Formal Elicitation of Expert Judgment: Issues and Approaches

Formal Elicitation of Expert Judgment: Issues and Approaches

The Kuwait Oil Fires John S. Evans, Sc.D. Harvard School of Public Health New England Chapter Society for Risk Analysis Boston, Massachusetts 28 May 2008 The Fires Public Health Impacts of Kuwait Oil Fires 28 May 2008 More Than 700 Fires First Fires Air War ~ 17 January 1991 Ground War ~ 23 February 1991 Liberation ~ 28 February 1991 Last Fire - 6 November 1991 Oil Burned ~ 4 x 106 barrels per day

PM Emissions ~ 3 x 109 kg The Question Were there substantial public health impacts of Iraqs 1990 invasion and occupation of Kuwait and the ensuing Gulf War? If so, how large were the impacts? what were the causes? Public Health Impacts of Kuwait Oil Fires 28 May 2008 The Hazards & Prior Assessment Mines and Ordnance Environmental Contaminants Smoke from the Fires Volatile Organic Compounds from the Oil Lakes

PAHs and Metals from the Fires, Oil Lakes and Oil Spills Depleted Uranium from Military Ordnance Psychological Trauma Public Health Impacts of Kuwait Oil Fires 28 May 2008 5.0 Kuwaitis 4.0 Deaths/1,000 p-yrs 3.0 2.0 Non Kuwaitis 1.0 0.0 1986 1988 1990 1992 1994 1996

1998 2000 Our Team Risk Assessment & Valuation Dr. George Gray Epidemiology & Medical Monitoring Dr. Abdulrahman Al-Muhailan Prof. Jaafar Behbehani Dr. David Mage Louise Hanson Dr. Andrew Wilson Dr. Josh Cohen Prof. Jim Hammitt Prof. Petros Koutrakis Prof. Douglas Dockery Martha Fay Dr. Alan Eschenroeder Prof. Debbie Bennett Expert Judgment Prof. David Christiani Dr. Elpis Soteriades Dr. Rosalind Wright Prof. Roger Cooke

Dr. Jouni Tuomisto Dr. Andrew Wilson Prof. Allan Hill Oswaldo Morales Marko Tainio Delft, KTL, INE, Earthtech Public Health Impacts of Kuwait Oil Fires 28 May 2008 Kadhema, Temple, KU, KISR The People . About 600,000 Kuwaiti Nationals 80 Very Young Population 100 R a u d h a ta in S a b riy a h 60 B a h ra

40 N o rth in g (k m ) ~ 25% >= 30 Years Old Many Outside of Kuwait During Occupation 20 0 -2 0 M in a g is h -4 0 B u rg a n U m m G u id a r -6 0 K u w a it A irp o rt M e t S ta tio n ~50% in Kuwait in mid February 1991 ~95% Had Returned by mid October of 1991 Public Health Impacts of Kuwait Oil Fires 28 May 2008 -8 0 -1 2 0

-1 0 0 -8 0 -6 0 -4 0 -2 0 E a stin g (k m ) . 0 20 40 60 80 The Measurements Time Series of PM at Mansouria Equipment Had Been Stolen or Destroyed by Iraq No Measurements During First Several Months of Fires PM10 Measurements at Three

Sites from mid-April through December of 1991 Typical Values ~ 300 g/m3 High Days 1000 to 2000 g/m3 Reflect ALL SOURCES of PM PMconcentration ( g/m 3) 2000 1800 Ambient PM10 (Measured) 1600 Ambient Average = 300 1400 1200 1000 800 600 400 200 0 Public Health Impacts of Kuwait Oil Fires 28 May 2008 The Model

US DOD Used HYSPLIT Model to Estimate Exposure of Allied Troops HSPH Obtained Results through Freedom of Information Request Values Vary Across Country and By Day Legend Modeled TSP (ug/m3), Feb-Oct 1.9 - 8.5 8.5 - 15 Typical Values ~ 10 g/m3 (in populated areas of Kuwait) 15 - 22 22 - 28 28 - 35 35 - 41 High Days > 300 g/m3 (in populated areas of Kuwait) 41 - 48 48 - 54 54 - 61 61 - 68

Model is Poorly Documented Public Health Impacts of Kuwait Oil Fires 28 May 2008 0 25 50 Miles Why Worry About PM? 3 increase in PM 10 Time-Series Studies Following the London Fog of December 1952 it was noticed that ~ 4000 excess deaths occurred. During the period of the fog, smoke levels reached 4500 g/m3 and averaged 1600 g/m3. The population of London was ~ 10 million at the time. In large cities around the world, numbers of deaths are higher on days with higher levels of PM, all other things being equal.

Such studies were first done in London and New York, but now have been repeated in hundreds of cities. 5 4 3 % change in daily mortality/10 ug/m 2 1 0 -1 -2 - - - - - - - - - Worldwide literature - - - - - - - - - - - - - Pooled worldwide estimate -3 Public Health Impacts of Kuwait Oil Fires 28 May 2008 Why Worry About PM? Cohort Studies Mortality rates are higher in cities with higher levels of PM, all other things being equal.

The Six Cities study followed the mortality experience of ~ 8000 adults living in 6 US cities with different levels of PM for ~15 years. The ACS study followed the mortality of ~ 500,000 adults for ~ 7 years living in 151 US metropolitan areas. Public Health Impacts of Kuwait Oil Fires 28 May 2008 Back of the Envelope Risk Assessment R ~ C Mo P Where is the risk coefficient (0.4% per g/m3 PM2.5 cohort (ACS) or 0.1% per g/m3 PM10 time series) C is the concentration (300 g/m3 PM10 or 10 g/m3 PM2.5 due to fires) Mo is the background mortality rate (3/1000 p-yr or 9/1000 adult-yr) P is the population (600,000 total OR 150,000 adults) Back of the envelope screening estimates :

35 deaths (2/10,000 risk among 150,000 adults) using ACS cohort coefficient 116 deaths using Six Cities cohort coefficient 0 deaths if epidemiology does not reflect causal relationships Public Health Impacts of Kuwait Oil Fires 28 May 2008 Key Issues Exposure Level and Pattern -- Kuwait oil fire exposure level and pattern is different than those of interest for most regulation, with background PM 10 levels in Kuwait of 200 or 300 g/m3, and PM2.5 increment due to fires averaging 10 g/m3 with spikes of several hundred g/m3. Should time-series or cohort studies be used to estimate risk? Composition -- Oil fire smoke differs in composition from typical urban aerosols in the U.S. and Europe. Should an adjustment be made for differential toxicity? Age-Structure of Population -- Kuwaiti population is far younger than US or European populations.

Do relative risk estimates from US/European studies apply directly? Causation Epidemiological studies may reflect association rather than causation due to various biases, failure to control for confounding, etc. Public Health Impacts of Kuwait Oil Fires 28 May 2008 The Experts -- European Elicitations Bert Brunekreef, Ph.D. Professor of Environmental Epidemiology, University of Utrecht, Netherlands Annette Peters, M.D., Ph.D. Assistant Professor, GSF National Research Center for Environment and Health, Germany Nino Kuenzli, M.D., Ph.D. Assistant Professor, University of Basel, Switzerland (now at USC) H. Ross Anderson, M.D. Professor of Medicine, University of London, England Ken Donaldson, M.D. Professor of Medicine, University of Edinburgh, Scotland

Juha Pekkanen, M.D., Ph.D. Head of Environmental Epidemiology, National Public Health Institute (KTL), Finland Public Health Impacts of Kuwait Oil Fires 28 May 2008 Rationale for Use of Expert Judgment Scientific data may not speak for themselves; require careful interpretation Scientific data may seem conflicting or inconsistent; require judgmental synthesis In the absence of data, assumptions are necessary; requires judgment about plausibility of assumptions Choice of and/or construction of models may require judgments that are beyond the expertise of the risk assessor Public Health Impacts of Kuwait Oil Fires 28 May 2008 The Question How many deaths among the exposed Kuwaiti National population are attributable to

exposure to smoke from Kuwait Oil Fires? TOO HARD ! Decompose Warm Up Start with Easy Questions Work Toward the REAL QUESTION. Public Health Impacts of Kuwait Oil Fires 28 May 2008 Mortality Impact of Permanent Decrease in PM2.5 of 1 g/m3 in the US Question 1 Setting US Exposure (Effect Interval) Long-term Change 1 g/mg/m3 Pollutant PM2.5 Composition Ambient Baseline 18 ug/m3

What is your estimate of the true, but unknown, percent change in the total annual, non-accidental mortality rate in the adult U.S. population resulting from a permanent 1 g/mg/m3 reduction in long-term annual average PM2.5 (from a population-weighted baseline concentration of 18 g/mg/m3) throughout the U.S.? To express the uncertainty associated with the concentration-response relationship, please provide the 5th, 25th, 50th, 75th, and 95th percentiles of your estimate. 5% :____________ 25%:____________ 50% :____________ 75%:____________ 95%:____________ Public Health Impacts of Kuwait Oil Fires 28 May 2008 Linking Evidence & Answers What evidence or theory suggests large values for this relationship? What is the highest plausible value? Tell us a little about your reasoning, the evidence, and theories that lead you to this value. Can you tell us of scenarios that would yield higher results? What evidence or theory suggests small values? What is the lowest plausible value? Tell us a little about your reasoning, the evidence, and theories that lead you to this value.

Can you tell us of scenarios that would yield lower results? Public Health Impacts of Kuwait Oil Fires 28 May 2008 Mortality Impact of Permanent Decrease in PM2.5 of 1 g/m3 in US (Green) or Europe 3 [% change ineibaseline mortality g/m PM %chang n baseline mortalityper per unit 1 g of m3exposure annual av(1 era gePM 2.5 )] 2.5 (Blue) 5

Mortality Impact 6 4 3 2 1 0 US EU Expert A Public Health Impacts of Kuwait Oil Fires 28 May 2008 US EU ExpertB US EU ExpertC US EU Expert D US EU Expert E US EU ExpertF The Sequence Exposure Duration Effect Window US

(Baseline: 18 g/m3) Permanent Longterm Q1 1 week Q3 One day One day 3 mont hs Q6 Timing of Expression of Impact Q7 & Q8 Differential Toxicity Q9 & Q10 Public Health Impacts of Kuwait Oil Fires 28 May 2008 MCMA (Baseline: 35 g/m3) Europe (Baseline: 20 g/m3) Q2

Q4 Q5 Pre-Elicitation Warm Up Questions What are the key properties of an ideal epidemiology study for measuring longterm mortality impacts of PM exposure? Similarly, what are the key properties of an ideal epidemiological study of shortterm mortality impacts of PM exposure? What factors need to be considered to decide whether epidemiology results should be viewed as causal? Public Health Impacts of Kuwait Oil Fires 28 May 2008 The Answer Deaths Attributable to Exposure to Smoke from the Kuwait Oil Fires Deaths 800 600 400 200 0

Expert A Public Health Impacts of Kuwait Oil Fires 28 May 2008 Expert B Expert C Expert E Expert F The Answer Deaths Attributable to Exposure to Smoke from the Kuwait Oil Fires Expert * 5% 50% 95% Approa ch E 6 13 21 TS A 4

32 63 TS C <1 54 426 C F 37 110 210 C B 16 164 872 C D 575

2874 11496 C Experts are listed in order of their median estimate of risk. Letter identifications are randomly assigned to experts. Public Health Impacts of Kuwait Oil Fires 28 May 2008 CalPUFF Model Harvard Used CalPUFF Model to Estimate Exposure of Kuwaiti Citizens . P e r io d A v e r a g e C o n to u r P lo t fo r A ll S o u r c e s F e b r u a ry 1 0 - O cto b er 1 5 , 1 9 9 1 100 Computed Plume Rise From Thermodynamics of Oil Fires 80 60 Used Improved Meteorological Data and Finer Grid Spacing 40 20

Accounted for Coastal Effects and Considered Plume Enhancement 0 -2 0 Values Vary Across Country and By Day -4 0 -6 0 Typical Values ~ 40-50 g/m3 (in populated areas of Kuwait) -8 0 -1 2 0 High Days 600 - 800 g/m (in populated areas of Kuwait) Public Health Impacts of Kuwait Oil Fires 28 May 2008 3 . -1 0 0 -8 0

-6 0 -4 0 -2 0 0 20 40 60 80 The Epidemiology HSPH conducted a cohort study of 5000 Kuwaitis older than 50 on the eve of Iraqs invasion. Information was gathered by questionnaire on health status, smoking, education, income, diet, exercise, location during the fires and exposure to trauma. The survival of those who were in Kuwait during the occupation was 20-30 % lower than the survival of those who were outside of Kuwait during this same period.

This difference was statistically significant and persisted after control for age, smoking, income and education. Survival curves after liberation by location 1.0 Out of Kuwait entire time Probability of Survival 0.9 In Kuwait entire time In and Out of Kuwait 0.8 0.7 0.6 2/27/91 2/26/93 2/27/95 2/26/97 Public Health Impacts of Kuwait Oil Fires 28 May 2008 2/27/99 2/26/01 2/27/03

Post Traumatic Stress Disorder The Al-Riggae Center conducted a study of ~2000 Kuwaitis in 1993 and a followup study of these same individuals in 1998. Information was gathered by questionnaire on sociodemographics, exposure to trauma and symptoms of anxiety, depression and PTSD. In 1993 among adults rates of PTSD were higher among those who had remained in Kuwait during the occupation than among those who were outside of Kuwait. Public Health Impacts of Kuwait Oil Fires 28 May 2008 Prevalence of PTSD By Location During Occupation Always Out In and Out Always In 14.4% 20.5%

25.2% (28/194) (168/819) (234/927) The Role of Trauma Hazard Ratio 2.5 Top figure shows mortality rate of participants in PHS by self-reported exposure to trauma. Bottom figure shows coronary heart disease morbidity rates of participants in PHS by self-reported exposure to trauma. The elevations among individuals attacked or arrested are statistically significant and those among individuals who witnessed violence are on the margin of significance. Both graphs present results after control for age, smoking and socioeconomic status. 2.0 1.5

1.0 0.5 0.0 I n Kuwait I n Hiding Witnessed Attacked or Violence Arrested 2.0 Hazard Ratio 1.5 1.0 0.5 0.0 I n Kuwait I n Hiding Witnessed Attacked or Violence Arrested Public Health Impacts of Kuwait Oil Fires 28 May 2008 Kuwaits Public Health Claim Deaths Attributable to Oil Fires

PAACs approach was to limit its claims to those which were well supported by science and to be entirely open in its presentation of the state of the relevant science. On the order of 35 deaths among Kuwaitis were due to exposure to smoke from the oil fires (based on US DOD model and conventional regulatory risk assessment). This claim is likely to be quite conservative (i.e., understated) in view of the new air pollution modeling results and the findings of the expert judgment study. The social cost to Kuwait of these 35 deaths is ~ 200 million US$ (based on a contingent valuation study done in Kuwait and extrapolation of VSL from the US and Europe). Public Health Impacts of Kuwait Oil Fires 28 May 2008 Daily Deaths in Kuwait -2 Aug 90 to 6 Nov 91 Daily Deaths Among Those In Kuwait (data from PACI and MOF files). Oil Fires Started mid-February 1991 Death Rate

Before Oil Fires -- 0.28 deaths/day During Oil Fires 0.47 deaths/day Correlation Between Deaths and Smoke Concentration ~ 0.6 (Weekly Averages) Not statistically significant However, only 200,000 exposed people and a relatively short period of 248 days. Public Health Impacts of Kuwait Oil Fires 28 May 2008 4 3 2 1 0 0 1 J UL 1 9 9 0 01SEP1990 0 1 NOV 1 9 9 0 0 1 J A N1 9 9 1 0 1 MA R 1 9 9 1

0 1 MA Y 1 9 9 1 Da t e 0 1 J UL 19 91 01SEP1991 0 1 NOV 1 9 9 1 0 1 J AN1 9 92 Public Health Impacts of Kuwait Oil Fires 28 May 2008 Current Ambient Air Pollution A Less Obvious, But Perhaps More Severe, Problem Public Health Impacts of Kuwait Oil Fires 28 May 2008 Fixed Site Monitoring Khaldiyah & Um Al-Haiman PM10 ~ 100 g/m3 annual mean Khaldiyah, Um Al-Haiman & Um Al-Aish PM2.5 ~ 45 g/m3 annual mean 1/3 crustal

Values Similar to MEXICO CITY ! Back of the Envelope Risk Assessment Elements of Risk Assessment Adult Population ~ 300,000 Baseline Mortality Rate ~ 9/1000 p-yr PM2.5 Level ~ 30 g/m3 Risk Coefficient ~ 0.4 % per g/m3 Results ~ 300 deaths per year Public Health Impacts of Kuwait Oil Fires 28 May 2008 The Public Health Study Phase I Medical Monitoring & Screening

HSPH conducted medical monitoring and screening of about 5% of the participants in Phase I. In addition to the questionnaire information, the participants height, weight and resting blood pressure were determined. Venous blood samples were collected and analyzed for cholesterol & blood sugar and for the metals lead and mercury. The results indicate high levels of both hypertension and total cholesterol in this sample of elderly Kuwaitis. Hypertension 50% 40% 35.5% 34.7% 30% 20% 19.6% 10.2% 10% 0%

< 120/80 120-139 / 80-89 140-159 / 90-99 160/100 Resting Blood Pressure (mm/Hg) Cholesterol 60% 40% 38.8% 36.3% 24.9% 20% 0% < 200 Cholesterol 200 & < 240 Cholesterol Level (m g/dl) Public Health Impacts of Kuwait Oil Fires 28 May 2008 240 Blood Mercury Levels Tentative Results from Phase I Medical Screening 1000.0

BloodMercury(ug/L) 100.0 10.0 1.0 0.1 -3.00 -2.00 -1.00 0.00 Normal Z-Score Public Health Impacts of Kuwait Oil Fires 28 May 2008 1.00 2.00 3.00 Lognormal distribution 15% <= LOD (1 g/dL) Median ~ 5 g/dL

GSD ~ 2.5 WHO and US EPA criteria: WHO PTWI = 0.5 g/kg-d or ~ 25 g/dL EPA RfD = 0.1 g/kg-d or ~ 5 g/dL Values regressed on fish consumption, gender and age: Womens levels 3 g/dL lower than mens. Local fish consumption important. All participants notified of results and provided with Arabic version of EPA/RfD guidance on mercury. Those with values above WHO criterion were notified in person by Dr. Behbehani and offered free retesting of their blood. Kuwait National Center for Environment and Health Epidemiology MOH Vital Statistics KU Faculty of Medicine Exposure

PHS I & II PM & VOCs Mercury in Fish Kuwait Longitudinal Health Study Chemical Body Burden PAAC KISR KU Science & Engineering EPA Integration & Interpretation Kuwait Burden of Disease Study Environmental Risk & Decision Analysis MOH Public Health Impacts of Kuwait Oil Fires 28 May 2008 EPA Citizens NGOs Industry Descriptive Epidemiology: Infant Mortality 1950-2005 No Obvious Reversal

180 Infant mortality rate per 1000 160 Males IMR 140 Females IMR 120 Registered IMR 100 80 60 40 20 0 1940 1950 1960 1970 1980 Year 1990 2000 2010 Descriptive Epidemiology 180

100% 160 90% 140 80% 70% 120 Males IMR 60% 100 Females IMR 80 Males 45q15 Females 45q15 60 50% 40% 30% 40 20% 20 10%

0 0% 1940 1950 1960 1970 Year 1980 1990 2000 2010 % surviving from 15 to 60 Infant mortality rate per 1000 Adult Survival: 1950 to 2005 A Different Picture Descriptive Epidemiology Comparing Male & Female Mortality: 2001 to 2005 Excess Mortality of Young Men 1 0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85

Age groups 0.1 Log nM x Males Females 0.01 0.001 0.0001 Unique Natural Experiment Historically, epidemiologic studies linking specific warrelated exposures (e.g., war-related trauma) to longterm physical morbidity have been challenging for a number of reasons Often difficult to examine direct linkages of the original experiences of war-related events given that most populations in this circumstance experience prolonged periods of armed conflict Even after the armed conflict, most endure prolonged economic crisis, lack of stable social systems and ongoing deprivation including displacement to other countries as refugees which may continue to impact health Unique Natural Experiment The invasion of Kuwait by Iraq in 1990 resulted in the 7 month long Iraqi occupation of Kuwait

After liberation, Kuwaiti nationals were encouraged to return and did not live in exile for long periods The physical and social infrastructure was restored in a comparatively short period of time Health and psychiatric care were made available to all Kuwaiti nationals Mind-Body Paradigm Webster, Tonnelli and Sternberg 2002 linking psychological stress and affective states to disruption of key physiological mechanisms (e.g. neuro-endocrine and immune functioning, oxidative stress, autonomic response) and ultimately to disease expression Major Salient Conditions: PHS I and PHS II Male Female Number of Men and Women Reporting Witnessing Specific War-related Events Number of Men and Women Reporting Being Victim of Specific Warrelated Events Summary Measure of War-Related Trauma Challenging to summarize

mulitple items Adopted modeling approach that places subjects on a continuous scale with higher scores indicating more severe trauma (Rasch modeling) Divided this equally no trauma low trauma War-Related Stressor Score and Asthma Incidence: Adjusted Hazards Ratio (95% Confidence Model Interval) War-related Stressors None Low Intermediate High Reference Group 1.0 (0.6, 1.8) 1.4 (0.8, 2.4) 2.3 (1.3, 3.9) Adjusted for: age, sex, education, literacy, smoking, BMI, oil fire pollution Multivariate Hazard Ratios of a 1-SD Increase in the War-Related Trauma Score Hazard Ratio (95% CI)

Events (Person Years) Non-Fatal Myocardial Infarction 1.21 (1.05 1.40) 186 (15021) Angina Pectoris 1.59 (1.13 2.22) 33 (15875) Coronary Heart Disease * 1.25 (1.09 1.44) 194 (14975) Adjusted for: age, sex, education, literacy, smoking, BMI, oil fire pollution * Includes MI and angina pectoris P<0.01 PHS Phase II Father Mother N~1800 N~1800 Child Child Child

0-3 yrs 4-7 yrs 8-11 yrs N~1200 N~1200 N~1200 Public Health Impacts of Kuwait Oil Fires 28 May 2008 55 PHS Phase II -Questionnaire Individual Characteristics Age, sex Height and weight Smoking Diet and exercise Medical history Date of death (Deceased only)

56 Current functioning Depression and anxiety Checklist Gulf War Syndrome Social network and support Coping strategies Traumatic events Location During invasion, occupation and oil fires Public Health Impacts of Kuwait Oil Fires 28 May 2008 Social/Psychological Before and After occupation During occupation PHS Phase II -- Biologic Markers

Anthropometry Height, Weight, and Blood pressure Clinical Measures (fingerstick, 89% participation) Immediate reading Blood drops stored on specially treated filter paper Hair sample (60% of possible) HgbA1C (blood sugar control) C-reactive protein (systemic inflammation) Future genetic testing Total cholesterol, HDL, LDL, triglycerides Blood glucose (random) Environmental metals (mercury) Salivary cortisol (Children only, 37% participation) Measure of stress response Public Health Impacts of Kuwait Oil Fires 28 May 2008

57 oo d sc en ce Ag e er Ad ul th Ol d PHS II PHS I Accelerated Lifecourse Research Design oo d dl eMi d Ea rly PHS II Ad ul th Ad o

le Pr en at al In fa nc Ch y ild ho od Pr en at al PHS III Longitudinal Follow-up The childhood shows the man, as the morning shows the day. John Milton, Paradise Lost (1667) PHS Phase II & Possible Extensions Father Mother Recruit Siblings

Interview Age N~1800 N~1800 Child Child Child Child Child <16 yrs 16-19 yrs 20-23 yrs 24-27 yrs 28+ yrs N~1200 Recruit Children of Second Generation Public Health Impacts of Kuwait Oil Fires 28 May 2008 N~1200 Grand Child N~1200 Grand Child

60 Grand Child Grand Child Grand Child Public Health Impacts of Kuwait Oil Fires 28 May 2008

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