So Bobby Pillowby is a distinguished expert in environmental health, occupational medicine, whose career has spanned over two decades of dedicated service. The more I find out about Al, I mean, we are brothers from a known mother. I'm so impressed with what he's done in the United States Navy. He started out in the special forces and supporting the SEALs in that community right up to 9-11. He did a wonderful job. He's at the Interregional Public Health Center right now in Virginia, where his executive team guides a multidisciplinary team tackling critical public health challenges from mold and health and in fuel spills to painkillers and red fuel, which he has been intimately involved in here lately, contamination of drinking water. His remarkable journey began as a diving and submarine medical officer supporting the SEALs in a role overseeing occupational health services and medical care for thousands of federal workers and military personnel. In October of 2008, Dr. Pillowby completed a one-year deployment as a public health clinician in Northeast Africa, while he was there, he supervised planning and execution of five large medical civic actions projects, known as MCAPs, providing medical care, prevention, and health services to more than 14,000 people in five countries as part of a combined joint task force formed with Africa, Hoa. His academic credentials are equally impressive with forced mutations in occupational preventives and undersea and hyperbaric medicine and a solid foundation in sports medicine. From his tenure as a Division I collegiate through team's position, joining us in well-being, Dr. Pillowby, a true leader. Thank you for having me speak here today. This is actually a lot, many of these slides, I have to give credit, they go to, credit goes to Colonel John O, who's at the Defense Health Agency, because I'm somewhat restrained a little bit, I will add some comments to the slides as we go through these personal comments, but as well as Diana Felton, who's the Senior Toxicologist for Department of Hawaii Public Health. Everybody, am I pressing right? Yeah, I might have started here. Usually if you toggle back and forth one time with this, it'll turn on your review, so I'm not trying to. The usual disclaimer, this represents, talk represents my views, but again, available for public release and prepared as part of our official duties with the U.S. Navy. Learning objectives, comprehending a little bit about the November 2021 release of JP-5 jet fuel into the water system at the Joint Base Pearl Harbor Hickam, that's a lot to spell out there, drinking water system, subsequent health impacts, recognizing many of the limitations associated with these type of exposures in the investigation, outline lessons learned, key takeaways, and future steps being used to evaluate long-term health effects from this exposure. Red Hill bulk fuel storage facility is very interesting. It was built in the 1940s as a part of the threat that we felt in the Indo-Pacific region from the Japanese during World War II. It's basically been carved out of a mountain outside Oahu, 20 tanks with 100 million gallons of jet fuel. The problem we have, folks, is that one of three primary drinking water sources for the city of Oahu is 100 feet below this fuel depot. I don't know who made that decision to do that, but that's what we have. You can see here miles of pipe and fuel connecting that to the Pearl Harbor area and the ships and planes that come in and out of that. We have histories of spills. What set this off in motion, 2014, there was about a 27,000-gallon fuel spill. Now, when you're talking millions of gallons, tens of thousands of spilled fuel, probably are not a lot. Much of that was recovered, but you can imagine with the environmental groups out in Hawaii, the Sierra Club and others, as well as the tourism out there, that's a big deal. And we'll go into a little bit more of the other exposures leading up to 2021 in a bit. There's a lot here, and I'm sorry it's so small, but basically this is the housing areas in the purple served by the water system. This is Pearl Harbor, real city here. There's a military reservation here, housing throughout here. So timeline, 2014, first release, 27,000 gallons. That set things in motion. There was a big public outcry and Department of Health, EPA, and Navy entered into an administrative order of consent for how they would monitor the Red Hill Fuel Depot, what actions they would take to prevent such leaks from occurring. And then we launched then to 2020. There was a small release of fuel down at the hotel pier we called, where the headers are at for providing ships with fuel. I can't tell you exactly how much was released, and it was pretty minimal. And then 38 gallons of JP5 released early in 2021. And then in November, 2021, the most recent 14,000 gallons released. And the rock there under the fuel depot is volcanic rock. It's somewhat porous. So that fuel is very easily able to percolate down into the water system, the water table system. So then in 2021, Navy reported release about 150 gallons at the pier. And then again, just days later, November 28, 2021, the Navy and Department of Health started receiving complaints of fuel-like odor in the drinking water system. So here's the actual dates, 28, 29, November, 2021. Hundreds of calls made to the Department of Health. Hawaiian Poison Control Center received about 30 calls of a sentinel event. And we add to this risk communication problem or issue that the commanding officer of the base was seen on TV on November 28th, holding a glass of water saying, well, I'm drinking the water, must be good. And this is not what we call good risk communication. And that was captured by the media and broadcast. Whereas the following day, we have the Department of Health issuing a do not drink water advisory. Do not drink water advisory. So again, some real miscommunication events here. So we've actually used that in some of our risk communication courses, what not to do when these types of things happen. There's no real historical or experimental model on this type of exposure. These are the unique things here. We've got reports to indicate that probably the exposure was about a week to 10 days max. How do we assess the immediate health impacts? How do we predict long-term health impacts? These are all questions that have come up. JP5 is a kerosene-like military-grade fuel, but it can contain up to 1,000 different smaller components. But the major components being these C5-A, C8-18, and C18-C32 aliphatics, both of them. So it's kerosene. There have been some toxicologic assessments on permissible exposure levels to military fuel vapors. This is one from 2014, conducted by NASA, National Academy of Science and Engineering Medicine. What do people complain about? They complained of stomach upset, nausea, vomiting, diarrhea, lightheadedness, dizziness. So, you know, primarily GI, neurologic, skin, dermal, and then, you know, some respiratory complaints. We did not see any cases of aspiration pneumonitis. That would involve, you know, large ingestion of large doses, JP5. So the big question is how much JP5 did people really get exposed to? And we really don't know, but I'll add more towards the end of the talk about what we do know. There was risk communication efforts made. There was complications because you got many groups out there. You got Navy, you got Army, you got Air Force, you have the Department of Health. You had, you know, the CDC and ATSDR getting involved. And so there was a lot of different messages being delivered. We tried to get it, the Navy tried to get ahead of that, but, you know, I should say the DOD is not, and we're not always getting out ahead of the media and the narrative there. But the Department of Health tried to get together with these various groups and come up with consistent and clear messaging. I was involved in some of that risk communication development for providers as well as the public. Many different partnerships, the slide's real busy, just shows that there were many agencies involved, federal, EPA, Army, Navy, Defense Health Agency, Coast Guard even, and Geologic Survey, and the Hawaii Congressional Delegation was quite vocal. And then again, a little bit of a timeline here on the 14,000 gallon release, and then the timeline for these events. So, you know, long and short of it is, you know, there's a very confined kind of timeline, but then in December of 17, I was also part of this group in December of 2021, kind of an interagency, we call it a federal interagency group. It was Interagency Drainage and Water System Team, IDSWST, that began months of work in trying to clear and flush the system, because there was a lot involved, public trust had been lost at that point, and the DOD's response, the Department of Health wanted the immediate suspension of the fuel tanks in their use, and the Navy appealed that order in state and federal court, only to, on 7 March of 2022, Secretary of Defense Austin issued a memorandum claiming that the DOD was gonna plan to close Redville within the year. So there was a lot of public pressure to do that. Finally, then on 18th of March, and it was really three months later, we were able to declare drinking water safe in 20 zones. Now, mind you, you know, 3,000 people were moved during this time, so there was a lot of emotions going on here too, because people were moved and put on bottled water. This is part of the Interagency Drinking Water Team. Goals were that team to protect public health and safety, ensure access to safe drinking water, which they did within just a few months, it was a Herculean effort, then sample and develop a long-term monitoring plan, which is still going on today. That was just extended for another year, actually. Recently, you might be seeing there were some total hydrocarbon contaminants that were found in some of the drinking water recently, and we believe that's probably lab air. It was just above the level of detect, but again, there was public outcry about these levels. It turns out that it's very likely laboratory air, the way that samples were processed, and not actual, you know, processed and not actual total hydrocarbons in water. I'm sorry for this computing slide here. One of my captions got closed there, but this was the drinking water recovery stages. Initially, we had granulated activated charcoal filtration to filter a lot of this water, and of course there was public outcry about discharging that into storm drains or over land, which you actually have very, very clean water, but again, public outcry about the discharge of that very, very clean water into the environment. Managed to make it through that stage two sampling and results being evaluated in stage three. Residents flushing, and then residents return to their homes eventually, stage four with the safety that occurred. We developed fact sheets. I was involved with some of the development of fact sheets, which had to be coordinated. Just for the public's information, or the group's information here, we did not recommend any biomonitoring or biologic testing. There was an outcry for that by some groups that we needed to test people, but hydrocarbons are very quickly eliminated from the body within about eight to 10 hours. So it would have been kind of useless to be testing people. Public websites were established, Defense Health Agency, and then ATSDR, Department of Health, as I mentioned in Hawaii, had their own website. Retrospectively, we sometimes have consternation when CDC and ATSDR steps into a situation like this because they don't always have all the background or knowledge or access to the medical records for that matter. But they did conduct an assessment of chemical exposure and ACE impact survey, which was conducted for about a month. And they say they had extensive recruitment, but that the exposure group, we estimate the exposure group to be around 30,000 people. That's since been extended most conservatively to 93,000 people. That's hard for me to believe, but we think the greatest impact was to about 38,000 people. And so you can see with this type of survey or investigation, you only had about 2,300 participants, a very big limitation in conducting studies like this. Then there was a follow-up settlement a year later. How did those people select them? They self-selected themselves. Oh, I do. Yeah. And there you identified a big key issue, right? About 14% of the baseline, 8% of the follow-up households were represented and about 80 to 90% were affiliated with the military. Yeah, 80, 87. It's interesting to see these self-reported surveys. Yeah, 87 reporting symptoms, 80% reporting improvement of their symptoms after switching water source, 37% sought medical care, hundreds of people treated for new mental health symptoms. And, you know, it's something key to mention here too, is, you know, stressful situation for many people. They were being moved from their homes and placed out in town in hotels. It was interesting. Hundreds of people reported symptoms in their pets. It's interesting. And then the fact that the majority were receiving their information from not so credible resources. You know, we had these websites and we had, we had official websites, but then there were the unofficial websites that people were going to getting information, much of it not factual. Here's the little graphic of the poison, again. This number here is 30. So yeah, you see what looks like a huge spike here, but, you know, right after the event, this is a November, early December timeframe calls to the Poison Control Center. And then that kind of dropped off. And then here in, oh, mid-December, 21, you know, a little bit of a spike again, a few more calls to the Poison Control Center. But really, you know, this spike, and then back to baseline. And these were some emergency, as poison control calls and emergency department visits. And you can see this myriad of complaints, rash, abdominal pain, nausea, coughing, irritation, dyspnea, you know, it goes on and on and on. Long-term health effects. This is the official DHA Navy stance that they're really not, no. We have, this is my opinion now, is that, you know, we have four reports that have not been released yet. And this is, this also speaks to the agendas that different groups have in these situations. So you've got me on the risk communication health side. Our group is believing this information needs to get out there to help inform the public narrative, right? Whereas the attorneys, they have a much different view of this. They want to lock all this down. They want to, they go into the defense mode. They want to prevent information from being shared other than during the discovery process. Very, very different. I have found through this whole thing, very different mindset. And we're working right now to get four reports released from the attorneys. One is a one year prior, one year after epidemiologic study, actually, where we have the medical records and we can see the, for those of you who are not in the military, we have an electronic health record and we have an epi team at my place of work or a number of people who have been looking at this data and information. So we've got a report showing this spike and then return back to baseline. Again, that's not purchase care out in the community. We don't always have the purchase care data. It's delayed. But we have data showing that there was a spike for nausea, vomiting, the things associated with JP5 exposure, and then return to baseline that following year. Same with mental health conditions. We see a real spike following the event for about a month. And then after that, following that, a return to baseline. So again, we're not seeing a whole lot from this exposure, but there again, we've got a registry. That's through the Defense Occupational Environmental Health System Registry and our roster, I should say, through that. Now there is a public outcry for a registry developing a long-term health registry, which many of you might know, it's very expensive and time-consuming. And some thoughts that they'll use some modeling to look at health effects. So as I reported earlier, extreme sources of stress for many people. We've got many people believing that their health effects are long-term and from this exposure. And changing that public narrative is very, very different. Other reports that haven't been released, we've got sampling data from, we've got, again, it's not the best QA, QC sampling data, but we've got about 200 samples or so that have not been released. But we've got some reports trying to help influence a little bit of the public health narrative on this. That exposures were not really, more than about a week to 10 days max, and were probably minimal. Just to clarify, the odor threshold for JP5 is very low. And so it's literally orders of magnitude greater to have any kind of toxicologic effect long-term. We're talking like two orders of magnitude greater. So again, odor threshold, much more sensitive than toxicologic threshold. Eight-month follow-up survey results from this ACE were that 80% of participants reported symptoms in the last 30 days. 65% were convinced that their symptoms are related to water, headaches, anxiety, skin, fatigue. 85% of those responding say they're using alternative water sources. And 50% reporting worse mental health. And then again, massive concern and frustration with the communication transparency and trust with the Navy and the DOD. So some of you have already identified limitations in studies like this. It's a convenient sampling, self-reported. The lack of exposure, actual exposure data. Again, talk about outreach barriers. Yeah, they did their best to try to reach people. But if you think about it, only those people who were, that believed that their symptoms were coming from this exposure would respond. So it's biased. Yeah, I think there's a number of differences in studying all the quality of water. And that really helps, particularly in the sample because you're not looking for generalized findings. It's good. That's excellent, Howard. That's a good point. That's another strength. Yeah, that's another strength to this. Yeah, you have a defined location, well-defined. So yeah, other strengths here, widespread partner engagement. Again, I questioned a large number of responses, but that's CDC, ATSDR, and then timely data. So the direct impacts of this ACE study were that, you know, again, partnerships were improved among the various agencies. We set up a Red Hill Clinic. I was not part of that. I was not out in Hawaii for that. We didn't actually have, I think we only had about 150, 160 people somewhere in that area show up for evaluation. I think it had to do with, again, the trust issue. You know, the DHA is setting up this facility. You know, we can't trust the military healthcare system. You know, we'll go out into town. And we've seen, you know, providers out in town capitalize on fears and order strange tests and biomonitoring tests and so forth. It really, for us here, we would kind of discount. So you get a third-party agency. Third-party agencies now involved with the, I think I mentioned the setup of this registry. And I think ATSDR CDC is going to probably be putting that into place here the next year or two. And then support for providers and education materials and so forth. What's next? Tracking health effects. And I don't really know what we'll see from that. But we got other, you know, again, ATSDR CDC involved with doing that. The DOD is going to be paying for that, setting up those activities. What has been proposed is a, this is just the last month or two, kind of a Red Hill National Academy's consensus study report, asking NASM to get involved with that. With VA, DOD collaboration. Just more independent review committee looking at health risks and clinical guidance. And having community involvement in the process. And having this being scientifically rigorous and evidence-based. We anticipate this will be about a two-year project until the final report. And the independence of this group, you know, it goes without being said, you know, it's going to be critical because of the loss of trust in the DOD, what happened here. Now, I know this is a little bit small to read. But this is from the challenge of persistent and complex symptoms. What we've been talking about this morning with some of these other talks. This is from one person. My ongoing symptoms as follows. I would like answers to each question regarding each symptom individual. Every day, chronic fatigue, to be constant inner ear pain. Where do we start with something like that? You know, and right there, Paul, right there. Equating this to long haul COVID symptoms, right? He says, you're left behind. You won't go to the shrine, that's the inner ear pain, I get it. Right, right. You know, that's the process. Right. That's going to be, you know, we're allowed, I'm able, but you know, our daughter was an airman. And she's going to base Pearl Harbor. And it just so happened that during this time, she started having fainting symptoms. And she got diagnosed with asymmetric hearing. And stuff is obviously coincidental in terms of the timing. But, you know, I can see why people naturally wonder just because it's so curious that, well, hell, I got sick and I was wearing a blue shirt. It must be the blue shirt, you know. That temporality. Yeah, yeah, yeah. And this is where, again, all of us in the room. It's foreign genetics. Yeah, well, yeah. I think the question really has to be covered. If you start taking a look at those firms that are being used here, these are very technical firms. So these have to be under advice, as opposed to kind of creative thinking. I'm not denying, but I'm saying what you're suggesting tends to be a little bit more superficial than this. Because you've got firms out there that only people under advising or they're slow to adopt or move. Correct. And that's how we're going to have to- And 2,000 people have now filed a clash action suit. Yep. Because they're going to do it all at once. And they're just going to pass, you know, hand a certain amount of money over to everyone. That's what the way it is. And this is what I think will happen with Camp Lejeune as well. There's $1 trillion in pending lawsuits regarding Camp Lejeune. You know, we'll grow broke. As well as, you know, paying for the legal judge to hear that. So what's next on the environmental side? I mentioned this long-term monitoring of the drinking water system. And it's gone very, very well. I can't explain to you how difficult it is to get all these agencies together to come up with a sampling plan. It's just- My partners at work have been toxicologists, industrial hygienists, risk assessors involved with this for years now, a couple years. And that long-term drinking monitoring plan has just been extended another year. I can't imagine the cost of all that. I'm not sure. 99.5% of the defueling of the Red Hill Depot has been completed. They're now just in the final flushing stages of the piping, the distribution piping and cleaning that up. And within the next year, the facility will be closed. The question is, what do you do with a facility like this? And what is the long-term monitoring plan? I would have to say the aquifer recovery, I think all but a few thousand gallons of the fuel were recovered just with the operations and filtration and so forth. And then, lastly, what will be the long-term environmental impact of having the facility there? These are some of the posters and signs and public outcry we saw. And then just finishing up with some key lessons and messaging, clear and consistent, I would say regular, ongoing, regular risk communication in terms of what we know, what we don't know is just critical. Engaging the experts. I believe the Navy and the DoD in general were slow to engage some of the experts early on, i.e. the embarrassment there with the do not drink water messaging from the Department of Health and the Navy saying everything's safe. Transparency and data sharing. And then recognizing, this is my takeaway, recognizing alternate agendas and realizing that others have agendas perhaps differently than the health or risk communication folks. And then remembering the goal, protecting human health and the environment. And a few references, but thank you.

environmental health

occupational medicine

JP-5 jet fuel

public health

risk communication

drinking water

Red Hill Fuel Depot