These are just some of the contradictory words that have been used to describe the practice of hydraulic fracturing (alternately called “hydrofracturing,” “hydrofracking,” and simply “fracking”). Proponents of this natural gas extraction process claim that it is an efficient, cost-effective, safe, and environmentally-friendly way to help America become energy-independent. Detractors allege that it is detrimental to ecosystems, and worse, that it negatively impacts the health of residents living in communities surrounding drilling activities. It is difficult to cut through the rhetoric, especially with such a lack of empirical data; that has not stopped advocates and critics from attempting to beat the loudest drum.
Things are much less black-and-white, but far more methodical, behind the scenes of the first and only study on the public health effects of hydraulic fracturing. Armed with the latest electronic health technologies and “unusually complete” data on hundreds of thousands of drilling region residents, the researchers are asking the big questions and pursuing bigger answers. Furthermore, they have no agenda but the truth, committing themselves to the most thorough, unbiased and scientifically sound research that has ever been afforded on the subject of hydrofracking.
In the following pages, you’ll meet the team behind this monumental study. You’ll discover what hydraulic fracturing is, what the potential risks could be, and how researchers seek to determine the effects on population health. You’ll also learn of the tremendous part that family physicians play in the process — and what you can do to help.
Make no mistake about it: this public health effects study gives new meaning to the term “groundbreaking.”
“Marcellus Shale play is the second-largest reserve of natural gas in the world. So it’s obviously attracted a lot of attention from an economic development standpoint,” said David Carey, PhD. In addition to serving as the associate chief research officer at Geisinger Health System and the director of its Weis Center for Research, Carey is the principal investigator of the as-yet-unnamed longitudinal health impacts study of the Marcellus Shale.
“It’s created, at least in the part of the world where we live, in north-central and northeastern Pennsylvania, a flurry of pretty intense industrial activity that our region’s not accustomed to,” said Carey. “As of the end of calendar 2011, there were almost 10,000 well permits issued in the state, and several thousand wells in active production.
“The techniques that are used for extracting the gas are what are considered ‘unconventional mining activities,’” he said.
Of course, the “unconventional” method Carey referred to is hydraulic fracturing. It’s not a particularly new phenomenon — commercial hydrofracking has taken place since the late 1940s. But thanks to easing regulations and more sophisticated natural gas extraction methods, Pennsylvania has seen an increase in fracking activity over the last few years. The process, though a complex marvel of modern engineering, is relatively simple to explain.
“Basically, said Carey, “you poke a hole in the ground and pump, under high pressure, lots of [what is] mostly water, sand, and some chemicals into the ground in order to literally fracture the rock miles underground. It releases the gas, it bubbles up and they capture it.”
The process is disconcerting to some — something every Pennsylvanian likely knows if they’ve picked up a local paper or turned on the 6 p.m. news lately.
“Because of the way that this unconventional mining is done, through hydrofracturing, there’s concern about exposure to chemicals that are used,” said Carey. “Although the chemical components of the hyrofracking fluid are only less than 5 percent of the total volume, there’s huge volumes of liquid that are used during the process. Most of it comes back — [but] not all of it comes back.”
That includes several chemicals and compounds you may remember hearing about in science class, like hydrochloric acid (toxic), acetaldehyde (carcinogenic), and ethylene glycol (poisonous). And that’s just of the chemicals pumped into the ground.
“Also, the so-called ‘flowback’ water, the part that comes back, contains a lot of material that’s leeched out of the rock from miles down,” such as radon, Carey said. “So there’s the possibility that it might contain potential contaminants that could harm health.
“[There are] different potential exposures at each phase of operation,” he said.” “There’s the clearing, there’s the drilling, the fracking, then there’s the capture, then there’s the distribution. Then, of course, you’ve got the impacts on communities.”
Regardless of the risks, of the potential exposures, and of the possible adverse impact on local infrastructure, there are plenty of benefits to having a hydraulic fracturing operation in one’s back yard — especially in a region that’s traditionally economically disadvantaged.
“The part of the state where we live is mostly rural, pretty economically underdeveloped, and also older than the national average and poorer than the national average. There are fairly high rates of poverty in many of the counties where we provide care and this activity is going on,” said Carey. “So they’re, I think in many ways, on the one hand, in need of economic development. On the other hand, they’re also … fragile communities that are vulnerable to some of the development that’s going on, especially if it’s not done in a controlled way.”
Yet, with livelihoods both physical and fiscal hanging in the balance, because of all the intricacies and entanglements involved, the single most important question has yet to be answered.
“The biggest problem to date is that there’s really no data to know whether this is a health concern or not,” Carey said.
That’s not to imply studies haven’t been conducted. But prior research hasn’t focused on public health; and, according to a white paper released by the Geisinger Health System Foundation, it has proven to be inadequate or deficient:
A major limitation of these data, however, is their fragmentary nature — many were obtained during “exposure investigations” in response to a specific complaint or concern. Moreover, the complex and diverse nature of mining activities, reluctance on the part of some energy industry companies to reveal the chemicals used, and lack of toxicology data on many compounds, make it extremely challenging to generate plausible hypothesis-driven studies to investigate specific exposures that might be relevant to health risk.
“The problem is there is no hard, scientifically sound, unbiased data on which to draw sound conclusions,” said Carey. “Nobody really has any idea if there is a health impact. That’s hopefully where we can come in.”
In autumn of 2011, Geisinger Health System President and CEO Glenn Steele, MD, PhD made what Carey called “a fairly impassioned plea for taking this seriously.”
“Really, from a patient-centric point of view, if there’s something to worry about, we’d like to know what it is so we can then figure out how to mitigate it or how to prevent it,” said Carey.
The Geisinger Health System already had a firm foundation for a wide-reaching study — more than 2 million patient records, with a data-rich core of about 500,000 patients for whom Geisinger provides primary and specialty care services. Nearly 300,000 of those patients are geocoded, and, as a consequence of Geisinger’s early adoption of electronic health record systems, the data is easily accessible. Moreover, the data has previously been used for other epidemiological research, including studies on everything from MRSA and animal feed operations to obesity and diabetes in communities near abandoned coal mines.
“The approach that we’re proposing is because we have comprehensive and longitudinal health data on large numbers of patients in this region,” said Carey. “We have this integrated system with the provider, the hospitals and the insurance company all using the same electronic health record on this large number of patients.
“We have fairly complete electronic data on all Geisinger patients back to about 2004,” he said. “So that gives us, I think, an unusually complete longitudinal record of the health of the people who live in this region.”
Geisinger Health System’s electronic record-taking acumen is coming in handy elsewhere, too. Some of the drilling activity in the state is also being geocoded and tracked, and researchers are recording multiple data points, including where well permits are issued and which wells are producing gas. This part of the process is fairly arduous: while drilling companies have to file locations and activity within the state, and while the well permits exist in a state database, the information isn’t stored electronically. That means manually perusing scanned public record documents — which, as one might imagine, is particularly time-consuming.
Even so, this kind of study is an incredible product of the digital age in which it’s being conducted.
“It’s a new way of looking at population health that … wasn’t possible until we had comprehensive electronic health record data,” said Carey. “I mean, it’s not something you would even think about when it was all on paper charts in a huge warehouse. But now that it’s electronic, I think it opens up the door to a whole new way of looking at population health.”
No matter how impressive, the copious plotting and graphing and record-taking isn’t the ultimate purpose of the project. While understanding health impacts is the thrust of the study, researchers aren’t oblivious to the incredible amount of work that has to take place on the front end.
“As a scientist, I look at the data collection process as just a means to an end,” Carey said. “I get impatient sometimes with talking about just building infrastructure. ‘Let’s do something. That’s the boring stuff.’”
“But it has to be done, and done well, before we can really ask the interesting questions,” he said. “Having some short-term goals, I think, will be critical.”
Carey, however, doesn’t want to suggest that the first bits of usable data will arrive in the far-off future.
“There are going to be both short-term and long-term outcomes that we’re going to look at,” he said.
One of the abiding benefits of the project will be the usability of the research methods — the information gathering process, the use of electronic health records, the data-crunching and interpretation — in future endeavors.
“It will have value that goes well beyond looking at the health impacts of this particular environmental exposure,” said Carey. “I view it as a whole new paradigm for looking at population health and for doing, basically, in silico epidemiology.”
Apart from the study’s ramifications on public health research, subtler implications exist, notably in the court of public opinion. An unfortunate byproduct of a lack of evidence is that the little information that exists is easily drowned out by a fever pitch of politicians, pundits, bloggers and special interest groups.
“Lack of data has not led to a lack of strong opinions,” said Carey. “I’ve heard at the same meeting to discuss the health impacts of hydrofracking, people stand up and proclaim that this is an environmental disaster that’s killing people, or that this is something that is totally safe and that we have nothing to worry about.
“We set very early in this process the goal of being as unbiased and objective as we can possibly be,” he said. “We’re not going into this with any preconceived bias. It’s not a ‘gotcha’ study. We’re not anti-fracking. We just would like to know.”
Carey has no idea what information the research might eventually dig up, and admits that even a negative finding would have to be qualified under a specific set of parameters. There’s only one stance he’s willing to commit to right now.
“This is kind of a vanguard study,” he said.
It was an “obvious extrapolation,” said Carey, to use Geisinger’s wealth of experience answering population health questions through electronic data collection to study potential health impacts of Marcellus Shale. And Geisinger Health System also knew that it wasn’t a problem to be tackled unilaterally, but collaboratively. Partners involved in the study include members of the Geisinger Health System; professors of subjects including epidemiology, gynecology, environmental health sciences and global change from universities like Duke, Brown and Johns Hopkins; the Pennsylvania Department of Health; the National Institute of Environmental Health Sciences; and the National Heart, Lung and Blood Institute.
Some of the most valued collaborators on the massive undertaking? Family physicians. About one-third of the 1,000 members of Geisinger Clinic, the health system’s multispecialty physician group practice, are primary care physicians. The data collected by these providers is an incredible resource for the researchers.
“We see them as a critical part of the coalition that we’re building,” said Andrew Deubler, Geisinger Health System’s executive vice president of resource development. “They’ve provided some of the baseline data for overall health effects that we’ve studied.”
“They’re the front door of our health system,” said Carey. “They see patients every day, and a lot of the data that’s in our electronic health record that is going to really drive the study, we couldn’t collect without them.”
Physicians also play another important role — educators. The dearth of data has been distinctly unhelpful for doctors in the shale region whose patients are concerned about possible adverse health effects.
“Physicians are faced with patients coming into their office saying, ‘Do I have something to worry about here?’” said Deubler. “And a physician or a care provider [needs] some resource from which they can draw some modest statement or direction.”
Deubler said that primary care physicians have honed the ability to collect and analyze meaningful data — an immeasurably important attribute in a study of this caliber. Researchers are looking for ways to continue including them without taking their skills for granted.
“It’s fair to say we’ve had many discussions about the sort of bidirectional value of the primary care physician being a part of what we’re trying to do,” said Deubler. “And that is, we’ve talked about the primary care physician, or those deployed in the community, as sentinels to a great extent.
“What we don’t want to leave anyone with [is] the impression that we’re looking at primary care physicians, or the physician population, as simply a reservoir of data disconnected from the research that we want to see happen,” he said. “We see that that cohort is an integral part of evolving progressive research in the community for health impacts. They are as much a part of the research question as they are a resource for data.”
Although it might seem like the large coalition will be perfectly able to handle the massive amounts of research, the planning group has a desperate desire to find more collaborators.
“It’s going to require a mix of different types of contributions and expertise,” Carey said. “Some of the collaborators we’re working with are people who are experts in epidemiology, or environmental health science, or environmental epidemiology. They certainly have a role.
“[We also need] people with expertise in health information technology,” he said. “A lot of it’s based on our ability to extract, transform, [and] consolidate the data into a useful format, and of course, people with expertise in statistics and study design.”
“I’d also say partners in the community,” said Deubler. “This is a longitudinal study that we can envision going out 20 years in phases. We’re going to have to talk and work with the community — not simply to convey things that we’ve discovered, but to better understand how we [can] query and engage the community as we release information or liberate information in the community that would be important for our data.
“The community has to be an active partner,” he said. “We, again, see that a care provider ends up being a wonderful ambassador to the community in a bidirectional way — we can push information out through the care provider, and then the care provider can engage the community. But we’re going to have to talk directly to the community, so collaborators and partners that represent the communities in which we’re looking at are key.”
It should come as no surprise that such a well-planned, well-executed study isn’t going to be a cheap thing to see through to completion, especially if the study is going to last years or decades. As it stands, the initial phases of the Marcellus Shale study are plotted out for eight years, but researchers are convinced that the foundation is solid enough for the project to last for quite some time (or, as Carey put it, “[the project will] certainly outlive my professional career”).
“A lot of people that we’ve talked to — and we’ve spent hours meeting face-to-face, talking to people on the phone, pitching this idea — the almost universal response was, ‘It’s a great idea, we’re glad someone’s doing this, it needs to be done. How are you going to pay for it?’” said Carey.
“Right now, really, [it’s funded] in two ways,” said Deubler. ”We’ve had a local foundation commit a million dollars to help us launch this study, and Geisinger’s committed its own resources. So it’s not a sustainable model — we very much need additional foundation support and private funding.
“It would be preferable to us to receive private, foundation funding to any other source of funding because it will come with the fewest strings attached, or perception of strings attached,” he said.
The difficulty in financing the project isn’t just in its scope, but in the controversial nature of hydraulic fracturing. Maintaining the sort of neutrality that has marked the study since its inception is a responsibility that the researchers take very seriously. Nevertheless, the project is an expensive one, and Geisinger Health System can’t feasibly foot the bill for a project with an indefinite price tag.
“We need a whole variety of different types of entities, agencies and individuals to step forth and help provide the funding to do this,” Deubler said. “Ultimately, it’s not sustainable if Geisinger were to try to fund this on its own, it’s not sustainable for Geisinger and a very generous but singular foundation. We need others to help us fund this.”
The public’s help and approval is also sought.
“We need the public to understand what we’re doing and to help support the initiative, and to better understand what else we need to provide to do that from a very practical perspective,” said Deubler. “We’re not going to be successful if we don’t raise support. We need funding. We need private funders, we need foundations, we need other entities to step forward and help us drive this process and to fund it.”
“I believe one of the sources of that funding is going to come from a popular opinion that what we’re doing makes sense,” he said.
According to Deubler, potential partners were initially hesitant because of the project’s emphasis on building a solid underpinning. Deubler was faced with the task of representing the value in collecting the data first to drive solid, long-term research.
“There really are two fundamental motives at play for what we’re trying to do,” said Deubler. “One is to enable good, quality, hypothesis-driven research … But, and this is somewhat of a sequential set of steps, we first have to be able to build the infrastructure in order to make that happen.
“Whether that be talking with potential research collaborators, talking with funders and the like, this was particularly frustrating to me in the beginning in that folks didn’t see the virtue of the data,” he said. “What they were rushing to was the virtue of asking and answering questions.”
So many complications factor into a venture of this magnitude that uncertainty started to creep in. Carey said the competing concerns of stakeholder interest and financial viability threatened the project so much so that, as recently as a few months ago, he wasn’t sure if the project could continue.
“I would have to say, there was a period of a few months earlier in 2012 when I had some serious doubts whether we could actually pull this off,” said Carey. “Now that we’ve got this … $1.1 million pledge from a local foundation, and we’ve been putting our own resources into it, I’m feeling a little better now. We can at least get started.
“Andy had been saying for a couple months, we needed to get out of the ‘just talking phase’ and into the ‘doing phase,’” he said. “Because, if we keep talking about it but not doing anything, we’re going to lose credibility outside and we’re going to lose interest inside, because people will just move on to other things.”
“I think we have enough momentum now, and a really good group of committed collaborators, and some funding to get started, that I’m feeling more optimistic now than I ever have,” said Carey.
The study is already producing results — if not conclusions, at least valuable information. A short while ago, researchers discovered that some of the wells aren’t even active at the moment.
“The drilling activity oscillates,” Carey said. “The activity where we live is actually kind of slowed, kind of tapered a little bit.
“But it’s interesting — and some of the energy industry folks we’ve talked to have confirmed this — they’ve stopped drilling new wells in the middle part of the state, and what they’re in the process of doing now is building the distribution infrastructure,” he said. “So there’s some wells they stopped. They’ve capped, and stopped collecting the gas, because they can’t transport it.”
The researchers say data doesn’t always take a long time to collect, and they’re just as eager to see what develops in the short-term as they are about the long-term health effects.
“Things that manifest quickly, we could see the data being available very quickly, and the ability to interrogate the data deeper on key questions once we’ve seen something that has a particular level of interest,” said Deubler. “That’s not necessarily going to take a long time to do.
“It’s funny how we’ve discovered over time … David and I have been talking about this for 18 months, how I think we left people with the impression that it’s going to take years for the data to be useful. And we don’t believe that,” he said. “It’s really gated by the question you’re asking.
Interestingly, one of the public health effects is fairly evident right now — and it has nothing to do with chemicals or flowback water.
“You’ve got lots of trucks coming in, [and] one of the anecdotal things we’re seeing is increases in traffic accidents,” said Carey. “[The area] is pretty rural, a lot of small, narrow country roads with these hills that wind around. There’s lots of extra truck traffic, and those roads weren’t built for that.
“It’s creating traffic and congestion that people aren’t used to, and I think it may be contributing to some of the angst that people are experiencing,” he said. “And then, of course, you’ve got more accidents. Is it a proportional increase based on just the increase in traffic, or is it more than that? Nobody knows yet, nobody has really analyzed it.”
The scope and breadth of the study is astonishing, considering that after more than 60 years of commercial hydraulic fracturing, the only data currently available is incomplete at best.
“It’s surprising,” Carey said. “I’m not aware of any comprehensive health impact studies that really have addressed any of these questions.
“There’s a widely-cited health impact assessment study — Roxana Witter is the lead author, she’s from the Colorado State Dept. of Health,” he said. “It was basically more kind of a ‘what if?’ kind of study. They talked to a lot of experts and said ‘What are the things that might happen?’ A lot of it was based on Environmental Protection Agency air quality data, which is what they focused on mainly.”
“I don’t think we’ve uncovered any study that’s directly engaged the health provider community and patient data to help define and drive critical questions on health effects,” said Deubler.
As misguided as it might sound, some scientists either undervalue or entirely discount the idea of a public health impact study — an attitude made abundantly clear at a recent hydrofracturing conference that Carey and Deubler attended.”
“Andy and I were at a meeting that the Institute of Medicine sponsored in April on the health impacts of hydrofracturing. Two-day meeting,” said Carey. “There was nobody who presented health or patient-level data.”
“Dave did a great presentation on what we’re trying to present,” continued Deubler. “And the scowling that occurred in that meeting … it was a national meeting with national public health figures, and a few folks had the courage of their convictions to articulate why they thought this was cynical: ‘Patient data isn’t useful here. There’s no way you can make it accessible for meaningful research.’”
“That was coming from the mainline academic environmental health scientists,” said Carey. “They’re just not used to working with that kind of data. It’s surprising when you look — people say there’s no data. I don’t think it’s an exaggeration. There is no data. But there’s lots of concern.”
The researchers are more than familiar with that concern, and how it can manifest itself in the public — dramatic talking heads, sweeping statements and broad conclusions based on limited data. Far from inserting their study into the morass of conjecture, the researchers are comfortable doing the difficult work behind the scenes, content in their desire to provide valuable health information to patients and their care providers above all else.
“Our primary audiences are caregivers and the community,” said Deubler. “That’s not to suggest that we’re naïve not to believe that will be an audience. But what we’re trying to do is focus the attention of our work to those who receive and give care.”
Family physicians — and those they care for — are waiting patiently for the answers.
Originally published in the 2012 Fall/Winter edition of Keystone Physician Magazine.