Adv. Mr. Amos Goren: He participated in his writing, he said it.
[....]
The Honorable Judge D. Chasdai: Forget it. I want to hear how the work was done. After all, in the end, what speaks is the position paper, but I will hear how the work was done, how the work was done. Yes.
The witness, Prof. A. Grotto: The method was implemented, the position paper was carried out using the method in which I actually deal with and write articles, or people who write articles in the medical literature with me, first of all by actually collecting all the data, there were partners of a number of people, some of them employees of the Ministry of Health, there was also someone who was a postdoctoral student, today she is an environmental health researcher at the University of Haifa, she is at Bar Ilan University, sorry, in Safed. Before that, she was also with me, I mean an environmental epidemiologist researcher, so basically everyone contributed their part and in the end of course I go through the position paper, confirm, look, make comments, that's how it is actually like ... Like any article. I can say that there are actually several stages here that I am involved in, including in the planning of the research, which literature to go to. And then at the stage of writing, and finally, of course, at the stage of recommendations, which is the policy.... (pp. 994-995)
- Moreover, with respect to the two appendices, and as emphasized above, the applicants-who claim to be an 'institutional record' must prove the cumulative conditions for their admissibility set out in section 36(a) of the Evidence Ordinance, such as:
- Because this is a registration that the institution (the Ministry of Health) customarily conducts during its regular management.
- Because the way the data is collected, the subject of the record and the way the record is edited, attest to the authenticity of its software.
- Similarly, the additional condition that requires that the proof of the conditions be done by the testimony of someone who knows about the matters personally, or by means of an affidavit, was not met.
- I doubt how Prof. Grotto, with all due respect, can attest to the truthfulness of the contents of the documents/data that are the subject of the various studies that he referred to in the papers he wrote and the aforementioned "method of data collection", which served as the basis for those studies.
- I do not believe that it is possible to say with respect to Prof. Grotto's documents [Appendices 4 and1] that they establish a presumption of credibility for their contents as they are an "institutional record".
- Since the aforesaid conditions have not been proven by the applicants, with the exception of their general claim in the summaries that the aforementioned appendices should be regarded as an "institutional record", the said documents cannot be recognized as such.
- Moreover, as stated above, the proof of an institutional record should be done by way of submitting an affidavit that comes to verify the facts that need to be proven or also by way of presenting an expert opinion – where the facts that need to be proven are facts of expertise. In his case, this was not This is especially true with regard to Appendix 4.1, which is based on 61 different sources/references, including articles and studies, from Israel and abroad, which, with the exception of Reference No. 38 "Transmission of Data on Cancer Morbidity to the Mayor of Haifa" in May 2015, were not edited by Prof. Grotto and were not written by him.
- The document is in fact a professional attitude of Prof. Grotto and his colleagues regarding morbidity in Haifa Bay, a kind of 'opinion' based on many sources and the editors' interpretation of the aforementioned sources and the findings described therein.
- Similarly, the aforementioned 'documents' cannot be regarded as representing the position of the Ministry of Health, and see in detail on this matter, inter alia, sections 406-408 and 413 below and Appendix M/46).
- Without prejudice to all of the above, and to the extent that I am found to have erred in not classifying the aforementioned appendices or any of them as an 'institutional record', and even in light of Prof. Grotto's investigation in the proceeding, I will address them below on their merits.
Summary of the Respondents' Expert Arguments
- Three of the experts on behalf of the respondent devoted parts of their opinion to the letter and the report published by Prof. Grotto during 2015.
- Gad Rennert referred to Appendix 4 (the letter) written by Prof. Grotto and the sources on which he relied in the letter, in the third part of his opinion (on pages 13-14).
- Regarding the first source (an article titled 'Cancer Incidence by Governorates in Israel 2002-2011'), Rennert noted , among other things, that he uses metastatic morbidity data, where metastatic disease at the time of diagnosis is relatively rare and has no connection to environmental exposures, and because its appearance has nothing to do with the causation of cancer. The expert also clarified that the article noted that in relation to lung cancer – which is the only one that was examined that was slightly related to air pollution – the incidence in the Tel Aviv, Acre and Hadera districts is greater than the incidence in Haifa, and that the Ashkelon and Jezreel-Nazareth districts also have an overincidence compared to the national average, so that contrary to Prof. Grotto's opinion, the article does not indicate a link between air pollution and morbidity in Haifa.
- Regarding the second source (by Rotenberg et al. from 2013), the expert noted, among other things, that the findings of the study are not valid and scientifically acceptable, since the study used unconventional research methods, was published in a new journal that is not recognized in the medical literature, the researchers are not well-known professionals in the field of epidemiology, the comparison between the Haifa district and those who are not the Haifa district is made in an unclear manner, and one table presents numbers and not rates, thus expressing the methodological weakness. According to him, there is an epidemiological lack of professionalism in the study, the treatment of smoking as an unacceptable factor is based on a survey of smoking rates, and the document takes an ecological approach that is scientifically poor. The expert clarifies that the characteristic of excess tumors (except in the colon) is actually a high dependence on smoking as a significant reason for their formation. The expert also emphasizes that only two of the 16 cancers reviewed in the article are causally related to air pollution, and in addition, the article does not take into account other relevant variables such as personal behavioral and risk factors, genetic factors, smoking history, etc.
- As for the third source (by Rabinovich et al. from 2012), it was presented that the incidence of cancer cases for the 0-19 age group in Haifa Bay [Haifa, Nesher and the Krayot] between the years 1997-2007 is 5 new cases per million human years. The same article also noted that the reported figure for the Tel Aviv area is 180.2 cases per million, and in the central region 178.1 cases per million, and therefore the incidence rate of cancer cases in the Haifa district is lower than in the center of the country.
- Rennert concludes by noting that what was stated in the first Grotto letter is unfounded, relies on invalid data and ignores long-standing data published in official state publications, and therefore does not provide real information that could attest to a connection between morbidity in Haifa and air pollution or any other environmental factor.
- In her opinion, Dr. Sari Libiki referred in paragraph 3.6 (pages 57-58 of the Hebrew translation) to the 2015 position paper (Appendix 1), and to two studies cited therein. According to her, the document identified two studies that draw conclusions, based on the spatial distribution of air concentrations, that may be defective. According to her, Prof. Grotto refers to an article by Portnov et al. from 2012 and an article by Lin et al. from 2011.
- Portnov's article examined the relationship between asthma rates in children and sulfur dioxide and particulate matter in the Haifa area. The article concludes that there is a link between particulate matter and asthma even with low exposure, and there is no connection to exposure to sludge and fried dioxide. According to her, the approaches to estimating the concentrations of half-hour environmental samples between monitors that used two approaches [IDW] and [Kriging], which refer only to air monitoring data and slip algorithms such as IDW, can be problematic and inadequately characterize significant sources of emissions such as transportation emissions, because slippage algorithms do not take into account the location of high-volume traffic roads. The expert clarifies that studies on the assessment of total concentrations of pollutants in cities show a strong effect of road emissions on local concentrations of pollutants in the air (especially of nitrogen oxides and fine particles). According to her, if important classification parameters are missing in the analysis, such as predictors of pollutant concentrations on roads, any attempt to link pollution to health effects is useless.
- In relation to Lin's article , it investigated the relationship between visits to the Department of Emergency Medicine and exposure to particles, pressure and heat. The work will not seek to isolate individual monitors, but rather evaluated the average of 8 monitoring stations in the area to determine an exposure estimate. The conclusion of the study was that there is a relationship between visits to the department and daily temperature and exposure to particles. According to her, the spatial accumulation used [an average of 8 monitoring stations] to characterize exposure does not reflect the real variability that exists throughout Haifa, and this study characterizes a relationship between two parameters but cannot be used to determine causation.
- Julie Goodman also referred to Appendix 4.1 [see in detail pp. 58-67 of the Discussion Venue Experience, translated into Hebrew]. In summary, Prof. Grotto does not estimate the concentrations of air components in Haifa, and mentions the concentrations in which health effects were observed in only one study. She notes that his analysis of morbidity in Haifa is based on a comparison of the rates in Haifa with the national averages, and this is a mistake [see also section 8.3.2 in detail]. According to her, since we are interested in determining whether industrial air pollution is responsible for diseases in Haifa, Haifa should be compared to other areas withsimilar or rabbinical status, similar socioeconomics and similar demographics (such as Tel Aviv's Lemish). The expert notes that a comparison between the city of Haifa and the city of Tel Aviv shows that the population of Haifa does not have abnormal/redundant rates of cancer, respiratory diseases or CVDS compared to Tel Aviv. She also notes that Prof. Grotto recognizes that the conclusion and presentation of morbidity and mortality data according to different spatial geographic units does not make it possible to determine the reason for the high cost of morbidity in a particular location.
- The expert further notes that most of the studies presented in the position paper did not fully take into account established risk factors such as smoking, family history of the disease, and lifestyle, considering that a family history of cancer can genetically influence a person to develop cancer, and similarly smoking and exposure to smoking increase the risk of cancer.
- According to Goodman, most of the studies mentioned by Prof. Grotto in the position paper are ecological studies, which do not include indo-visual data, in which case it is impossible to know whether the people with the health conditions studied were exposed or if the exposure is a causal factor for the reported health status. Such studies also cannot explain personal risk factors such as smoking and family history [see section 8.3.1 in detail].
- The expert refers to another study mentioned in a 2010 document by Eitan et al., in which the authors reported a positive but not significant association between PM10 and lung cancer in men in Haifa Bay, but the authors note that the findings were not.represent causation relationships that must be valued at the individual level and are normally multifactorial." Goodman further notes that the study used the Bayesian method to assess possible associations, and that the Sadetzky Committee, in a 2016 report (see M/46), rejected the use of this model, saying that this approach may lead to an assessment of inaccurate exposures [see further section 8.3.1].
- Goodman notes in her opinion that the position paper is based on unreliable sources that have a number of limitations, including poor research planning, apparently incorrect exposure classification, inappropriate statistical analyses, uncontrolled intervention variables, and incorrect comparison of morbidity and mortality rates in Haifa to the national averages, and that the sources together do not support a causal relationship between air pollutants and health outcomes. According to her, Prof. Grotto did not show that industrial air pollution contributes to morbidity and mortality in Haifa [see section 8.3.5 in detail].
Testimony of Prof. Itamar Grotto
- Grotto was questioned about Appendix 4, and was shown that after the publication of the letter, an article was written on the website of the Association of Public Physicians in Israel, and he was asked and answered as follows:
Adv. Mr. Amos Goren: An article, I am trying to remind you, an article that was published, as I said on the website of the Association of Public Physicians in Israel.