Testimony by North Carolina’s state epidemiologist sheds light on discord among health experts on the decision to rescind do-not-drink advisories for wells near coal ash waste.

By Catherine Clabby

As state regulators prepare to release risk assessments of Duke Energy coals ash waste impoundments this week, a state health official divulged that some health officials opposed the state’s reversal of warning that drinking wells near the waste posed health risks.

Megan Davies, the state epidemiologist and epidemiology section chief in the Department of Health and Human Services, in sworn testimony also disclosed that politics, not just health-risk assessments, played a role in the March DHHS decision to back off from do-not-drink advisories for the wells.

The physician divulged too that she had reservations about the accuracy of the first line in the state’s safe-to-drink letters sent to well owners. It said: “We have reviewed the do not drink usage recommendation because we have determined your water is as safe to drink as water in most cities and towns across the state and country.”

Davies revealed this and more under oath during a pre-trial deposition taken May 4 by the Southern Environmental Law Center, which represents environmental groups in a lawsuit against Duke Energy regarding clean up of its coal ash.

DHHS leaders criticized release of Davies’ deposition. “It is misleading that the Southern Environmental Law Center would release partial information before our citizens have the complete facts,” said DHHS Communications Director Kendra Gerlach.

Crystal Feldman, deputy secretary for the state Department of Environmental Quality, agreed that the deposition is misleading. “Dr. Davies’ deposition only provides one viewpoint,”  Feldman said.

SELC released a transcript of the deposition just days before the deadline – this Wednesday – when the DEQ is due to release risk assessments from coal ash impounded on 10 of 14 Duke Energy properties. The assessments could decide how fast and how aggressively clean up of the waste must occur on all sites.

Intermediate-risk sites must be excavated and closed by 2024; low-risk ponds must be closed, but not excavated, by 2029.

Better to wait

Well owners and environmentalists have criticized the DHHS and DEQ move in March to rescind 2015 DHHS advice that people not drink water in 320 drinking wells located near Duke Energy coal ash waste sites. That came after tests of the wells detected contaminants associated with coal ash, mostly hexavalent chromium and vanadium.

“The initial ‘do-not-drink’ advisory was a very cautious recommendation,” the March letter said. “In fact the recommendation regarding one of the elements is based on a potential one in a million risk for an average person consuming well water everyday for more than 70 years. Now that we have had time to study and review more data, we have concluded that it’s appropriate to return to drinking and using your water for cooking and other uses.”

Davies said she and Danny Staley, director of the DHHS Division of Public Health, favored waiting until the source of two contaminants in the well water was made clear before telling residents that drinking their water was safe.

Some well owners and environmentalists suspect coal ash is the source of both.

“We both felt it made more sense to wait on source determination,” Davies said under oath during her deposition. “That is relevant because if it were a contaminant, there might be ongoing contamination of wells with the increase in levels. So we felt we should wait until all the information was in and DEQ had made a determination, and then communicate with the well owners in that full context.”

DEQ has said groundwater, the primary source of well water, has been contaminated underneath all of the Duke Energy properties with coal ash waste but the risk of the contamination to drinking water is not clear. DEQ’s assessment of whether contaminants from coal ash could reach drinking wells is one thing that state risk assessments expected this week could clarify.

Politics in play?

The picture Davies paints of discussions among state health officials is more complex than the policy-focused description that DEQ Assistant Secretary Tom Reeder described recently.

“DHHS went back and revised original health-risk evaluation. They decided to make their recommendation consistent with federal safe drinking-water rules,” Reeder said while giving a talk last month at UNC-Chapel Hill.

Davies said Randall Williams, deputy secretary of health services, shared her worry that people advised to drink water from other sources would experience stress as a result, a potential health threat. But Williams also voiced concern that state legislators might limit state public involvement in assessing well water if the letter was not dispatched.

“So was Dr. Williams concerned that if you did not send out a ‘do-not-drink’ letter, that members of the General Assembly might restrict the administrative authority of the Department of Public health?… Did he express that concern?,” asked Frank Holleman, senior litigator for the SELC.

“Yes,” answered Davies, whose organization issued do-not-drink advisories based on screening levels established by state epidemiologists.

Two bills introduced in the House and Senate after the letters were sent would limit local, county and state officials from releasing health advisories for wells and public drinking water to cases where federal or state regulatory contaminant standards are exceeded.

Davies stressed that she did not favor releasing a letter that said the well water was as safe to drink as most public water systems in the state and the country, which are regulated by federal standards, when the letter did not disclose to well owners that federal rules do not yet regulate hexavalent chromium or vanadium in drinking water.

Safe as what water?

Also, the claim that well water was as safe as most public drinking-water supplies contradicted what she’d seen regarding levels of hexavalent chromium in public drinking water in Raleigh and Charlotte, which were lower than those detected in some wells near coal ash sites, Davies said.

“They are, on average, lower than those measured … in the drinking wells under the [Coal Ash Management Act] sampling,” Davies said.

California and North Carolina share the lowest groundwater standard for hexavalent chromium in the country. The standard, 10 parts per billion, is used to determine levels at which polluters must clean up. Only eight states in the U.S. have groundwater standards for vanadium; North Carolina’s is 8 ppb.

Drinking water contaminated with hexavalent chromium has been associated with increased risks of stomach tumors, Davies said during her testimony. Vanadium has been observed to create effects to kidneys and blood cells in toxicological studies of lab animals, she said.

Holleman queried Davies closely on discrepancies between the March letter’s claim and sampling of well water in Salisbury, near the Buck Steam Station treatment plant. One well test found levels of hexavalent chromium of 21.8 micrograms per liter, about 300 times more than the state screening level, Holleman said, citing a state notification to the well owner.

“Would you agree that this gentleman’s well water is less safe than the well water in Salisbury?… This well water has more hexavalent chromium in it, and therefore a higher associated risk for the adverse health effects of hexavalent chromium, which is cancer, right?” Holleman asked.

“Yes,” Davies said.

“And would you agree, therefore, the water in this gentleman’s well is not as safe as the drinking water at the Salisbury Public Water System, which has less than one parts per billion?,” he asked.

“Based on the hexavalent chromium level, yes,” Davis answered.

In cross-examination, Brent Rosser, a Charlotte attorney representing Duke Energy, emphasized the low increase in cancer risk represented by the state’s hexavalent chromium screening level.

“The one-in-a-million risk standard is higher than the lifetime odds of death from getting struck by lightning, a lethal dog bite, and a cataclysmic storm; correct?” Rossner asked.

“Yes,” said Davies.

“And, in fact, if my math is correct, the one in a million standard is over seven times more likely – or I guess you are seven times more likely to get struck by lightning and be killed than to develop cancer under the one in a million standard. Does that sound right?,” he said.

“Approximately, yes,” Davies responded.

Public health mission

But a second exchange with Holleman regarding the screening levels noted this: “The standard you used is the one in a million standard, which is the standard generally accepted in the field of toxicology and epidemiology; is that correct?,” Holleman asked.

“It is the standard laid out in the 2L Rule,” a state rule that regulates state groundwater quality, Davies responded. “And it is a generally accepted standard in the field of health-risk evaluation.”

Holleman also noted that the letters rescinding the do-not-drink orders referred to the state’s health mission of protecting North Carolinians.

“Now, the next to the last sentence says, ‘Our mission at the Department of Health and Human Services and the Department of Environmental Quality is to protect the health and safety of all North Carolinians.’ Do you believe this letter supported that mission or was consistent with that mission?” Holleman asked.

Davies’ answer was one word.

“No.”

Safe To Drink Letter (Text)

Davies Deposition (Text)

DEQ says all Duke Energy coal ash waste must be dug up, but wants permission to be more lenient if improvements occur.

By Catherine Clabby

State regulators have raised the risk designations for some of Duke Energy’s coal ash dumps, a move that could require 25 impoundments to be dug up by 2024.

Or not.

The Department of Environmental Quality wants the power to lower risk rankings in 18 months if the utility proves that coal ash is not polluting nearby drinking water and repairs dams at its waste sites.

Classifying risks posed by coal ash waste sites is a key step to North Carolina’s efforts to force Duke Energy to shut down coal ash ponds on 14 properties storing about 100 tons of coal ash. This drive began in 2014 after a spill at a Duke Energy in Rockingham County property dumped 39,000 tons of coal ash into the Dan River.

That event prompted an investigation that resulted in Duke Energy pleading guilty to nine criminal violations of the federal Clean Water Act and agreeing to pay a $68 million criminal fine and spend $34 million on environmental projects.

On Wednesday, it became clear for the first time that Duke Energy is considering providing alternative water supplies to water-well owners living near its waste. While in early planning stages, utility staff are considering running municipal water line extensions to affected homes, digging new community wells or providing filtration devices.

Low, medium or high

DEQ officials said they must ask legislators for permission to re-determine risk designations down the road because the state’s Coal Ash Management Act required the agency to prepare final risk designations by Wednesday.

“The deadlines in the coal ash law are too compressed to allow adequate repairs to be completed. It also does not allow for revisions to the classifications based on new information,” DEQ Sec. Donald R. van der Vaart said in a written statement. “Making decisions based on incomplete information could lead to the expenditure of billions of dollars when spending millions now would provide equal or better protection.“

That same law previously designated eight impoundments as high risk, requiring their fast-track excavation by 2019.

Lowering a dump’s risk status would save Duke Energy a lot of time and money. Low-risk sites need only be closed and capped by 2029, meaning water could be drained from a coal ash pond but waste would stay put. Dumps designated as an intermediate risk must be closed and dug up by 2024.

Duke Energy CEO Lynn Good said the utility wants all 25 sites now ranked intermediate to be labeled low risk. The company is drilling more monitoring wells at DEQ’s request, but studies the company commissioned to date indicate they do no environmental harm, she said.

“We disagree with intermediate ranking,” Good said. “That would be the most extreme option costing the most money and creating decades of disruption to communities without additional benefits.”

Alternative drinking water

By way of example, Good said coal ash stored at the utility’s Marshall Steam Station in Catawba County totals the equivalent of 800,000 truckloads. If the company moved 100 trucks a day from there every day of the year, hauling away the waste would take more than 20 years.

Duke Energy is using trains to haul waste from some sites.

Good stressed that she believes DEQ has the authority to change the risk assessments without obtaining legislative approval, but that DEQ’s leadership does not agree it has that power.

Coal ash’s effects on drinking water is one of DEQ’s biggest concerns. The waste has polluted groundwater underneath all 14 utility properties stashing coal ash, DEQ Assistant Secretary Tom Reeder has said. And contaminants linked to coal ash, typically stored in unlined pits, have been detected in wells.

Duke Energy CEO Lynn Good discusses ash basin closure options. Video courtesy Duke Energy

But it’s not simple to pinpoint coal ash as the source of the contamination. Two suspect contaminants – hexavalent chromium and vanadium – can occur naturally in North Carolina, for instance.

Duke Energy says research it has submitted to DEQ indicates that groundwater flowing near ash basins travels away from neighbor’s wells, except for at its Sutton Plant in Wilmington, where the utility has taken steps to address it. But the utility recognizes that studies conducted by outside experts may not provide the level of assurance that some people are looking for, Duke spokesman Erin Culbert said.

“Proving alternative drinking-water sources would give well owners peace of mind and enable the utility to preserve a wider range of options when shutting down its basins,” she said.

The state’s reversal this spring regarding 2015 health advisories it issued to owners of hundreds of wells near coal ash waste is one of the most controversial aspects of DEQ’s drive to force Duke Energy to clean up its coal ash.

Draft DEQ rankings last December designated 12 dumps as intermediate risks and four as low risk. Nine were placed in an uncertain category labeled “low-to-intermediate” due to gaps or deficiencies with data submitted by Duke Energy, Reeder of DEQ said at the time.

DEQ collected public comments on its earlier rankings in writing and in person, staging meetings in March in every county hosting coal ash containment sites.

The new ranking list “reflects countless hours of scientific and technical work by both state engineers and Duke Energy as well as thousands of comments by the public,” van der Vaart’s statement said.

Rankings released Wednesday confirm that digging up all coal ash in North Carolina is the best solution, said Brooks Rainey Pearson, a lobbyist for the Southern Environmental Law Center. The fact that DEQ might reclassify the sites in 18 months, after statewide elections in November, including a re-election bid for Gov. Pat McCrory, concerns her, she said.

“That sounds a lot like not making a final classification as the Coal Ash Management Act required, but moving the situation down the road,” she said.

Doc makes it his mission to bring subspecialists to rural southeastern North Carolina.

By Taylor Sisk

Fernando Moya, requires little sleep – which is fortunate, given that his days are stretched pretty thin.

Moya, a neonatologist, is founder, president, and CEO of Coastal Children’s Services, a pediatric subspecialty group. The practice is based in Wilmington, but, by design, has no stand-alone offices of its own. Moya’s objective in creating Coastal Children’s Services was to enhance quality neonatal care in Wilmington and then reach out into the largely rural southeast, placing neonatologists and other pediatric subspecialists where they’re needed most.

In additional to its offices at Wilmington’s New Hanover Regional Medical Center, the practice now has pediatric specialists in four hospitals in the region: Onslow Memorial Hospital, Camp Lejeune Naval Hospital, Southeastern Regional Medical Center, and Columbus Regional Healthcare System.

On a recent Tuesday morning at Southeastern Regional in Lumberton, Moya is clutching an extra-large cup of Dunkin’ Donuts coffee and sporting a day’s growth of stubble. He’s just had, he allows, “a rough night” in the neonatal ICU. But he’s eager to discuss his ambitions for pediatric care here in Robeson County, a county with the state’s lowest median household income, at $30,248, and some of its worst health indicators.

Coastal Children’s Services has been providing care at Southeastern Regional since August of last year. Moya hasn’t yet hired someone to oversee operations here, so he’s still very hands-on. But that’s his modus operandi anyway: right in the thick of things. He spends a few days each month practicing throughout the region.

“I like to be here because I like to try to bring the enthusiasm of what we’re trying to do,” Moya says. “I enjoy it.”

An opportunity to make a difference

A native of Chile, Moya began his pediatric training there and completed it at Yale. He remained on faculty at Yale for 6 years, served as associate director of neonatology at Louisiana State University and then chief of the division of neonatal-perinatal medicine at the University of Texas McGovern Medical School in Houston.

In 2005, he was recruited to come to Wilmington. Negotiations had begun to build a children’s hospital at New Hanover Regional, and Moya was attracted by the opportunity to bolster neonatal care in the area. He now serves as associate director of neonatology at New Hanover Regional and medical director of the Betty Cameron Children’s Hospital.

At the time of his arrival, the nearest NICU was in Fayetteville, nearly 100 miles away. Moya began to plot a regional strategy, with New Hanover Regional as the hub and Level 2 NICUs in the surrounding more rural areas.

Alan Stiles, UNC Health Care system’s vice president for Network Development and Strategic Affiliation and former chair of pediatrics at the N.C. Children’s Hospital, says that what Moya is providing was much needed.

“The southeastern region of North Carolina mainly has smaller rural hospitals with limited capacity to do more than stabilize and send premature or sick newborns to larger hospitals, often at great distances from their families and home,” Stiles says.

According to research conducted by NC Child, in Orange County — home of the UNC Health Care system — there are 3.4 infant deaths per 1,000 live births and life expectancy at birth is 81.7 years. In Robeson County, only a 2-hour drive away, there are 13.4 infant deaths per 1,000 live births and life expectancy at birth is 74.2 years.

Providing care where most needed

Moya founded Coastal Carolina Neonatology in 2009. His first regional alliance was with Onslow Memorial in Jacksonville, an hour from Wilmington.

In May 2010, he launched a broader initiative, Coastal Children’s Services, an LLC, which today employs 25 physicians and about the same number of advanced practice clinicians. Pediatric subspecialists now practice either in the hospitals or in already established practices throughout the region.

“Our vision has been to bring the care to [the hospitals], help them elevate the level of care, and keep as many patients as they can there,” Moya says. “We’ll support them locally. Whatever cannot be managed there will go either to Wilmington or elsewhere, with the appropriate triaging.”

Stiles, who calls Moya a “highly accomplished neonatologist and academic leader,” emphasizes the importance of the relationships with academic medical centers that Moya has forged to ease transfers when necessary.

Joann Anderson, president and CEO of Southeastern Regional and past president of the American Hospital Association’s Small and Rural Hospital Council, has embraced Moya’s initiative: “With Dr. Moya’s help, our staff is learning to care for more complex health care issues in neonates.

“By doing this, we’re hoping to be able to keep the infant near its support family while potentially improving outcomes because care is more readily accessible.”

Results take time. But according to NC Child data, the number of children up in Onslow County (where Moya formed his first alliance) receiving early-intervention services in their first 3 years rose by 45 percent from 2009 to 2013.

How it works

Making this work, Moya says, entails several critical elements.

First, “we recruit extraordinary people who can multitask.” That means, for example, that Janet Hoffer, who handles marketing and PR, also assists with education initiatives. It also means an all-hands approach to administrative duties.

Second is keeping overhead low. Being based in hospitals and established practices helps considerably in that effort.

Moya says he negotiates “reasonable contracts” with the hospitals, providing a number of services at cost. “It would be very hard to try to milk a lot of resources out of hospitals that are struggling,” he says.

Education and research

Coastal Children’s Services is also cultivating alliances beyond the region. The University of Chicago Medicine Celiac Disease Center, for example, has provided training, and Moya hopes to establish his practice as an affiliate.

He and his colleagues host three annual conferences, offering “world-class” speakers, Moya says. A recent symposium speaker was Richard Polin, MD, a member of the American Academy of Pediatrics’ Committee on Fetus and Newborn and co-author of the widely used Workbook in Practical Neonatology.

Hosting such events, Moya says, is central to the mission: “We have the connections, we have the insight, we have the motivation. And we also learn ourselves.”

The practice also conducts clinical research — both its own and in multi-center trials — and New Hanover Regional is now a member of the Pediatric Trials Network.

Unacceptable outcomes

North Carolina’s infant mortality rate (in 2014, 7.1 deaths per 1,000 live births) has consistently been among the nation’s highest. It’s considerably worse in the southeastern region of the state.

Moya believes that in an area so close to nationally recognized medical centers, including UNC and Duke, such outcomes are unacceptable.

“We hope to be a vehicle to summon that collective strength,” he says. For that to happen, “We need to partner with others, improve access to general care, then some specialty care. And then let’s try to recognize the time needed to interact, educate, and improve quality — and then see where those rewards go.”

“When he approached me about collaborating, he described his vision and reasons for it,” Southeastern Regional’s Joann Anderson says. “He told me he believed a regional approach to issues related to infant mortality was needed.

“I fully support that vision.”

The report is only produced every four years and examines markets in the entire U.S.

By Rose Hoban

The performance of some health systems in North Carolina has improved during the past four years, but according to a new report, they could serve people better if the state expanded Medicaid.

In a report that’s issued every four years, the Commonwealth Fund found that some North Carolina “hospital referral regions” improved on measures such as access to care and avoidable hospitalizations. But, in general, areas in states that have expanded Medicaid, as allowed under the Affordable Care Act, have seen more improvement in efficiency, access to preventive care and better outcomes.

“We do find there’s a strong relationship between access to care and quality of care,” said Douglas McCarthy, a senior researcher at the Commonwealth Fund. “Although it’s still too early to judge the long-term effects of the Affordable Care act, improvement in these domains could contribute to better outcomes in the long term.”

The New York City-based Commonwealth Fund, is a foundation that focuses on research about improving the health care system. This is the second time the organization has examined the performance of 309 hospital referral regions across the country, areas that delineate health care markets. In the Commonwealth Fund methodology, there are nine of these referral regions in North Carolina.

Medicaid expansion was not the only factor that drove improvement in health-care outcomes, said Sarah Collins, who studies health care coverage and access for the organization.

“If you look at the top 16 states that had the biggest improvement in coverage and access, about half were in Medicaid expansion states and the others were not,” Collins said.

She noted that other factors, such as a four-year-old Medicare program that penalizes hospitals with too many patient readmissions, as well as better reporting about injuries in nursing homes, have moved the needle on improving the way health systems deliver care.

‘Poverty is not destiny’

While the study found a strong relationship between low income and poor outcomes, Commonwealth Fund president David Blumenthal noted that some low-income communities performed well. He said some have even improved “dramatically,” largely due to collaboration within communities.

Blumenthal pointed to Stockton, Calif., a city that declared bankruptcy in 2013 after the city’s housing market and tax base collapsed during the depths of the Great Recession.

In recent years, that city has embraced a nurse-led program to support pregnant African-American women for a year after the birth of their infants. Meanwhile, local hospitals encouraged more breastfeeding. That helped the infant mortality rate to drop in Stockton. The city also allowed a nonprofit organization to run health clinics in four local high schools. The clinics provided check-ups, gave flu shots and helped address students’ behavioral health issues.

Closer to home, Collins said, in Wilmington, where 39 percent of households have incomes less than 200 percent of the federal poverty level ($48,600 for a family of four), rankings on health outcomes improved and exceeded those in most other parts of North Carolina.

See box below for how each hospital region’s ranking changed over time.

“The share of adults 18 and older who went without care because of costs went from 20 percent in 2011 to 13 percent in 2013-14,” she said. Collins added that many of the people who got insurance in a ACA marketplace plan were some of the highest-risk people who had the greatest health care needs.

“I think people shifted from probably skimpier, poorer coverage in individual markets and small group markets to much more comprehensive coverage in the [ACA] marketplaces,” Collins said. “So even in the non-expansion states you see the effects of the Affordable Care Act’s expansion of insurance.”

Adam Zolotor, head of the North Carolina Institute of Medicine, said that areas of North Carolina with more improvement have been doing some innovative things.

“It was interesting to me to see Asheville and Wilmington near the top of the list; those are both health systems that are doing a good job with care management around avoidable readmissions,” Zolotor said. “Mission Health in Asheville is one of the better hospital systems in the state in terms of patient and family engagement.”

However, he said, in some instances an area’s poverty might overwhelm the positives of a local hospital system.

Zolotor said that’s probably the case in Durham, where Duke University Medical System has entered into collaborations with local clinics to address community needs. Nonetheless, Durham’s ranking dropped in this survey.

“And Vidant [in Greenville] is great for their work in patient and family engagement, but the health system is covering the poorest third of the state,” Zolotor said. “It’s hard to improve their health outcomes without improved access to care and improved insurance rates.”

Frayed safety net

Many markets that saw improvement during the past four years shared one feature — they have robust networks of community health centers. Even though the Commonwealth researchers did not look specifically at those clinics, they said there’s other data showing the positive effect of the clinics on a community.

“From our case studies, we do hear anecdotally how important community health centers are,” McCarthy said. “In Stockton, about half of the Medicaid beneficiaries that are enrolled in the county health plan are served by community health centers. The collaboration between the plan and those clinics is really critical.”

Collins said in the 19 states that haven’t expanded Medicaid, community health centers have kept the safety net intact.

“There are many lower-income people who remain uninsured,” she said.

But Ben Money, the head of the North Carolina Community Health Center Association, bemoaned state leaders’ resistance to expanding Medicaid.

“We’re doing well with the resources that we have, but we could do far better with the resources we could get through Medicaid expansion,” he said.

Money noted that the federal Bureau of Primary Health Care, which provides funding and support for community health centers, has not been giving any extra help to centers in non-expansion states.

“I can’t blame a federal agency that says why should we give you money to do what you could be doing if your state expanded Medicaid,” he said.

“Why treat you differently if your state hasn’t taken advantage of a resource?” he asked. “It’s like if your kid says ‘I’m hungry, but I won’t eat my peas. Give me ice cream.’ Well, you gotta eat your peas first.”

Hurricane Matthew flooding will produce multiple hazards at home, indoors and out. Accurate information and time are required to help families cope.

By Catherine Clabby

There’s little worse than the vast flooding Hurricane Matthew has unleashed in North Carolina. Dirty water has breached homes, storefronts, nursing homes. People have been trapped in cars stalled in rushing water. Death tolls are rising.

But as people of this coastal state know too well, the trouble will not fade when Matthew’s floodwaters recede.

A rising crest of health threats is also on its way, public health experts say, including some unexpected risks. Families already battered by flood damage need to take steps to protect themselves all over again.

“People get very concerned about dirty water, that fuel oil might have leaked or sometimes their septic tanks. In reality, most of that doesn’t pose much of a health risk,” said Dr. Julie Casani, head of the state public health division’s Public Health Preparedness and Response branch.

“I worry more about people getting injured during the cleanup.”

Floyd, Fran and friends

Experience from previous storms backs that up. After a flood, homes that normally are shelters become altered environments hosting all sorts of hazards, contributing to an expected post-flooding uptick in emergency department visits.

For six weeks after Hurricane Floyd struck in 1999, incidence of bone and tissue injuries, respiratory problems, gastrointestinal trouble and heart disease were higher at 20 hospitals in 18 counties than they were over the same period the previous year.

Suicide attempts, dog bites, fevers, skin problems, and people seeking help with basic medical needs such as oxygen and medication refills, dialysis and vaccines all were more common during the six weeks after Floyd. So were spider bites, diarrhea, asthma attacks and injuries from assault, gunshot wounds and rape.

People can take steps to protect themselves. To begin with, people should stay clear any water that is slow to drain, said John Morrow, PItt County public health director. Its depth can be deceptive and may pose a drowning risk, the most common cause of death from floods.

“Just stay out of the water, period. Particularly children,” Morrow said. “They are too likely to say I’m just going to swim out there and get my ball.”

Casani agrees. “You can’t see what you can’t see. While plodding through water you may not be able to see something that is submerged. People can get cut. Or they trip and fall or sprain an ankle.”

Air it out

During a flood cleanup, people sometimes bring petroleum-powered devices — generators and power washers included — inside their homes or garages. That should never occur, Morrow said, because the carbon monoxide emissions can be deadly.

“Exhaust collects. Before you know it, you get dizzy and can’t get to fresh air or turn the thing off in time,” he said.

Ten cases of carbon monoxide poisoning were reported in weeks after Hurricane Floyd, compared with none during a comparable period in the previous year.

There is plenty to do indoors. And while water laced with chemicals or sewage is not the biggest threat people will encounter while cleaning up their homes, that remains a potential risk. So cleaning with protective gloves and boots is recommended.

“You don’t want flood water to come in contact with your face or mouth. The risk of sickness is low. But pathogens can pass through cuts and scrapes,” said Tim Kelley, the director of the environmental health program at East Carolina University.

The North Carolina State University Extension offers detailed guidance on how to proceed with cleanups at home after a flood. A priority is to shovel out mud or silt before it dries and to wash down flooded walls and floors with hoses and then get them dry.

Drywall acts like a sponge, extension materials warn, and it might be necessary to remove wall board above the flood line. Wet insulation also must go. Sometimes holes must be drilled into the siding to fully dry walls, a process that can take months.

Much of that effort is required because of mold growing inside a home. Mold isn’t a health risk to everyone, but it can be a serious risk to people with asthma and allergies, or people with suppressed immune systems due to HIV infection, cancer treatments or other health conditions.

“One of the things about eastern North Carolina is that we’re surrounded by mold. You can’t avoid it, it is so damp and musty. There are thousands of species,” said Paul Barry, from the Department of Public Health at ECU.

The state Department of Public Safety recommends people treat every item touched by floodwaters as contaminated and disinfect those items with household cleaning products. It also recommended that people stay clear of any flood-damaged material that may contain asbestos. Discard mattresses, upholstered furniture, carpets and padding, and books and paper products touched by floodwaters, department officials urge.

Choose caution

Then there’s food and drinking water safety to attend to.

When it comes to food, be conservative, health officials say. Discard any food touched by floodwaters, including edibles in cans, bottles or jars. Food that was in a refrigerator or freezer that reached more than 40 degrees should be thrown away, the N.C. State University Extension materials recommend.

If all the above isn’t enough, there are also disease-carrying insects to worry about. Mosquitoes lay their eggs in water and multiply more quickly after big rains and floods. State health officials recommend people wear insect repellent and empty any standing water in birdbaths, tires, flowerpots and other containers.

Casini, who lost a home to damage from Hurricane Isabel in Maryland in 2003, stressed that natural disasters, and all the challenges that follow, put a strain on anyone’s mental health.

She encourages people to slow down and not try to put everything back together at once, indoors or out.

“This isn’t your standard fall cleanup. This is happening in treacherous conditions,” Casini said.

Instead, do only what is feasible to tackle safely, she said. Try to get your family on what feels like a normal schedule. And reach out to other people in the same boat.

“Maybe they were never your friends,” Casini said. “But something like this becomes a collective experience.”

By Rose Hoban

Veterans at VA hospitals and clinics in North Carolina and Virginia had longer wait times for appointments, care and referrals to specialists, including for mental health care, than the electronic scheduling system showed  to regional Veterans Affairs leadership.

An audit released last week by the Veterans Health Administration Office of the Inspector General found that 36 percent of appointments for new patients at facilities in the Veterans Integrated Service Network that covers North Carolina and Virginia had wait times of longer than a month.

For people with extended waits for new appointments, their average wait was 59 days. And because of inaccurate wait time data supplied to the VISN leadership, those same veterans were denied the opportunity to seek treatment outside the VA system under the Veterans Choice Program.

“For those veterans who did not receive care through Choice within 30 days, we estimated they waited an average of 98 days to receive their care,” the report said.

The audit noted that inspectors reviewed the cases of 84 patients in the longer-wait-time group who either died or had “significant delays in care.” Reviewers determined that none of these patients had suffered “any harm.”

“Much of the data covered in the audit captures a period extending back into 2014, offering a refracted portrayal of our care for Veterans. since the environment has been in a state of continual regulatory and operational change,” said a statement from the regional leadership.

Delayed start

The audit looked at a sample of more than 1,400 appointments made from October through December 2015. Auditors from the Inspector General’s office visited a dozen facilities in Virginia and North Carolina, including hospitals and healthcare centers in Asheville, Charlotte, Durham, Fayetteville, Greenville, Kernersville, Wilmington and Salisbury, as well as smaller clinics throughout the state.

The auditors found that in their sample of new appointments, 36 percent of veterans had to wait for an average of 59 days. Extrapolated out to the entire region over the same time period, it appears that as many as 20,600 people had similar waits for care.

“This was notably higher than the 5,500 appointments (10 percent) that VHA’s electronic scheduling system showed were scheduled greater than 30 days,” the report read.

A further breakdown of those numbers found that potentially:

The report found that the inaccuracies in wait time data occurred because “medical facility staff did not consistently enter correct clinically indicated or supported preferred appointment dates” when they were making appointments for new patients.

This means that in about three-quarters of the appointments with long wait times, staff members erroneously entered dates into the scheduling system for clinics that weren’t seeing patients on a given day or entered appointments that were not for the correct clinical service.

And those inaccuracies made it appear as though wait times were shorter than 30 days.

“VA data reliability continues to be a high-risk area,” wrote Assistant Inspector General Larry Reinkemeyer in the report.

Referring to a report on VA data published by the US Government Accountability Office in 2015, Reinkemeyer said VA data reliability was a problem “because of inadequate oversight and accountability.”

“In its report, GAO stated VA’s oversight efforts are often impeded by its reliance on facilities’ self-reported data, which lack independent validation and are often inaccurate or incomplete.”

Officials respond

“We recognize that there is always opportunity for improvement,” said Mark Shelhorse, MD, acting Mid-Atlantic Health Care Network (VISN 6) director in his statement.

“Since 2014, we have continually taken steps to ensure proper scheduling practices and have made substantial investments to apply the right combination of staff, facilities, and tools to increase access to care for Veterans in the VISN.”

The release noted that in the last two years, five community-based outpatient clinics and three health care centers had been opened in Virginia and North Carolina region.

“In fact, VISN 6 has opened more than one million square feet of clinical space over the last year,” the statement said.

The VA Durham Medical Center director DeAnne Seekins said in a separate statement her facility has been facing increased demand, and has been scaling up.

“Since April 2014, we hired 1,325 staff, including more than 100 physicians and 250 nurses. Today, 3,428 clinical and support staff stands ready to provide quality healthcare that meets the unique needs of Veterans,” Seekins said.

Seekins said that as of February, about 93 percent of patients were being seen within 30 days of a desired appointment date, and that wait times for mental health services had been whittled to 3.2 days. She also said that Durham’s Scheduler Service Line was a best practice noted by the Inspector General’s auditors.

She admitted there’s a need for improvement, even while noting the Virginia and North Carolina region is the fastest growing VA network in the country. About 337,000 veterans are currently registered to receive care from VA facilities in the two states.

Limited “Choice”

After initial reports of significant delays in getting veterans care nationwide, in 2014, Congress passed the Veterans Access, Choice and Accountability Act, which allows veterans to obtain care at a nearby civilian medical facility if waits at a VA center are longer than 30 days.

The law also required that the VA post wait times for scheduling an appointment online.

Reinkemeyer’s team found that the data available on the public postings and the information going to VISN 6 leadership was not reflective of the reality in the clinics.

And because of inaccurate data, auditors “estimated staff did not identify about 13,800 of these 15,300 appointments (90 percent) where veterans should have been added to the Veterans Choice List.”

The errors occurred because, “VISN 6 and medical facility management did not ensure staff from medical facilities consistently implemented [Veterans Health Administration] scheduling requirements,” the report read. This occurred despite the fact that, since the nationwide scandal broke in 2014, the VA has “provided periodic guidance and training to clarify scheduling procedures.”

The inspectors also found internal audits on scheduling, which have been required since the beginning of 2008, were not being performed in the medical facilities. Earlier in 2014, the auditors noted that regional leaders provided guidance and examples of how to do the scheduling audits to medical facilities in North Carolina and Virginia.

Only “some” audits of scheduling staff were performed, however. And the documentation on those audits provided only spotty information for reviewers from the Office of Inspector General on how many scheduling clerks were audited, what their error rates were and whether the results were even discussed with the staff members making the mistakes.

By Catherine Clabby

Harmful algal blooms, particularly the periodic explosive growth of cyanobacteria species, appear to be increasing in frequency and severity globally, researchers from the EPA and the Centers for Disease Control and Prevention say.

While most algae pose no risk, harmful algal blooms, whether green or reddish masses floating on the surface of water, can produce toxins that even in tiny amounts can harm people.

Young children are likely at greatest risk.

Swallowing or swimming in water during a dangerous bloom can produce skin rashes, liver injury and neurological changes. Toxic algae metabolites can also harm or kill pets and livestock.

The North Carolina Department of Environmental Quality confirmed the presence of potentially harmful cyanobacteria algae 19 times across North Carolina during the summer of 2016 alone.

How many potentially harmful blooms occurred in North Carolina in 2016 is unknown. State officials did detect cyanobacteria toxins called microcystin at five locations: Pamlico Sound, Albemarle Sound, a Brunswick County storm water pond, a Davie County pond and Greenfield Lake in New Hanover County, said Cobey Culton, a state Department of Health and Human Services spokesman.

The same uncertainty exists nationally. Blooms occur unpredictably and are not always documented, never mind assessed for their full chemical content.

“We need more data to inform prevention and mitigation of harmful-bloom health effects,” said Lorri Backer, a senior CDC environmental epidemiologist who spoke this week at a meeting of the North Carolina One Health Collaborative at Research Triangle Park.

To achieve more clarity on this risk nationally, the CDC has launched a surveillance program, One Health Harmful Algal Bloom System. Public health programs in states, including North Carolina, report human and animal illness linked to algae exposure, as well as environmental conditions where the blooms occur.

The goal is to expand understanding and prevention of harmful blooms and illnesses associated with them.

Why now?

Scientists link evidence of increased incidences of toxic algal blooms to climate change. Because algae have been around for millions of years, they have adapted to live pretty much anywhere on this planet.

But they often thrive in warmer waters and as Earth’s surface temperatures rise, so does that water.

It doesn’t help that human activities feed algae. Nitrogen and phosphorous that wash into our waterways from lawn and crop fertilizers, livestock animal manure, and underperforming sewage treatment plants are nutrients that feed algae.

North Carolina is no stranger to these blooms. They appear here mostly in freshwater ponds and sometimes quite dramatically in rivers, including the Chowan River last summer, said Mark Vander Borgh, a DEQ senior environmental biologist.

Sometimes they surge in estuaries as well, he said.

But they occur unpredictably, which can make them hard to catch, never mind quantify. Even as DEQ receives more complaints than ever, agency staff can’t say conclusively that more are occurring, Vander Borgh said.

“We don’t have the data to say if they are more common,” he said.

Mina Shehee, of the North Carolina Division of Public Health, said after Backer’s talk she wonders if small farmers raising livestock are losing more animals than they realize to toxins produced by algal blooms.

She’s heard reports of animals dying for unknown reasons, she said, and wonders if ponds with algae might sometimes be to blame.

“We don’t know the extent of it. They are out there but we’re not capturing it,” said Shehee, who works in the Occupational and Environmental Epidemiology Branch the Division.

She and colleagues are considering partnering with North Carolina Cooperative Extension agents to collect more data on animal deaths coinciding with algal blooms to get a clearer picture, she said.

Linking human, animal and environment

Spreading the word on the rising risk from harmful algal blooms fits well with the goals of the One Health movement, which strives to increase awareness of ways that the health of people, animals and the environment overlap.

There is good evidence that pets have been sentinels to the presence of cyanotoxins.

While no human deaths have been linked to exposure to cyanobacteria in North Carolina, for instance, dogs have been made sick and may have perished from contact, according to state Department of Health and Human Services educational material on bloom threats.

“If water is stinky and green, people are not going to go into it. But a dog will,” Backer said.

Zach McKinney, a North Carolina State University graduate student in physiology attending the talk, said the general public is probably most in the dark about potential risks of harmful algae blooms.

While growing up in Pamlico County, he said, a member of the church his family attended had intense algae blooms strike ponds where he grew fish for profit. As the green slime spread, his fish were dying.

To help out, volunteers, including children, jumped into the water to scoop out the surviving fish to try to save them. That produced a lot of splashing and close contact with whatever the algae might have released into the air.

“No one considered the potential harm,” he said.

Editor’s note: Locations where state officials detected toxic microcystins in 2016 were added to this story on April 22.

By Rose Hoban

Michael Stoiko drove up from Wilmington on Tuesday evening with several coworkers so he could speak for two minutes.

By the time Stoiko, a pediatric critical care physician, finished speaking to about 250 people attending a public hearing on North Carolina’s Medicaid reform plan, you could hear a pin drop.

That’s because he told a heart wrenching tale of unnecessary death.

“I again recently had the experience of looking down at a beautiful 5-year-old girl with fixed and dilated pupils, because she was brain dead, because she had asthma,” he said.

Stoiko works with Coastal Children’s Services, a practice which provides subspecialty care at hospitals throughout the southeastern part of the state. He said this child had not had regular access to primary care.

“She arrived in our ED brain dead after arresting at home,” he continued.

“That’s maybe the fourth or fifth hundred child I’ve seen die of a completely preventable cause because they did not have access to primary care, and they did not have access to some specialty care,” Stoiko said. “I’m getting kinda tired of that.”

Prevented

Forty-two people who spoke at the McKimmon Center on the N.C. State University campus for the listening session hosted by the Department of Health and Human Services, at least 30 of them directly told HHS Secretary Mandy Cohen that the state’s Medicaid overhaul should include expanding Medicaid.

Many of the physicians’ stories were about patients they saw too late.

“Throughout my career, I saw patients with heart failure, stroke, end-stage renal disease, mostly from untreated hypertension, diabetes or high cholesterol,” said James Foster, a retired cardiologist who practiced in Wake County and also taught at UNC Chapel Hill.

“In many cases, they might have been prevented if they had been able to afford medical care, but now their lives were devastated,” Foster said of his patients who were ineligible for Medicaid coverage and were uninsured.

Cohen, Medicaid director Dave Richard and other DHHS staff heard from medical students, primary care physicians, the head of UNC Healthcare, volunteers and county health directors, all of whom had the same message: find a way to extend insurance to more people in the state.

But it’s not DHHS that  will ultimately make that decision. A 2013 law leaves that decision in the General Assembly’s hands.

“I think the reason why it’s important we hear those comments is because you know there are members of the legislature that care about that,” said Richard. “I think what people have said to us here is that coverage is really important.”

Opioids, children at the forefront

Some of the strongest themes in Tuesday night’s meeting were around the impact of Medicaid on children.

“Medicaid is children’s health insurance,” said Theresa Flynn, a pediatrician in Wake County who sees mostly low income children. She pointed out that children make up the majority of the enrollees in Medicaid, but account for less than a quarter of the costs.

Several speakers noted that social issues such as poor housing, poverty, diet or access to transportation are big players in health outcomes. In some parts of the state, the opioid epidemic is affecting children’s health.

Stoiko’s co-worker, Elizabeth Harris, noted that in the neonatal intensive care unit at the Wilmington hospital where they work, 15 to 20 percent of the babies are in withdrawal from opioids they were exposed to in utero.

“And in Lumberton, it’s 30 to 50 percent,” she added.

About three-quarters of Coastal Children’s Services patients are children Harris told the crowd.

Afterward, Cohen noted how children’s health predominated the issues raised at this meeting, while services for people with intellectual or developmental disabilities was the big issue in Greensboro and dental care issues took precedence in Greenville. She was unable to attend the Asheville meeting which took place last week.

In all the meetings this month, however, Medicaid expansion was the common thread.

“This process has been very helpful in understanding where folks are and where consensus is developing,” Cohen said.

By Rose Hoban

A four-line provision in the North Carolina Senate’s budget could make it more difficult for hospitals and other providers who receive state dollars to perform abortions in North Carolina.

In past years further restrictions on abortion have come in the form of high-profile bills making their way through raucous committee hearings. But this has been a quiet swipe at abortion services, a 65-word section tucked into the 360-plus page budget passed by the Senate on May 15 states that “no State funds shall be allocated to any provider that performs abortions.”

The language in Section 11F.4 resembles language placed by legislators in the final 2011 budget which prohibited North Carolina Medicaid or the health insurance plan for state employees from reimbursing for any abortion procedures.

A provision with similar language appeared again in the 2015 state budget. But that provision was more specific in its language, forbidding the state from entering into any contracts for providing teen pregnancy prevention training programs with any provider who did abortions. That effectively cut Planned Parenthood out of a contract to provide the training in Cumberland and New Hanover counties.

Sen. Ralph Hise (R-Spruce Pine), the chair of the Senate Health Care Committee and lead budget writer for the health and human services portion of the Senate budget, confirmed to North Carolina Health News that language in this year’s bill is “broader.”

“A provider… they would still be able to receive all of their payments from Medicaid, the State Health Plan for all the services,” Hise said. “It would prohibit the department from entering with them into contract for something else.”

Sarah Gillooly from the North Carolina chapter of the ACLU said she read the language as seeking to put hospitals in a bind.

“[This] seems to force physicians and facilities to either refuse to provide a common medical procedure or to give up important public health funding from DHHS,” wrote Sarah Gillooly from the North Carolina ACLU in an email to NC Health News.

Few, but complicated

Hise said he believed hospitals such as UNC Healthcare and East Carolina University do not perform abortions.

However, academic medical centers which train the next generation of obstetrician/ gynecologists often perform abortions, in particular, the later term cases that result from fetal abnormalities, congenital problems and genetic problems that start to become detectable in the second trimester of pregnancy, starting around 14 weeks.

In 2015, the last year data is available, there were 27,631 abortions performed in North Carolina according to the N.C. State Center for Health Statistics.

Kathleen Vessey-Jones from the Center said state law prevents her from saying how many procedures were done in each location, but she could say that in 2015, 1.2 percent, or about 330 abortions were performed in a hospitals. The rest were done in clinics.

The distribution of where abortions occur in the state show there are only 10 counties where abortions took place – Buncombe, Cumberland, Durham, Forsyth, Guilford, Mecklenburg, New Hanover, Onslow, Orange and Wake – all of which have medical centers and also have private clinic abortion providers. But it’s impossible to know which hospitals did the procedures, and how many.

So, there would be abortions performed within the walls of hospitals, and many of those same facilities receive state dollars to perform a variety of services. Those services range from the state’s Poison Control Center, housed at Carolinas Medical Center in Charlotte to the Telestroke Network at Wake Forest Baptist Health, to the Center for Telepsychiatry and e-Behavioral Health, which works with Vidant Hospital in Greenville.

And in academic medical centers, residents in OB/GYN training programs are being taught how to do the procedure. Since 1996, the American Council on Graduate Medical Education began requiring abortion training as part of accredited obstetrics–gynecology residency programs. Data from the Council indicate that there are OB/GYN training programs at eight academic medical centers and hospitals around the state.

How broad is broad?

“I agree that the language is broader. I don’t know if that means the actual restriction is broader,” wrote Jill Moore, who monitors public health law at the UNC Chapel Hill School of Government in an email.

“I don’t have a sense of what the practical effect of this provision would be, because I don’t know which state funds that are appropriated to DHHS are then passed along to hospitals or other abortion providers for some purpose other than reimbursement for services under the state health plan or Medicaid,” Moore wrote.

Gillooly said she felt the intent was “perfectly clear.”

“Legislators who oppose safe, legal abortion are attempting to disqualify physicians who provide abortion from other government funding,” Gillooly wrote.

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She argued that the language could cause the state run afoul of U. S. Supreme Court rulings.

“Courts have been very clear that it is unconstitutional to disqualify organizations from government funding simply because they are providing patients with a health care service that is a constitutionally protected right,” she wrote. “The law may allow the government to say it will not directly fund that service, but it can’t tell a private entity what to do with its own money.”

No guarantee

When the House amended the budget bill, the Senate’s language was removed. In its place, House budget writers included a provision which appropriated $1.3 million to the Carolina Pregnancy Care Fellowship, a network of about 80 pregnancy care ministries. The money will go toward purchasing medical equipment for the centers, which are not clinics, but counseling centers which encourage women not to have abortions.

Now that a compromise budget is being hashed out behind closed doors, there’s no guarantee this language would be eliminated altogether.

Multiple health care lobbyists and advocates at the legislature privately expressed concern about the outcome of the provision in the budget negotiations. But when asked, none were willing to make a public statement, citing fear of reprisal from lawmakers.

By Catherine Clabby

Twice in recent years, tough-to-extract, industrial chemicals have been detected in the Cape Fear River, a source of drinking water for millions of North Carolinians.

Both compounds pose health threats at certain concentrations but neither, as of yet, is regulated by federal water standards, which states help to enforce.

This month, the headline-grabbing culprit is GenX, a replacement chemical for a dangerous and persistent compound, perfluorooctanoic (PFOA). DuPont and other manufacturers have been sued for using PFOA for decades to make durable products such as Teflon and stain-resistant coating on carpeting.

A prior contaminant was 1,4 dioxane, a common manufacturing ingredient in plastics and other products that companies were releasing into municipal sewer lines in the upper reaches of the Cape Fear River without disclosure or measurement.

After both chemicals were disclosed, local and state government found themselves hustling to slow or stop the flow of substances not removed by equipment at most public drinking water plants.

And this cycle is very likely to occur again, said N.C. State University water quality scientist Detlef Knappe, whose laboratory was instrumental in uncovering the presence of both compounds. So it’s time to get more proactive about preventing unwelcome surprises, he has concluded.

“The chemicals are often protected as confidential business information,” Knappe said. “It’s much harder for scientists, regulators and drinking water providers to even know what’s in the water.”

Complex contaminants

GenX is an excellent example of a compound that few experts expected to find in public waterways until they did.

Manufacturers no longer use PFOA because it’s too dangerous; the compound persists indefinitely in the environment and accumulates in the human body. Epidemiologists have identified a probable link to PFOA exposures and high cholesterol, ulcerative colitis, thyroid disease, testicular cancer, kidney cancer, and pregnancy-induced hypertension..

A DuPont spinoff company, Chemours, which operates a former DuPont plant in Fayetteville, replaced PFOA with GenX, a similar compound that was expected to degrade more easily than PFOA.

Companies such as Chemours have disclosed few specifics about the chemical structures and potential toxicities of PFOA replacements, making it difficult for anyone to assess if they too pose a threat, a team of EPA scientists reported in a 2015 paper.

In 2016, the scientific journal Environmental Science Technology Letters recognized the EPA team for its “stand out” study that described GenX and related compounds in the Cape Fear River. Some of the news was sobering: They found GenX and related compounds could not be removed by conventional or advanced drinking water treatment processes.

The fact that they don’t break down easily was concerning, Knappe said. “The thinking is the toxicity could be similar because structurally they are similar,” he said.

In December 2016, Knappe’s lab, working with the same EPA scientists, published a subsequent study. In that paper, the authors detailed how they detected the newer compounds at drinking water system intakes in Brunswick and Pender Counties and Wilmington.

The researcher notified water systems about the results. When word of that hit the pages of the Wilmington Star News newspaper this month, residents voiced anger, staged protests and demanded a cleanup.

Not the plan

Once, there was good reason to think this could not happen. When Chemours started producing GenX at its Fayetteville Works facility, about 100 miles upstream from Wilmington, it was required to prevent 99 percent of the compound from reaching surface waters.

It now appears that the GenX in the Cape Fear River, however, may be a byproduct of chemicals released at a vinyl ether processing facility at the Fayetteville Works site, said both Knappe and the office of U.S. Rep. David Rouzer, which is keeping his constituents apprised of GenX developments here.

Chemours has issued a statement saying that releases from its Fayetteville facility have not had an impact on the safety of the drinking water that comes from the Cape Fear River. But DEQ officials are investigating for themselves. They announced Monday that they will sample 13 locations in the Cape Fear over four weeks.

Chemours has agreed to pay for the sampling and testing.

While stressing they have no evidence that GenX contamination poses a health threat, Department of Health and Human Services officials have stressed they will keep lower Cape Fear region residents informed of whatever they find.

“We are working closely with DEQ to understand more about GenX and we will keep people informed as we get more information,” Department of Health and Human Services Secretary Mandy Cohen said in a press statement.

A better way?

It’s reasonable to think that North Carolinians will be surprised again in the future about chemicals in public waters, said Susan White, executive director of the Water Resources Research Institute for the University of North Carolina system and North Carolina Sea Grant.

“EPA regulates only a portion of the chemicals we find in our waters,” White said. “That’s a challenge as our development of new chemicals increases so rapidly. We still aren’t always entirely sure of what is present.”

To prevent unpleasant surprises, companies that discharge chemicals into waterways should disclose more detail rather than shielding information for proprietary reasons, Knappe said. And regulators should be more cautious about allowing even small amounts to reach waterways.

“We’re seeing more and more chemicals that are almost impossible to remove from water. So, that makes it either extremely expensive or almost impossible for drinking water systems to remove all contaminants,” he said.

In North Carolina, funding for water quality protection has been cut in recent years, by 41 percent according to one informed estimate. But it should be expanded, Knappe said.

Executing widespread monitoring of river waters would help, White said. But she said it’s a complex and expensive job that requires frequent tests, statistically sound sample sizes and care not to let temperature or other conditions distort results.

“Monitoring is unsexy. No one wants to pay for it,” she said.

On top of that, questions will always persist about the best way to treat new contaminants once they are found.

“Is nanotechnology the best approach?” White asked. “If you answer yes, one of these days we’ll be trying to figure out what nanoparticles are doing in the water. It’s a trickle-down problem.”

By Taylor Knopf

The final state budget includes a little more than $10 million in state funds to combat opioid addiction and overdoses across the state over the next two years. That’s half the amount pledged earlier this year.

Throughout the session, it’s been unclear how much the state would allocate to the cause. Lawmakers have made passionate speeches about victims of opioid overdoses, and yet the Senate and House versions of the budget contained very little funding to address the issue.

The STOP Act (Strengthen Opioid Misuse Prevention Act), a bill heavily backed by bipartisan state leadership, focuses on decreasing the number of narcotics in the state and adding substance abuse treatment services. The bill initially came with attached funding of $20 million for community treatment, but the money was removed from the bill, causing concern in the addiction community.

In April, House Appropriations Chair Rep. Nelson Dollar (R-Cary) pledged at least $20 million toward addiction recovery as part of the STOP Act.

Neither the Senate nor the House budgets included STOP Act funds.

When House leaders announced their budget during a press conference in May, Dollar said his chamber was still working on finding funding for the STOP Act. He said state officials had been discussing how to use a $31 million federal substance abuse treatment grant first, and then they would determine what state funds are needed where.

That grant will be spread over two years and 80 percent of the money will directly fund treatment and recovery services, starting immediately. Funds are already being made available to treatment centers through the state’s seven behavioral health management agencies.

The final budget allocates an additional $10 million in state funds for addiction treatment and recovery services over the next two years. It’s one-time funding, but recovery advocates say it’s a start.

“This bipartisan budget funds opioid treatment statewide,” Sen. Phil Berger said during a Thursday press conference, where he told Gov. Roy Cooper to stop complaining about the budget.

“I think this is progress,” said Mark Ezzell, executive director of Addiction Professionals of North Carolina. “I think that it’s important that the state has stepped up to provide direct treatment dollars.”

He said while it would be great to have recurring money, the $10 million will help create infrastructure to help address addiction long term.

Rep. Greg Murphy (R-Greenville), a surgeon and a STOP Act primary sponsor, said the money will be directed to the state  Department of Health and Human Services to distribute to organizations that apply for it.

He said treatment centers looking to expand, such as Triangle Residential Options for Substance Abusers (TROSA) in Durham, could apply to DHHS for a grant.

Lawmakers also slated $200,000 over the next two fiscal years to supply law enforcement agencies and the North Carolina Harm Reduction Coalition with more naloxone, an overdose reversal drug.

Guilford County will receive $250,000 during fiscal year 2017-18 to start an opioid overdose rapid response team.

Additionally, lawmakers funded a opioid pilot project for New Hanover County. In at least one survey, Wilmington was found to have the highest rate of overdose in the country.

By Taylor Knopf

One morning in March 2015, Michael Page, now 37, found himself shivering, yet dripping with sweat while sitting on a curb in downtown Wilmington.

He didn’t know how he got there.

His head was pounding, his senses overloaded by the sound of passing cars and the sun overhead. A firefighter repeatedly told him to stay calm. She had just brought him back from a heroin overdose.

That was the last of three separate times someone saved Page’s life using naloxone, an overdose reversal drug.

“I wouldn’t be here if it wasn’t for naloxone,” Page said.

Page was one of 1,548 opioid reversals across the state in 2015 reported to the North Carolina Harm Reduction Coalition. In 2016, there were 3,684 overdose reversals reported to NCHRC, and 1,468 reported by the end of May of this year.

Law enforcement and EMS have started carrying naloxone kits, and NCHRC and some county health departments have given them out to community members.

Law enforcement is responsible for only some of the reversals, even as 159 North Carolina law enforcement agencies in 68 counties currently have staff carrying naloxone. Of those, 65 agencies reported a total of 547 overdose reversals since 2014, according to NCHRC.

On the whole, it’s other addicts and EMS who most commonly administer naloxone.

How it works

When someone is overdosing on an opioid, their breathing slows to a dangerous level, putting them at risk of suffocation. Naloxone comes most commonly in the form of a nasal spray or intramuscular injection, and once administered, it quickly gets into the bloodstream, where it immediately attaches to opioid receptors in the brain, blocking the opioids.

Almost instantly, the person can breathe again, as the respiratory suppression is gone.

The effects of the opioid are gone too. After naloxone is administered, a person often goes into  withdrawal, experiencing symptoms such as irritability, vomiting, diarrhea, body aches, rapid heart rate and increased blood pressure, according to Project Lazarus.

The cost

Funding for naloxone kits can be a challenge, in no small part because the price of the drug has surged over the last decade. Until 2005, the price of an injectable naloxone dose was less than a dollar, according to Human Rights Watch. But prices have gone up to around $50 to $75 per kit, according to Robert Childs, NCHRC executive director. He said the prices often vary, depending on who is buying and how much they are ordering.

In the state budget approved last month, lawmakers slated $200,000 over the next two fiscal years to supply law enforcement agencies and the North Carolina Harm Reduction Coalition with more naloxone.

“We could equip about 1,300 law enforcement officers with naloxone with their portion of the money,” said Tessie Castillo NCHRC Communications and Advocacy Coordinator. “With our allocated money, I, unfortunately, can’t disclose the price of the kits we purchase from Pfizer, but I would estimate that we could purchase over 10,000 kits, which would be used by about 2,000 people over the course of two years.”

For some municipalities, buying naloxone for their first responders could mean thousands of dollars extra, said Donnie Varnell, Dare County Sheriff Department investigator and NCHRC law enforcement advisor.

But many are taking advantage of grants and donations, he added.

Law enforcement support

Varnell said the majority of law enforcement across the nation is on board with the idea of naloxone.

“It will become a standard piece of equipment,” he said. “And quite frankly, it’s a liability not to carry it.”

He said more and more, law enforcement agencies are requesting naloxone – to care for their own. Officers and EMS personnel have overdosed on crime scenes, said Varnell. If first responders are accidentally stuck with a needle or walk into a place where there is fentanyl in the air, they can experience overdose symptoms.

“Officers are very susceptible to it,” he said. “They usually have no tolerance.”

Varnell said North Carolina law enforcement is ahead of many other states on the naloxone front because of NCHRC and the information and training the organization offers to law enforcement.

He said sheriffs and police tend to be a conservative group, and there will always be people opposed to change. Some don’t like the idea of helping a person who might just overdose again the following week, such as the Sheriff making headlines in Butler County, Ohio.

“As first responders, we don’t get to choose the lives we save,” Varnell said. “Regardless of who you voted for, which team you root for or what school you’re from, you respond to that call.”

He and others are working toward more Law Enforcement Assisted Diversion (LEAD) programs that direct people to substance abuse treatment rather than into the criminal justice system.

A new life helping others

Page finally got sober on April 28, 2015, a month after the Wilmington firefighter saved his life with naloxone.

“That incident didn’t do it,” he said “I wish it had.”

Page had used hard drugs for about 14 years. That time included multiple arrests and stints in  jail, which eventually led to rehab and a court-ordered banishment from the state of North Carolina. He ended up with four felonies and nine misdemeanors on his record.

And he contracted Hepatitis C from unclean needles and was treated for the disease.

“I wasn’t getting the effect of the drug anymore,” Page said. “Unfortunately drugs were the solution to deal with myself. At that point, I needed to change my ways and do something different. The one thing that made everything OK wasn’t working anymore. I needed to give recovery a real shot. So I checked myself into detox.”

Over the past two years in recovery, Page accomplished more than just shaking his drug addiction. Page said he had to re-establish his identity.

Today, he has a master’s degree in social work and a full-time job in the mental health field. He’s a member of a church and has renewed relationships with his family.

“My family wants to be around me,” he said. “My mom use to not want me on her property, and now I have keys to her house.”

Page also volunteers with NCHRC and operates a mobile syringe exchange in Wilmington. He drives around delivering clean needles and naloxone. He said he offers hope and reminds people of their treatment options.

“The people I work with in Wilmington are dear to my heart,” Page said. “They count on me.”

“If my life wasn’t more rewarding today, I would go back to getting high,” Page added. “But each day is better than the day before.”

By Catherine Clabby

Six weeks after his customers learned an industrial chemical called GenX had contaminated the Wilmington drinking water supply he manages, Jim Flechtner was still briefing his bosses on new questions related to the pollution.

The uncertainties range widely, such as: What will be the best way to extract and safely release 49 million gallons of water the utility stored underground potentially tainted with GenX? Does affordable technology exist to scrub out the treatment-resistant chemical? What else of concern lurks in the river water they depend on?

“We need to document and understand out what is in the river,” the visibly weary Flechtner stressed to Cape Fear Public Utility Authority board members in a morning meeting in Wilmington last week.

Other weighty questions persist about GenX pollution in the Cape Fear beyond the tough ones that Flechtner’s utility and two others are grappling with. Among them:

• How much GenX originated from wastewater released by the Fayetteville Works production facility that DuPont Co. ran for decades?
• How frequently did its concentrations exceed newly announced state concentration goals for drinking water?
• Who knew when that a suspect chemical was flowing from an industrial site toward public drinking supplies, possibly since the 1980s?

“There is not a lot of clarity yet about who knew what when,” said Derb S. Carter, Jr., director of the Southern Environmental Law Center for North Carolina.

One thing is certain, however. This GenX problem arrived on the tail of some sobering history.

A complex backstory

Neither the EPA nor North Carolina regulates GenX or related chemicals that EPA scientists first detected in the Cape Fear in 2012. However, in 2009 the EPA did require DuPont Co., and later its spin off Chemours Co., to prevent GenX from escaping from any manufacturing processes with “99 percent efficiency.”

EPA obtained that consent order after concluding that GenX and similar compounds, introduced to replace similar chemicals, could be toxic to people and the environment.

GenX and similar chemicals replaced a group of voluntarily phased-out compounds called perfluorinated chemicals known as PFOA and C8. Maybe best known as an ingredient for making Teflon, they were used to make many more products valued for their toughness, a quality that also allowed them to accumulate in the environment.

The consent order followed EPA’s 2005 settlement with DuPont of allegations that the company had failed to disclose evidence multiple times over more than 20 years that the older compounds posed risks to people and the environment.

DuPont agreed to pay $10.25 million, EPA’s largest civil administrative penalty at that time, in the settlement. In addition, the company paid $6.25 million, partly for projects to investigate the potential of nine of DuPont’s fluorotelomer-based products to breakdown to form PFOAs.

The controversy ticked on. In February of this year, DuPont settled a class-action lawsuit involving PFOA water contamination in the mid-Ohio Valley for $670.7 million.

A Chemours spokeswoman did not respond to a request by phone or email to comment on the origin of GenX in the Cape Fear. But in writing, Chemours, which manages wastewater emissions for three companies at Fayetteville Works, has stressed that GenX emissions there are low and the chemical is unlikely to pose a risk.

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“Our polymerization processing aid, sometimes referred to as GenX, has been well characterized and undergone extensive safety evaluations,” Chemours has written. “In addition, regulatory agencies required substantial data to be developed on the alternative chemistries that have been introduced. This data shows that the polymerization processing aid offers a favorable toxicological profile and very rapid bioelimination.”

That said, an EPA agency spokeswoman confirmed last week that the EPA is investigating whether Chemours has complied with the 2009 Toxic Substances Control Act consent order. Failure to do so, in general, can result in civil and criminal penalties, the EPA has said.

Chemours staff members told state and local officials last month in a meeting that the company is in compliance because any amounts of GenX that floated down the river were small and were an unintentional byproduct from a process not covered by the EPA order.

The EPA consent order does exempt GenX produced as byproducts from the order.

“We had an unregulated chemical,” said Kathy O’Keefe, Chemours product sustainability director, as quoted in notes DEQ posted from the June 22 meeting, which was closed to the public and to all but one news reporter. “There’s no requirement to capture emissions of that chemical but we put abatement technology in place and we did that in November of 2013.”

Even if that is the case, observers such as the SELC’s Carter wonder how the company or DEQ, if the state agency was aware that GenX was being discharged, could have allowed any of the suspect compound to reach the river.

“Someone has to explain this, either the state or Chemours, of both,” Carter said.

Shifting waters

In addition to questions, new developments regarding GenX contamination in the Cape Fear keep cropping up.

Just Friday the state Department of Health and Human Services lowered by 99.8 percent a provisional “health goal” limit for GenX amounts in drinking water,  reducing it from 70,000 parts per trillion (ppt) to 140 ppt. Created with help from the EPA and the U.S. Centers for Disease Control and Prevention, this is not a regulation. It’s a provisional estimate built with limited data of the contamination level below which exposure is unlikely to do harm to people, including developing fetuses and bottle-fed babies over a lifetime of exposure.

The uproar over GenX started early last month after the Wilmington Star News reported research by N.C. State University water chemist Detlef Knappe and collaborators. Their study detected mean levels of GenX at 631 parts per trillion in 37 samples of untreated water drawn in 2013 from the Cape Fear Public Utility – that’s four times higher than the new “health goal” level.

The researchers also found related chemicals, some at significantly higher levels, in the untreated water.

Also on Friday, results from testing for GenX in drinking water samples, which Chemours is paying for, brought good news. GenX levels in the samples collected from June 29 to July 6 in three counties show levels of GenX declining, with all but one of the most recent samples below the new DHHS “health goal” of 140 ppt level.

Knappe and his collaborators also reported that efforts to remove the compounds using standard water treatment, such as coagulation, ozonation, biofiltration, and disinfection, had “negligible” success.

Also on Friday, DEQ announced that Chemours had alerted the state agency that GenX discharges had not stopped during the third week in June – as the company had believed it had – but they are now fully stopped.

That news didn’t sit well with Mike Brown, chairman of the Cape Fear Public Utility Authority who works in commercial real estate.

“In June CFPUA requested that DEQ monitor Chemours discharges daily and to monitor the internal waste streams into the Chemours wastewater treatment facility,” Brown posted on a GenX update he composes for the utility, sometimes multiple times per day. “We are very discouraged that this additional GenX discharge was not identified sooner.”

Looking forward

While trying to sort out how the GenX contamination developed, the Cape Fear Public Utility Authority is also working to reduce the risk of Fayetteville Works site releasing GenX or sister chemicals in the future. DuPont and a Japanese company also have facilities on the site.

The utility has asked DEQ for information on any GenX chemicals released from the Chemours site. A letter to DEQ Michael Regan from the Greensboro law firm of Brooks Pierce on behalf of the authority also pushed for explicit requirements in Chemours’ state wastewater discharge permit.

The company’s previous permit is expired but state rules allow a company to continue with discharges as long as it submits a written renewal request, which Chemours has done. The company also included a request that it no longer be required to test for PFOAs, the now-phased out chemicals that GenX and others replaced.

Knappe has observed some of those chemicals in the Cape Fear.

The water authority wants GenX discharges limited to “only such amounts as shall not render the waters injurious to public health,” the letter states.

The water utility is also evaluating whether any company or organization  carries financial liability for the trouble the release of GenX has caused the utility and its customers.

“All the facts are not available to us yet” chairman Brown said. “We are collecting information to see where it might lead us.”

Correction: This story has been updated, noting corrected GenX levels in samples taken from the Cape Fear River.

By Catherine Clabby

Gov. Roy Cooper has vowed to stop the Chemours Company from releasing the unregulated chemical, GenX, into the Cape Fear River. And his administration will review whether previous releases merit a criminal investigation.

In recent years, university and federal scientists have led the charge in this state to find and raise alarms about such chemicals, including GenX and 1,4 dioxane. Each compound may be hazardous to people exposed to them at certain concentrations over long periods of time. And each has flowed from the Cape Fear into the plants of public water suppliers unable to remove them.

A 2009 EPA consent order forbids DuPont, and subsequently Chemours, from releasing all but 1 percent of GenX produced in any of its manufacturing activities. Company staff did not return calls or emails on Monday. But previously they have said that GenX in the Cape Fear originated from a source exempt from the EPA order.

Cracking down

Cooper unveiled the most detail to date Monday regarding his administration’s response to the release of GenX, one among a class of chemicals that have replaced perfluorinated chemicals known as PFOA and C8. These are compounds previously used to manufacture materials such as Teflon. PFOAs were phased out; their release into the environment had produced broad legal trouble for DuPont.

The governor said:

• The state Department of Environmental Quality will deny Chemours, a DuPont spinoff, a permit to discharge GenX in wastewater released from its Fayetteville Works production campus about 70 miles upstream from Wilmington.
• The State Bureau of Investigation will assess whether a criminal probe is needed to determine if Chemours violated North Carolina law forbidding intentional violations of the U.S. Clean Water Act or the EPA consent order. That order was produced after EPA settled charges accusing DuPont of hiding research showing PFOAs posed health risks.
• In any future waste release permits granted to Chemours, DEQ will also reserve the right to restrict the release of any other chemicals of emerging concern at the facility. The EPA, Cooper said, is looking into whether its consent order with Chemours needs to be updated or tightened. The N.C. Attorney General’s Office last week initiated a civil investigation into Chemours marketing practices regarding its representation about GenX’s safety.
• To address emerging contaminants of concern, DEQ will also alter its discharge permit application process more broadly and require all companies to disclose more about the unregulated pollutants they release. Cooper will expand the scope of his administration’s reconstituted Science Advisory Board to review the research and assist the state in identifying and prioritizing responses to unregulated industrial chemicals that may threaten water quality.

When the General Assembly returns to Raleigh in early August, Cooper said he will push for legislation to pay for expanded DEQ and Department of Health and Human Services staffing to implement the new programming. That would include hiring more inspectors, engineers, environmental specialists and chemists; resources for water sampling; and a reversal of a recent budget provision that required more than $1 million in budget cuts at DEQ.

Michael Regan, DEQ secretary, estimated at the conference Monday that would cost about $3 million. He said at present, DEQ is too understaffed to address the issue aggressively, a situation he blamed on years of budget cuts to the agency.

Multiple agencies involved

State officials will continue to press the Centers for Disease Control and Prevention for an assessment of potential long-term health effects of GenX, which Chemours recently disclosed it has been releasing since 1980. Cooper said that new CDC director Brenda Fitzgerald has told him the CDC will pursue these studies.

The governor said he will continue to urge the EPA to swiftly complete a health assessment to help the state generate regulatory standards for GenX.

Cooper did not answer a query Monday regarding how long state officials have known that Chemours was releasing GenX into the Cape Fear, a question to which residents and local officials have wanted answers.

After one failed attempt, Chemours has said it stopped all GenX discharges into the Cape Fear this month. But the Cape Fear Public Water Utility, which provides drinking water to some Wilmington residents, is still detecting concentrations above 140 parts per trillion, a conservative, non-binding health recommendation that DHHS released this month.

DHHS Secretary Mandy Cohen, also in attendance Monday, stressed that she believes it’s safe to drink water downstream of Chemours that is still laced with traces of GenX. That’s because the amounts now being detected are below or close to the recently lowered goal, which was calculated with limited information and assuming someone would drink water contaminated with GenX over a lifetime of 70 years.

Not everyone is ready, however. Tests of Cape Fear Public Water Utility water last week turned up levels exceeding the health goal at its Sweeney Water Plant, with measurements there as high as 286 parts per trillion.

The utility on Monday was still offering customers an option other than drinking from their home spouts: water pumped from the ground. “This water is supplied by aquifers that have not been affected by Chemours’ discharge of GenX,” the utility promised on its website.

By Taylor Knopf

A 2016 report found that people who abuse opioids are more likely to live in the rural south than anywhere else in America.

Twenty-two of the 25 top cities for opioid abuse are located in southern states, according to the report by the health care information company Castlight. Wilmington is at the very top of that list, with more than 11.6 percent of the population abusing opiates.

Three other North Carolina cities made the top 25 list: Hickory at 9.9 percent; Jacksonville at 8.2 percent; and Fayetteville at 7.9 percent of residents using opiates.

During the same period, Wilmington, Hickory and Fayetteville also made the top 25 list for number of opioid prescriptions abused. About 50 percent of all opioid prescriptions are abused in those three cities, according to the analysis.

Castlight’s report defined opioid abuse by two criteria: a patient who received more than a 90-day supply of opioids who also received an opioid prescription from four or more physicians between 2011 and 2015.

Other key findings in the Castlight report:

• People who abuse opioids cost their employers about twice as much each year in medical expenses than those who don’t. On average, they cost $8,597 more than their non-using colleagues in 2015. Castlight estimates that opioid addiction costs American employers about $8 billion a year.

• Castlight reported that people abuse one out of every three opioid prescriptions. Those who abuse opioids have twice as many pain-related conditions. The top four diagnoses are joint pain, neck pain, abdominal pain and back pain.
• People older than the age of 50 are four times more likely to abuse opioids than those under 30, Castlight reported. About 7.4 percent of Baby Boomers misuse opioids, while only 2 percent of Millennials do.
• Income makes a difference. About 6.3 percent of people living in America’s lowest income areas abuse opioids. These are places where the average income is less than $40,000. In areas where residents make an average of $85,000 or more, about 2.7 percent of people abuse their opioid prescriptions.
• People living in states with marijuana legalization laws are less likely to abuse opioids. About 2.8 percent of people living in these states abuse opioids, compared to the 5.4 percent of people in states without marijuana laws.
• People diagnosed with a mental illness are three times as likely to abuse opioids. About 8.6 percent of people with mental health issues abuse opioids, while only 3 percent of people without abusing them.

By Frank Taylor and Michael Gebelein

Adult care homes in North Carolina provide housing to large numbers of people with mental illness and physical disabilities, and these facilities face legal requirements to provide adequate supervision, nutrition, medical care and safe facility conditions. A regimen of county and state inspections monitor the quality and safety of these facilities.

For the past six months, Carolina Public Press has reviewed inspection records for each of the approximately 1,200 adult care homes in North Carolina. The smallest facilities can house six residents, while the largest may have 150 or more.

In reviewing three years of total monetary penalties issued to adult care homes across the state’s 100 counties — as a part of an investigative reporting series on housing issues faced by those living with mental illness — a Carolina Public Press analysis shows that the facilities listed below had the highest fines (as of June 30, 2017).

Each case is different.

When inspectors find problems, they issue plans to correct those issues. The N.C. Division of Health Service Regulation may decide that financial penalties are also appropriate, especially in egregious cases or those in which a facility has repeatedly failed to follow through with a plan to fix problems. Carolina Public Press also analyzed the effectiveness of this inspections process.

Some adult care homes appeal some fines. In cases where an appeal or settlement reduced a fine, or where delayed payments increased the total amount due, the latest amount available was used. In cases where an appeal is pending, the original amount is used. It is possible that some of these amounts will be adjusted through appeal or settlement following publication of this report.

Carolina Public Press reached out to every facility listed here that remains open. None responded to requests for comment.

The following lists the 10 most penalized cases, according to state records:

10. Aurora of Statesville, $46,946.04
Statesville, Iredell County
Star rating: 1
Status: Open

Aurora of Statesville, was fined $43,500 in December 2014 for violations related to medication administration for two residents.

The 80-bed facility, located on a residential street in Statesville, paid nearly $45,000 in the case, and made a final payment in 2015.

Earlier in 2014, the facility was also fined $2,000 for failing to administer medication for a resident in accordance with a doctor’s orders. That issue went unresolved, which led to the December penalty.

Since the time of those penalties, Aurora of Statesville has been listed as either a one- or zero-star facility. The facility was cited twice for medication management issues during the state’s 2015 annual inspection, which, among other issues, led to a zero-star rating.

Prior to the three-year period that CPP looked at for penalties, a complaint investigation led the state to suspend Aurora’s ability to admit new residents in January 2011, but the state lifted the suspension in March 2011. Aurora began receiving extra merits in 2012 toward its star rating for several improvement efforts, including adding automatic sprinklers and an emergency power backup system. These helped offset demerits from multiple violations during the same inspections.

9. Brockford Inn, $51,800
Granite Falls, Caldwell County
Star rating: 0
Status: Open

Brockford Inn in Granite Falls has received and paid six separate financial penalties over the past three years. Granite Falls is a small town in Caldwell County, just north of Hickory.

The 67-bed facility has zero stars in the state’s four-star rating system and has been a zero-star facility since 2015.

It was most recently inspected for construction issues on March 22. During that inspection, which regulators perform every two years to evaluate structural issues at facilities, state officials found that concrete steps at Brockford Inn were uneven, water was standing at the base of the stairs and steel handrails attached to the stairs weren’t secured. Regulators also found that emergency lights weren’t working and that an emergency release switch for magnetically locked doors was inaccessible because of filing cabinets placed in front of the switch. The state has not yet issued any fines related to that inspection.

The state fined the facility $13,200 in December 2014 for a failure to provide a resident with a thickened liquid diet in accordance with a doctor’s orders. The facility settled that penalty for $8,000 in 2015. Also in 2015, the facility was fined $2,000 for failing “to provide supervision and interventions for two residents with falls resulting in severe facial bruising and hip contusion.” The facility paid the full amount for that penalty.

The state fined Brockford Inn $16,000 in April 2016 for two penalties, one for failing to properly supervise residents who were a fall risk and for having beds with unpadded bedrails, and another for not investigating allegations of neglect affecting two residents and “injuries of an unknown source” that appeared on another resident.

However, at the same time the state handed down that penalty for those earlier violations, the state lifted a suspension of new resident admissions at Brockford Inn that had been in place since September 2015.

The facility also failed to report neglect and injuries to the Health Care Personnel Registry, according to state documents. Brockford Inn was fined $7,000 in June 2016 for failing to provide appropriate supervision to a resident who was suffering from confusion related to a urinary tract infection.

The facility’s largest fine for a single violation over the past three years came in January 2017, when regulators penalized Brockford Inn $13,600 for failing to investigate injuries from an unknown source that appeared on a resident, and for failing to report an investigation into verbal abuse of a resident by a staff member. The facility has worked out a payment plan and paid $2,526.50 so far toward this penalty.

8. Gabriel Manor Assisted Living Center, $52,000
Clayton, Johnston County
Star rating: 0
Status: Open

Gabriel Manor Assisted Living Center, which began operations in 2013, sits beside a UNC system medical complex, not far from the main highway connecting to nearby Raleigh. Nearby are newer residential communities.

Currently the site operates 77 beds, with zero out of four stars rating and a numerical score of 24.25 out of 100, well below any others in Johnston County.

The state issued six separate penalties to the facility on March 18, 2016, all of which were paid on May 3, 2016. Four citations were for $12,000 apiece, with two for $2,000 each. These penalties stemmed from incidents identified during inspections in 2015. The state suspended new admissions to the facility in May 2015, then lifted the suspension in September 2015.

The larger fines included citing the facility administrator for not assuring operations to meet state health, safety and residential rights rules. Records shows that the administrator and other supervisors told inspectors they were unaware of some requirements for staffing ratios, nutrition and documentation.

The state found that referrals and follow-ups with five residents with infections and head injuries didn’t occur. Failure to notify physicians of serious health issues was also a concern. This included insufficient monitoring of a resident with diabetes, who had to be hospitalized for high blood glucose.

The state imposed separate fines for poor documentation of carrying out physicians’ orders for seven residents with serious health concerns. Issues with administering ordered medication affected several residents with problems ranging from allergies and constipation to infection and diabetes.

The smaller fines related to inadequate supervision of a resident who experienced falls resulting in emergency room visits and failing to report promptly on an allegation that a staff member shoved a resident down, as well as failing to conduct an investigation of that accusation within five business days.

Gabriel Manor’s parent company, Ohio-based Saber Healthcare Group, did not respond to a request for comment prior to publication.

The Clayton facility was one of three Saber-owned adult care homes targeted in a 2016 class-action suit. That lawsuit is discussed in more detail below under Franklin Manor, the state’s most penalized facility.

7. Clinton House Assisted Living, $56,416.67
Clinton, Sampson County
Star rating: 0
Status: License revoked

The N.C. Division of Health Service Regulation revoked Clinton House Assisted Living’s license in December 2016, after a series of complaints and investigations that identified deficiencies.

Located alongside a public-housing facility on the outskirts of Clinton, the 60-bed facility is padlocked and stands vacant today.

After briefly achieving a three-star rating in 2012, intermittent problems had Clinton House operating with between zero and two stars since that time. During its final year it had no stars. A disastrous complaint investigation in December 2016 resulted in its license being revoked and a final rating of zero stars and a subzero numerical score of -65.

Previously, the state issued one citation of $4,000 against Clinton House in 2015 for a problem with administering medication to several residents for ailments ranging from liver disease, to seizures and dementia, resulting in multiple hospital visits for one patient. This fine was paid in full, including a late fee, at the end of 2015.

Following the facility’s closure, the state issued six additional citations for fines on Feb. 28, 2017, stemming from problems identified during a series of negative reports earlier in 2016, though not from the report that led to its closure.

Issues included in these citations included not assisting in feeding a blind resident who has dementia, not ensuring proper disinfection of equipment for 10 patients sharing glucose monitoring and lancing devices, not following up with residents’ physicians, neglecting bed repositioning, not administering prescribed medications and not supervising a resident who had multiple falls and was eventually diagnosed with a subdural hematoma.

Other issues were identified later, though no new penalties have been assessed so far. While a change in ownership was underway in 2016, no qualified administrator was on duty. Other qualified staff needed to provide round-the-clock care to the facility’s severely disabled residents were not present in sufficient numbers.

The final complaint investigation report in December weighed in at 75 pages, though those findings have not yet resulted in fines.

The issues described in that December report include: a staff member physically assaulted a resident causing injuries and was allowed to continue working there; the facility failed to promptly report or investigate known allegations of abuse; nothing was done to protect the personal funds of residents who lacked the cognitive ability to manage their own finances; and improper locking mechanisms and alarms on doors allowed a resident to repeatedly leave without staff being aware.

In the case of alleged assault, several witnesses told inspectors that the resident with bipolar disorder became upset with a staff member, whom she attempted to spray with cans of hair spray and bug spray concealed in her walker, then cut with scissors. The staff member knocked the resident down and held her down by her wrists, some witnesses said.

The facility waited two days to notify police about the incident, though they are required to report such cases within 24 hours.

The resident was later put in jail, where inspectors interviewed her. She said the staff made her scared to say anything.

“I was wasn’t the kind of person they wanted to be friends with,” she said, according to the report. “I got angry with the staff a lot and hurt their feelings.

The December report noted that this resident had a history of mental illness and was supposed to be receiving mental health services. She used a walker to get around and had limited arm strength. She needed supervision with personal care.

In relation to the improper door mechanisms, the inspection found that a resident with severe dementia had repeatedly been found wandering outside the building, including walking in the road toward a busy nearby highway without knowledge of the staff.

The owners had actually removed the required locks and door alarms several months earlier, for reasons unknown, the report said.

The same investigation identified irregularities with the administration of medications including opioid painkillers to residents, with staff not promptly notifying the primary care physician of a need to renew prescriptions.

Social services officials in Sampson County talked with Carolina Public Press about their general procedures but would not discuss their handling of the Clinton House case, saying only that they follow the appropriate laws.

6. Clare Bridge / Brookdale Wilmington, $57,021.88
Wilmington, New Hanover County
Star rating: 1
Status: Open

Clare Bridge of Wilmington, which has changed its name to Brookdale Wilmington, was fined in 2014 for issues related to unlocked doors that led to at least two incidents of residents leaving the facility without supervision.

According to a 2014 report in the StarNews of Wilmington, a driver saw a resident outside of the facility in October 2013. Clare Bridge was previously cited after a resident escaped from the facility in August 2013.

New Hanover County Department of Social Services officials told Carolina Public Press that issues with the facility, which is supposed to be locked, were identified during previous inspections and weren’t corrected, which led to the penalty being listed as an “unabated” issue.

After being rechristened Brookdale Wilmington, the 38-bed facility was inspected in June 2017 and received a one-star rating from the state. Regulators found issues with medication management and resident care and services during that inspection, though the state has not yet considered those issues for potential fines.

According to documents related to that inspection, which was conducted jointly between the state and New Hanover social services, the facility had lapses in taking residents’ blood pressure in accordance with physician recommendations, failed to adequately treat a resident with an ear infection and hadn’t reported injuries of an unknown origin to a resident to the Health Care Personnel Registry, as required by law.

The one-star rating that Brookdale Wilmington received after last month’s inspection is its lowest since at least 2009.

5. A New Outlook of Taylorsville, $58,000
Taylorsville, Alexander County
Star rating: 0
Status: Open

A New Outlook of Taylorsville, a 34-bed facility in rural Alexander County, received a $58,000 fine related to a fire that occurred there in December 2014.

A resident of the facility set fire to a mattress in the early morning hours, leading to the evacuation of the home. Complicating matters was the absence of both the facility employees who were supposed to be supervising the home’s residents. One staff member had left the facility to go to a nearby store and the other fled from the home when law enforcement arrived because he was wanted on charges of failure to appear in court, according to local media reports at the time of the incident.

As described in the first article in this series, emergency responders had to help residents escape and said publicly that the incident would likely have been deadly if they had not arrived quickly.

State regulators ultimately found that the facility had failed to adequately supervise two residents with fire-setting tendencies and had also failed to properly administer medications to those residents.

The state also cited the facility for the administrator’s failure to be present during the evacuation and for the neglect of the home’s residents during the evacuation.

While only the fire led to fines, deficiencies found in August 2013 dropped A New Outlook to zero stars with a suspension of new resident admissions for about two months. After recovering to a one-star rating in October 2013, the investigation following the fire dropped the facility back to zero stars and suspended admissions in December 2014. That second suspension was lifted in March 2015. A New Outlook has maintained its zero-star rating since that time.

4. Essex Manor Assisted Living, $59,000
Louisburg, Franklin County
Star rating: 0
Status: Closed

Essex Manor Assisted Living, a 56-bed adult care home located just outside Louisburg that operated with zero stars for most of its final year of operation, eventually closed in October 2015. Prior to a complaint investigation in early 2015, the facility had three stars and score of 92.5 out of 100, prior to a complaint investigation in early 2015. Its final reported score before closing in October was below 0 on the 100-point scale, at -36.5.

According to state records and reports in The Franklin Times, poor conditions at Essex Manor prompted the state to suspend it from accepting further residents in February 2015. But the state later found that the facility violated that agreement in July 2015. As a result, operators agreed to surrender their license rather than having it revoked outright.

The Times interviewed Franklin County Department of Social Services Director Nicki Perry about the situation. “I can’t recall during my (15 years as director) that a facility has had a shut down,” said Perry. Since that time, the state closed another Franklin County facility, Autumn Wind, though its penalties were not high enough for inclusion in this list.

Perry said her team helped to relocate the former residents of Essex Manor as a result. “If they were a Franklin County resident, we worked with them or a family member or point of contact, and if they were not a Franklin County resident, then we worked with their residing county to identify appropriate placement for them,” she told The Times.

“In addition, based on their individual needs, we tried to find an appropriate level of care for them.”

During its final months of operation, the facility did not have heat in one wing of the building during the winter. A later construction visit found filthy carpets and damaged furniture, poor outside maintenance, lack of privacy in bathrooms and bedroom windows that someone from outside could easily see into, according to public records.

Essex Manor received seven citations with fines between Oct. 15, 2015, and Sept. 21, 2016, even though it had ceased operations prior to any of these citations. No payments have been made on any of the citations, which could affect the former owners if they attempted to reopen.

Citations included failure to report or investigate an injury, failure to communicate with residents’ health care providers, failure to supervise a resident who assaulted staff and other residents, failure to ensure an administrator was handling basic responsibilities for health and safety, failing to administer diabetic medications to patients who had to be hospitalized and, neglecting residents while not providing necessary climate control and not ensuring a patients’ multiple medications were available.

3. Cornerstone Living, $59,640
Bryson City, Swain County
Star rating: 0
Status: Closed, building demolished

Cornerstone Living was a 50-bed adult care home operating just south of Bryson City.

While operating with three or four stars for several years, problems emerged in early 2015, and the facility operated with zero stars until it closed on Sept. 15, 2015. The facility had been suspended from admitting new residents in, but that restriction was lifted in March 2015.

Because it was Swain County’s only assisted living facility, Swain Department of Social Services staff were involved in finding a new home for residents.

Prior to Cornerstone’s closure, the site and rights to those beds were purchased by Hickory-based Meridian Senior Care, which is currently building a new facility on the site of the old one.

According to Swain County DSS Director Sheila Sutton, Cornerstone “needed to be torn down.”

In December 2015, two months after closing, the facility paid off a series of fines levied in April 2015 after an earlier inspection found that residents had to share glucose monitoring equipment and lancing devices without proper disinfection.

Other citations issued at the same time covered problems with giving medicine to several residents and failure to follow up on residents’ medication needs after behavior changes.

A second set of much higher fines was issued in May 2016 several months after Cornerstone had closed. These citations addressed the ultimate failure to fix the previously identified problems with giving medication. These fines, totaling $47,000, have not been paid, according to state records.

Meridian did not respond to a request for comment prior to publication of this article.

2. Sunrise Assisted Living at North Hills, $82,300
Raleigh, Wake County
Star rating: 3
Status: Open

Sunrise Assisted Living at North Hills operates a 160-bed facility in an upscale residential and commercial neighborhood in northern Raleigh.

An annual inspection in March 2017 raised the facility back to three stars out of four, with a 98 out of 100 score. However, it had dropped to two stars in July 2015 after problems were found during a state inspection, and to zero stars after a negative follow-up. Inspections in 2016 had it operating as a one-star facility.

Wake County Human Services adult home specialists first identified serious problems in mid-2015 during a complaint response and investigation. The complaints at the time related to inadequate supervision of a disoriented resident who left the facility without the staff’s knowledge. A similar incident with another resident resulted in an additional fine and a requirement for additional staff training.

The state suspended new resident admissions to Sunset Assisted Living of North Hills in September 2015, but this was lifted in November 2015.

Following an appeal, the fines were settled and paid, with training completed by late 2016.

In September 2016, the company was again cited for failing to supervise residents, as well as not fixing problems identified in earlier citations. Inspectors levied a second and steeper fine of $61,500 for failing to fix the locking mechanism on the special care unit exit doors, which allowed residents to leave without the knowledge of staff. Special care units operate within adult care homes to work with residents having severe cognitive disorders.

The company paid these fines in full as of December 2016.

Wake County Human Services officials told Carolina Public Press they were prevented from discussing Sunrise Assisted Living at North Hills directly, on advice of the county attorney, though they did discuss their general procedures.

Virginia-based Sunrise Senior Care, which owns the facility, did not respond to requests for comment.

1. Franklin Manor Assisted Living Center, $104,016.67
Youngsville, Franklin County
Star rating: 1
Status: Open

Franklin Manor Assisted Living Center, which opened in 2013, is a 54-bed facility with a designated special care unit dealing with residents having dementia or other cognitive disorders.

The facility was rated with three out of four stars until 2015, but issues emerged during an annual inspection and follow-up surveys, resulting in it operating with one star, as it did for most of 2016 through the end of June.

The state suspended new resident admissions to Franklin Manor in December 2015, but this was lifted in April 2016.

The N.C. Division of Health Service Regulation eventually issued financial penalties and citations against Franklin Manor in late 2016. All fines have been paid in full without recourse to appeal or settlement.

One citation was for the facility’s failure to provide two-person assistance to a patient whose leg was lacerated as a result. Another was for failing to follow-up with a patient after contacting emergency medical services about a fractured hip and knee. Although it is not clear from state records, The Franklin Times reported that the case involved a resident who fell out of a wheel chair.

A few months later, the state cited Franklin Manor for not promptly following doctors’ orders, both for medical screening and providing residents with walkers. The latter situation resulted in falls with injuries.

A final group of penalties were for failure to abate problems with administering medication and doctor-ordered supplements to residents and for failure to provide residents with adequate personal care, which resulted in scrapes and bone fractures.

In 2016, Franklin Manor was one of three Saber-owned homes targeted by a class-action lawsuit, along with Gabriel Manor of Clayton, which also appears on this list. According to an April 28, 2016, article in The Franklin Times, an attorney representing two former Franklin Manor residents filed the suit in Franklin County Superior Court. They accused Saber of understaffing both facilities, as well as one it operates in Charlotte. They blamed the low staffing levels for poor care and falls that resulted in hospital visits.

They pointed to issues identified by Franklin County Social Services workers and the N.C. Division of Health Services Regulation as supporting their claims.

“These are some of the worst conditions I have ever seen in a long-term care facility,” The Franklin Times quoted plaintiffs’ attorney Steve Gugenheim as saying. “And I’ve spent my career filing cases against adult care homes.”

A fellow plaintiff’s attorney told The Times that a major goal was to force Saber to increase staffing levels.

Not all of the problematic issues found by inspections resulted in fines, though the state may still be contemplating fines based on earlier problems. However, some of these additional issues are prominent in the lawsuit.

This includes a finding in late 2015 that personal care aides and medication aides were doing double duty as food service providers, in violation of state regulations. As a result, providing food was erratic and some residents went for periods of time with no food, The Franklin Times reported.

The same thin staffing led to residents left sitting in their own waste, according to both the lawsuit and the inspections.

The Ohio-based Saber Healthcare Group, which owns the facility, did not respond to requests for comment.

Penalties not the whole story

Although this listing focused on facilities that were severely fined, it also noted that some offenses were found that so far have not resulted in financial penalties.

In other cases that Carolina Public Press examined, facilities were forced to close without ever racking up the types of fines or star-rating penalties that occurred elsewhere.

One case that never would have made this list for numerical reasons stands out as a reminder that the dollars assessed against adult care homes don’t tell the whole story. Windy Hill Assisted Living in Morganton was accused, in 2015, of two cases of sexual abuse of residents by a staff member.

Located in rural Burke County, the family care home operated with six beds or less. Initially, it was fined $6,000 in the case. Following a settlement, that fine was eliminated on the condition that Windy Hill permanently close. It remains closed today.

Carolina Public Press has asked the Burke County Sheriff’s Office for records related to this case and how it was handled as a law enforcement issue. That information was not made available prior to publication.

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About Frank Taylor and Michael Gebelein

By Taylor Knopf

On Wednesday afternoons, Michael Page and Hyun Namkoong load up a gray, nondescript minivan with short and long syringes, cotton balls, alcohol swabs, tourniquets, hazardous waste disposal cups, condoms, water bottles, granola bars and doses of an overdose reversal drug called naloxone.

As they drive around downtown Wilmington, they schedule back-to-back meet up points behind fast food joints, gas stations, strip malls and at some individuals’ homes.

“We got DJ down here, and got your guy on Castle Street,” Page said. “Lynn moved, I don’t know where she went. Her number isn’t working.”

“You want me to call George?” Namkoong asked.

“Hit up George. I’m gonna call Bruce,” Page said.

Page texted another woman about her supply. The woman replies that she doesn’t need anything. She quit using.

A mini celebration breaks out in the van.

Page and Namkoong work with the North Carolina Harm Reduction Coalition. They love to see syringe exchange participants stop using drugs and move into addiction treatment. That’s the goal.

But in the meantime, they deliver clean supplies and naloxone to prevent those using intravenous drugs from contracting HIV and hepatitis C, or worse, dying from a drug overdose. In 2016, there were 3,684 overdose reversals reported to NCHRC.

Page is a former drug user and actually contracted hepatitis C through sharing supplies. An estimated 110,000 North Carolinians currently live with hepatitis C, a fourfold increase since 2009.

What Page and Namkoong do is legal as of last year when the General Assembly passed a law allowing syringe exchanges in North Carolina. There are now of 22 needle exchanges in the state.

However, what people do with many of these supplies is definitely illegal.

How it works

The NCHRC in Wilmington has between 400-500 registered participants. Very little personal information goes into the identification card. Page said he sometimes doesn’t even ask for a last name.

Namkoong explained that state law requires there to be some form of written verification for members of a needle exchange program. Additionally, the law provides limited immunity for needle exchange participants in possession of injection supplies and any residue in them, she said. In theory, if a needle exchange participant in possession of syringes is stopped by an officer, they should be able to present their ID card and avoid a paraphernalia charge.

Some feel comfortable enough to come to the NCHRC fixed site at 3951 Market St. for supplies. However, for those with limited transportation or who are just uncomfortable coming to an office, there is the Wednesday mobile syringe exchange.

One participant said the mobile exchange helps her and her neighbors because she and many others don’t have a car.

“If it wasn’t for them being mobile, we wouldn’t be able to use their services,” said Jen who requested her last name be omitted.

She’s been using the exchange for a couple months and appreciates that she can keep herself free from disease. Before the exchange, Jen said she would the same syringe for a week or more.

While she isn’t ready for substance abuse treatment yet, Jen said she plans to look into it and holds on to the list from NCHRC of all the resources available to her.

“I tell everybody about [the mobile exchange],” she said. “Three or four people have come with me before. I explain to them that these are really good people. They are not judgmental.

“They are here to help.”

Jen initially came into contact with NCHRC while at the county jail visiting her boyfriend. As she was leaving, she ran into Namkoong who was leaving her overdose prevention class for inmates. Namkoong offered her a ride.

“I saw the Narcan bottles she has as earrings so I asked her about it,” Jen said. “She explained what she did, and I went to the office and volunteered to help her out some.”

NCHRC staff make jewelry and key chains out of naloxone vials used to save a life. They then sell them for $20, which enables them to buy three more naloxone kits.

Last Wednesday, Page and Namkoong met about two dozen people, collected 1,300 dirty needles and gave out 1,680 clean ones. They considered it a good night and a decent return rate on the needles.

NCHRC has a contract to incinerate the dirty needles so they don’t end up on the ground or sticking a city trash worker.

Judgment free zone

Every participant getting supplies at the mobile exchange emphasized that it’s important that they don’t feel judged for their addiction.

“I can tell (Mike’s) out to change things,” said Joe, an alias name for one of the men who received supplies last Wednesday when the van stopped behind a temporary logging facility.

“He breaks the stereotype that only a certain color or certain kind of person does drugs or helps people on drugs,” Joe continued. “He doesn’t see color. He just sees people. And he can relate.”

Joe described himself as a soccer dad on disability from a back problem who is just trying to take care of his family.

“I’m just taking it one day at a time,” he said. “I continue going to meetings. Just staying positive.”

Another syringe exchange participant said she likes to get rid of her old syringes to protect the environment.

“I saw something on Facebook where a bird had made a nest out of used syringes that it had found. It was so sad,” said Allison whose last name is omitted for anonymity.

She’s been using the exchange for about a year.

“They are so nice. They don’t make it awkward or anything,” Allison said.

The mobile syringe exchange van made a stop in a neighborhood where a mom, her son and her son’s girlfriend all came out for supplies. People from nearby houses came out to take a look and grab a few things also.

DJ and his girlfriend Melissa both live with his mom. Melissa is pregnant, stopped using drugs and got a full-time job. DJ is trying to do the same.

He told Namkoong that he had an appointment to get into treatment the next day.

“I’m super stoked!” DJ said. “I’m doing it for my kid.”

Note: Hyun Namkoong contributed to NC Health News before taking a position with NCHRC.

By Taylor Knopf

By some measures, Wilmington, N.C. ranks number one in the nation for opioid abuse.

But for all its problems, the city’s residents and those in the addiction recovery community say that reputation is a bit unfair.

“There are a lot of different theories about why it’s so problematic in Wilmington specifically,” said Michael Page, a North Carolina Harm Reduction Coalition worker who helps operate a mobile needle exchange in Wilmington.

“I feel that it has a lot to do with the polar opposite, which is recovery. Wilmington is a mecca for recovery,” he argued.

Page and others in the area say that there are close to 300 twelve-step meetings a week in the city. It’s filled with halfway houses and substance abuse outpatient programs. It’s also important to note that according to NC Department of Health and Human Services, Wilmington does not have the highest number of opioid deaths in the state.

The city is also home to Wilmington Treatment Center, which for a long time was considered one of the premier addiction treatment centers in the country.

Wayne Ray, director of Launch Pad, a full-service recovery community near Wrightsville Beach, hitchhiked from Goldsboro to Wilmington a couple decades ago to be near the water. He’s been in recovery for 21 years from cocaine addiction and said that people often come to the water for healing and a new start.

Ray’s heart and work are in Wilmington, and he says the study by Castlight Health — which ranks Wilmington as the top city for opioid abuse — gives his “town a black eye.”

“I’m a little defensive about that ranking,” he said, emphasizing how many addiction recovery efforts are happening in Wilmington.

One aspect of the Castlight study to keep in mind is that it only surveyed employed populations through commercial workforce claims. Those on Medicaid and Medicare, which makes up close to 38 percent of North Carolinians, were not included in the study.

“An assumption is made that people gainfully employed are not impacted by this problem,” said Kristin Torres Mowat, senior vice president at Castlight Health. “But it’s an issue that affects everybody.”

The Castlight study illustrates that point.

Mowat said that hopefully in the future, Castlight will conduct a similar study and the numbers will show improvements as elected officials, medical professionals and community groups work to fight opioid addiction.

Strength in numbers

Wilmington and Asheville have the two largest and strongest recovery communities in the state, according to Donald McDonald, director of advocacy and education for Recovery Communities of North Carolina.

McDonald said it’s vitally important for people recovering from addiction to have a strong community of support, which is why so many people go to these places.

“It’s unfortunate that nationally Wilmington is characterized by the problems it’s facing,” he said. “It’s an unfair characterization. I know it has to hurt a little bit for the people there doing great work.”

That being said, an area with a large addiction recovery community is also going to experience a good amount of relapse and return to use.

Addiction relapse rates are between 40 and 60 percent, according to the National Institute on Drug Abuse. These rates are similar to people afflicted with other chronic diseases such as asthma or type 1 diabetes.

“People that have some sort of recovery in their story and then return to use, they are 13 percent more likely to suffer an overdose because their tolerance has gone down,” Page said.

“Because of the shame and guilt that they have because they are returning to use, they use more to try to numb themselves,” he said.

Page added that some people surmise that the drug problem is worse in Wilmington because it’s a port city.

“But the heroin we are getting is not coming on cargo containers,” he said. “I really think it has to do with the fact that it’s a college town and the amount of recovery that’s here.”

Ray seconded that the University of North Carolina at Wilmington, which is considered a “party school,” adds to the problem. He also theorized that the number of older retired folks and former military personnel who settle in Wilmington could add to the number of opioid prescriptions for ailments related to age and military service.

“These are all hypotheses. We really won’t know, will we?” Page said.

Grassroots recovery

‪Anna Goddard‬, president of a new nonprofit called Heart of Wilmington, echoed the others.

“When you compare our area to other counties nearby, they are resource deserts,” she said. “So people have to come here.”

Goddard, who is also in recovery, recently started a campaign called “Get the H out of Wilmington.” It all started with a Facebook post. She was frustrated and sad about all the friends she had lost to addiction.

Heart of Wilmington launches their ‘Get the H Out of Wilmington’ project in early June. The grassroots group hopes to grow into the central clearing house for substance abuse information and services in the greater Wilmington area.

“We want to help but don’t know how. We were waiting for an answer and that answer never came,” she said. “I wanted to call a family dinner where we could get together to discuss what to do. With all of our ideas together, I figured we would have a better chance at tackling it.”

The first dinner was a success. News crews came, as well as people from across the addiction recovery community.

They decided to focus on aggregating all treatment and resource options in one place. Goddard said it’s often hard for people to find the right fit. Her organization is working on a website and app where people can build a profile and see all the recovery services that are best suited for them in their area.

For example, there are three nonprofits in Wilmington that offer free job interview clothes, she said, but people are unaware of the service.

“I’m only alive today because of Narcan reversal,” she said.

“I overdosed 10 years ago. I have a strong personal connection. I was in ICU for over a week. I credit my life to my strong family. They are incredible. But leases don’t end because you decided to get recovery,” Goddard said. After being discharged from the hospital, she had to go back to her apartment where her roommate was still using drugs.

Goddard said the best resource the people in Wilmington have is the community of people that want to help with whatever skills they have. They can help with those life things that prevent people from going to detox, such as helping out with rent, pets, childcare or jobs.

“Treatment shouldn’t have to be that hard,” Goddard said. “Addiction is hard enough.”

Heart of Wilmington is hosting its next event on Aug. 31 at the Greenfield Lake Amphitheater with elected officials, law enforcement, musicians and recovery advocates.

By Catherine Clabby

Although extremely serious on its own, contamination by the industrial chemical GenX in the Cape Fear River is significant beyond potential risks to the public drinking water downstream.

Public scrutiny of how the industrial chemical got there in the first place is raising awareness of scientific concerns about potential hazards from unregulated GenX and similar compounds. It is also bringing new attention to how well multiple government agencies and industry, in this case Dupont and its spinoff Chemours, protect people from potential risks.

GenX is one of many human-made compounds called per- and polyfluoroalkyl substances, or PFASs. While not household names, PFASs make up a category of super-tough substances used in many common products that consumers love, including non-stick cooking pans, stain resistant carpets, waterproof clothing and food packing.

But that toughness has a downside: the chemicals stick around rather than degrade quickly once released into the environment.

U.S. companies voluntarily stopped using an older generation of PFASs, including the compound PFOA (also known as C8). Research has shown associations between exposure to some older generation PFASs and several health problems, including increases in cholesterol levels, thyroid and liver disease, pregnancy related high blood pressure (known as pre-eclampsia) and other ailments, said East Carolina University toxicologist Jamie DeWitt, who has studied GenX.

Chemours for years has heralded GenX as an improved substitute for PFOA and similar substances due to differences in its chemical structures which it was anticipated would make it less persistent in the environment, thus reducing any potential health risks. But some scientists are finding reasons to be concerned.

Chemours Co., a DuPont spinoff, repeatedly has said levels of GenX released since possibly the 1980s from its Fayetteville Works plant, upstream from Wilmington and other communities, are at levels that pose no health hazards.

In that context, persistent and big questions regarding GenX pollution in Cape Fear remain extremely important, including:

•      For how long did DuPont and Chemours, the spinoff, release GenX and similar compounds?
•      Have people been harmed by drinking water tainted by chemicals that they did not know tainted their water?
•      Did DuPont or Chemours violate state or federal laws when releasing GenX upstream of drinking water intakes in Wilmington and nearby communities?
•      Did government agencies, from the local to the federal, do all they should have to prevent the pollution?

That final question is developing political overtones in the state capitol.  Republican senators on Tuesday announced a legislative hearing to question Democratic Gov. Roy Cooper’s administration regarding “inconsistencies” in its response to the discharge of GenX and how money he’s requesting “would be used to meaningfully improve water quality and public safety in the lower Cape Fear region.”

Cooper, as part of a plan to better research and monitor GenX and many other unregulated pollutants of concern in this state’s rivers, has asked the legislature for $2.58 million in funding. When he made the requests, Cooper noted that legislative budget cuts in recent years resulted in the loss of 70 positions within the state Department of Environmental Quality. Those cuts included eliminating staff available for permitting, compliance and enforcement programs.

The emerging political conflict is not sitting well with some people on the receiving end of that water in Wilmington, where GenX has been detected in drinking water, including former Mayor Harper Peterson, a Democrat active in the group Clean Cape Fear. That alliance of local groups hosted a community non-partisan forum on GenX last month.

“Let’s come with an agenda that focuses on action and address the issue: the risk of unsafe drinking water. Leave your party affiliation at the door,” Peterson said.

To keep up as this story unfolds, it’s useful to know its history, particularly what’s listed in the timeline below.

1980s: According to notes taken at a meeting with Chemours staff, the Fayetteville Works facility has produced and discharged substances identified now as GenX since the 1980s.

2002: DuPont starts producing PFOA (also known as C8) in North Carolina, at its Fayetteville Works property adjacent to the Cape Fear River on the border of Cumberland and Bladen counties. This information is according to a Securities and Exchange Commission document filed by an activist DuPont shareholder.

2004: EPA charges DuPont with violating the Toxic Substances Control Act (TSCA) due to multiple failures from 1981 onwards to report evidence of human health risks from PFOA in Ohio and West Virginia. Cited was evidence that a female employee had transferred the chemical to her developing fetus and confirmation of contamination of public water supplies in West Virginia and Ohio.

2005: DuPont agreed to pay $10.25 million, EPA’s largest civil administrative penalty at that time, to settle PFOA charges. It also agreed to commit another $6.25 million, partly to pay for research assessing if other DuPont products break down to form PFOA, which could result in widespread contamination.

2009: DuPont, which commits to not making, buying or using PFOA by 2015, is deploying GenX to create high-performance fluoropolymers, according to company marketing materials. EPA, in a consent agreement, requires the company to prevent GenX from escaping from any manufacturing processes with “99 percent efficiency.”

2015: A research paper is published showing that EPA scientists and collaborators, using chemical detective work, detected GenX and other newer generation PFAS compounds in the Cape Fear River.

2016: Research by Harvard scientists disclose that EPA-mandated sampling detected PFASs in public drinking-water supplies for 6 million people between 2012 and 2015. Most of those samples were collected near manufacturing facilities and other sites where they are used. North Carolina ranks third nationwide for the number of detections.

2016: A research publication by N.C. State University water chemist Detlef Knappe and others report finding GenX in untreated drinking water drawn from the Cape Fear River. The paper also notes the compound’s resistance to standard water cleaning treatments. Knappe had notified state and water utility officials of the finding before publication.

January 2017: A publication by ECU toxicologist Jamie DeWitt shows that in lab mice GenX appears to leaves a body sooner and may be less potent than PFOA. That said, the chemical did generate some of the same physiological changes observed in lab studies after exposure to older generation PFAS compounds, although at lower concentrations.

June 2017: Wilmington Star News reports that GenX, which is unregulated, was detected but local utilities and the state, alerted to the problem by Knappe, did not publicize the findings. Residents in Wilmington and nearby towns criticize local, state and federal officials for not acting sooner.

June 2017: Chemours staff, in a closed-door meeting, tell state and local utility officials that GenX’s release, which took multiple attempts to stop, originated from a process at Fayetteville Works exempt from the EPA consent order. They also reveal that releases likely started in the 1980s. Company representatives maintain that levels released are too low to pose a hazard.

July 2017: Multiple investigations are launched:

EPA starts investigating whether Chemours complied with the 2009 Toxic Substances Control Act consent order. Failure to do so usually results in civil and criminal penalties. The federal agency also starts assessing if changes to the consent agreement are needed.

Federal prosecutors subpoena documents, research and monitoring data from DEQ as part of a grand jury probe.

Attorney General Josh Stein launches a civil investigation into Chemours marketing practices regarding its representation about GenX’s safety.

Cooper directs the State Bureau of Investigation to assess whether a criminal probe might be needed to determine if Chemours violated North Carolina law forbidding intentional violations of the U.S. Clean Water Act, or violations of the EPA consent order.

July 2017: The state Department of Health and Human Services lowered by 99.8 percent a provisional “health goal” limit for GenX amounts in drinking water, reducing it from 70,000 parts per trillion (ppt) to 140 ppt. The number is a provisional estimate built with limited data of the contamination level below which exposure is unlikely to do harm to people, including developing fetuses and bottle-fed babies over a lifetime of exposure.

August 2017: Cape Fear Public Utility Authority attorneys announce plans to sue Chemours and DuPont in federal court to enforce federal Clean Water Act (CWA) requirements due to the pollution.

August 2017: In a press release, Republican senators this week announce a plan to stage a legislative hearing regarding “inconsistencies” in the Cooper administration’s handling of GenX pollution.

August 2017: In response, DEQ Secretary Michael Regan and Health and Human Services Secretary Mandy Cohen said they are ready and willing to cooperate fully. They note that in May or June 2016 the administration of former Republican Gov. Pat McCrory received information about EPA and N.C. State University research on GenX in the Cape Fear.

The letter also posed its own criticism. “We should also warn that the General Assembly is poised to eliminate a provision in G.S. 150B-19.3 that restricts regulators’ ability to address threats to public health, safety and welfare.” The text links to a conference report for House Bill 162 which was not published, but circulated to legislators, state officials and reporters.

August 2017: A group of N.C. State and ECU researchers are applying for National Institutes of Environmental Health Sciences funding to test for PFASs levels in blood and urine of people living in the Cape Fear River basin.

By Kirk Ross

Co-published with Coastal Review Online

WILMINGTON — A House and Senate environmental oversight committee toured a water plant here, heard a heated debate between the local delegation and got an earful from worried residents as the legislature considers next steps in dealing with the state’s worst water contamination crisis since the February 2014 coal ash spill in the Dan River.

Although the community’s continued anguish over the chemical GenX was again present and sometimes vividly presented Wednesday during a public hearing, this was the first opportunity for a legislative committee to hear directly about the contaminant. Stories relating fears for loved ones and lingering doubts about the region’s drinking water supply came from both colleagues and the public at large.

“The presence of GenX and all the possible pollutants in the Cape Fear River have caused me to have serious concern about the quality of drinking water,” Rep. Ted Davis (R-Wilmington) said.

Sen. Mike Lee (R-Wilmington), said when news first broke that he and his wife, like many of his constituents, wondered if the contamination played a role in their son’s health problems. Lee called for quick action by the commission.

“We need an action plan today,” he said. “I think that’s what people in this area, this Cape Fear watershed, drinking the water every day want. They want action.”

Concern about the safety of the water supply, which serves roughly 300,000 residents of New Hanover, Brunswick and Pender counties has grown rapidly since an analysis of the presence of per- and polyfluoroalkyl substances (known collectively as PFASs) in the Cape Fear River released in June revealed that conventional water treatment methods failed to remove the contaminants from the drinking water supply.

PFASs make up a category of tough substances used in many common products such as non-stick cooking pans, stain resistant carpets, waterproof clothing and food packing.

Unlike the like Dan River coal ash spill, which released a massive plume of ash and contaminated water from a Duke Energy storage pond, the contamination of the Cape Fear River with GenX and other compounds has been a slow-motion crisis with a substance that persists in the environment.

Although the extent of the contamination was only recently detailed, GenX, or something like it, has been discharged since the 1980s from a Bladen County plant first operated by DuPont and since 2015 by Chemours, the company created in 2015 when DuPont spun off its performance chemicals unit.

They’re different cases, but the responses to both coal ash and GenX have taken a similar, two-prong approach: finding an immediate way to stop the contamination while studying past mistakes and new research to develop policies and practices to prevent it from happening again.

“How did that permit get through? That to me is a huge question,” said Rep. Pat McElraft (R-Emerald Isle) Wednesday after the Wilmington meeting of the legislature’s Environmental Review Commission. McElraft said there needs to be a thorough review of how Chemours was granted a permit to discharge GenX into the river, but right now, she said, the public wants to see solutions.

It’s not just a matter of stopping the discharge, which Chemours did voluntarily in June, she said, but doing something to remove contaminants that have built up in the river over time.

“We’ve stopped it now. We don’t want it to start again and now we’ve got to find out some way to clean their water from all the residues,” McElraft said. “It’s going to be in the water for a while.”

Commission members toured the Cape Fear Public Utility Authority’s Sweeney Water Treatment Plant and reviewed new equipment installed to test the filtering process. The utility is looking at both reverse osmosis and granulated activated carbon filtering to remove GenX and other related compounds from the water.

In testimony before the commission, Larry Cahoon, a University of North Carolina Wilmington professor of marine biology who specializes in aquatic ecology, said finding a way to remove the contaminants on an ongoing basis is critical given that deposits in the river are likely to continue to be a source.

Cahoon said the issue goes beyond just GenX, which he stressed is an industry-created term, and detailed findings on worrisome presence of related compounds, some in higher concentrations than GenX. The effects on human health of the other, so-called, “emerging contaminants” are even less known.

“We’re not talking about a single compound here. Let’s be clear about that,” Cahoon said. “The permitting of the discharge of GenX ignores the fact, one way or the another, that we are talking about a host of compounds.”

During questioning by commission members, Cahoon said he believes that the company violated its permit and the Clean Water Act because it failed to disclose those additional compounds as required.

Commission members subsequently pressed Department of Environmental Quality Secretary Michael Regan on his department’s investigation, asking why DEQ had yet to issue a formal notice to the company that it is in violation of its permit.

Regan replied that the department was trying to make sure it had first completed its investigation, saying it was important DEQ “get it right,” given the legal implications of any action.

Representatives of Chemours declined an invitation from the commission to give a statement at the hearing.

Molly Diggins, executive director for the North Carolina Sierra Club, said that when a department is as understaffed and underfunded (as DEQ) it can’t do the necessary oversight that prevents a GenX or coal ash contamination from happening.

“DEQ doesn’t even have sufficient staffing to address expired permits,” she said. “What confidence can the public have that water quality is being watched out for? If DEQ doesn’t have inspectors, what confidence does the public have?”

Money and Politics

While investigations and the search for solutions continue, the political battle over GenX continues to heat up.

During the hearing, both Regan and Department of Health and Human Services Secretary Mandy Cohen continued to urge lawmakers to pass a $2.8 million emergency funding package to cover the costs for more testing and analysis as well as monitoring for signs of contamination. Asked by Sen. Brent Jackson, R-Sampson, one of the Senate’s chief budget writers, how more money for staff would make a difference, Regan responded with President Ronald Reagan’s adage of “trust but verify,” saying extra monitoring is important, especially given the public’s concerns about Chemours’ record of disclosure.

Regan said the department’s resources, already stretched due to budget cutbacks and continued demand for coal ash response, still has a backlog of permits. He noted that Chemours was operating with an expired permit when the contamination study was released and that, at present, about 40 percent of the discharge permits issued by the state are expired.

Sen. Lee, who said he is working on a strategy document, told the commission he thinks emergency funding should be focused locally. Lee called for the ERC to adopt a strategy that would provide an additional boost of funding for the Cape Fear Public Utility Authority and cover additional testing and research by UNC-Wilmington experts.

Davis also agreed that the authority should play a lead role going forward.

But Rep. Deb Butler (D-Wilmington) encouraged the commission to back the administration’s plan, saying the utility authority should not be allowed to do its own oversight and that Lee’s effort lacks the transparency necessary to win back the community’s trust.

Butler, who was the first to raise the GenX issue in the North Carolina General Assembly in June when she called for a rollback of DEQ budget cuts during the state budget debate, said initial bipartisan support for a plan announced by Gov. Roy Cooper in July seemed to quickly evaporate.

“Here I am today again asking you to honor the governor’s reasonable, specific request for help, the pleas of this community for help. It is $2.5 million in $23 billion budget that has a rainy-day fund,” she said. “It’s raining in Wilmington and we need that appropriation. These agencies need the resources to put teeth behind these permits.”

Cooper, who made his third GenX-related trip to the region Thursday when he toured the Brunswick County water treatment plant, continues to press for the appropriation.

“This is not a problem we created, but it is one that we’ve taken swift action to fix,” Cooper’s spokesperson Ford Porter said in a statement released Wednesday following the commission hearing. “Protecting families’ drinking water should be a top priority, and it’s disappointing that the committee didn’t take up the legislative request to strengthen water quality given the strong public support that was displayed for it.”

During the hearing, Environmental Review Commission Chair Sen. Trudy Wade (R-Greensboro) said she didn’t expect the commission to take up the funding request during the current weeklong redistricting session. Wade said any funding request would likely be considered in September.

The commission did approve a motion by Rep. Chris Millis (R-Hampstead) based partly on Lee’s request, to have commission staff begin work on an action plan coordinating with the utility authority, local governments, DEQ and DHHS.