color photograph of a factory smokestack at sunset
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Lelia Winfield used to be called the “Singing Nurse.” Working in the same-day surgery unit, she comforted patients with gospel music, which she said can “light a fire underneath you.” Patients and their family members wrote letters thanking her for calming their nerves, and for helping them to feel less alone before their operation.

Now, Winfield plays music for her patients from her phone. She can no longer sing because of chronic hoarseness and other respiratory issues. She believes that the culprit is ethylene oxide (EtO), a flammable, colorless gas used in chemical manufacturing factories and medical sterilization facilities. Winfield said that she’s lost a part of herself in losing her voice and her ability to connect with and soothe others. 

“I’m angry about that because [singing] was a part of me,” Winfield said. 

Winfield, who is 60 years old and a lifelong resident of South Memphis, Tennessee, said she lives less than a quarter of a mile from Sterilization Services of Tennessee (SST), a Memphis-based 45,000 square-foot facility that sterilizes medical equipment using EtO. Sterilization Services also operates facilities in Atlanta and Richmond, Virginia. 

Though Winfield still lives in the home she grew up in and likes to offer the home as a place for her 14 grandchildren to play and rest, she no longer feels safe in it. In mid-October, she and other members of the South Memphis community learned that a carcinogenic gas was leaking from SST and likely polluting the air. 

The hospital where Winfield works is on the other side of town, but when she goes home after her shift ends she starts to get headaches. A couple of years ago she worked with her doctor to figure out what was causing her to fall ill with bronchitis every “five-to-six weeks,” requiring her to take antibiotics. Her doctor wasn’t able to locate the cause. 

Now she wonders, “Is this because of what I’m breathing in when I’m at home?”

For many environmental advocates, there’s no question that EtO emissions are making people sick. Today, the nonprofit environmental law group Earthjustice filed a lawsuit against the Environmental Protection Agency (EPA) for violating the federal Clean Air Act, which requires the agency to update its rules regulating EtO emissions every eight years. The EPA missed previous deadlines to update its rule in 2014 and 2022. 

If successful, the suit will push the agency to update its emissions rule to align with the agency’s own understanding of the chemical’s carcinogenic potential—which is 60 times more toxic than previously thought by epidemiologists and linked with non-Hodgkin’s lymphoma, breast cancer, respiratory illnesses, and other mutagenic illnesses. 

Sterilization Services of Tennessee did not respond to Prism’s request for comment. 

In effect, the lawsuit is an attempt to fill the void resulting from the EPA’s neglect of public health policies regarding communities’ exposure to EtO. Inadequate air quality testing, a lack of communication from federal and state environmental and health officials, and the difficulty of testing for EtO in the body—which requires blood tests on very recent and high exposures—means residents like Winfield are left to defend themselves against chemical corporations, an industry that has a role in setting its own emissions standards, and an EPA that is in violation of federal law by refusing to update pollution regulations. 

“The Clean Air Act is explicit that the EPA’s job is to protect public health, and so far has been failing to do so,” said Marvin C. Brown, an associate attorney with Earthjustice. “What’s really frustrating is that communities still have to live with the emissions that are coming out from these facilities while waiting for the EPA.” 

Battling legacies of inaction and pollution 

Memphis is one of 23 cities across the country where the EPA has found elevated risk of EtO exposure. In these cities, the risk of developing cancer is 100 per 1 million people, meaning that in a scenario where 1 million individuals are exposed to EtO every hour of the day for 70 years, approximately 100 of those people would become ill. 

The EPA does not provide a demographic analysis of the communities where the 23 highest-polluting entities are located. But Darya Minovi, a senior analyst at the Union of Concerned Scientists, said that by and large the communities that live within 1 mile of a polluting facility, also called the “fenceline,” tend to be lower income and communities of color, as well as communities where English is not a first or spoken language. 

The EPA has known since 1985 that EtO exposure has the potential to cause cancer. The agency refined this assessment in 2006 when it officially recorded the chemical as carcinogenic to humans, and only later updated the chemical’s toxicity value in 2016 to reflect those findings. The National Toxicology Program and the International Association of Research on Cancer also state that EtO is carcinogenic. 

Use of ethylene oxide increased in the mid-20th century because it was found to sterilize devices without steam or high heat, and it is now used to sterilize about 50% of the country’s medical devices: the gas is pumped into chambers where medical equipment awaits, and then the supplies are aerated to remove residual EtO before shipping out to medical facilities. 

Despite the knowledge that EtO is mutagenic and carcinogenic, many of these sterilization facilities are located in residential areas, Minovi said. This is due to federal housing practices like redlining, discriminatory lending policies by financial institutions, and state and county zoning regulations that overburden low-income and BIPOC neighborhoods with factories, chemical plants, and refineries. 

Research from the Harvard University School of Public Health found that while overall, levels of particulate matter have fallen in the past two decades, BIPOC neighborhoods have continued to face unhealthy levels of pollution. The same study concluded that as the number of Black residents in a particular neighborhood increased, so too did the particulate matter concentration. 

But rather than tighten emissions regulations, the agency in 2019 opted for a “suite of actions” that largely included researching EtO. And this year, in response to community outcry, and likely as the result of a Democratic administration, the EPA conducted outreach meetings in affected cities as well as established some air monitoring efforts.

EtO is regulated under a category of Hazardous Air Pollutants, also referred to as “HAPs.” “The general rule for the HAPs is ‘innocent until proven guilty,’” said Dan Jaffe, a professor of atmospheric and environmental chemistry at the University of Washington-Bothell. In 2019, Jaffe was selected to review the EPA’s National Ambient Air Quality Standards. 

Rather than establish the most stringent air quality standards for facilities to abide by, Jaffe said that the EPA looks to establish a middle ground of emissions, a threshold that allows industries to operate without posing a significant threat to human health. 

The EPA establishes HAPs regulations in part on a risk assessment of the agency’s understanding of a chemical’s carcinogenic value, but it remains to be seen how reliable the EPA’s data even is. 

“We really don’t have very good data on human exposure to [EtO], even around the factories that have been producing it and the sterilization facilities. We’re only making our best guess as to what people were exposed to,” Jaffe said.

In other words, regulations are based on data, but if the data is lackluster, the regulations also fall short.

Challenges with measuring emissions 

Advocates agree that there’s never been adequate, substantive, or long-term research into the environmental and human health impacts of EtO on communities where commercial sterilizers, like SST, are located. And rather than prevent illness by ensuring that polluting entities keep emissions at a level non-threatening to human health, advocates say that the EPA has instead waited for residents to sound the alarm bells. 

While the EPA is charged with establishing emissions standards for pollutants, discretion on environmental testing, observation, and accountability are left to individuals within the agency. Most state agencies leave emissions monitoring up to the facilities themselves, the results of which state environmental agency workers can request upon inspection. 

Sheila Serna, the climate science and policy director at the Rio Grande International Study Center, which is a part of the Earthjustice lawsuit and located in Laredo, Texas, previously worked for the Texas Commission on Environmental Quality (TCEQ). As an inspector for TCEQ, Serna saw firsthand how the agency, an underfunded and understaffed arm of the state government, “is more focused on industry than public health.” 

When she was at the agency, there was no formal schedule of inspections. Serna said she was the first investigator to inspect Midwest Sterilization’s Laredo plant—one of the largest EtO emitters in the country—in the 14 years that it had been in operation. 

The thoroughness of inspections was left up to the discretion of investigators like Serna. In the case of EtO, which you can’t see, an investigator might use a portable air monitor to take a reading. These devices had their fallbacks, Serna said, given that some machines weren’t sensitive enough to measure the air in parts per billion or trillion.

Another tool called an optical gas imaging camera would be used to look at a factory’s stack, a kind of industrial chimney that dispenses gas higher into the atmosphere so that concentrations can dissipate more safely. But oftentimes, Serna said, the cameras were used to view methane or volatile organic chemicals (VOCs) and had difficulty distinguishing one gas from another. Currently, the main EPA-approved method for evaluating EtO concentrations in air is with a TO-15, a device about the size of a small propane tank that can be placed in different areas. (“TO” stands for toxic organics.) 

The canisters pull in air from the vicinity, and that air is later evaluated in a laboratory. And while the canisters can distinguish between chemicals, they can’t distinguish where those chemicals are coming from, said Wendy Heiger-Bernays, a clinical professor in the Department of Environmental Health at the Boston University School of Public Health.

This can lead to a problem of attribution, said Heiger-Bernays. Essentially, if there’s a region with multiple kinds of pollution—who is to say which pollution comes from which source? 

Serna said that industry interests have tried to use this question to dissuade local officials from taking seriously any air quality monitoring in the Laredo area. The town of 250,000 is also home to the country’s largest inland port; 14,000 trucks cross the city’s commercial bridges each day. A canister could record emissions from multiple polluting sources.

But that’s not a reason not to take action, Heiger-Bernays said, since “[t]he responsibility of the regulatory authority is to parse what the contribution [is] from one source versus another.” 

Even where environmental or air quality monitoring does happen, there’s no law that requires federal or state agencies to hold polluters accountable. And when agencies do bring forth punitive measures, the main mechanism at their disposal is to levy a fine. 

Even while imperfect, the air monitoring is essential because “measuring the ethylene oxide in a person is virtually impossible,” Heiger-Bernays said. Blood tests can only be run following recent exposures, and waiting until someone has developed a form of cancer before taking action to limit EtO emissions may be waiting too long, she said. Besides, there are other, trackable health consequences associated with EtO pollutants that are not cancer, Heiger-Bernays said, like headaches and respiratory irritation. 

“I think it behooves the regulators to get a much better understanding of what’s coming out of the stacks of these facilities, and once that is done, and the regulatory authorities have the ability to do that, it is within their purview to require stack testing,” Heiger-Bernays said. “They’re loath to do it because it means that if levels are found that are problematic, then they’re going to have to put controls on their stacks, and that costs money.”

“We really feel violated”

South Memphis is a majority-Black neighborhood, where the median household income in 2019 was $26,962. Within 10 miles of Memphis there are 65 polluting entities, according to EPA data. In 2020, South Memphis was targeted for a pipeline construction project because it was seen as the “path of least resistance.” This year, residents learned that the Tennessee Valley Authority agreed to transport 100 trucks per day by some residents’ count of toxic coal ash from the Allen Fossil Plant to the South Shelby Landfill in South Memphis. Residents of South Memphis are already overburdened. 

In October, residents learned that public health was even more threatened than they previously thought in a formal presentation given by regional EPA and county health officials. Justin J. Pearson, a co-founder of Memphis Community Against Pollution (MCAP), said that his organization sent out over 11,000 mailers and 14,000 text messages to make sure that residents of South Memphis knew about the meeting.

It was there Pearson learned that the EtO exposure risk level was well past the 100 per million threshold—and actually hovered around 2,000 per million in the “areas closest to SST,” according to the EPA. 

“We’re in a terrible situation,” Pearson said. “EPA is making this kind of a centerpiece of their focus on environmental justice, but the reality is people are dying … it’s good that EPA is focusing on [EtO], but they knew about it since 2016.”

Rose Sims attended the meeting, which is where she learned of the EtO exposure. 

“We really feel violated,” Sims said. “I really don’t want to stay here no more. I don’t. I really want to move.” 

Sims moved to Memphis from St. Louis when she was a toddler. Now 58, she’s lived in South Memphis since 1998. She said she’s always wondered why so many young people, including her children and grandchildren, have asthma. Now that she knows about EtO, she’s scared to go outside. 

Since that meeting, Sims said she hasn’t received communication from the county, city, or regional EPA office. 

Allison J. Fouché, the chief communications officer for the City of Memphis, did provide a memo from air quality monitoring conducted by Tioga Environmental Consultants. Air quality measurements were taken from July 19-22, 2022, from the corner of East Industrial Avenue and South Main Street, 500 feet away from SST, according to the document. 

“Because of the cross sensitivity of direct read instrumentation used for this study and because passive dosimeter badges did not record concentrations of ethylene oxide, we cannot definitively conclude that ethylene oxide is or is not present,” the memo reads. “If they are present, it does not appear that concentrations of ethylene oxide are above levels determined to by [sic] harmful by OSHA.”

The City of Memphis, EPA, and County Health Department did not make themselves available for an interview or provide a comment. 

Cheryl Ballard also attended the meeting. She said that residents asked officials how they could find out if they’d been exposed and what they could do to protect themselves. She said county health officials directed residents to utilize Shelby County Health facilities. 

Both Sims and Ballard said that they want SST to shut down or move to another, less populated location. 

“I know that businesses need to exist. I know that there’s a need for hospital and dental equipment to be sterilized,” Ballard said. “There are a lot of other things that I cannot control in my life, but I want to be able to come home and enjoy my home without the threat of ethylene [oxide] seeping into my home.”

Ray Levy Uyeda is a staff reporter at Prism, focusing on environmental and climate justice. Find Ray on Twitter @raylevyuyeda.