Krogh, C. Letter to Health Canada — Pamphlet & Preliminary Results March 6, 2015

March 6, 2015

The Right Honourable Stephen Harper Prime Minister of Canada pm@pm.gc.ca
The Honourable Peter Gordon MacKay Minister of Justice and Attorney General mcu@justice.gc.ca 

(see other recipients at the bottom of this page)

Dear Prime Minister Harper, Hon. Minister of Health, Hon. Minister of Justice and Attorney General and members of the Health Canada Wind Turbine Noise and Health Study, 

Re: Preliminary Results Pamphlet: Wind Turbine Noise and Health Study

On November 6, 2014 Health Canada posted on their website Wind Turbine Noise and Health Study: Summary of Results1 [the Study]

In early 2015, Health Canada initiated public distribution of a pamphlet entitled Wind Turbine Noise and Health Study: Summary of Key Findings. [Scanned version available on request]

The purpose of this letter is to raise concerns regarding the Health Canada pamphlet and share observations conveyed to me by some of those reporting adverse health effects associated with the start up of wind turbine operations. 

I am requesting that the current pamphlet be redacted and replaced in order to enhance public disclosure relating to statistically related effects. 

In addition, I am requesting that ongoing concerns about the impact of policy oversight of the Study be clarified including that of an industry-led:government-supported Wind Technology Roadmap.2 

I declare no potential conflicts of interest and have received no financial support with respect to the research and authorship of this commentary. 

This commentary is public and may be shared. 

A brief bio and list of references for which I am an author/co-author is provided in the Appendix.

Health Canada Pamphlet

Health Canada has distributed a pamphlet which is being placed in numerous mail boxes. The envelope has Health Canada’s logo. It is addressed to the householder/occupant and includes the home owner’s mailing address. 

A scanned copy of the brochure being distributed appears identical in content to the brochure published on the web site. [Attached web version] 

The contents emphasize what was not found:

 

 It indicates a finding of very or extremely annoyance without defining annoyance as an adverse health effect and without indicating context including disclosure of statistical findings obtained by objective and subjective measurements:

 

The preliminary results published by Health Canada, Page 4 Section 5 states statistical findings relating to wind turbine noise annoyance by subjective and objective measurements. 

A few excerpts: 

WTN annoyance was found to be statistically related to several self-reporting health effects including, but not limited to, blood pressure, migraines, tinnitus, dizziness, scores on the PSQI, and perceived stress ” as well as related to “measured hair cortisol, systolic and diastolic blood pressure.”

“A statistically significant increase in annoyance was found when WTN levels exceeded 35 dBA. “3

This is a relevant finding. For example, the Ontario Ministry of Environment wind turbine noise guidelines model for 40 dBA i.e., 5 dBA more than the Health Canada findings. A limit of up to 51 dBA with increased wind speed is allowed. [Excerpt of an Ontario Renewable Energy Approval]

(See chart on downloadable document) 

Annoyance may seem of little consequence in general parlance; however, in respect of health, annoyance is acknowledged by a number of authorities including Health Canada and the World Health Organization as an adverse health effect.4,5,6,7.8

Several studies published by the World Health Organization have revealed findings related to the serious nature of annoyance including increased morbidity: 

The result confirms the thesis that for chronically strong annoyance a causal chain exists between the three steps health – strong annoyance – increased morbidity.”9

“… confirmed, on an epidemiological level, an increased health risk from chronic noise annoyance.”10 

Regarding noise induced annoyance the US Environmental Protection Agency states:

“…“annoyance” can have major consequences, primarily to one’s overall health.”11

Additional references regarding the effects of chronic noise annoyance are available on request.

 In my opinion, the emphasis on the lack of findings while not disclosing to the public statistically related findings adds credence to the premise of an “…industry-led, government supported initiative that has developed a long-term vision for the Canadian wind energy industry and identified the major technology gaps and priorities to achieve a major increase in deployment of wind energy in Canada.”12

On November 14, 2014, NRCan announced the Pan-Canadian Wind Integration Study and the contribution of $1,755,000 through the NRCan ecoEII for which it is reported to be “the first national, system-level study of high wind energy penetration in Canada.”13 [Attached] 

The Prime Minister of Canada’s website comments: 

“… we are continuing to expand Canada’s international trade and to create the green jobs befitting our growing stature as a clean energy superpower.”14

 Typically, regarding the concept of clean energy, wind energy is considered part of the energy mix. It is unclear whether industrial wind turbines are included in the context of a “clean energy superpower.”

2. The Role of Policy Oversight

 Based on an Access to Information and Privacy request (ATIP), it appears there is policy oversight associated with the Health Canada Study. 

An excerpt of an Access to Information Privacy (ATIP) states:

 

Health Canada has engaged the Council of Canadian Academies (CCA) which has assembled an expert Panel to review the existing scientific evidence which would help address the following question: 

“Is there evidence to support a causal association between exposure to wind turbine noise and development of adverse health effects?”15

 Based on correspondence, the Council of Canadian Academies’ review of a causal association between wind turbines and adverse health will not be providing policy recommendations.16

 Typically, an assessment or literature review precedes a study design phase to assist with ensuring up to date information which can be incorporated into the design. It can be a useful tool for summarizing the information available at a point in time. However, an assessment has limitations as it cannot be equated to an investigation. By definition, an assessment will not have investigated those that are reporting harm. 

3.0 Research Issues

The Health Canada study is based on a random sample of: wind turbine sites, homes and individuals. 

“All homes within 600m of a wind turbine are identified for recruitment with random sampling procedures applied to all remaining dwellings up to a distance of 10 km away from the wind turbine. 

Upon confirmation of the number and ages of all people residing in the home and in order to mitigate the risk of self-selection bias, a computer assisted random selection method is applied to select one eligible individual per household between the ages of 18–79 who is then asked to participate in a personal interview, i.e. questionnaire, and physical measures collection.”17 

Health Canada states “… up to a distance of 10 km away from the wind turbine.” 

It is not clear how this method will be applied if a home has more than one turbine nearby. 

A randomized study has limitations. By definition, it will not necessarily select affected individuals, some of whom are reporting serious adverse health effects including those who have left their homes. 

Health Canada’s preliminary results indicate that:18 

  • Ÿ 1570 of 2004 potential dwellings identified were valid addresses
  • Ÿ 434 were coded out-of-scope
  • Ÿ 1238 of 1570 dwellings participated

Correspondence from Health Canada dated February 12, 2015 provided a break-down of the out-of-scope dwellings.19 

Type of out-of-scope location Total number
Demolished for unknown reasons

82

Vacant for unknown reasons

138

Unoccupied seasonal

107

>79 years of age

96

Otherc

11

*Please note that other refers to homes under construction, institution, participant unavailable to participate. These specific data were suppressed here to protect the identify of individual participants.

 In 2013, Health Canada indicated a target of 2000 dwellings:

 “The targeted sample will consist of 2000 dwellings at setback distances ranging from less than 500 metres to distances of up to 10 kilometers randomly selected from communities in the vicinity of 8 to 12 wind turbine installations.”20

 A request to confirm whether there was the capability to replace the out-of-scope dwellings in order to maintain the target of about 2,000 dwellings received this response:21

 “The study required a sample size of approximately 1100 participants–not 2000, as suggested in your comment. In order to achieve this sample size Statistics Canada built a sampling frame with 2000 “potential” addresses. This was partially based on previous research by Statistics Canada (unrelated to wind turbines) that about 20–25% of these potential addresses on the address registry would not be valid locations (i.e. out of scope for a number of reasons). The number of targeted dwellings was also based on an a-prior assumption that the study’s final estimated response rate would be approximately 70% (i.e. from the identified valid dwellings). The final response rate was actually higher at 78.9%. Out-of-scope dwellings were identified in both the Ontario and PEI sampling areas.”

Reports of residents abandoning their homes are compelling and which can be measured. It would have been helpful to capture these associations. It is a lost opportunity to investigate the out-of-scope homes by various methods such as consulting with neighbours and township records. 

Health Canada also confirmed that:22 

“… all members of the household would have been outside the age range when a potential dwelling was coded as out-of-scope (age) by Statistics Canada field interviewers, i.e. over 79 years.” 

The World Health Organization indicates that the elderly and children are vulnerable population groups 

“Who is most affected?
Some groups are more vulnerable to noise. As children spend more time in bed than adults, they are more exposed to night noise. Chronically ill and elderly people are more sensitive to disturbance. Shift workers are at increased risk because their sleep structure is under stress. In addition, the less affluent who cannot afford to live in quiet residential areas or have adequately insulated homes, are likely to suffer disproportionately.23

 It is unclear whether vulnerable population groups were considered for inclusion during the Study design phase.

 4. Summary 

The following observations are drawn from comments I have received and are being shared with those on this list. 

Residents trusted that the Health Canada Study would assist with documenting the relationship between exposure to industrial wind energy facilities and reported adverse health effects. 

Health Canada advised that the results would not be definitive on their own and the November 6, 2014 results are preliminary. However, the circulation of a pamphlet in the zones where many are reporting adverse health effects and incomplete disclosure is now a sensitive topic. 

In addition, the process to randomize sites and participants and to not take the opportunity to investigate out-of-scope dwellings is disappointing. 

For several years the Government of Canada Ministers associated with this file have stated to residents seeking resolution that the Government of Canada is committed to protecting the health of Canadians with respect to renewable energy sources but at the same time stating the provinces are responsible for the generation and distribution of electricity. 

In my view, these two concepts need to be urgently reconciled. 

Health Canada states its mission of “helping Canadians maintain and improve their health, while respecting individual choices and circumstances”24 For those who report their health has declined with the onset of industrial wind turbine operations, the Government’s commitment to protecting health has lost credibility. 

In the case of industrial wind energy facilities, non-participating Canadians have no choice – the wind turbines are imposed without consent. 

Furthermore, this response is now met with scepticism and residents look to the Government of Canada to take action and provide protection as promised. 

Requests: 

  • ŸPlease advise what initiatives will be taken to ensure Canadians receive full disclosure of the Health Canada Wind Turbine Noise and Health Study preliminary results including that related to the pamphlet being distributed to households.
  • Ÿ Please advise how the NRCan initiatives, the Wind Technology Roadmap and Pan– Canadian Wind Integration Study, will be reconciled with Health Canada’s mission to maintain or improve the health of Canadians while respecting individual choices.

 Respectfully submitted, 

Carmen Krogh, BScPharm Ontario, Canada

Attachments

Pan-Canadian Wind Integration Study
Web posting of Health Canada pamphlet

Appendix

Brief Bio 

I am an independent, full time volunteer and published researcher regarding health effects and industrial wind energy facilities and share information with: communities; individuals; federal, provincial and public health authorities, wind energy developers; the industry; and others. I am an author or co-author of peer reviewed articles and conference papers presented at wind turbine noise scientific conferences. 

I have held senior executive positions at a teaching hospital, as a drug information researcher, a professional organization and Health Canada (PMRA). I am a former Director of Publications and Editor in Chief of the Compendium of Pharmaceuticals and Specialties (CPS), the book used by physicians, nurses, and health professionals for prescribing information in Canada. 

Articles Peer reviewed 

Robert Y McMurtry and Carmen ME Krogh, Diagnostic criteria for adverse health effects in the environs of wind turbines http://shr.sa gepub.com/content/5/10/2054270414554048 JRSM Open 2014 5:1–5 The online version of this article can be found at: DOI: 10.1177/2054270414554048 http://shr.sagepub.com/ PMID: 25383200 [PubMed] PMCID: PMC4221978

http://www.ncbi.nlm.nih.gov/pubmed/?term=Dia gnostic+criteria+for+adverse+health+effect s+in+the+environs+of+wind+turbines

Roy D. Jeffery, Carmen M.E. Krogh, and Brett Horner, Industrial wind turbines and adverse health effects Can J Rural Med 2014;19(1) http://www.ncbi.nlm.nih.gov/pub med/24398354 PMID: 24398354 [PubMed — indexed for MEDLINE

Roy D. Jeffery, Carmen Krogh, and Brett Horner, Adverse health effects of industrial wind turbines Can Fam Physician 2013; 59: 473–475 (Commentary) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653647/ PMCID: PMC3653647 

Roy D. Jeffery MD FCFP, Carmen Krogh, Brett Horner CMA, Adverse health effects of industrial wind turbines, Letter to editor, Can Fam Physician. 2013 Sep;59(9):921, 923–5 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3771715/ PMCID: PMC3771715 

Carmen M.E. Krogh, Industrial Wind Turbine Development and Loss of Social Justice? Bulletin of Science Technology & Society 2011 31: 321, DOI: 10.1177/0270467611412550, http://bst.sagepub.com/content/31/4/321 

Carmen M.E. Krogh, Lorrie Gillis, Nicholas Kouwen, and Jeffery Aramini, WindVOiCe, a Self-Reporting Survey: Adverse Health Effects, Industrial Wind Turbines, and the Need for Vigilance Monitoring Bulletin of Science Technology & Society 2011 31: 334, DOI: 10.1177/0270467611412551. http://bst.sagepub.com/content/31/4/334 

Brett Horner, Roy D. Jeffery and Carmen M. E. Krogh, Literature Reviews on Wind Turbines and Health: Are They Enough? Bulletin of Science Technology & Society 2011 31: 399. DOI: 10.1177/0270467611421849 http://bst.sagepub.com/content/31/5/399 

Stephen E. Ambrose, Robert W. Rand and Carmen M. E. Krogh, Wind Turbine Acoustic Investigation: Infrasound and Low-Frequency Noise–A Case Study, Bulletin of Science Technology & Society published online 17 August 2012 DOI: 10.1177/0270467612455734, http://bst.sagepub.com/content/early/2012/07/30/0270467612455734 

Robert W. Rand, Stephen E. Ambrose, and Carmen M. E. Krogh, Occupational Health and Industrial Wind Turbines: A Case Study, Bulletin of Science Technology & Society 2011 31: 359DOI: 10.1177/0270467611417849. http://bst.sagepub.com/content/31/5/359 

Birds and Bird Habitat: What Are the Risks From Industrial Wind Turbine Exposure? Terry Sprague, M. Elizabeth Harrington, and Carmen M. E. Krogh, DOI: 10.1177/0270467611417844 http://bst.sagepub.com/content/31/5/377 

Canadian Medical Association Journal (CMAJ) Blog

Carmen Krogh, BScPharm25 and R Y McMurtry, M.D., F.R.C.S.©, F.A.C.S.26, Health Canada and Wind Turbines: Too little too late? CMAJ • November 28, 2014 http://cmajblogs.com/health-canada-and-wind-turbines-too-little-too-late/ 

Conference papers 

Krogh CME Noise and Children’s Risk Factors including Industrial Wind Energy Facilities, Paper presented at the 7th International Symposium: Global Perspectives Safety & Health in Agricultural & Rural Populations (SHARP), Saskatoon, Saskatchewan, Canada October 19– 22, 2014 

Wind Turbine Facilities’ Perception: A Case Study from Canada Peter N. Cole MD, MHSc, FRCP© and Carmen Krogh, BScPharm

5th International Conference on Wind Turbine Noise Denver 28 – 30 August 2013 (published in proceedings but not presented) Audit report: literature reviews on wind turbine noise and health Brett Horner, Carmen ME Krogh, Roy D Jeffery Paper presented at the Wind Turbine Noise conference 2013, August 28 to 30, Denver, Colorado, USA 

Trading off human health: Wind turbine noise and government policy Carmen ME Krogh, Joan Morris, Murray May, George Papadopoulos, Brett Horner, Paper presented at the Wind Turbine Noise conference 2013, August 28 to 30, Denver, Colorado, USA 

Carmen ME Krogh, Roy D Jeffery, Jeff Aramini, Brett Horner, Wind turbines can harm humans: a case study, Paper presented at Inter-noise 2012, New York City, NY

Carmen ME Krogh, Roy D Jeffery, Jeff Aramini, Brett Horner, Wind turbine noise perception, pathways and effects: a case study Paper presented at Inter-noise 2012, New York City, NY 

Carmen ME Krogh, Roy D Jeffery, Jeff Aramini, Brett Horner, Annoyance can represent a serious degradation of health: wind turbine noise a case study, Paper presented at Inter-noise 2012, New York City, NY 

Stephen E. Ambrose, Robert W. Rand and Carmen M. E. Krogh, Falmouth, Massachusetts wind turbine infrasound and low frequency noise measurements, Invited paper presented at Inter-noise 2012 New York City, NY 

References 

1 Health Canada, Environmental and Workplace Health, Wind Turbine Noise and Health Study: Summary of Results, November 6, 2014 http://www.hc-sc.gc.ca/ewh-semt/noise-bruit/turbine-eoliennes/summary-resume– eng.php

2 Krogh and Horner, Industry Led – Government Supported Following Canada’s Wind Technology Roadmap and Health Canada’s Wind Turbine Noise and Health Study, November 10, 2014

3 Health Canada, Wind Turbine Noise and Health Study: Summary of Results, November 6 2014. Available from: http://www.hc-sc.gc.ca/ewh-semt/noise-bruit/turbine-eoliennes/summary-resume-eng.php,

4 Health Canada. (2005). Community noise annoyance. Available from http://www.hc-sc.gc.ca/hl-vs/iyh– vsv/life-vie/community-urbain-e ng.php#he

5 Michaud, D. S., Keith, S. E., & McMurchy, D. (2005). Noise annoyance in Canada. Noise Health, 7, 39–47

6 Maschke, C., & Niemann, A. (2007). Health effects of annoyanceinduced by neighbour noise. Noise Control Engineering Journal, 55, 348–356

7 Suter, A. H. (1991). Noise and its effects. Administrative Conference of the United States. Retrieved from http://www.nonoise.org/library/suter/suter.htm

8 World Health Organization, Guidelines for Community Noise,1999

9 Niemann Dr Hildegard, Maschke Dr Christian, LARES Final Report Noise Effects and Morbidity, World Health Organization, (2004)

10 Niemann H, Bonnefoy X, Braubach M, Hecht K, Maschke C, Rodrigues C, Robbel N. Noise-induced annoyance and morbidity results from the pan-European LARES study. Noise Health 2006;8:63–79

11 US Environmental Protection Agency web site, Noise Pollution, [cited June 30, 2010] http://www.epa.gov/air/noise.html

12 Government of Canada, Natural Resources Canada (NRCAN) Wind Energy | Canada’s Wind TRM (Technology Road Map) http://www.nrcan.gc.ca/energy/renewable-electricity/wind/7323

13 NRCan http://www.nrcan.gc.ca/node/16634

14 Priorities | Prime Minister of Canada http://www.pm.gc.ca/eng/priorities

15 Council of Canadian Academies, Assessments in progress, Wind Turbine Noise and Human Health. http://www.scienceadvice.ca/en/assessments/in-progress.aspx

16 Krogh personal correspondence (February 5, 2015), Council of Canadian Academies

17 Michaud DS, Keith SE, Feder K, Soukhovtsev V, Marro L, Denning A et al, Self-reported and Objectively Measured Health Indicators Among a Sample of Canadians Living Within the Vicinity of Industrial Wind Turbines: Social Survey and Sound Level Modelling Methodology, 2013 December, www.inceusa.org, www.noisenewsinterna tional.net, www.i-ince.org

18 Health Canada’s Wind Turbine Noise and Health Study, Results Overview, Briefing Slides, Fall 2014

19 Krogh correspondence Health Canada February 12, 2015

20 Health Canada, Health Impacts and Exposure to Sound From Wind Turbines: Updated

Research Design and Sound Exposure Assessment February 10, 2013 http://www.hc-sc.gc.ca/ewh– semt/cons ult/_2013/wind_turbineeoliennes/research_recherche-eng.php

21 Krogh correspondence Health Canada February 18, 2015 [2]

22 Krogh correspondence Health Canada February 18, 2015

23 World Health Organization, Europe, Noise — Facts and Figures (2012), http://www.euro.who.int/en/what-we– do/health– topics/environme nt-a nd– health/noise/facts-and– figures cited dec 23 2012

24 Health Canada, About Health Canada, Retrieved from http://www.hc-sc.gc.ca/ahc-asc/index-eng.php, Cited August 24, 2012

25 Carmen Krogh (retired), is a peer reviewed IWT health researcher and former Director

of Publications and Editor-in-Chief of the CPS.

26 Dr. McMurtry is Professor Emeritus (Surgery) of Western University (formerly University of Western Ontario). Dr. McMurtry was also an ADM at Health Canada 2000-02

All other recipients of the letter:

The Honourable Rona Ambrose Minister of Health, Health Canada minister_ministre@hc-sc.gc.ca
David Michaud, Ph.D. Principal Investigator/Project Manager, Research Scientist, Health Effects and Assessment Division Health Canada
david.michaud@hc-sc.gc.ca 
Katya Feder, Ph.D. Project Co-ordinator, Research Scientist, Health Effects and Assessment Division Health Canada, katya.feder@hc-sc.gc.ca
Tara Bower, M.Sc. Director, Office of Science Policy Liaison and Co-ordination Health Canada, tara.bower@hc-sc.gc.ca 
Dr. James Brooks M.D., FRCPC Chief, National Lab HIV Genetics Public Health Agency of Canada James.brooks@phac-aspc.gc.ca 
Shirley Bryan, Chief Subject Matter, Canadian Health Measures Survey Physical Health Measures Division Statistics Canada Shirley.Bryan@statcan.gc.ca 
Allison Denning, M.E.S. Regional Environmental Assessment Co-ordinator Health Canada — Atlantic Region allison.denning@hc-sc.gc.ca
Paul Dockrill M.Sc. Acting Program Manager, Wind Energy Technology Group Natural Resources Canada Paul.Dockrill@NRCan-RNCan.gc.ca 
Christopher Duddek, M.Sc. Senior Methodologist Statistics Canada Christopher.Duddek@statcan.gc.ca 
Stephen Keith, Ph.D. Research Scientist, Consumer & Industrial Products Division Health Canada, stephen.keith@hc-sc.gc.ca 
Antoine Lacroix, Eng, M.Sc. Wind Energy Engineer, Renewable Energy Technologies Natural Resources Canada, Antoine.Lacroix@NRCan-RNCan.gc.ca 
Eric Lavigne, Ph.D.Epidemiologist, Environmental Issues Division Public Health Agency of Canada eric.lavigne@phac-aspc.gc.ca 
Serge Legault B.Sc Survey Manager, Special Surveys Statistics Canada Ser ge.Legault@statcan.gc.ca 
Tony Leroux, Ph.D. Professor of Audiology, Faculty of Medicine, University of Montreal tony.leroux@umontreal.ca 
Leonora Marro, M.Sc, Statistician, Population Studies Division, Biostatistics Section Health Canada, leonora.marro@hc-sc.gc.ca 
Darcy McGuire, B.A., Senior Policy Analyst, OSPLC Health Canada darcy.mcguire@hc-sc.gc.ca 
Brian James Murray, MD FRCP© D, ABSM, Director of Integrated Medical Education, University of Toronto Department of Medicine Associate Professor, Neurology and Sleep Medicine Vice Chair, Research Ethics Board Sunnybrook Health Sciences Center mbrian.murray@sunnybrook.ca 
Denis Poulin, M.A. Chief, Special Surveys Statistics Canada, Denis.Poulin@statcan.gc.ca 
Werner Richarz, Ph.D., P.Eng., FASA Chief Acoustical Engineer, Echologics Mississauga, Ontario wricharz@echologics.com 
Jason Tsang, P.Eng. Senior Acoustics and Vibrations Engineer Canadian Transportation Agency Jason.Tsang@otc-cta.gc.ca 
Paul Villeneauve, Ph.D. Associate Professor,Institute of Health: Science, Technology and Policy Carleton University, paul.villeneuve@carleton.ca 
Shelly Weiss, M.D., FRCPC Neurologist, Director of Faculty Development Associate Professor, University of Toronto Past President, Canadian Sleep Society,
Department of Pediatrics, The Hospital for Sick Children shelly.weiss@sickkids.ca 
Chantal Whelan, , M.D., F.R.C.P.©, Team Psychiatrist, Carlington Community and Health Services Associate Professor, Faculty of Medicine, University of Ottawa, Care of: Ms Lynn Bertrand, Program Administrator lbertrand@toh.on.ca

International Advisors 

Roelof H. Bakker, Ph.D. Senior Researcher, Applied Health Research University Medical Center Groningen Groningen Area, Netherlands r.h.bakker@med.umcg.nl 
Norm Broner Ph.D. Practice Leader — Acoustics, Noise and Vibration Sinclair Knight Merz, Melbourne, Australia nbroner@skm.com.au 
Sabine Janssen, Ph.D. Senior Research Scientist, Urban Environment and Safety, TNO Department of Environment and Health, (Netherlands Organisation for Applied Scientific Research) sabine.janssen@tno 
Hideki Tachibana, Ph.D. Professor Chiba Institute of Technology Professor Emeritus The University of Tokyo, Japan tachiban@biol.sci.kobe-u.ac.jp 
Frits van den Berg, PhD Senior Advisor Amsterdam Public Health, fvdberg@ggd.amsterdam.nl

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