pollution—both with respect to asthma and other respiratory and cardiovascular effects, whole series of effects of air pollution. Particularly issue of local effects right around busy roadways is one that hasn’t been addressed. This new research is ripe for policy and remains unaddressed. The regulatory paradigm would have to be different from what we’ve done up until now, which is to regulate pollutant concentrations over a wide geographic area. This really has more urban planning applications to it—implications for roadways, schools, housing, play and exercise areas, etc.

 Michael Lerner, Commonweal: Polly, what do you see as a potential direction for the working group from others on the call?

Jeanette Swafford, Collaborative on Health and the Environment: Let’s transition and conclude the question and answer, and move into a discussion, which is a great segue. Rob is speaking on a documentary called “Children on Asthma” on KQED. The video came out in 2002, and is still very solid. We’ll include the link in the notes: http://www.filmakers.com/indivs/ChildrenAsthma.htm. Need to have some agreement on the structure of the group. As a little background, in 2003 we had a CHE Call on asthma, in 2004 a call on particulate matter. After that, a core group came together and began the evolution of this particular discussion group. The purpose is to share ideas and talk about the emerging science on asthma. CHE’s goal is to raise the level of professional and public dialogue: scientists, community based groups, health advocates, and health-affected groups.

Polly Hoppin, U. Mass Lowell: We’ll spend the next few minutes, and this is unusual, in the future, we won’t spend time—talking about the focus of the group and structure. We’ll take time now to do that to ensure that this is a useful effort for all of us. My thought about the focus of the group is that focusing on asthma is an agenda that is both large, but manageable. The science is evolving rapidly, and asthma is a large concern among many constituencies. The thrust of financing for asthma has been on asthma management and pharmaceutical treatment, important aspects of management. But the environment has been a stepchild, both in clinical setting, and in science. In the last few years, the science has evolved very rapidly. Providers and research communities, those involved in financing, and coalitions, have recognized the importance of environment in asthma and focused on integrating efforts. There is much ground to be gained on work in asthma by addressing the environmental piece.

 Air quality, indoor and outdoor, is central to the environmental aspects of asthma. Air contamination is linked to asthma, and also other health issues that are topics of conversation in CHE. Should we have the focus of a group on air quality and health, or on asthma with air quality being one element? We suggest that we do the latter, and focus on asthma. Other health effects may come up, and we may want to take on other acute and chronic health concerns over time. But the proposal for now is that we focus on asthma. We’d like to hear your response in terms of focus. Then we’ll move on to outreach in the last minutes of the call. And we’ll also discuss the timing of the calls.

Ronald Saff, Allergy and Asthma Diagonostic Treatment Center: I’m an asthma specialist in Tallahassee. Happy to hear about the focus on asthma--let’s keep in mind that asthma affects only 7% of the US population, and half of the incidences are pretty mild. However, if you open it up and include the general effects of heart and lung disease, and consider that air pollution is carcinogenic, more people would be interested.

Sylvia Swan, Tri-County Watchdogs: In our 25-mile radius, have many facilities contributing to a wide array of diseases, MS, heart disease, lung disease and other problems. Because the population is too small, can’t get a good study with only asthma. Nationally, incinerators are going to small communities where studies on a single disease can’t be informative.

Aileen Gagney, American Lung Association, of Washington: I’m working with the Environmental Coalition of South Seattle and the Children’s Hospital of Seattle. We’re focusing on local programs right now, and fighting asthma through reduction of environmental triggers in the home. Hopefully, we’ll secure future funding for more general projects. If you’re interested in participating, please contact me at agagney@alaw.org. We’re expanding project onto other effects. I wonder if that expansion in this group would dilute the information

John Balbus, Environmental Defense: ED has grappled with the issue over the last year—to focus on asthma or take a broader focus. Focus groups demonstrate that you’ll have more of the general public interested by broadening beyond asthma. But if the Collaborative is focused on health-affected groups, an initial focus on asthma could be very effective. Community groups and others are primarily focused on medical interventions, rather than environmental. We could do great work with a focus on asthma and the environment.

Barbara Wilkie, Environmental Health Network: I’d like to segue between today’s lecture and a question about the home environment. An article appeared in the LA times in March of 2003 “Chemicals in the home are a big smog source.” Commonly used consumer products, personal care and cleaning and maintenance products, come in second to vehicular exhaust for creating smog. Barbara emailed the URL’s, below.

 Chemicals in Home a Big Smog Source
 GARY POLAKOVIC / LA Times 9mar03

 " Cleansers, cosmetics and other products pump 100 tons of pollutants daily into the Southland's air, ranking second to tailpipe emissions, studies show.

 " Ordinary household products such as cleansers, cosmetics and paints are now the Los Angeles region's second-leading source of air pollution, after auto tailpipe emissions, air quality officials say. ..."
http://www.mindfully.org/Air/2003/Home-Chemicals-Smog9mar03.htm

Neil Gendel, Healthy Children Organizing Project: Exposures to fetuses, infants, toddlers and small children, mostly in the mothers womb and in the home at an early age are the main part of our work. Let’s begin by focusing on asthma with a realization that when we do it will help us to broaden over time. There are things we can do now in the home right now. We may be able to do more in the home than outside the home right now. Especially interesting is the emerging research on small children, causes of asthma, and susceptibility to allergens.

Polly Hoppin, U. Mass Lowell: We’ll send around to the listserv additional comments on focus. Also, please respond to Jeanette’s email about various possible of focuses. We welcome general comments, but also specific topics for future calls, or suggestions about particular presenters. We’ll be moving to 2-3 presenters on a given call.

Jack Fox, Citizens Protecting our Rural Environment: I wanted to second Sylvia’s comment and emphasize the need for work on asthma for people who are health-effected.
 Michael Lerner, Commonweal: There was an extraordinary response to this call—perhaps we could alternate calls for the Working Group. There are voices for asthma and voices for the broader respiratory issues. We could try both approaches, and come down to smaller number of people on each call to create more opportunity for interactions.

Jeanette Swafford, Collaborative on Health and the Environment: We’ll continue the discussion via the listserv to hone the focus. We did not decide on a frequency of future calls. With the number of people, and our busy schedules, I’d like to propose that we perhaps meet every other month? Perhaps ML’s proposal would affect that a bit: every month, but alternating?

Michael Lerner, Commonweal: There are strong voices both ways, and CHE is here to serve the partnership—we could reflect on it, but have a monthly call, and alternate back and forth, so that asthma and air quality could both be discussed.

Jeanette Swafford, Collaborative on Health and the Environment: If you have an opinion, please email Polly, Jeanette, or Ani. Notes from the call will be distributed along with the participant list. If you don’t want your contact information distributed, please contact Ani Gupta. Thank you.

[session end]

 1. Aileen Gagney, American Lung Association of Washington
 2. Ameesha Mehta-Sampath, MPH, Asthma Projects Coordinator, EPA  Region II:DEPP-RIAB, New York
 3. Amy Friedman, MPH, Univ. of Michigan School of Public Health
 4. Amy D. Kyle, PhD MPH, UC Berkeley School of Public Health
 5. Andrea Hricko, MPH, Community Outreach and Education, Southern  California Environmental Health Sciences Center
 6. Ani Gupta, Center for Environmental Health
 7. Anthony DeLucia, PhD, Board of Directors, Kingsport Tomorrow
 8. Barbara Kwetz, Director, BWP Planning & Evaluation Division
 MA Dept. of Environmental Protection
 9. Barbara Wilkie, President, Environmental Health Network of California
 10. Bonnie Holmes-Gen, Assistant V.P., Government Relations, American  Lung Association of California
 11. Brenda Afzal, RN, MS, Environmental Health Education Center,  University of Maryland School of Nursing
 12. Brenda Olsen, RN, Assistant CEO/Director of Governmental Affairs,  American Lung Association of Florida, Inc.
 13. Carolyn Wysocki, MA, MHSA, President, Ecological Health Organization,  Inc.,
 14. Claire L. Barnett, Executive Director, Healthy Schools Network
 15. Deanna Rossi, MPH, Health Educator/Policy Specialist, California  Department of Health Services, Environmental Health Investigations  Branch
 16. David Schoenbrun, Transportation Solutions Defense and Education  Fund
 17. Diana Vanek, Outreach Coordinator, Center for Environmental  Health Sciences, University of Montana
 18. Don Milton, MD, DrPH, Professor, School of Health & Environment,  U. Massachusetts Lowell, Senior Adjunct Professor, Harvard School  of Public Health
 19. Doug Brugge, Ph.D. Tufts University School of Medicine
 20. Eleni Sotos, MA, National Coordinator, Collaborative on Health  and the Environment
 21. Elizabeth Toomer, City of Detroit Department of Environmental  Health
 22. Ellen Dorsey, PhD, Program Officer, Heinz Endowments
 23. Esther Bush, Asthma Coordinator, Coalition for Community Health
 24. Félix Aguilar, MD, MPH, FAAFP, Long Beach Department  of Public Health
 25. Frances Dwyer, PhD, MSN, Massachusetts Department of Public  Health, Bureau of Environmental Health Assessment
 26. Frieda Nixdorf, Administrative Specialist, Collaborative on  Health and the Environment
 27. James Krieger, MD, MPH, Chief, Epidemiology Planning and Evaluation  Unit, Public Health - Seattle and King County
 28. Jean Armbruster, MA, Children's Health Analyst, Los Angeles  County Department of Health Services
 29. Jean Zotter, Director, Boston Urban Asthma Coalition
 30. Jeanette Swafford, MHEd, Director of Health Initiatives, Collaborative  on Health and the Environment, Commonweal
 31. Jack Fox, Citizens Protecting our Rural Environment
 32. Joe Perez, South Bronx Clean Air Coalition
 33. Joel Ervice, Associate Director, Regional Asthma Management  and Prevention Initiative
 34. John Balbus, MD, MPH, Director, Health Program, Environmental  Defense
 35. Jonathan Levy, ScD, Assistant Professor of Environmental Health  and Risk Assessment, Harvard School of Public Health
 36. Juan Miguel Turnil, Coordinator, Community Organizer, Little  Village Environmental Justice Organization
 37. Julia Earl, MS, Preventing Harm Minnesota, Coordinator, Women's  Cancer Resource Center
 38. Julie Osgood, MS, Program Manager, Clinical Integration, MaineHealth
 39. Kevin Kennedy, Environmental Health Program Manager, Allergy,  Asthma, Immunology, Children's Mercy Hospital, Kansas City, MO
 40. Laurie E. Zylstra, RN, Asthma Care Manager, Neighborhood Health  Plan of Boston
 41. Lavinia Weissman, WorkEcology
 42. Leyla McCurdy, Senior Director, Health and Environment Programs,  National Environmental Education and Training Foundation
 43. Lisa Papi, Executive Director, MoldAcrossAmerica, Inc.
 44. Lynn Carroll, PhD, Database Manager, The Endocrine Disruption  Exchange
 45. Margaret Gordon, West Oakland Healthy Homes Collaborative
 46. Maria Valenti, Program Director, Greater Boston PSR
 47. Marie Chan, BS, Chemistry, Novato Unified School District's  Indoor Air Quality Steering Committee
 48. Marie Hoemke, RN, PHN, BS, MPA, MA, Public Health Nurse, San  Francisco Asthma Task Force
 49. Mark Mitchell, MD, MPH, President, Connecticut Coalition for  Environmental Justice
 50. Martha Dina Arguello, Director of Health and Environment Programs,  Physicians for Social Responsibility, Los Angeles
 51. Mary-Frances Kornak, MPH, DC Department of Health, Primary  Care and Prevention Administration
 52. Mary Jo Harris, RN, MS, Program Director, Baltimore City Health  Department Childhood Asthma Program
 53. Mary Ostrem, Boston Public Health Commission
 54. Mathew Barlow, PhD, Atmospheric and Oceanic Diagnostics, AER,  Inc.
 55. Matt Richards, Tri-County Watchdogs
 56. Melinda Sobin, Regional Environmental Advocate, New York PIRG
 57. Michael Lerner, PhD, President, Commonweal
 58. Michelle Gottlieb, MEM, Greater Boston PSR
 59. Molly Jacobs, MPH, Research Associate, University of Massachusetts,  Lowell
 60. Molly Miklosovic, MPH, Univ. of Michigan School of Public Health
 61. Myriam Laura Beaulne, Biologist and Environmental Health Organizer,  Massachusetts Clean Water Fund and Clean Water Action
 62. Nancy Boyce, BSN, MA MarinLink
 63. Neil Gendel, Director, Healthy Children Organizing Project,  Consumer Action San Francisco
 64. Norman Anderson, MSPH, American Lung Association of Maine
 65. Olin Webb, Bayview Hunters Point Community Advocates
 66. Pamela Elizabeth, Project Director, ‘Beating Asthma’ Neighborhood  Health Plan of Rhode Island
 67. Patricia Heinrich, RN, MSN, Chief Quality Improvement Director,  New Product Design, NICHQ - The National Initiative for Children's  Healthcare Quality
 68. Polly Hoppin, ScD, Director, Environmental Health Initiative,  Lowell Center for Sustainable Production, School of Health and  Environment, University of Massachusetts, Lowell
 69. Rebecca Clouse, RN, BS, Environmental Health Liaison/State  Government Affairs, American Nurses Association
 70. Rhonda Duerst, RRT-NPS, CQI Coordinator, Fight Asthma Milwaukee  Allies
 71. Robert McConnell, MD, Keck School of Medicine, University of  Southern California
 72. Robert Gould, MD, President, San Francisco Bay Area Physicians  for Social Responsibility
 73. Robert L. Wahl, DVM, MS, Environmental Epidemiologist, Division  of Environmental and Occupational Epidemiology, Michigan Department  of Community Health
 74. Robert S. Knorr, MPH, Director, Environmental Epidemiology  Program, Center for Environmental Health, Massachusetts Department  of Public Health
 75. Robin Dodson, MS, Doctoral Candidate, Harvard School of Public  Health
 76. Ronald H. Saff, MD, Allergy & Asthma Diagnostic Treatment  Center
 77. Sandra Roseberry, Coalition for Environmentally Safe Communities,  ME
 78. Sandy Ross, Health and Habitat
 79. Sara Donahue, Environmental Health Initiative, University of  Massachusetts, Lowell
 80. Sarah Gourde, Coalition for Environmentally Safe Communities,  VA
 81. Sonya Lunder, Environmental Working Group
 82. Stephanie Chalupka, Stephanie M. Chalupka, EdD, APRN, BC, CNS,  Professor, Department of Nursing, University of Masachusetts Lowell  , School of Health and Environment
 83. Steve Redd, MD, Chief, Air Pollution and Respiratory Health  Branch, CDC
 84. Sylvia Swan, Tri-County Watchdogs
 85. Terry A. Greene, Research Associate, JSI Center for Environmental  Health Studies
 86. Theodore Carrington, New Jersey Work Environment Council
 87. Tracey Woodruff, PhD, MPH, National Center for Environmental  Economics, US Environmental Protection Agency