{"id":2985,"date":"2014-01-26T13:52:36","date_gmt":"2014-01-26T18:52:36","guid":{"rendered":"http:\/\/blogs.edf.org\/health\/?p=2985"},"modified":"2024-02-12T11:01:33","modified_gmt":"2024-02-12T16:01:33","slug":"epic-fail-in-west-virginia-chemical-spill-poor-information-poor-communications-poor-decisions","status":"publish","type":"post","link":"https:\/\/blogs.edf.org\/health\/2014\/01\/26\/epic-fail-in-west-virginia-chemical-spill-poor-information-poor-communications-poor-decisions\/","title":{"rendered":"“Epic fail” in West Virginia chemical spill: Poor information, poor communications, poor decisions"},"content":{"rendered":"

Richard Denison, Ph.D.<\/em>,<\/em> is a Senior Scientist.<\/p>\n

[UPDATE 1\/28\/14:\u00a0 See updates at several places in this post regarding a 2011 Eastman safety data sheet on crude MCHM<\/em> \u2013 which,\u00a0though more recent than the 2005 version initally circulated, still does not reference the additional oral toxicity studies conducted by Eastman in the 1990s.]<\/em><\/p>\n

Little more than two weeks after the January 9, 2014, spill of multiple chemicals into West Virginia\u2019s Elk River, it\u2019s becoming increasingly clear that the private and public sectors at all levels failed miserably with regard to protecting the public\u2019s health.\u00a0 There is plenty of blame to go around.<\/span><\/span><\/span><\/p>\n

Our focus in <\/span>the blogging we\u2019ve done<\/span><\/a> about this terrible incident has been and remains on the lack of reliable information available on the chemicals involved in the spill, the failure to promptly share what was available with the public, and the shaky science upon which decisions and public communications as to the critical safety questions were based.\u00a0 In this post, I revisit several aspects of the initial and ongoing information gaps to add some additional perspective.\u00a0 <\/span><\/span><\/span><\/p>\n

I discuss in some detail below two major problems that I believe demand close examination in the Chemical Safety Board\u2019s and others\u2019 investigations into the causes and consequences of the spill:<\/span><\/span><\/span><\/p>\n

    \n
  1. State and federal officials appear to have initially relied on Eastman Chemical Company\u2019s incomplete and out-of-date Material Safety Data Sheet (MSDS) on \u201ccrude MCHM,\u201d and as a result sowed confusion from the outset that has led to widespread public mistrust.<\/span><\/span><\/span><\/li>\n
  2. Those same officials appear to have accepted without scrutiny the adequacy, accuracy and relevance of Eastman\u2019s additional toxicity studies of MCHM, based only on summaries<\/i><\/span> of those studies when they were finally provided by Eastman.<\/span><\/span><\/span><\/li>\n<\/ol>\n

    I end by briefly describing some of the implications of this tragic incident that need to be addressed going forward.<\/span><\/span><\/span><\/p>\n

    One caveat:\u00a0 Because information on this incident has emerged in a piecemeal and haphazard manner, I cannot vouch for the accuracy of every detail provided in this post.\u00a0 I have strived to the best of my ability to accurately describe the sequence and nature of events based on the available information.\u00a0 <\/span><\/span><\/span><\/p>\n

     <\/p>\n

    An incomplete Material Safety Data Sheet set in motion much of the ensuing mess<\/span><\/span><\/span><\/b><\/p>\n

    In situations like this, MSDSs are supposed to provide the information needed to inform appropriate responses.\u00a0 Because quick decisions need to be made, it is essential that such documents are complete and current.\u00a0 In this case, nothing could have been further from the truth.<\/span><\/span><\/span><\/p>\n

    Eastman Chemical Company\u2019s <\/span>2005 MSDS<\/span><\/a> for \u201ccrude MCHM,\u201d which surfaced in the first days after the spill, provided a single acute toxicity value for oral ingestion:\u00a0 a median lethal dose, or LD50, of 825 milligrams per kilogram of body weight.\u00a0 <\/span><\/span><\/span>A press report<\/span><\/a> in the Charleston Gazette<\/i> on January 11 indicated that Eastman regarded the unpublished 1998 study that was the source of that LD50 value to be proprietary and hence would not be made public.<\/span><\/span><\/span><\/p>\n

    [UPDATE 1\/28\/14:\u00a0 Eastman’s recently posted Q&A on the West Virginia spill<\/a> provides a link to a 2011 version of its “safety data sheet” for crude MCHM<\/a>.\u00a0 This 2011 document refers to the same LD50 value as did its 2005 MSDS and notably still does not provide any reference to the “no-observed-effect” level discussed further below.]<\/em><\/p>\n

    [UPDATE 1\/31\/14:\u00a0 This morning, Eastman posted an updated version of its Q&A document on its website (linked to in the above paragraph), and took down the earlier version.\u00a0 Here is the original version<\/a>, the updated version dated 1\/31\/14<\/a>, and a redline comparison of the two versions<\/a>.]<\/em><\/span><\/p>\n

    It is now quite clear, from that January 11 press report citing West Virginia health officials as well as from the Centers for Disease Control\u2019s (CDC) own January 20 \u201c<\/span>Summary Report of Short-term Screening Level Calculation<\/span><\/a>,\u201d that CDC used this acute lethality value as the sole basis for initially setting the one part per million (1 ppm) \u201csafe\u201d level for MCHM in drinking water.\u00a0 CDC\u2019s methodology for doing so has never been disclosed.\u00a0 I <\/span>blogged previously<\/span><\/a> about how this reliance on a median lethal dose to set a safe level for nonlethal effects was fraught with problems.<\/span><\/span><\/span><\/p>\n

    The first indication that additional studies on MCHM had been located came six days after the spill, in a January 15 <\/span>letter from the Director of CDC to the West Virginia Secretary of Health<\/span><\/a>.\u00a0 That same evening, <\/span>West Virginia health officials issued<\/span><\/a> their \u201c<\/span>Water Advisory for Pregnant Women<\/span><\/a>\u201d advising pregnant women not to drink the water at all until none of the chemical could be detected in the water.<\/span><\/span><\/span><\/p>\n

    It was not until a full week after the spill \u2013 late on January 16 \u2013 that Eastman decided to make its <\/span>studies public<\/span><\/a>, and even then, it only provided summaries<\/i> of them \u2013 more on this below.\u00a0 That same day, in a press call, CDC for the <\/span>first time described in more detail<\/span><\/a> how it had derived the 1 ppm \u201csafe\u201d drinking water level for MCHM.\u00a0 <\/span><\/span><\/span><\/p>\n

    But what CDC did not say was that it had pulled a switch<\/i>:\u00a0 Gone was any mention of the first and at that time only available study \u2013 the acute lethality study referred to in Eastman\u2019s MSDS \u2013 on which it had first relied.\u00a0 Instead, CDC said it set the value based on one of the newly found studies, a 1990 Eastman study that claimed to have identified a \u201cno-observed-effect\u201d level of 100 milligrams per kilogram of body weight per day (100 mg\/kg\/day).\u00a0 Miraculously, this second study CDC said supported the same \u201csafe\u201d level of 1 ppm it had set previously using the LD50 study.<\/span><\/span><\/span><\/p>\n

    I\u2019ll have more to say about CDC\u2019s reliance on the second study in a moment.\u00a0 But let\u2019s go back to why all this confusion and midstream switching happened in the first place:\u00a0 All indications are that state and federal officials relied on that incomplete and out-of-date MSDS from Eastman. \u00a0As I noted, that 2005 MSDS provides only a single oral toxicity value, the LD50 derived from Eastman\u2019s 1998 study.\u00a0 Despite the fact that Eastman\u2019s additional study that provided the \u201cno-observed-effect\u201d level CDC later used was conducted in 1990, no mention of it is made in its MSDS issued 15 years later.<\/span><\/span><\/span><\/p>\n

    [UPDATE 1\/28\/14:\u00a0 Eastman’s recently posted Q&A on the West Virginia spill<\/a> provides a link to a 2011 version of its “safety data sheet” for crude MCHM<\/a>.\u00a0 In the initial days after the spill, government officials appear to have been using the 2005 MSDS and only later was the 2011 version being circulated.\u00a0 However, this discrepancy is largely or entirely moot, as neither of the versions would have alerted officials to the additional data:\u00a0 the only acute oral toxicity data for crude MCHM provided in the 2011 version is the same LD50 value provided in the 2005 MSDS; the 2011 version still does not provide any reference to the “no-observed-effect” level.]<\/em><\/p>\n

    Eastman has now made available summaries of or references to several other unpublished oral and dermal toxicity tests, as well as a mutagenicity test \u2013 all conducted by Eastman long before 2005.\u00a0 Yet none of these is referenced in its MSDS.\u00a0 [UPDATE 1\/28\/14:\u00a0 These omissions apply to the 2011 as well as 2005 versions of the MSDS.]<\/em><\/span><\/span><\/span><\/p>\n

    [Believe it or not, this spill involves yet another example of an incomplete MSDS leading to confusion:\u00a0 As we now all know, <\/span>a second chemical<\/span><\/a> (actually apparently a mixture of chemicals) \u2013 called \u201cPPH, stripped\u201d \u2013 was in the leaking tank.\u00a0 That information was first revealed by the tank owner, Freedom Industries on January 21, 12 days after the spill.\u00a0 At that time, Freedom Industries made available <\/span>its MSDS on the substance<\/span><\/a>, which is dated October 2013.\u00a0 That MSDS references very little in the way of toxicity data.\u00a0 Yet the next day Freedom Industries revealed that \u201cPPH, stripped\u201d was actually a mixture of <\/span>two products made by The Dow Chemical Company<\/span><\/a>.\u00a0 It then provided Dow\u2019s MSDSs for those products, both of which predate Freedom Industries\u2019 MSDS and describe a considerable amount of toxicity data \u2013 virtually none of which is included in Freedom Industries MSDS.] <\/span><\/span><\/span><\/p>\n

    Under the Occupational Safety and Health Administration’s (OSHA) <\/span>Hazard Communication Standard (HCS)<\/span><\/a>, it is the obligation of chemical manufacturers and employers to maintain and provide accurate and current MSDSs.\u00a0 Obviously these requirements have been badly breached in this case.<\/span><\/span><\/span><\/p>\n

    \u00a0<\/span><\/p>\n

    CDC\u2019s apparent reliance on only a summary of Eastman\u2019s \u201cno-effect-level\u201d study and its unquestioning acceptance of Eastman\u2019s interpretation of the data were unwarranted<\/span><\/span><\/span><\/b><\/p>\n

    As noted earlier, Eastman posted <\/span>summaries of its studies to its website<\/span><\/a> a week after the spill, on January 16.\u00a0 This allowed the public for the first time to scrutinize the data CDC had relied on.\u00a0 None of these studies has been published or peer reviewed<\/i>, and up until their posting Eastman had indicated that all of the studies were proprietary.<\/span><\/span><\/span><\/p>\n

    Upon examining the key <\/span>\u201cno-observed-effect\u201d study<\/span><\/a> CDC is now indicating it used as the basis for the 1 ppm level, two things were quickly apparent:<\/span><\/span><\/span><\/p>\n

    First, the study was conducted on a different test substance than what actually spilled<\/span>.\u00a0 While the <\/span><\/span><\/span>LD50 study<\/span><\/a> had tested \u201ccrude MCHM\u201d \u2013 the material that actually spilled into the Elk River on January 9 \u2013 the \u201cno-observed-effect\u201d study had been conducted on \u201cpure\u201d (97.3%) MCHM \u2013 a rather different test substance.\u00a0 <\/span><\/span><\/span>Some experts<\/span><\/a> argue that distinction is far from trivial.\u00a0 At the very least, CDC should have prominently flagged this difference between what was tested and what was spilled, and discussed its implications.<\/span><\/span><\/span><\/p>\n

    Second, the study summary indicates that effects from exposure to MCHM were actually observed at the \u201cno-observed-effect\u201d level asserted by Eastman, as well as at the lowest dose tested in the study<\/span>.\u00a0 Nonetheless, Eastman had dismissed their significance and still used the study to set the no-effect-level at 100 mg\/kg\/day.\u00a0 This is common practice in industry toxicity studies:\u00a0 Present the data and then argue why an observed effect isn\u2019t real.<\/span><\/span><\/span><\/p>\n

    NRDC toxicologist Dr. Jennifer Sass pointed all this out in an <\/span>excellent post to her blog dated January 19<\/span><\/a>.\u00a0 She notes that the study showed changes in both body and organ weight even at the lowest dose tested, but that Eastman had rejected them by arguing that the effects either were not statistically significant or did not change uniformly with dose.\u00a0 She points out that very small numbers of rats \u2013 only two males and two females \u2013 were exposed at each dose level, which calls into question the statistical grounds on which Eastman dismissed rather than included the effects seen even at the lowest dose.<\/span><\/span><\/span><\/p>\n

    The implications are far from trivial:\u00a0 In her blog post, Dr. Sass notes that use of the lowest dose tested as a lowest-observed-effect level would have reduced CDC’s “safe” level by a factor of 40.<\/span><\/span><\/span><\/p>\n

    While experts may disagree in interpreting these kinds of data, here\u2019s the problem: CDC seems to have accepted Eastman\u2019s conclusions without any question.<\/i><\/b>\u00a0 And that\u2019s especially problematic because, as Sass notes, the Eastman document is only a summary<\/i> of the full study.\u00a0 <\/span><\/span><\/span><\/p>\n

    Indeed, Tables 1 and 2, which present the results, are titled \u201cSummary of Repeated Exposure Study.\u201d\u00a0 They only provide qualitative indicators of the actual results \u2013 all assigned by Eastman.\u00a0 So, for example, rather than providing actual measurements, the authors merely indicated that various measured parameters were \u201cnormal\u201d or used up or down arrows and a numeric 1-3 scale to indicate whether there were \u201cslight,\u201d \u201cmoderate\u201d or \u201cgreat\u201d increases or decreases.\u00a0 None of these terms is defined, nor is how the authors determined whether the results were statistically significant or not.<\/span><\/span><\/span><\/p>\n

    In the absence of access to the actual study data, there is simply no way for independent observers \u2013 whether from CDC or the public \u2013 to draw their own conclusions about what effects the study did or did not find and at what doses.<\/span><\/span><\/span><\/p>\n

    There is no indication that Eastman has provided the full study to anyone; if CDC has it and has analyzed it, then it needs to state so publicly and provide its own assessment of the data.<\/span><\/span><\/span><\/p>\n

    It should be noted that Eastman provided summaries of multiple studies, and this same concern about lack of scrutiny by CDC and lack of access to full study results applies to all of them.<\/span><\/span><\/span><\/p>\n

    Simply accepting at face value the chemical manufacturer\u2019s own interpretation and conclusions from the data, and doing so without access to and examination of the underlying data, is a huge breach of the public\u2019s trust. <\/span><\/span><\/span><\/p>\n

     <\/p>\n

    Implications<\/span><\/span><\/span><\/b><\/p>\n

    Unfortunately, the damage to public trust has been done and will not be easily undone.\u00a0 I do empathize to some extent with government officials, who were caught by the spill with little to go on and had to make decisions on the fly.<\/span><\/span><\/span><\/p>\n

    But in some ways, that\u2019s the whole point:\u00a0 Flaws in the system like the ones I have described often don\u2019t become apparent until there is a crisis and the need for information and utmost transparency becomes paramount.\u00a0 And there is nothing to indicate that the possibly of a spill like the one we have just witnessed could not have reasonably been anticipated. <\/span><\/span><\/span><\/p>\n

    All of this means we need a system that prepares in advance<\/i> for such circumstances as we\u2019ve seen play out in West Virginia this month:\u00a0 That would be a system that: <\/span><\/span><\/span><\/p>\n