Chemicals used to treat drinking water actually might raise the risk of cancer or cause other health hazards by creating toxic byproducts that need tighter federal regulation, according to an environmental advocacy group.

Fair Warning reports that the Environmental Working Group, a Washington, D.C.,-based advocacy organization, also wants the government to reduce the need for chemical treatment by cleaning up sources of public drinking water.

The Environmental Working Group says the problem is that chlorine and other chemicals that public utilities add to drinking water to kill microorganisms can react with other material – such as sewage and manure – to create hundreds of toxic byproducts, many of which aren’t regulated at all.

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According to Fair Warning’s post:

Researchers analyzed results from water quality tests done in 2011 at 201 large municipal water systems that serve more than 100 million people in 43 states. They found trihalomethanes, a byproduct of chlorination, in every system. The EPA calls some members of this class of chemicals “probable human carcinogens” and studies have linked them to bladder cancer, birth defects and miscarriages. However, only one water treatment system exceeded the EPA’s limits for the chemicals, which was set at 80 parts per billion in 1998.

But the report argued that the EPA’s limits are too lax, citing several studies linking even lower levels of the chemicals to health problems. For example, in 2011 a French research team analyzing data from three countries found that men exposed to more than 50 parts per billion of trihalomethanes [try-hal-o-MEH-thanes] had significantly increased cancer risks.

You can read the full Environmental Working Group report here.

Read more from Fair Warning here.

Here’s more coverage from Open Channel on drinking water and health issues:

• NC neighbors aghast to learn drinking water contaminated for years
• How an EPA project backfired, endangering drinking water with lead
• Farming communities facing crisis over nitrate pollution, study says

A new campaign by the tanning industry to promote the safety of sunbed use has come under fierce attack from the American Academy of Dermatology, which is accusing the industry of making claims that are “ridiculous” and unsupported by scientific evidence.

In the latest exchange between the two sides, the dermatologists blasted the newly formed American Suntanning Association for disputing the medical consensus that tanning indoors increases the risk of skin cancers, including melanoma, the deadliest kind.

“The recent statements by the American Suntanning Association (ASA) are ridiculous and there is no data to support them,” the dermatology group said in a statement. “Indoor tanning is dangerous.”

In a statement responding to the charge, the tanning association said: "The public does not benefit from the continuation of a protracted, sound-bite oriented fight between professional sunbed salons and anti-UV (ultraviolet light) lobbying groups about the relative safety of UV exposure. We promote a fair and balanced message about UV exposure.’’

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The creation last month of the tanning association, made up of 1,400 salon owners, steps up the $5 billion industry’s campaign to defend itself against mounting evidence of the harms caused by indoor tanning. Already, industry members have mounted an extraordinary effort to portray doctors and other health authorities as conspiring to unnecessarily scare the public about tanning, as FairWarning reported in August.

The tanning association describes its strategy in a document bearing its letterhead that was posted last month on TanToday, an online industry forum: “Promoting the indoor tanning industry will require retention of scientists throughout the world to help us debunk the scientific reports being used against us, and a major PR and lobbying campaign to bring the truth about indoor tanning to the government and to the public at large.” 

Alex Howe, a spokesman for the group, said the passage is not the group’s official position. He did not respond to follow-up questions about why the statement was prepared.

However, the tanning association has hired a major public relations firm, is planning a lobbying campaign, and, Howe said, will work with what he characterized as “the many scientists who already support a balanced message about UV exposure.”

In a podcast last week, Doug McNabb, a board member of the tanning association described the new group’s goal: “The sort of mission of the organization that we all agreed on was that our main objective has to be to get more people in tanning beds. … The direction we’re going to take is going to be around media relations and regulatory relations that direct people to indoor tanning salons.”

Deceptive statements?
The World Health Organization says ultraviolet light from sunbeds causes cancer. DeAnn Lazovich, a cancer epidemiologist at the University of Minnesota Cancer Center, whose own research has linked sunbed use to melanoma, said the industry’s long-running efforts to cast doubt on the science are just “smoke and mirrors” and an attempt to continue selling a service linked to cancer.

“They say, ‘Tan responsibly,’ but I think it is irresponsible for them to promote their product when we know it is a cause of skin cancer,” said Lazovich, whose work previously has been attacked by the tanning industry.

Jerod Stapleton, an assistant professor of medicine at the Cancer Institute of New Jersey who has studied the tanning industry, said many of the contrary studies cited by indoor tanning proponents are not peer reviewed and appear to rely on cherry-picked data, have methodological flaws or have been funded by industry. “It’s an interesting way of going about it,” he said. “If you don’t like what the science says, just go do your own.”

The tanning association has hired the prominent public relations firm Global Strategy Group, which lists high-profile companies like Goldman Sachs, General Electric and the New York Yankees among its clients, to represent it.

Howe, the salon association’s spokesperson, would not respond to questions about the group’s legislative strategy. But the industry wants to persuade the Food and Drug Administration not to tighten restrictions on sunbeds, as the American Cancer Society and other groups are advocating.

Even before the new group formed, the industry was trying to prevent states and local governments from passing laws making it illegal for teens to tan indoors. At least 30 states already have imposed some limits on teen tanning and Vermont and California ban anyone under age 18 from using a sunbed.

The industry has argued that tanning is a good source of Vitamin D, which is created by the body in response to UV light. It blames dermatologists for scaring people about exposure to the sun and inducing an epidemic of vitamin D deficiency in the process.

As FairWarning has reported, tanning’s proponents – including a network of non-profit organizations with ties to tanning salons – tout the vitamin as a panacea for ills ranging from autism to breast cancer. However, the Institute of Medicine, part of the National Academy of Sciences, says there isn’t enough evidence to say the vitamin provides any benefits other than improving bone health and disputes the notion that there is an epidemic of vitamin D deficiency.

UV light for medical treatments
As the statement last week from the American Academy of Dermatology noted, in 2010 the Federal Trade Commission reached a settlement with another industry group, the Indoor Tanning Association, over allegations it made misleading statements about the health benefits of sunbeds. The FTC says that under the settlement, the ITA agreed to refrain from making deceptive statements. 

Separately, the Texas Attorney General has sued a salon chain for claiming sunbeds reduce the risk of cancer and provide other health benefits. That case is set to go to trial in September.

The dermatologists group, in its recent statement, specifically criticized the American Suntanning Association for claiming that research pointing to indoor tanning’s ill effects is misleading. The ASA maintains that much of this research wrongly lumps in sunbed use at professional salons – which it contends is less risky – with sunbed use at doctor’s offices and homes. When the use of sunbeds in salons is considered on its own, “the risk virtually disappears,” the salon group said. 

The dermatologists dismissed that claim, saying ultraviolet light is used in treatments for some skin conditions, including psoriasis and atopic dermatitis. The “crucial disparity,” the dermatologists’ group said, is that the procedure is done by a medical doctor with appropriate training and expertise. “This type of medical care is not provided at an indoor tanning salon, where operators have minimal knowledge about the potential side effects of UV light,” the statement said.

Related: Embattled tanning industry fights back, taking its cues from Big Tobacco

FairWarning is an investigative news organization based in Los Angeles that focuses on on safety and health issues.

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An Open Channel post last week from the Food & Environment Reporting Network drew the attention of Steve Everley, a spokesman for Energy In Depth, a research and public education program of the Independent Petroleum Association of America. Here is his rebuttal to the article, which appeared in a longer form in The Nation.

A recent article in The Nation magazine, in collaboration with the Food & Environment Reporting Network (FERN), made a series of declarations and assertions about the impacts of hydraulic fracturing, specifically with respect to agriculture and America’s food supplies. It was a frightening tale, but the facts that were left out were just as notable (if not more so) than what was selectively chosen to be included.

The central thesis of the article is that shale development, including hydraulic fracturing, is contaminating the food we eat. As the author states early on, “there’s growing evidence that these two impulses, toward energy and food independence, may be at odds with each other.”

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From there, the story advances as one would imagine. Using the fatally flawed Bamberger-Oswald “study” on hydraulic fracturing as the focal point, the author weaves a carefully constructed narrative that does everything from repeating common (and debunked) activist talking points to claiming America’s cows are being poisoned to death by oil and natural gas development.

Of course, the story would have been much different had the author included (instead of deliberately omitting) scientific assessments that weren’t tailor-made for an anti-natural gas crowd.

How do we know they were deliberately omitted? Well, to her credit, Elizabeth Royte (the author of the piece) reached out to Energy In Depth several weeks ago about this article. She acknowledged having read EID’s work on the subject, and then asked me some pointed (but fair) questions about potential impacts on livestock and crops from hydraulic fracturing. I sent her a detailed response, including links to studies (more on that below) that demonstrate little if any negative impact on health as a result of nearby shale development. I also emphasized that concerns about public health should always be taken seriously, and the industry naturally does exactly that. But I also cautioned that simply blaming impacts on the most convenient thing (i.e. hydraulic fracturing) without scientific evidence does not solve problems, nor does it encourage the proper kind of public dialogue to address concerns.

Unfortunately, Ms. Royte did not see fit to print any of that, choosing only to include a brief mention of the lack of scientific pedigree in the Bamberger-Oswald paper – which was promptly bracketed by ascribing fault to the natural gas industry for a supposed lack of disclosure.

So, what else didn’t make it into the report?

First of all, the flaws in the Bamberger-Oswald study have been publicly documented. Dr. Ian Rae, for example, a Co-Chair of the Chemicals Technical Options Committee for the U.N. Environment Programme, called the study “an advocacy piece” written by individuals who “cannot be regarded as experts” in the subject about which they were writing. “It certainly does not qualify as a scientific paper,” Rae added. Rae also critiqued the journal that published the study – New Solutions: A Journal of Environmental and Occupational Health – by saying “the refereeing process evidently was not very stringent.”

I shared all of this information with Ms. Royte, but Dr. Rae’s commentary on the Bamberger-Oswald paper was omitted entirely from the story.

Secondly, although the article purports to be part of an “investigative reporting” effort, there was clearly a lack of interest in discussing anything that deviated from the Bamberger-Oswald paper’s conclusions. Here are just a few items relating to health impacts from development that I shared with the author, who nonetheless did not see fit to print:

• Denton County, Texas: An analysis by two public health experts found that, “even as natural gas development expanded significantly in the area over the past several years, key indicators of health improved across every major category during those times.” Denton County is situated atop the massive Barnett Shale, one of the largest natural gas fields in the United States.

• Fort Worth, Texas: An air quality study conducted for the City of Fort Worth – the largest and most comprehensive of its kind to date – determined there were “no significant health risks” from shale development in the area. Fort Worth, located in Tarrant County, also sits atop the Barnett Shale.

• Pennsylvania: The Pennsylvania Department of Environmental Protection, in two separate reports of air monitoring in Pennsylvania – one each for the northeastern and southwestern portions of the state – “did not identify concentrations of any compound that would likely trigger air-related health issues associated with Marcellus Shale drilling activities.”

There are, of course, many more examples, including hard data from the Bureau of Labor Statistics that undermine the suggestion that hydraulic fracturing is a grave threat to occupational or community health. Most of us also know about the AP investigation earlier this year, which found that activists’ claims about hydraulic fracturing causing cancer and other health problems had little or no basis in fact, much less scientific evidence.

So again, why were these examples omitted from the report? It’s really anyone’s guess. The one common denominator, however, is that none of them conforms to the notion that hydraulic fracturing is somehow a “tornado on the horizon” – as Sandra Steingraber, the lead-in voice to the Bamberger-Oswald paper, once put it. In fact, a sober review of these materials – and a proper weighting of the credibility of those who released the information – might even lead people to realize that claims about impending doom are hyperbolic and, in many cases, flat out untrue.

Read the original piece: Livestock falling ill in fracking regions

Here’s the bottom line: Landowners, farmers, and any other individuals can and should ask questions about the impacts of natural gas development. Those who ask questions should demand answers based on facts, and communities weighing the costs and benefits should, by definition, seek input on both sides and make decisions based on a careful review of that information.

The problem with Ms. Royte’s report, though, is that it did not seek to be a part of that good faith dialogue. By relying on anecdotes and a single, fundamentally flawed research paper – and refusing to even discuss findings that contradict the singular message that those sources conveyed – the story that was presented to readers was not only one-sided, but actually harmful to the broader public discussion about developing oil and natural gas from shale.

Despite that, the story has been reprinted in news outlets and other media as if it carefully weighed competing viewpoints and came to a frightening conclusion. But the truly scary part is that the author, in more than 4,000 words, flat out refused to include even a few sentences about the scientific findings that fell outside what was apparently a pre-determined conclusion.

Maybe the next investigative report will examine the reasoning behind such a glaring omission, though we won’t be holding our breath.

Click here to read Food & Environment Reporting Network's Elizabeth Royte response.

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In the midst of the domestic energy boom, livestock on farms near oil- and gas-drilling operations nationwide have been quietly falling sick and dying. While scientists have yet to isolate cause and effect, many suspect chemicals used in drilling and hydrofracking (or “fracking”) operations are poisoning animals through the air, water or soil.

Earlier this year, Michelle Bamberger, an Ithaca, N.Y., veterinarian, and Robert Oswald, a professor of molecular medicine at Cornell’s College of Veterinary Medicine, published the first and only peer-reviewed report to suggest a link between fracking and illness in food animals.

The authors compiled 24 case studies of farmers in six shale-gas states whose livestock experienced neurological, reproductive and acute gastrointestinal problems after being exposed — either accidentally or incidentally — to fracking chemicals in the water or air. The article, published in “New Solutions: A Journal of Environmental and Occupational Health,” describes how scores of animals died over the course of several years. Fracking industry proponents challenged the study, since the authors neither identified the farmers nor ran controlled experiments to determine how specific fracking compounds might affect livestock.

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The death toll is insignificant when measured against the nation’s livestock population (some 97 million beef cattle go to market each year), but environmental advocates believe these animals constitute an early warning.

Exposed livestock “are making their way into the food system, and it’s very worrisome to us,” Bamberger said. “They live in areas that have tested positive for air, water and soil contamination. Some of these chemicals could appear in milk and meat products made from these animals.”

In Louisiana, 17 cows died after an hour’s exposure to spilled fracking fluid, which is injected miles underground to crack open and release pockets of natural gas. The most likely cause of death: respiratory failure.

In New Mexico, hair testing of sick cattle that grazed near well pads found petroleum residues in 54 of 56 animals.

In northern central Pennsylvania, 140 cattle were exposed to fracking wastewater when an impoundment was breached. Approximately 70 cows died, and the remainder produced only 11 calves, of which three survived.

In western Pennsylvania, an overflowing wastewater pit sent fracking chemicals into a pond and a pasture where pregnant cows grazed: Half their calves were born dead. Dairy operators in shale-gas areas of Colorado, Pennsylvania, West Virginia, and Texas have also reported the death of goats exposed to fracking chemicals.

Drilling and fracking a single well requires up to 7 million gallons of water, plus an additional 400,000 gallons of additives, including lubricants, biocides, scale- and rust-inhibitors, solvents, foaming and defoaming agents, emulsifiers and de-emulsifiers, stabilizers and breakers. At almost every stage of developing and operating an oil or gas well, chemicals and compounds can be introduced into the environment.

Cows lose weight, die
After drilling began just over the property line of Jacki Schilke’s ranch in the northwestern corner of North Dakota in 2009, in the heart of the state’s booming Bakken Shale, cattle began limping, with swollen legs and infections. Cows quit producing milk for their calves, they lost from 60 to 80 pounds in a week and their tails mysteriously dropped off. Eventually, five animals died, according to Schilke.

Ambient air testing by a certified environmental consultant detected elevated levels of benzene, methane, chloroform, butane, propane, toluene and xylene -- and well testing revealed high levels of sulfates, chromium, chloride and strontium. Schilke says she moved her herd upwind and upstream from the nearest drill pad.

Although her steers currently look healthy, she said, “I won’t sell them because I don’t know if they’re OK.”

Nor does anyone else. Energy companies are exempt from key provisions of environmental laws, which makes it difficult for scientists and citizens to learn precisely what is in drilling and fracking fluids or airborne emissions. And without information on the interactions between these chemicals and pre-existing environmental chemicals, veterinarians can’t hope to pinpoint an animal’s cause of death.

The risks to food safety may be even more difficult to parse, since different plants and animals take up different chemicals through different pathways.

“There are a variety of organic compounds, metals and radioactive material (released in the fracking process) that are of human health concern when livestock meat or milk is ingested,” said Motoko Mukai, a veterinary toxicologist at Cornell’s College of Veterinary Medicine. These “compounds accumulate in the fat and are excreted into milk. Some compounds are persistent and do not get metabolized easily.”

Veterinarians don’t know how long chemicals may remain in animals, farmers aren’t required to prove their livestock are free of contamination before middlemen purchase them and the Food Safety Inspection Service of the U.S. Department of Agriculture isn’t looking for these compounds in carcasses at slaughterhouses. 

Documenting the scope of the problem is difficult: Scientists lack funding to study the matter, and rural vets remain silent for fear of retaliation. Farmers who receive royalty checks from energy companies are reluctant to complain, and those who have settled with gas companies following a spill or other accident are forbidden to disclose information to investigators. Some food producers would rather not know what’s going on, say ranchers and veterinarians.

“It takes a long time to build up a herd’s reputation,” said rancher Dennis Bauste of Trenton Lake, N.D. “I’m gonna sell my calves and I don’t want them to be labeled as tainted. Besides, I wouldn’t know what to test for. Until there’s a big wipeout, a major problem, we’re not gonna hear much about this.”

Fracking proponents criticize Bamberger and Oswald’s paper as a political, not a scientific, document. “They used anonymous sources, so no one can verify what they said,” said Steve Everley, of the industry lobby group Energy In Depth. The authors didn’t provide a scientific assessment of impacts -- testing what specific chemicals might do to cows that ingest them, for example -- so treating their findings as scientific, he continues, “is laughable at best, and dangerous for public debate at worst.” Bamberger and Oswald acknowledge this lack of scientific assessment and blame it on the dearth of funding for fracking research and on the industry’s use of nondisclosure agreements.

The National Cattlemen’s Beef Association, the main lobbying group for ranchers, takes no position on fracking, but some ranchers are beginning to speak out. “These are industry-supporting conservatives, not radicals,” said Amy Mall, a senior policy analyst with the environmental group, Natural Resources Defense Council. “They are the experts in their animals’ health, and they are very concerned.”

Last March, Christopher Portier, director of the National Center for Environmental Health at the U.S. Centers for Disease Control and Prevention, called for studies of oil and gas production’s impact on food plants and animals. None is currently planned by the federal government.

As local food booms, consumers wary
But consumers intensely interested in where and how their food is grown aren’t waiting for hard data to tell them their meat or milk is safe. For them, the perception of pollution is just as bad as the real thing.

“My beef sells itself. My farm is pristine. But a restaurant doesn’t want to visit and see a drill pad on the horizon,” said Ken Jaffe, who raises grass-fed cattle in upstate New York.

Only recently has the local foods movement, in regions across the country, reached a critical mass. But the movement’s lofty ideals could turn out to be, in shale gas areas, a double-edged sword.

Should the moratorium on hydrofracking in New York State be lifted, the 16,200-member Park Slope Food Co-op, in Brooklyn, will no longer buy food from farms anywhere near drilling operations -- a $4 million loss for upstate producers. The livelihood of organic goat farmer Steven Cleghorn, who’s surrounded by active wells in Pennsylvania, is already in jeopardy.

“People at the farmers market are starting to ask exactly where this food comes from,” he said.

This report was produced by the Food & Environment Reporting Network, an independent investigative journalism non-profit focusing on food, agriculture, and environmental health. A longer version of this story appears on TheNation.com. 

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By Joe Eaton
Center for Public Integrity

Like a growing number of disabled Americans on Medicaid, Keith Foreman, a 57-year-old in Metropolis, Ill., qualified for a personal caregiver to help him with daily activities like dressing, shaving, and preparing meals.

Foreman, who prosecutors say suffers from a spinal injury, hired his girlfriend, Sheila McDonald, for the job. In 2011, McDonald received almost $5,000 from Medicaid for six months of care she provided to Foreman.

These personal care services, which are available in all 50 states, are designed to help the sick, elderly, and disabled remain in their homes — and out of expensive nursing facilities.

But Foreman was not living at home. During the days marked on McDonald’s timesheets, Foreman was housed in the Massac County jail in Illinois, serving time for forging a stolen debit card signature at a local liquor store.

Like Foreman and McDonald, who both pleaded guilty to charges of making false statements, unscrupulous beneficiaries and home health workers are increasingly targeting personal care services programs for illegal money-making schemes, according to a new federal report. Investigators say lax requirements for both caregivers and patients, along with poor state and federal oversight, has made the rapidly growing programs a lucrative target for fraud.  And this isn’t the first time they’ve issued such a warning.

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Report faults federal oversight of state programs
A Health and Human Services Office of the Inspector General (OIG) report scheduled to be released Thursday faults the Centers for Medicaid and Medicare Services (CMS) for inadequate oversight of personal care services programs, whose costs are shared by states and the federal government, as is the norm for Medicaid.  The report, which brings together six years of OIG investigations and 23 reports on the topic, describes a program hindered by poor claims documentation, insufficient monitoring of claims data for fraud and waste, and a crazy-quilt of varied requirements for personal care workers in different states.

“Historically, CMS has left a lot of the responsibility for overseeing waste, fraud and abuse to the states,” said Christi Grimm, special assistant to the principal deputy inspector general. “As a result, we have 301 different sets of requirements for caregivers across the states.” 

Although some states mandate criminal background checks and licensing for home health workers, Grimm said others lack even the most basic requirements, including age minimums,

which has led to cases in which juveniles escape prosecution for fraud and abuse. Worker requirements are set by counties in a number of states, she added, which has led to a hodge-podge of rules that are difficult to enforce, and nearly impossible to monitor.

“We are asking CMS to step up to the plate,” Grimm said, and use its authority to regulate and monitor the state programs.

The report includes six previous OIG recommendations to CMS and state agencies which have gone unimplemented. In a 2008 report that found five states may have paid up to $11 million in error for personal care services during one quarter of 2005, OIG recommended that the CMS work with states to stop payments for personal care when patients were receiving care in institutions, not at home. The agency agreed with the recommendation, but according to the OIG, the work has not been completed.

In addition to asking the agency to address previous recommendations, the report offers four new goals for CMS to improve oversight and monitoring of state plans, including standardizing rules for personal care workers to set minimum age and education levels, and require criminal background checks.

The report, however, seems unlikely to spur the agency to follow the OIG’s specific suggestions..  In a written response, CMS — part of the Department of Health and Human Services — explicitly concurred with only one of  the OIG recommendations: that it should provide states with claims data to help root out cases in which beneficiaries are simultaneously receiving both institutional care and home health services.  In response to the recommendation on establishing federal guidelines for personal care workers, CMS pointed out there is a shortage of care attendants.

 “Personal care services are an important part of keeping people in their homes and out of nursing homes, which lowers costs and improves the quality of life of the patient,” said CMS spokesman Brian Cook. “We are working to protect personal care from fraud and abuse by promoting stronger training programs for workers who provide personal care, working with states on background check programs for these workers, and developing new data methods to analyze claims for potential fraud and abuse."

Grimm called the CMS response to the report unacceptable. “It’s not uncommon for CMS … to identify things on the horizon, or things they hope to do, but not necessarily commit to doing something,” Grimm said, adding that CMS’s efforts so far simply have not worked. “[CMS] has the authority to do what we are asking. It has not done it yet. And it hasn’t committed to doing it after reading our report.”

A wealth of opportunities
According to investigators, most fraud schemes in personal care services involve billing for care that was not provided or was not allowed. Self-directed programs, which allow beneficiaries to hire and manage their helpers, may be particularly vulnerable, but some prosecutions have also involved home health care agencies.

In January, for example, the owner of a Minnesota home health care company outside Minneapolis was sentenced to two years in prison for cheating Medicaid out of more than $650,000 in charges for personal care services. In March, the owner of Families First Home Health Care in Sparta, N.C., pleaded guilty to fraud and money laundering stemming from a scheme in which she billed Medicaid for personal care services she did not perform and split the proceeds with plan members.

“Fraud goes where the money is,” said Barbara Zelner, executive director of the National Association of Medicaid Fraud Units, which represents state law enforcement agencies that investigate Medicaid fraud.  After nursing homes, Zelner said, home health represents one of the larger slices of state Medicaid budgets.

Personal care services programs have grown quickly since a 1999 Supreme Court decision held that unjustified segregation of the disabled is a civil rights violation. The ruling led to increased spending for home health services; in 2011, Medicaid paid more than $12 billion for personal care services, up 35 percent since 2005, according to the OIG. Investigators say program fraud has kept pace. In 2010, state Medicaid fraud units investigated more than 1,000 cases involving personal care services, more than any other type of Medicaid service.

Not everyone agrees with the OIG’s views on personal care services.  In 2011, an OIG review of Medicaid claims for personal care services in New Jersey found that 40 percent should have been denied. Sherl Brand, president of the Home Care Association of New Jersey, which advocates for home health care providers, questions the OIG’s work, saying the agency often draw broad conclusions from examinations of a limited number of claims. “It is almost a bit ridiculous because of the extrapolation they do,” Brand said.

New Jersey home health workers face criminal background checks and certification and licensure requirements, Brand said. Personal care services programs save money, she said, in addition to helping disabled people live better lives. When New Jersey was faced with budget cuts, Brand said the association determined the average weekly cost for personal care services was $242 dollars a week, only slightly higher than the cost of a single day in a nursing home.

But as funding for the programs increase, fraud follows. Kirk Ogrosky, a former top federal health care fraud prosecutor who is now a partner at the Washington law firm Arnold & Porter, said home health has long been a hotbed of fraud, both in Medicaid and in Medicare. The fraud, he said, is not hard to uncover. Ogrosky recalled that after an extensive analysis of Medicare claims, he sent agents out to interview questionable beneficiaries. When the agents knocked on the doors, they often learned the person they were looking for was at work, Ogrosky recalled.  “That’s utterly preposterous,” he said, “since home health requires that you are homebound.”

In other cases, Ogrosky said, agents found that home health care agencies were filing claims for beneficiaries who did not live at the homes indicated on the claims. “One of my favorite stories is about a homeless guy we found,” Ogrosky said. “He didn’t even have a home to be homebound to.”

The Center for Public Integrity is a non-profit independent investigative news outlet. For more of its stories visit publicintegrity.org.

CHICHIGALPA, Nicaragua – You won’t see a road sign pointing to “La Isla de Viudas,” or “The Island of Widows,” as it’s not the community’s official name. It’s a nickname born from a horrific body count. 

In the past 10 years, it’s believed that hundreds, if not thousands, of residents of Chichigalpa — mostly male sugarcane workers — have died from chronic kidney disease, or CKD. That in a city of nearly 60,000, roughly the size of Ames, Iowa. 

The mysterious and hidden epidemic, first highlighted by the Center for Public Integrity, has claimed thousands more lives across Central America. In El Salvador and Nicaragua alone, the number of men dying from the excruciatingly painful disease has risen five-fold in the last two decades. High rates of CKD also have been found in rural villages in India and among the rice paddies of Sri Lanka.

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Sacorro Mendez Flores, who lives in the “La Isla” district of Chichigalpa, remembers when her son first fell ill. Jorge Luis Silva didn’t look sick at first, but inside he was dying. His kidneys struggled to filter waste from his body, to no avail. Five months ago, Flores buried him. 

“The same thing happened to my husband,” she said. “They both died the same.”

Researchers are searching for answers about why this disease is ravaging not only the bodies of its victims, but the communities they leave behind. 

The illness spreads
More than 20 million Americans aged 20 and older have chronic kidney disease, according to the Centers for Disease Control and Prevention. In developed countries like the U.S., CKD often goes hand in hand with obesity, diabetes and hypertension. With treatment, including dialysis and kidney transplants, many with the disease survive. 

The CKD plaguing parts of Central America, however, is something scientists have never seen before.

“It affects people who don't have diabetes or hypertension, which are the usual risk factors for chronic kidney disease,” said Sasha Chavkin, a CPI reporter who has covered the mysterious epidemic for several years. “No one can figure out what it is that's making all these people sick.”

“It comes at great social, economic and humanitarian cost,” said Dr. Daniel R. Brooks, an associate professor of epidemiology at the Boston University School of Health who is leading a research team looking for the cause of the epidemic. “These are working-age people who are being struck down, and whole communities are really hurt and devastated by this disease.” 

And with little or no access to the life-saving treatments available in the developed world, a CKD diagnosis is often tantamount to a death sentence. 

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In Nicaraguan sugarcane community, workers stare death in the face

Chronic kidney disease: 'Silent killer' may have multiple triggers

“Where we stand right now is that ultimately this disease is not treatable in this community,” said Nate Raines, a researcher with the Mt. Sinai School of Medicine Global Health program, which is collaborating with two organizations in Nicaragua on research independent from the Boston University group. “What we need to do is find the cause. That's the only way to really help the health situation.” 

Many in Chichigalpa believe that the root of the disease lies in chemicals sprayed in the sugarcane fields while men are working, or seeping into the water supply. A spokesperson from the sugar industry says the chemicals used are standard fertilizer and are not used to excess.  

Science, so far, points to a more complicated answer. 

'Markers' of kidney damage found
The research team from the Boston University has linked the disease in Central America to strenuous labor, dehydration and environmental conditions in which chemicals may play a role. That theory was supported by the group’s most recent study, which found “markers” of kidney damage in adolescents as young as 12 in affected communities. 

Thousands of miles away, research in Sri Lanka’s affected communities also indicates chemicals may play a key role in the illness devastating communities there.

As reported last month by the Center for Public Integrity, the country’s health ministry and World Health Organization announced in June that a years-long study had identified chemicals thought to be an essential cause of the disease: cadmium and arsenic. Both are heavy metals found in fertilizers and pesticides that can cause an array of health effects, including the type of kidney damage ravaging communities in Sri Lanka and Nicaragua.

While most of those tested had lower levels of the toxic elements than officially designated as dangerous by the United Nations, researchers believe that long-term exposure, likely through the food chain, may explain the high incidence of CDK. 

The findings, due to be officially released in October, represent a potential breakthrough in the research about CDK worldwide, including the epidemic in Nicaragua. 

Researchers in Central America have not pinpointed a chemical cause. But the new research on adolescents indicates the kidneys of those going into the fields may already be damaged, making the long days and repeated dehydration in the fields potentially deadly. 

Some experts also suggest that sugarcane workers may also unwittingly be harming themselves as they struggle to stay hydrated while cutting up to 11 tons of cane a day by hand.

For a refreshing pick-me-up, they occasionally slice a stalk of cane, peeling back its “bark” and sticking it in their mouths, where it produces a sweet sugary liquid. 

But investigators now wonder: Could that constant flow of sucrose, combined with 90-plus degree temperatures and severe daily dehydration, be a deadly cocktail that slowly brings on CKD? 

“We believe high amounts of sugar solutions may not cause much kidney damage,” said Dr. Richard Johnson, head of the division of renal disease and hypertension at the University of Colorado, Denver. “But under certain circumstances, such as dehydration, we’re concerned the sugar may actually be toxic in causing damage to the kidneys.”

The sugar link
Whether or not sugar consumption plays a direct role in causing the Central American form of CKD, activists say it is a thread that connects the disease to its northern cousin.

In the U.S., rampant sugar consumption – Americans eat an average of 22.2 teaspoons of sugar per day according to the American Heart Association—drives many of the diseases linked to CKD, including diabetes and hypertension. 

And with recent steep increases in the price and demand for sugar, more people are working longer hours in the sugarcane fields of Central America. In 2011, the U.S. imported 330,000 metric tons of raw sugar from Central America, or nearly one-quarter of total raw sugar imports that year, according to the United States Department of Agriculture.

“Not only is the production of sugar killing people, but the consumption of it is killing people,” said Jason Glaser of La Isla Foundation, a nonprofit group he founded to focus attention on the epidemic and fund research that he hopes will solve the mystery. “It's bad for you and it's bad for workers.” 

The sugar industry, however, rejects suggestions that it is causing the epidemic of CKD among workers at its mills and plantations.

“We are not responsible for it,” said Mario Amador, a spokesman for the sugarcane industry. “We’re working to find a solution.”

He also blames the workers themselves, saying they drink too much alcohol. “It’s part of our culture,” Amador said. “It’s part of the things we do in our country. Poor people do it a lot.” 

Amador also speculated that active volcanoes in the region could have contaminated the water supply. But he admits he does not know why so many have died from CKD.

No matter what the research finds, Central America is unlikely to curb its cane production anytime soon. The world market for sugar is strong, and the industry receives direct help from abroad. 

The International Finance Corp., the private-sector arm of the World Bank, has provided loans of more than $100 million to promote production and biofuel in Nicaragua in recent years. Though the loans went to two plantations whose workers have been heavily affected by kidney disease, they were approved without formal consideration of the disease because the IFC did not find a link between the cane fields and CKD, according to the Associated Press. 

After workers complained about the loans, the IFC helped to negotiate an $800,000 donation to sponsor the ongoing Boston University study, the Center for Public Integrity reported. The money was provided by Nicaragua Sugar Estates Limited, a major sugar producer in the west of the country, part of more than $4 million it has committed toward research and community development in recent years.

Waiting to die
But for many in Chichigalpa, the results of the research – whatever they may be – will come too late. 

Like most of the men in this community, Maximiliano Lopez, spent years in the fields cutting sugarcane. He began at 5 a.m., when the air was cool, and continued to work as the sun beat down, sometimes logging 14 hours a day. Then he was informed he had CKD.

Even after his diagnosis, which bans him from working in the fields or at the mill, the muscular 32-year-old said he used a friend’s identification to return to cutting cane. Nicaragua is the second-poorest country in the Western Hemisphere, he explained, and many workers continue to work the harvest after being diagnosed with kidney disease because it is the only work they can find. 

“A lot of people do it out of necessity,” Lopez said. “They have a big family and they're the head of the household, so even if they're sick, you have to find work to support your family.” 

But, as Lopez and other cane workers eventually discovered, short-term survival may mean leaving behind the families that they labored so mightily to support.

“I began working there to earn a living and instead I earned death,” he said. “I’m just waiting for the day to come.” 

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By Stephanie Woodard
100Reporters

A youth-suicide epidemic is sweeping Indian country, with Native American teens and young adults killing themselves at more than triple the rate of other young Americans, according to federal government figures.

In pockets of the United States, suicide among Native American youth is 9 to 19 times as frequent as among other youths, and rising. From Arizona to Alaska, tribes are declaring states of emergency and setting up crisis-intervention teams.

“It feels like wartime,” said Diane Garreau, a child-welfare official on the Cheyenne River Sioux Reservation, in South Dakota. “I’ll see one of our youngsters one day, then find out a couple of days later she’s gone. Our children are self-destructing.”

So dire is the alarm that of 23 grants the U.S. federal government awarded nationally to prevent youth suicides in September, 10 went to Native American tribes or organizations, with most of them receiving nearly $500,000 per year for three years.

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A former Democratic senator from North Dakota, Byron Dorgan, who chaired the U.S. Senate Committee on Indian Affairs for 18 years, called those efforts good but insufficient. Dorgan is founder of the Center for Native American Youth, which promotes Indian child health and emphasizes suicide prevention. He describes the Indian Health Service, which serves the nation’s 566 tribes, as chronically underfunded.

"We need more mental-health services to save the lives of our youngest First Americans,” Dorgan said. “Tribes and nonprofits may get two- or three-year grants to address an issue that cannot possibly be resolved in that amount of time. We fund programs, then let them fall off a cliff.

"The perception may be that tribes have a lot of gaming funds, but that is simply not true for more than a few,” Dorgan said.

Legacy of trauma
The suicide risk factors for Native youth are well known and widely reported. In their homes and communities, many Native youngsters face extreme poverty, hunger, alcoholism, substance abuse and family violence. Diabetes rates are sky high, and untreated mental illnesses such as depression are common. Unemployment tops 80 percent on some reservations, so there are few jobs—even part-time or after-school ones. Bullying and peer pressure pile on more trauma during the vulnerable teen years.

Native youngsters are particularly affected by community-wide grief stemming from the loss of land, language and more, researchers reported in 2011. As many as 20 percent of adolescents said they thought daily about certain sorrows—even more frequently than adults in some cases, the researchers found.

“Our kids hurt so much, they have to shut down the pain,” said Garreau, who is Lakota. “Many have decided they won’t live that long anyway, which in their minds excuses self-destructive behavior, like drinking—or suicide.”

Suicide figures vary from community to community, with the most troubling numbers in the Northern Plains, in Alaska and in parts of the Southwest. In Alaska, the suicide rate for young Native males is about nine times that of all young males in the United States, while Native females in Alaska kill themselves nineteen times as often as all U.S. females their age, according to the Alaska Native Tribal Health Consortium.

After a cluster of suicides in 2001, the White Mountain Apache Tribe wanted to develop a prevention program. It mandated reporting of all suicides and attempts on their Arizona reservation, discovering that between 2001 and 2006, their youth ended their lives at 13 times the national rate.

The trauma behind the numbers is excruciating. “When my son died by suicide at age 23, I didn’t even know how to think,” said Barbara Jean Franks, who is Tlingit and was living in Juneau, Alaska, at the time. “I couldn’t imagine that hope existed.”

The tragedies ripple through entire communities. Reservations are essentially small towns, and tribal members are often related, whether closely or distantly, Garreau said. “People are numbed, overwhelmed. Sometimes they’ll say, I just can’t go to another funeral.”

Because suicide is so common in some Native communities, it’s become an acceptable solution for times when burdens build up, said Alex Crosby, medical epidemiologist with the CDC’s injury-prevention center: “If people run into trouble—relationship problems, legal problems—this compounds the underlying risk factors, and one of the options is suicide.”

"Is it in our blood?"
“It crosses your mind,” said Jake Martus, whose Yupik/Eskimo/Athabaskan father was born in a tiny, remote village on the Yukon River. “I’ve never acted on suicidal thoughts, but they’ve been there my entire life. It’s sad, it’s shocking, but in our communities it’s also somehow normal.”

Martus, who is 26 and a patient advocate for the Alaska Native Epidemiology Center, said suicide is so frequent among his people, he has to ask, “Is it in our blood?” Martus’ father killed himself in jail after being arrested for drunk driving. Behind his dad’s alcoholism were overwhelming memories of sexual abuse by his village’s Catholic priest, Martus said. Similar stories echo throughout Indian country, where lawsuits against the Catholic Church have detailed sexual, physical, and emotional abuse by clerics in parishes or on staff at the notoriously violent boarding schools that Native children were forced to attend until the 1970s.

The lasting effect of the abuse and the loss of land and culture is often called historical trauma. Martus calls it genocide. “They set us up to kill ourselves," he said. "The point of all the policies was ‘take them out.’”

In some communities, suicide has become so ordinary that boys in particular may dare each other to try it, said Ira Vandever, a Ramah Navajo chef in western New Mexico. He works with Music Is Medicine, a local group that brings guitars, drums and lessons from rock and traditional musicians to Native youngsters. Speaking after dinner at his restaurant, La Tinaja, he said, “Around here, some who have died by suicide weren’t depressed. They were just responding to a dare.”

Incredible as it may sound to adults, adolescents may not fully understand that shooting or hanging themselves can have permanent results, said social worker Patricia Serna, who helped develop a nationally recognized suicide-prevention program for a New Mexico tribe. “Youth who survived suicide attempts would tell us they just wanted a break from their problems, a little time off.” She explains that important decision-making parts of the brain are not fully developed in adolescents—of all population groups, not just Native youngsters. As a result, they may not foresee the consequences of their actions.

Part of the boys’ difficulty is misunderstanding the warrior tradition that makes up much of Native male identity, according to Alvin Rafelito, Ramah Navajo and director of his community’s health and human services department. “We have a prayer that describes a warrior as someone who goes the distance spiritually for his people. Nowadays, that ideal has been reduced to simply fighting and violence. In teaching kids to be modern warriors, we have to convey the term’s full, traditional meaning.”

Tradition as a life raft
Tradition is key, said Anderson Thomas, Ramah Navajo and director of the community’s behavioral health program. On his reservation, he points out, it’s typically young men who are dying by suicide, not young women. “I’d say more than 90 percent of girls here go through their traditional coming-of-age ceremony,” he said. In contrast, little is done for young males. In large part, he said, that’s because traditional male activities like hunting have diminished, so rituals related to them have dropped off as well. Though Ramah Navajo men and boys can obtain conventional therapy, they also need ceremonies, Thomas said.

“It was my tradition that brought me to safety,” Franks said. As time went on, she went back to school, got a degree and these days promotes suicide prevention statewide on behalf of the Alaska Native Tribal Health Consortium. “Now, I can move forward. Instead of saying my son died by suicide, I can say he gave me 23 years of his life.”

According to Crosby, tradition is one of the so-called “protective factors” that can counter the risk factors—even the deeply embedded ones that afflict tribes. For indigenous people, tradition is distinctive and powerful, say researchers. It incorporates family and clan relationships, reverence for elders and a deeply-held spiritual life. Supporting these traditions and ties makes Native youngsters feel valued and gives them encouragement to seek help, U.S. and Canadian scientists have concluded in study after study.

You don’t have to be a scientist to figure this out. Alaska Native Tessa Baldwin was a 17-year-old high school student when she learned that feeling connected is vital. At age 5, she had lost an uncle to suicide and in succeeding years, several friends and a boyfriend. “I finally realized it wasn’t something affecting just me,” she said. “It was a lot bigger.” In 2011, she founded Hope4Alaska, one many small grassroots suicide-prevention groups in Indian country.

Through Hope4Alaska, Baldwin traveled to schools in Alaska Native villages to tell her story and find out what other teens thought would help.

“We had youth–elder discussions, and the kids said they felt useless. They wanted to better their communities but saw no way to make a contribution. The elders were touched, and the kids felt they’d connected with them in an important way,” recalls Baldwin, who has just started her freshman year at the University of California, San Diego.

To make sure Cheyenne River’s children feel part of a community that values them, Diane Garreau’s sister, Julie, runs the Cheyenne River Youth Project, a busy after-school facility. Kids listen to elder storytellers, play basketball and tend a two-acre organic garden. They get healthy meals and homework help. They study in a library, go online in an Internet café, stage fashion shows and organize local beautification projects. In 2011, a youth-leadership group visited the White House.

“Everything we do—from serious to seemingly frivolous—is about letting our kids know we care,” Julie Garreau said.

Continuity counts
“You could define many things—a school camping trip, a traditional dance group—as suicide prevention,” said Zuni Pueblo’s Superintendent of Schools Hayes Lewis, co-creator  of the Zuni Life Skills Development curriculum, one of the first suicide-prevention programs designed for Native Americans, in the late 1980s. The school-based lesson series teaches coping skills like stress management, as well as role-playing responses to suicide threats. It was created after a rise in youth-suicide rates at Zuni—thirteen deaths between 1980 and 1987, according to a paper Lewis co-wrote in 2008.

After Zuni adopted the curriculum in 1991, youth suicide stopped almost immediately, according to Lewis’s co-author, Stanford University education professor Teresa LaFromboise. Fifteen years later, the pueblo’s schools shelved the program. Suicides crept back, and the shocked community asked Lewis to resume the post of school superintendent and re-establish the curriculum. Over the past two years, he’s done just that, he said.

When the Zuni school system ended its program, the officials there didn’t realize “how fragile the peace was,” Lewis testified to the Senate Committee on Indian Affairs in 2009, telling then-Senator Dorgan and other members: “Suicide prevention and intervention require constant vigilance.”

Agencies, nonprofits, foundations and others can partner with tribes in the effort to protect Native children. Ultimately, though, it’s up to the communities, Lewis said. “We adults have to practice our core cultural values of compassion, respect, cooperation and concern for our children. We have to talk to youngsters about relationships, clans, societies—all the connections they’re a part of.”

“We have to tell our kids how wonderful they are,” adds Julie Garreau. “We have to give them safe places to learn and have fun and reassure them that they can have a productive life with healthy relationships.”

Franks recently participated with grieving family members in a memorial walk. The group circled a lake in one direction to honor those they’d lost, and the other direction to express support for those who remain. “Prevention includes acknowledging the bereaved and helping them talk about what happened,” Franks said.

Rafelito was hopeful. He was standing in a Ramah Navajo community garden, surrounded by ripening squashes, corn and other heirloom crops. He noted that today’s Native people and their traditions endure, despite centuries of depredations and violence. “Look at our history,” Rafelito said. “It’s been survival of the fittest. We’re the smartest and the toughest anyone can be.

“Our message to our kids should be, ‘We’re OK.’”

Stephanie Woodard is a member of 100Reporters, a nonprofit investigative news center. This article, the first in a series on preventing Native youth suicide, was made possible by grants from the Fund for Investigative Journalism and The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School of Journalism. The series will be co-published with Indian Country Today.

More than six years after Gulf Coast victims of Hurricane Katrina began experiencing adverse health effects while living in travel trailers provided by the federal government for temporary housing, a federal judge in New Orleans has given his final approval to a $42.6 million settlement of a class-action lawsuit alleging that the units emitted hazardous levels of the toxic chemical formaldehyde.

U.S. District Judge Kurt Engelhardt approved the deal Thursday after hearing from attorneys who brokered the agreement between the plaintiffs and more than two dozen manufacturers of mobile homes provided by the Federal Emergency Management Agency in the wake of Hurricanes Katrina and Rita.

Roughly 55,000 residents of Louisiana, Mississippi, Alabama and Texas will be eligible for shares of $37.5 million paid by more than two dozen manufacturers, the Associated Press reported. They also can get shares of a separate $5.1 million settlement with FEMA contractors that installed and maintained the units.

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Dan Balhoff, a court-appointed special master, will determine the plaintiffs' awards, the AP said. Up to 48 percent of the total settlement money – or approximately $20,5 million -- will be deducted for attorneys' fees and costs, it said. Assuming the remainder is divided equally among 55,000 plaintiffs, the plaintiffs would receive about $4,020 apiece.

Payments are expected to go out late this year or early next year, the AP said.

Engelhardt presided over three trials for claims against FEMA trailer manufacturers and installers after he was picked in 2007 to oversee hundreds of consolidated lawsuits. The juries in all three trials sided with the companies and didn't award any damages.

As msnbc.com (now NBCNews.com) first reported in July 2006, residents of the trailers began complaining of headaches, nosebleeds and breathing difficulty shortly after moving into the trailers, which were trucked to the Gulf Coast by the tens of thousands after Katrina and Rita devastated the area in rapid succession in 2005.

Air quality tests of 44 FEMA trailers in early 2006 conducted by the Sierra Club found formaldehyde concentrations as high as 0.34 parts per million – a level nearly equal to what a professional embalmer would be exposed to on the job, according to one study of the chemical’s workplace effects.

And government tests on hundreds of trailers in Louisiana and Mississippi announced in 2008 found formaldehyde levels that were, on average, about five times what people are exposed to in most modern homes. 

FEMA, which isn't a party to the settlements, had long downplayed the health risks from formaldehyde exposure before those test results were announced.

It eventually began auctioning off the units as “scrap” — meaning they should not be used for human habitation — in October 2008, but some unscrupulous buyers apparently were able to dodge regulations and return them to the housing pool. 

Formaldehyde gas -- the airborne form of a chemical used in a wide variety of products, including composite wood and plywood panels in the travel trailers that FEMA purchased to house hurricane victims -- is considered a human carcinogen, or cancer-causing substance, by the International Agency for Research on Cancer and a probable human carcinogen by the EPA.

Gerald Meunier, a lead plaintiffs' attorney, told the AP that the deal provides residents with "somewhat modest" compensation but allows both sides to avoid the expense and risks of protracted litigation.

"Dollar amounts alone do not determine whether a settlement is fair and reasonable," he said.

Jim Percy, a lawyer for the trailer makers, said Engelhardt would have had to try cases individually or transfer suits to other jurisdictions if the settlement wasn't reached.

"It was not going to end quickly, and it was going to be even more monumental for all the parties concerned," he said.

But that doesn't mean the deal isn't a disappointment for many residents who blame their illnesses on the cramped trailers they occupied for months on end.

"We were told not to look for much," said Anthony Dixon, a New Orleans resident who says he developed asthma while living in a FEMA trailer for two years.

Dixon, 58, attended the hearing with his wife and mother to learn more about the deal.

"We're glad to get it over with," he added.

Engelhardt noted he received a letter from a woman whose 66-year-old mother, Agnes Mauldin, of Mississippi, died of leukemia in 2008 after living in a FEMA trailer. Mauldin's daughter, Lydia Greenlees, said the settlement offers "very little" for what her family considers to be a wrongful death case.

"I am saddened about the settlement in that I feel like it makes a mockery of my mother's life," Greenlees wrote. "I don't want anyone to think for one second that I view this settlement as a fair trade for my mother's life. I do not."

A group of companies that includes Gulf Stream Coach Inc., Forest River Inc., Vanguard LLC and Monaco Coach Corp. will pay $20 million of the $37.5 million settlement with the trailer makers.

Shaw Environmental Inc., Bechtel Corp., Fluor Enterprises Inc. and CH2M Hill Constructors Inc. are among the FEMA contractors that agreed to pay shares of the separate $5.1 million settlement.

Only a handful of formaldehyde-related claims are still pending, including some against FEMA by a group of Texas residents.

Mike Brunker is the projects editor for NBCNews.com; the Associated Press contributed to this article.

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A doctor in a white lab coat stands at the pearly gates. The voice of God booms, “And your good deeds?” The man responds, “Well, as a dermatologist, I’ve been warning people that sunlight will kill them and that it is as deadly as smoking.”

His smug smile fades as God snaps, “You’re saying that sunlight, which I created to keep you alive, give you vitamin D and make you feel good, is deadly? And the millions of dollars you received from chemical sunscreen companies had nothing do with your blasphemy?”

A bottle of SPF 1000 sunscreen materializes in the dermatologist’s hand. “You’ll need that where you’re going,” God says.

The scene is part of a training video for tanning salon employees made by the International Smart Tan Network, an industry group. FairWarning purchased the video from Smart Tan's website for $75. 

The tone is tongue-in-cheek but it’s part of a defiant campaign to defend the $4.9 billion industry against mounting evidence of its questionable business practices and the harm caused by tanning. And, in an extraordinary touch, it is portraying doctors and other health authorities as the true villains – trying to counter a broad consensus among medical authorities that sunbed use increases the risk of skin cancer including melanoma, the most lethal form.

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To sway public opinion, the industry is drawing on its vast network of outlets; there are more tanning salons in the U.S. than there are McDonald’s restaurants. Some salon operators are putting trainees through a “D-Angel Empowerment Training” program that uses the video. It is intended to give employees talking points to use outside the salon to argue that tanning is a good source of vitamin D, and thus a bulwark against all manner of illness, including breast cancer, heart disease and autism.

The industry has also gone on the offensive with tactics that appear cribbed from Big Tobacco’s playbook to undermine scientific research and fund advocacy groups serving the industry’s interests.

Central to the industry’s message is the idea that tanning’s critics -- such as dermatologists, sunscreen manufacturers and even charities like the American Cancer Society -- are part of a profit-driven conspiracy. These critics are described as a “Sun Scare industry” that aims to frighten the public into avoiding all exposure to ultraviolet light. The tanning industry blames this group for causing what it calls a deadly epidemic of vitamin D deficiency, and tries to position itself as a more trustworthy source of information on tanning’s health effects.

New Jersey tanning mom denies charges of child endangerment

What tanning’s proponents rarely point out is that the notion of a vitamin D epidemic is disputed, and that even if you need more of the vitamin, you can safely and easily get it from dietary supplements and certain foods.

Even as they themselves use techniques cigarette companies pioneered, some in the tanning industry compare the Sun Scare group to the tobacco industry. “The Sun Scare people are just like Big Tobacco, lying for money and killing people,” Joseph Levy, executive director of Smart Tan, said in the D-Angel video.

Feeling the heat
The indoor tanning industry’s image has taken a beating since 2009, when the International Agency for Research on Cancer designated UV-emitting tanning devices as carcinogenic. The American Academy of Pediatrics and American Academy of Dermatology urge minors not to use sunbeds.

California and Vermont prohibit youths under 18 from tanning indoors, and New York this month imposed a ban for those under 17. Thirty-three states regulate teen tanning to a lesser extent, according to the research firm IBISWorld.

'I feel weird and pale': 'Tan mom' reveals new tan-free look

The Federal Trade Commission and Texas Attorney General have tried to rein in marketing messages that misrepresent tanning’s risks. The Texas lawsuit is pending, but the FTC reached a settlement with the industry’s largest trade group, the Indoor Tanning Association, in 2010.

Still, misleading messages continue to be the norm, Democrats on the House Energy and Commerce Committee reported in February. Undercover investigators phoned 300 salons and found 90 percent of the employees they spoke with said tanning did not pose a health risk. What’s more, 51 percent denied sunbeds increase cancer risk. Industry groups say the questions were posed in a leading way and that investigators would have been more fully informed of risks had they visited salons in person.

Despite the bad press, the indoor tanning industry is holding steady. It showed slow but continued growth over the last three years, and revenues are expected to edge up to $5 billion by 2017, according to IBISWorld. White women ages 18-21 are the leading customers: 32 percent of them tanned indoors in 2010, including 44 percent in the Midwest, according to the Centers for Disease Control and Prevention. An estimated 28 million Americans tan indoors each year.

The changing demographics of melanoma
At an age when most feel invincible, 25-year-old Chelsea Price of Roanoke, Va., lives life in three-month increments. In January 2011, she was diagnosed with Stage III malignant melanoma.

Price’s first reaction was giggles. Her doctor, a kidder, had seemed unconcerned about the mole he’d removed, even reassuring her that he did it just to be safe. “I wish I was joking,” he said when he delivered the news.

After two invasive surgeries, Price shows no sign of melanoma today. But Stage III melanoma has a high rate of recurrence, so Price has a skin exam, CT scan and blood tests every three months to make sure she’s still cancer-free. “It dictates my life.”

Like many melanoma patients, Price is young, female and a former indoor tanner though it’s impossible to say with certainty whether the time she spent in sunbeds caused her illness. Price tanned indoors for just a couple of months each year and she never sunburned, “I am the person who did it safely and in moderation, but yet I’m here,” Price said.

Price is hardly alone. Skin cancer is the most common cancer in the U.S. and diagnoses of melanoma, though still rare, have increased steeply over the last 40 years. Melanoma among white women ages 15-39 has shown a particularly striking rise, up 50 percent from 1980 to 2004, according to the National Cancer Institute.

What caused the NJ tanning mom's leathery look?

The typical melanoma patient has changed in a generation, says Dr. Bruce Brod, associate professor of dermatology at the University of Pennsylvania. Twenty years ago, Brod’s melanoma patients were mainly middle-aged men. Today, he treats mostly young women for the cancer. “I think that’s thanks to the tanning salons,” Brod said.

Misleading messages
To neutralize its critics, the Indoor Tanning Association mounted an ad campaign in 2008 that claimed there were no compelling links between tanning and melanoma. It also praised UV light as a good source of disease-fighting vitamin D. The campaign’s architect was Richard Berman, the public relations executive whose work to defend the alcohol industry, and discredit unions and Mothers Against Drunk Driving, earned him the nickname “Dr. Evil” among his critics.

The FTC accused the tanning association of making false claims. The result was a 2010 settlement barring the group from making misleading statements or unfounded health claims. Advertisements suggesting that tanning improves health by providing vitamin D also sparked the Texas case against Darque Tan, a chain with more than 100 salons.

Yet the threat of sanctions has had a limited impact. Some even say the FTC agreement gave the Indoor Tanning Association carte blanche to make any vitamin D health claims it wants, as long as it displays a disclaimer. “The FTC suit was a triumph,” Robbie Segler, president of Darque Tan, wrote on the online industry forum TanToday in 2011.

The focus on vitamin D shifts the debate from tanning’s risks to its potential health benefits in a manner reminiscent of early tobacco marketing, said David Jones, a dermatologist in Newton, Mass. He co-authored a 2010 paper comparing tobacco and tanning advertising that found that cigarette makers once portrayed their products as healthy. “The tanning industry is doing the same thing,” he said.

Vitamin D plays a widely acknowledged role in bone health and immune function, but evidence that vitamin D prevents cancer is inconclusive. The National Cancer Institute says there is evidence that the vitamin may reduce risk of one cancer, colorectal cancer, but even those results are inconsistent.

Sowing doubt
Taking another page from the tobacco playbook, the tanning industry attacks research linking sunbeds to cancer. Industry leaders insist the relationship between melanoma and UV exposure is not well-understood. But DeAnn Lazovich, a cancer epidemiologist at the University of Minnesota, says the latest research “provides even stronger evidence” that UV light from sunbeds is carcinogenic.

The industry also takes aim at its critics’ integrity. The D-Angel video, using vintage cigarette ads that featured doctors, tries to portray the medical profession in general as having shilled for the tobacco industry. While the American Medical Association pocketed industry money, and some tobacco companies claimed that doctors endorsed their brands, Levy makes the dubious assertion that the medical profession broadly endorsed smoking as healthful. He contends that physicians continue to endanger public health in the interest of profit. “It’s no longer tobacco that they're selling,” Levy says in the video. “Today, it's chemical sunscreen and (an) anti-UV message designed to tell you that any UV exposure is bad for you. It’s the same thing as doctors being arm-in-arm with Big Tobacco.”

Levy is a pivotal figure in defending the tanning industry. While a vice president of Smart Tan, he also served as an officer of two non-profit vitamin D advocacy groups – The Vitamin D Foundation and the Vitamin D Alliance – and was the executive director of a the Vitamin D Society, a Canadian group.

Yet the close ties between the tanning industry and the web of nonprofit groups that promote the health benefits of Vitamin D often are not readily apparent. The website for the Vitamin D Foundation, for example, discloses no industry affiliation, though tax documents reveal that their top personnel were all people in the business. In addition to Levy, they include the CEO of Beach Bum Tanning, a chain with 53 salons, and the president of the Joint Canadian Tanning Association, who also owns a large chain of salons.

These groups funnel money to vitamin D researchers and organizations that reinforce the industry’s claims about the vitamin’s health benefits. One such organization is the Breast Cancer Natural Prevention Foundation, which promotes vitamin D for breast cancer prevention. The founders include Dr. Sandra K. Russell, an obstetrician-gynecologist who appeared in advertisements for Smart Tan wearing her lab coat and a stethoscope.

Superman v. Clark Kent
In promoting the health benefits of UV-induced vitamin D, the tanning industry must tread carefully – after all, health claims were central to the FTC complaint, the Texas Attorney General’s case and the congressional report that blasted the industry. But the FTC cannot police what salon employees say when they are off the clock, and the D-Angel training program takes advantage of that.

In the training video, Levy is explicit about what employees can say at work and what they should say only on their own time. He encourages the D-Angels to follow what he calls the “Clark Kent/Superman” model. At the salon, employees should be Clark Kents who refrain from making health claims about vitamin D. Beyond salon walls, however, he urges employees to be superheroes who expose the lies about tanning and vitamin D. “Outside the salon, you can be a D-Angel,” Levy says. “You can promote a message to your friends and neighbors that the Sun Scare people are just like Big Tobacco, lying for money and killing people.”

But the reality for salon employees is more complex, says Lisa Graubard, a 15-year industry veteran who managed three salons on the New Jersey shore. Graubard, who lives in Lakewood, N.J., is not anti-tanning but says salon employees need better training. “There are definitely salons in the industry that are like, ‘We’re not going to use the c-word,’” she said, referring to the cancer risk.

Graubard acknowledged that some of her own customers kept tanning even after developing skin cancer. One man, she recalled, came to tan still bandaged from melanoma surgery. Graubard left the business after years of tanning left her face discolored.

The clientele at Graubard’s salon grew increasingly younger; eventually girls as young as 14 were begging to tan without the legally required permission slips. She said she would say no, but a chain salon down the street was known to turn a blind eye to the rules. “Consent? It was like a joke,” she said.

Meghan Rothschild, a self-described “splotchy white girl” from Northampton, Mass., says tanning gave her a confidence boost that she still misses today, eight years after being diagnosed with melanoma at age 20. She was angry with herself when she got the news, “The only thing I could think of is, ‘You did this to yourself, you idiot.’”

Today, Rothschild blames an industry she says downplays tanning’s risks, along with inadequate regulations that leave the decision of whether to tan up to youth who don’t always understand the consequences.

Schools teach kids to avoid alcohol and tobacco, Rothschild said. “But the kids aren’t smoking anymore. They are using tanning beds. The tanning booth is going to be the cigarette of our generation.”

FairWarning is a nonprofit, online investigative news organization focused on safety and health issues.