789
DUTY TO REPORT HAZARDS: A PUBLIC-HEALTH PERSPECTIVE* DAVID H. WEGMAN, M.D. Associate Professor of Occupational Health Harvard School of Public Health Boston, Massachusetts
T HE duty to report hazards, occupational or otherwise, is too often interpreted strictly according to regulatory requirements. From a public health perspective, however, it is important to expand this limited concept of both duty and report. This paper will consider duty as an obligation of health professionals to take all possible actions to prevent illness and to promote the health and well being of all people. At the same time reporting will be expanded to the much larger idea of communication. Thus, reporting will mean the collection and dissemination of information to educate and to inform interested and appropriate persons, groups, or agencies. With this much broader concept of the duty to report hazards, the subject can be divided into three questions-who reports, what is a hazard, and to whom is the report given?
WHO REPORTS? Within an industry this is both the right and the responsibility of the professionally trained occupational-health individual, not the legal or management staff. What about a small industry where there are no occupational health professionals? In such situations a management representive should be identified and assigned the responsibility, and, to be successful, such an assignment must be accompanied by sufficient education and training to learn how and what to report. If this is seen sirmply as the paperwork responsibility of a bureaucrat it will fail to serve any public health purpose. Separate from the company, a union, a member of a union, or any worker has an obligation to report a hazard or a suspected hazard. Al*Presented at a Conference on Ethical Issues in Occupational Medicine cosponsored by the New York Academy of Medicine and the National Institute for Occupational Safety and Health and held at the Academy June 21 and 22, 1977.
Vol. 54, No. 8, September, 1978
79079
D
H
D.H. WEGMAN WEMA
though such reports may not be detailed or conclusive, they may be the first indication of a problem previously unknown. The education of working people about occupational disease and hazards will improve the quality and purpose of such reports. Finally, the scientific community must report early findings or suspicions, not only to scientific colleagues but also to affected parties in companies and the work force. Too many times we have recognized a material as a hazard and controlled it long after the first suspicions were published in scientific journals. Such reports are overlooked or forgotten if the scientist does not see the obligation to make the implications of such work known, understood, and acted upon by those ultimately affected. WHAT IS A REPORTABLE HAZARD?
It is helpful to consider the reporting process in a manner which determines both the nature of the report and the nature of the action to be taken. Thus, I have divided what is reportable into 1) substances known to be hazardous, 2) substances suspected to be hazardous, and 3) circumstances where work-related illness occurs. 1) Known hazardous substances are relatively easy to deal with. First, there is the known hazardous material which is already in use. Here the basic question is what determines the need to report? Is use alone sufficient reason to report? Do we apply a criterion like an action level (exposure measured over zero and less than a threshold limit value), or are reports of exposures to such hazards necessary only when they are associated with specific diagnosable acute or chronic illness? To some degree the use to which the report is to be put determines the answer. An action level, however, has the appeal of a middle ground where indiscriminate reporting is avoided but frank health effects are not necessary. What determines the action level will differ with who receives the report. Separate from the known hazard in use is the problem of a material known to be hazardous and being considered for, but not currently in use. Here the nature of reporting is different, but includes management, labor, and health professionals. Although handled on a case-by-case basis, the guiding principle should be that a material's impact on occupational health needs to be part of the formula determing its acceptability. 2) Suspected hazardous substances are much more difficult. Many materials in use in industry have been evaluated only by acute animal Bull. N.Y. Acad. Med.
PERSPECTIVE HEALTH PUBLIC PUBLIC HEALTH PERSPECTIVE
791
791~~~~~~~~~~~~~~~
toxicology studies or have not been evaluated at all. Part of the reporting here must be a determination that sufficient evidence exists to treat the material as though it were a known hazardous substance. How much and what data are necessary to determine this? Analogy may be sufficient to report a material as being hazardous. Acute or chronic animal studies would be a more stringent requirement. (I think Dow Chemical should be commended for the research on vinyl chloride in the early 1960s and the action they took based on the results). Some think that actual human disease must be present to result in a report. This raises the question: What is adequate proof that human disease is clearly associated with exposure? I believe we must rely primarily on experimental data carefully interpreted according to standard criteria. Waiting for well-established human disease is waiting too long. When analogy suggests a high risk then waiting for experimental data may also have to be foregone. 3) Work-related illness. Distinct from known or suspected hazards, I would like to include the concept of occupational illness under the category of a hazard. Occupational illness is really the end point we care about. A hazard may not be known precisely, but the association of an illness or a series of symptoms with a work process may be clear. Such work-related illnesses should be reported, and control of a likely source of the hazard without really knowing the hazard may often be possible. For example, in some of the research work done at Harvard we have associated curing fumes in rubber tire manufacturing with some chronic lung impairment. We asked ourselves whether we need to identify the material in the fumes which produces this hazard whether we can act on the association alone. The primary issue is prevention of illness, and we have already recommended control without knowing the specific causative agent. The ability to identify and report work-related illness without knowledge of a specific hazard requires a systematic evaluation program based on the principles of epidemiology. Every company of moderate size should do a companywide mortality study today, if it has not been done already. In addition, there should be selected morbidity studies where there is exposure to materials not yet evaluated for occupational-disease potential. These should be based on literature review of analagous materials or route of exposure (lung, skin, ingestion, etc.). The lack of information on the hazardousness of certain materials requires evaluation to conclude that there are, in fact, no ill Vol. 54, No. 8, September, 1978
792
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D.H. WEGMAN
effects associated with the work exposure. Thus, we must build into any reporting system research efforts to identify hazards revealed only through organized study. REPORT TO WHOM?
Who should receive the reports? The list is long, but each of those on the list should be considered when any report is made. Management. First, it is necessary to report any hazard or illness to management to educate and reeducate them to the necessities of occupational disease control and to the need for health promotion to fit into the operations of a modem industrial establishment. Further, it is to inform them of the types and importance of the occupational disease problems and the need to initiate or maintain controls. For example, Eckardt has written of his experience when his corporation once considered the use of berylliumni' He let management know what would be necessary to handle beryllium safely and, thus informed, management reevaluated its understanding of the desirability of this new process. Workers. There are several reasons to report to workers. One is to advise those who are at risk that they have a risk. Even if that risk is under control, the individual should be informed about the exposures and the risks of uncontrolled exposure. Another reason to inform the workers is that they must cooperate in the control of work exposures. I have been quite impressed in Massachusetts in consulting with unions how cooperative workers can be when they understand what the potential risks are and what their role is in controlling them, and how uncooperative they can be if they are not so informed. A third reason is that workers many times know how to control the hazards. The individual worker may be the only one who really understands how a particular machine or process is operating day to day, and he may be the one best able to show how to control the hazard. Separate from the need to report to current employees is the need to inform past employees who may still be at risk. For example, who is looking out for the workers exposed to vinyl chloride who left employment before it was identified as a carcinogen? How can we possibly look out for them? Whoever thought 20 years ago to keep the records of employment when the custom was to throw them out after seven years? Now at least we *Eckardt, R.E.: Annals of industry-Noncasualties of the workplace. J. Occ. Med.: 16:472-77, 1974.
Bull. N.Y. Acad. Med.
PUBLIC HEALTH PERSPECTIVE
PUBLIC
HEALTH
PERSPECTIVE
793 793
know about that problem. To some extent, the Occupational Safety and Health Administration (OSHA) is mandating the maintenance of records. Independent of OSHA's mandate, however, records should be maintained in some form so that, if necessary, we can retrieve the appropriate names. Government. The National Institute of Occupational Safety and Health, OSHA, and state agencies obviously need to be informed, and in many instances reports are mandated. Beyond the mandated report, health professionals should take some of the responsibility of these federal and state agencies into their own hands. I have been impressed when visiting some Massachusetts plants already inspected by OSHA that OSHA did not look at the injury log nor ask about disease associated with a particular workplace hazard. In a sense we need to draw the attention of the inspectors to the important problems that health professionals are watching which are not being reviewed by appropriate agencies. Publication. There is an obvious duty to report in scientific and professional journals. But what about nonpublication or delayed publication in association with a risk under evaluation in an industry? It is difficult to separate purposeful delay from delay to confirm beyond a reasonable doubt. The basic guideline the professional should follow is to establish a personal rule to report as early as possible according to professional, not public relations, needs. Finally, there is the responsibility of the health professional to make sure that every worker he can reach is protected, even those not under his direct care. To me this means becoming much more aware of the importance of lay publications, particularly the newspaper. If we do not help the newspaper writers understand the problems of occupational disease and of scientific method, they may not understand but they will continue to report. It must be our responsibility to make sure they report our science accurately, rather than to avoid public reporting because past reporting has been inaccurate. WHAT IS THE FoRm OF THE REPORT?
I have no general recommendations about form. The form will vary tremendously with the audience that is to be addressed. The principle that should be primary is maximal educational impact-education in the broadest sense, that is, education for scientists, for workers, for public agencies, and for the public at large. The form of a report to workers needs particular attention. It must Vol. 54, No. 8, September, 1978
79479
D.H. WEGMAN D..WGA
inform, not mystify or obfuscate. A variety of educational programs, some of which have been discussed, are part of the answer. But the issues that we have to address more directly as health professionals are those of the use of generic names and of adequate warning labels. The current limited use of generic labels rather than trade names makes hazard control much more difficult. There are some legitimate instances where use of generic terms would reveal critical trade secrets. Much more often it is simply a company's specific product label. Custom rather than reason seems to determine that generic labels do not accompany trade names. If a worker is informed of the presence of a hazard through a generic label and is properly educated about the risk, then hazard control has already begun. I have been astonished by the uninformative warning labels I see, not only for workers but for management untrained in occupational diseases or hazards. Two years ago I investigated a methylcellosolve poisoning. Two workers were hospitalized with hypoplastic anemia and toxic encephalitis and two others probably should have been hospitalized. The warning label on the solvent was i"... good ventilation should be maintained.... Breathing of vapors and contact of liquids with skin should be avoided...." That is an inadequate warning label. Warning labels must be designed with a much greater sense of their educational and informational function. The particular importance of appropriate labeling is that the impact can be felt even if the health professional has no direct access. In conclusion, I think the interpretation of the "duty to report" must be as broad as possible. In fact, as occupational-health professionals we must seek maximum opportunities to report-we must even make such opportunities. From the public health perspective, this duty is in a sense the opportunity to change and improve the health of all workers, one which really is the fundamental duty that we all have.
Bull. N.Y. Acad. Med.
DUTY TO REPORT HAZARDS: A PUBLIC-HEALTH PERSPECTIVE* DAVID H. WEGMAN, M.D. Associate Professor of Occupational Health Harvard School of Public Health Boston, Massachusetts
T HE duty to report hazards, occupational or otherwise, is too often interpreted strictly according to regulatory requirements. From a public health perspective, however, it is important to expand this limited concept of both duty and report. This paper will consider duty as an obligation of health professionals to take all possible actions to prevent illness and to promote the health and well being of all people. At the same time reporting will be expanded to the much larger idea of communication. Thus, reporting will mean the collection and dissemination of information to educate and to inform interested and appropriate persons, groups, or agencies. With this much broader concept of the duty to report hazards, the subject can be divided into three questions-who reports, what is a hazard, and to whom is the report given?
WHO REPORTS? Within an industry this is both the right and the responsibility of the professionally trained occupational-health individual, not the legal or management staff. What about a small industry where there are no occupational health professionals? In such situations a management representive should be identified and assigned the responsibility, and, to be successful, such an assignment must be accompanied by sufficient education and training to learn how and what to report. If this is seen sirmply as the paperwork responsibility of a bureaucrat it will fail to serve any public health purpose. Separate from the company, a union, a member of a union, or any worker has an obligation to report a hazard or a suspected hazard. Al*Presented at a Conference on Ethical Issues in Occupational Medicine cosponsored by the New York Academy of Medicine and the National Institute for Occupational Safety and Health and held at the Academy June 21 and 22, 1977.
Vol. 54, No. 8, September, 1978
79079
D
H
D.H. WEGMAN WEMA
though such reports may not be detailed or conclusive, they may be the first indication of a problem previously unknown. The education of working people about occupational disease and hazards will improve the quality and purpose of such reports. Finally, the scientific community must report early findings or suspicions, not only to scientific colleagues but also to affected parties in companies and the work force. Too many times we have recognized a material as a hazard and controlled it long after the first suspicions were published in scientific journals. Such reports are overlooked or forgotten if the scientist does not see the obligation to make the implications of such work known, understood, and acted upon by those ultimately affected. WHAT IS A REPORTABLE HAZARD?
It is helpful to consider the reporting process in a manner which determines both the nature of the report and the nature of the action to be taken. Thus, I have divided what is reportable into 1) substances known to be hazardous, 2) substances suspected to be hazardous, and 3) circumstances where work-related illness occurs. 1) Known hazardous substances are relatively easy to deal with. First, there is the known hazardous material which is already in use. Here the basic question is what determines the need to report? Is use alone sufficient reason to report? Do we apply a criterion like an action level (exposure measured over zero and less than a threshold limit value), or are reports of exposures to such hazards necessary only when they are associated with specific diagnosable acute or chronic illness? To some degree the use to which the report is to be put determines the answer. An action level, however, has the appeal of a middle ground where indiscriminate reporting is avoided but frank health effects are not necessary. What determines the action level will differ with who receives the report. Separate from the known hazard in use is the problem of a material known to be hazardous and being considered for, but not currently in use. Here the nature of reporting is different, but includes management, labor, and health professionals. Although handled on a case-by-case basis, the guiding principle should be that a material's impact on occupational health needs to be part of the formula determing its acceptability. 2) Suspected hazardous substances are much more difficult. Many materials in use in industry have been evaluated only by acute animal Bull. N.Y. Acad. Med.
PERSPECTIVE HEALTH PUBLIC PUBLIC HEALTH PERSPECTIVE
791
791~~~~~~~~~~~~~~~
toxicology studies or have not been evaluated at all. Part of the reporting here must be a determination that sufficient evidence exists to treat the material as though it were a known hazardous substance. How much and what data are necessary to determine this? Analogy may be sufficient to report a material as being hazardous. Acute or chronic animal studies would be a more stringent requirement. (I think Dow Chemical should be commended for the research on vinyl chloride in the early 1960s and the action they took based on the results). Some think that actual human disease must be present to result in a report. This raises the question: What is adequate proof that human disease is clearly associated with exposure? I believe we must rely primarily on experimental data carefully interpreted according to standard criteria. Waiting for well-established human disease is waiting too long. When analogy suggests a high risk then waiting for experimental data may also have to be foregone. 3) Work-related illness. Distinct from known or suspected hazards, I would like to include the concept of occupational illness under the category of a hazard. Occupational illness is really the end point we care about. A hazard may not be known precisely, but the association of an illness or a series of symptoms with a work process may be clear. Such work-related illnesses should be reported, and control of a likely source of the hazard without really knowing the hazard may often be possible. For example, in some of the research work done at Harvard we have associated curing fumes in rubber tire manufacturing with some chronic lung impairment. We asked ourselves whether we need to identify the material in the fumes which produces this hazard whether we can act on the association alone. The primary issue is prevention of illness, and we have already recommended control without knowing the specific causative agent. The ability to identify and report work-related illness without knowledge of a specific hazard requires a systematic evaluation program based on the principles of epidemiology. Every company of moderate size should do a companywide mortality study today, if it has not been done already. In addition, there should be selected morbidity studies where there is exposure to materials not yet evaluated for occupational-disease potential. These should be based on literature review of analagous materials or route of exposure (lung, skin, ingestion, etc.). The lack of information on the hazardousness of certain materials requires evaluation to conclude that there are, in fact, no ill Vol. 54, No. 8, September, 1978
792
792
D.H. WEGMAN
effects associated with the work exposure. Thus, we must build into any reporting system research efforts to identify hazards revealed only through organized study. REPORT TO WHOM?
Who should receive the reports? The list is long, but each of those on the list should be considered when any report is made. Management. First, it is necessary to report any hazard or illness to management to educate and reeducate them to the necessities of occupational disease control and to the need for health promotion to fit into the operations of a modem industrial establishment. Further, it is to inform them of the types and importance of the occupational disease problems and the need to initiate or maintain controls. For example, Eckardt has written of his experience when his corporation once considered the use of berylliumni' He let management know what would be necessary to handle beryllium safely and, thus informed, management reevaluated its understanding of the desirability of this new process. Workers. There are several reasons to report to workers. One is to advise those who are at risk that they have a risk. Even if that risk is under control, the individual should be informed about the exposures and the risks of uncontrolled exposure. Another reason to inform the workers is that they must cooperate in the control of work exposures. I have been quite impressed in Massachusetts in consulting with unions how cooperative workers can be when they understand what the potential risks are and what their role is in controlling them, and how uncooperative they can be if they are not so informed. A third reason is that workers many times know how to control the hazards. The individual worker may be the only one who really understands how a particular machine or process is operating day to day, and he may be the one best able to show how to control the hazard. Separate from the need to report to current employees is the need to inform past employees who may still be at risk. For example, who is looking out for the workers exposed to vinyl chloride who left employment before it was identified as a carcinogen? How can we possibly look out for them? Whoever thought 20 years ago to keep the records of employment when the custom was to throw them out after seven years? Now at least we *Eckardt, R.E.: Annals of industry-Noncasualties of the workplace. J. Occ. Med.: 16:472-77, 1974.
Bull. N.Y. Acad. Med.
PUBLIC HEALTH PERSPECTIVE
PUBLIC
HEALTH
PERSPECTIVE
793 793
know about that problem. To some extent, the Occupational Safety and Health Administration (OSHA) is mandating the maintenance of records. Independent of OSHA's mandate, however, records should be maintained in some form so that, if necessary, we can retrieve the appropriate names. Government. The National Institute of Occupational Safety and Health, OSHA, and state agencies obviously need to be informed, and in many instances reports are mandated. Beyond the mandated report, health professionals should take some of the responsibility of these federal and state agencies into their own hands. I have been impressed when visiting some Massachusetts plants already inspected by OSHA that OSHA did not look at the injury log nor ask about disease associated with a particular workplace hazard. In a sense we need to draw the attention of the inspectors to the important problems that health professionals are watching which are not being reviewed by appropriate agencies. Publication. There is an obvious duty to report in scientific and professional journals. But what about nonpublication or delayed publication in association with a risk under evaluation in an industry? It is difficult to separate purposeful delay from delay to confirm beyond a reasonable doubt. The basic guideline the professional should follow is to establish a personal rule to report as early as possible according to professional, not public relations, needs. Finally, there is the responsibility of the health professional to make sure that every worker he can reach is protected, even those not under his direct care. To me this means becoming much more aware of the importance of lay publications, particularly the newspaper. If we do not help the newspaper writers understand the problems of occupational disease and of scientific method, they may not understand but they will continue to report. It must be our responsibility to make sure they report our science accurately, rather than to avoid public reporting because past reporting has been inaccurate. WHAT IS THE FoRm OF THE REPORT?
I have no general recommendations about form. The form will vary tremendously with the audience that is to be addressed. The principle that should be primary is maximal educational impact-education in the broadest sense, that is, education for scientists, for workers, for public agencies, and for the public at large. The form of a report to workers needs particular attention. It must Vol. 54, No. 8, September, 1978
79479
D.H. WEGMAN D..WGA
inform, not mystify or obfuscate. A variety of educational programs, some of which have been discussed, are part of the answer. But the issues that we have to address more directly as health professionals are those of the use of generic names and of adequate warning labels. The current limited use of generic labels rather than trade names makes hazard control much more difficult. There are some legitimate instances where use of generic terms would reveal critical trade secrets. Much more often it is simply a company's specific product label. Custom rather than reason seems to determine that generic labels do not accompany trade names. If a worker is informed of the presence of a hazard through a generic label and is properly educated about the risk, then hazard control has already begun. I have been astonished by the uninformative warning labels I see, not only for workers but for management untrained in occupational diseases or hazards. Two years ago I investigated a methylcellosolve poisoning. Two workers were hospitalized with hypoplastic anemia and toxic encephalitis and two others probably should have been hospitalized. The warning label on the solvent was i"... good ventilation should be maintained.... Breathing of vapors and contact of liquids with skin should be avoided...." That is an inadequate warning label. Warning labels must be designed with a much greater sense of their educational and informational function. The particular importance of appropriate labeling is that the impact can be felt even if the health professional has no direct access. In conclusion, I think the interpretation of the "duty to report" must be as broad as possible. In fact, as occupational-health professionals we must seek maximum opportunities to report-we must even make such opportunities. From the public health perspective, this duty is in a sense the opportunity to change and improve the health of all workers, one which really is the fundamental duty that we all have.
Bull. N.Y. Acad. Med.
