Hearing on Compensation for Work-Related Diseases for
Department of Energy Workers
Committee on the Judiciary
Subcommittee of Immigration and Claims
United States House of Representatives
Testimony of Steven B. Markowitz, M.D.
Center for the Biology of Natural Systems
Queens College
Flushing, N.Y. 11367
Telephone: 718-670-4184
September 21, 2000
My name is Steven Markowitz, MD. I am a physician specializing in occupational medicine, that is, identifying and reducing workplace exposures that impair or threaten human health. After receiving my undergraduate degree from Yale University and my medical degree from Columbia University, I completed five years of training in internal medicine and occupational medicine in New York City. I had the excellent fortune of training under the late Dr. Irving Selikoff, the noted asbestos researcher at Mount Sinai School of Medicine. I currently serve as Professor and Director of the Center for the Biology of Natural Systems of Queens College and Adjunct Professor of Mount Sinai School of Medicine, both in New York City.
My research interests center on the surveillance and identification of occupational and environmental disease. I co-authored a book entitled Costs of Occupational Injuries and Illnesses that was published this month by the University of Michigan press. It was based on a study commissioned by the National Institute for Occupational Safety and Health concerning the extent and costs of occupational disease and injury in the United States.
I thank you for the opportunity to speak before this committee today. I wish briefly to highlight two central problems in occupational health at the gaseous diffusion plants of the Department of Energy (DOE), at Oak Ridge, Tennessee; Portsmouth, Ohio; and Paducah, Kentucky. Furthermore, I will discuss our response to those problems through the initiation of the Worker Health Protection Program. I will start first with our response and then briefly elucidate the core problems.
A. The Worker Health Protection Program
In 1996, we initiated the Worker Health Protection Program (WHPP) at the three Department of Energy gaseous diffusion plants. It is a medical screening and education program established as collaboration between Queens College of the City University of New York and the Paper Allied-Industrial Chemical and Energy (PACE) International Union with the full cooperation of the employers at the plants. This program developed as a result of Congressional passage of Section 3162 of the National Reauthorization Defense Act of 1993. Section 3162 required that the Department of Energy to conduct a medical surveillance program for former DOE workers who a) were at significant risk for work-related illness as a result of prior occupational exposures at DOE facilities, and b) would benefit from early medical intervention to alter the course of those work-related illnesses. We received a contract from the DOE through a competitive, merit-based review process and conducted a careful needs assessment and planning process. We then instituted the Worker Health Protection Program at the three gaseous diffusion plants in Paducah, Portsmouth, and Oak Ridge as well as the Idaho National Engineering and Environmental Laboratory.
The goal of the Worker Health Protection Program is to detect selected work-related illnesses at an early stage when medical intervention can be helpful. At a broader level, the goal of our program is to help former DOE workers understand whether they have had exposures in the past that might threaten their health and to ascertain whether, in fact, an injury has resulted from these exposures. For the first time, former workers of the DOE gaseous diffusion plants have the opportunity to obtain an independent, objective assessment of their health in relation to their prior workplace exposures by a physician who is expert in occupational medicine. We screen for chronic lung diseases, such as asbestosis and emphysema, hearing loss, and kidney and liver disease. We have not heretofore emphasized cancer screening, because the screening tests available to date for the principal cancers of concern have been inadequate, and because the gaseous diffusion plants were historically been considered sites of high radiation exposure. We implement the program based on a common medical protocol through local clinical facilities in Oak Ridge, Portsmouth and Paducah. This is not a research activity, but a clinical service program, intended to be of direct and immediate benefit to participants.
In addition, we provide a two hour educational workshop during which former DOE workers have the opportunity to learn about past exposures and their possible impact on present health. These workshops are run by current and former DOE workers, because they have credibility and expertise. We also believe that a participatory model of education is in and of itself health-promoting. The direct and full involvement of current and former DOE workers in designing and conducting our program has been a key to its success.
B. Results of the Worker Health Protection Program
The Worker Health Protection Program has received an outstanding response from former gaseous diffusion plant workers. Since beginning the screening program only 17 months ago, we have received nearly 3,000 telephone calls from former and current workers to our national toll-free number to request participation in the Worker Health Protection Program. We have medically evaluated approximately 1,800 former gaseous diffusion plant workers during the past 17 months. All of these participants volunteered for the screening program. We have not publicized our program, except for a single initial press conference in each community. We have not conducted any significant outreach, nor have we pro-actively invited individual workers for screening. Yet, thousands of gaseous diffusion plant workers have called us to ask to participate.
Why have we received such a positive response? Without question, the newspaper coverage of the contamination of the Portsmouth and Paducah gaseous diffusion facilities by transuranic materials has helped. More fundamentally, though, the chord that we have struck relates to our mission. Workers in the Department of Energy complex want an answer to a simple set of questions: Have my years of work for the Department of Energy affected my health? Has my exposure to radiation and chemicals at the gaseous diffusion plant, which I performed as a service to my country, caused any illness or injury that I might have? If so, what can I do about this illness or injury? This is a simple yet powerful set of questions, and they deserve a truthful and appropriate response.
Our Worker Health Protection Program is beginning to provide a response to these questions. We have results available for report on 1,317 former gaseous diffusion workers in total at the three sites, Paducah, Portsmouth, and Oak Ridge. Approximately 10% of participants show scarring of the chest that is consistent with significant occupational exposure to asbestos. Approximately 20% of former gaseous diffusion plant workers have chronic bronchitis and/or emphysema, to which their exposure to hydrofluoric acid and other powerful lung irritants in the gaseous diffusion process played a significant contributing role. Fifteen of the first 544 former Oak Ridge K-25 workers, or 3%, have confirmed beryllium sensitivity based on repeat lymphocyte proliferation testing. Fifty of these 544 workers (9.2%) had an initial positive beryllium lymphocyte proliferation test. There is a very high rate of hearing loss, mostly moderate or severe, which is hardly surprising, given high occupational noise levels at the gaseous diffusion plants. We have seen minimal rates of clinically significant kidney and liver disease among the workers tested to date, and most appears to be readily explained by the presence of other disease such as hypertension or diabetes.
In addition, the educational arm of our program has also been enormously successful. Our current and former worker educational coordinators have conducted more than 80 two hour workshops in 17 months, through which over 1,000 former workers actively participated.
It is essential to understand that the Worker Health Protection Program is not a comprehensive screening program for all potentially work-related conditions of former DOE workers. Section 3162, which established the Former Worker Medical Surveillance Program, directed the Department of Energy to establish a medical screening program for potentially work-related health conditions for which early diagnosis and intervention would be beneficial. Despite medical advances in screening, however, many health problems are not amenable to screening on a population basis and do not necessarily lead to medically beneficial interventions. Neurologic symptoms, for example, are usually complex and require a careful in-depth diagnostic work-up to provide insight into the nature of the illness. Screening techniques for selected cancers, such as leukemia or lymphoma, have not yet been developed. Thus, for reasons of program design, limited budget, and current medical science, the Worker Health Protection Program does not address all health conditions about which former gaseous diffusion plant workers may be concerned.
There is an important caveat in interpreting our current program results. The former gaseous diffusion plant worker population is large, numbering in the tens of thousands. The first screening program participants are a self-selected group and may not reflect the broader health or exposure experience of the former DOE workforce. They may be more or less ill than the former worker population as a whole. We expect to develop an improved sense of the health of this larger population as we screen additional workers in the coming years.
C. The Enhanced Worker Health Protection Program
In the current program year, the Worker Health Protection Program has received increased funding from Congress: a) to accelerate our medical testing and education program; b) to include current workers in the program; and c) to begin screening for the early detection of lung cancer through the use of low-dose computerized tomography (CT) scanning. We are highly appreciative of Congress and of the Department of Energy for giving us an enhanced capacity to meet the needs of DOE workers. Since we estimate that there are at least 15,000 former or current workers who could benefit from our program, we clearly have much work ahead of us.
Lung cancer is the most important specific cancer risk for workers at the gaseous diffusion plants of the Department of Energy. Occupational exposure to lung carcinogens at the gaseous diffusion plants, including asbestos, uranium, plutonium and beryllium produce excess risk of lung cancer. If early detection of lung cancer is achievable as a result of medical screening, its implementation should be accorded the highest priority among gaseous diffusion plant workers, especially for those at the highest risk of lung cancer. I am pleased to report that in October 2000 we will begin to offer such screening in the Worker Health Protection Program.
Our lung cancer program is based principally on the results of the Early Lung Cancer Action Project, undertaken by Henschke and colleagues at Cornell University and New York University Medical Schools, and published in Lancet in July, 1999. Their results have been confirmed by other similar studies that were reported at the Second International Conference on Screening for Lung Cancer at Cornell University Medical School in New York in February, 2000. Seven studies have now been undertaken in 4 different countries and have screened over 13,000 people for lung cancer. Approximately 75% of the cancers identified through screening were early (Stage I) cancers and, therefore, amenable to surgery and presumably cure.
With the support of Congress, we will offer such an early lung cancer detection program to screening participants of the Worker Health Protection Program at the gaseous diffusion plants of the Department of Energy. We have leased a state of the art CT scanner, which is being installed on a large mobile unit. The unit will be ready next week, and we will begin screening in Paducah in mid-October, 2000. We will transport it on a regular basis between Portsmouth, Oak Ridge, and Paducah. This component of our program will be offered to individuals, both current and former workers, who meet pre-determined criteria for lung cancer risk, as constituted by age, duration and likelihood of exposure to occupational lung carcinogens, and history of cigarette smoking. This program component is being integrated into the existing protocol of the Worker Health Protection Program and, thereby, achieve considerable efficiency and costs savings, especially in participant recruitment, baseline testing, follow-up, and overall program administration. We expect to screen at least 2,000 former and current gaseous diffusion plant workers in the next 12 months.
This medical advance is beginning to be offered in metropolitan areas of the United States such as New York, San Francisco, and Chicago. We are proud that we will now make Paducah, Portsmouth and Oak Ridge among the first communities in the nation to receive the potentially enormous benefits of this life-saving screening technique. The United States Congress and the Department of Energy will accrue enormous gratitude from the current and former gaseous diffusion plant workers as a result of literally saving the lives of a significant number of such workers through its support of lung cancer screening and the Worker Health Protection Program.
D. Why DOE Workers Need Compensation for Occupational Diseases
Having screened 1,800 gaseous diffusion workers in the Worker Health Protection Program, we can now say with confidence that there are sizable numbers of former DOE workers who have had significant occupational exposures in their lifetime, who have occupational illnesses, and who are not receiving compensation for these illnesses. The barriers to compensation have been reported to us by participants in our screening program. These barriers are many. They include:
1. Failure of the personal physician to recognize the illness as occupational in origin;
2. Failure of the physician to ask and understand the occupational exposures of the patients;
3. Lack of availability of objective, expert occupational medicine physicians to diagnose occupational illnesses;
4. Chronic occupational Illnesses may begin years after cessation of work for DOE;
5. Lack of knowledge by DOE workers that their condition might be covered by workers' compensation;
6. Lack of knowledge by DOE workers that workers' compensation might pay for medical bills;
7. Disinterest of attorneys in pursuing cases of workers' compensation for occupational illnesses;
8. Refusal by insurance carriers to recognize occupational illnesses.
In summary, no part of the current workers' compensation system works for former workers at DOE's gaseous diffusion plants. It is not the case that the weakest link deters overall progress in remedying the problem of lack of compensation for occupational illness among DOE workers. There are only weak links in this system, and a piecemeal approach to addressing the needs of DOE workers for compensation will not work.
Let me expand on two of the more difficult issues facing workers as they ask whether their illnesses might be occupational, the first step in determining the need for compensation.
The first core problem in occupational health at the gaseous diffusion plants of the Department of Energy problem is the lack of access of former and current DOE workers to objective, expert, independent care in occupational medicine. When any of us develop a heart arrhythmia, a neurologic syndrome, or cancer, we fully expect to see a physician who will give us his or her candid, specific, expert opinion that is the distillation of many years of specialized training and clinical experience. We further expect that this opinion will be unencumbered by any conflict of interest of the physician, such as a financial interest in a particular medical tool or laboratory, which would influence the opinion of that physician, sometimes to our detriment. These conditions frame a basic standard of care that we have come to expect in our country.
These conditions, however, do not currently exist, and indeed have never existed, for the workers at the three gaseous diffusion plants of the Department of Energy, or probably throughout much of the DOE complex. Such workers have never as a rule had an opportunity for this simple encounter: to have a potentially work-related illness evaluated by a physician who has the knowledge to determine whether the illness is work-related and is free to make that determination without concern about ramifications to the employer. Instead, workers in Paducah, Portsmouth, and Oak Ridge raise their health concerns with their primary care providers who do not ask about or know about occupational hazards. Or their health concerns arise with physicians who are employed by or under the influence of DOE contractors and thereby have dual loyalties. It is little wonder, therefore, that workers, who are very proud of the service that they have performed for the past 5 decades, nonetheless feel that they have been treated unfairly with reference to occupational illness.
Two immediate consequences result from this failure to provide a basic standard of occupational health care. First, occupational illness is not properly diagnosed and treated. This harms the individual. It also harms co-workers and future workers, because it prevents the return of vital information to the workplace, information that could be used to prevent other workers from becoming ill.
The second consequence is that workers and their families will form their own opinions about whether the workplace is the source of their ills. In the absence of external expert knowledge, workers will use their own expertise to decide about the work-relatedness of their problems. Often they will be correct. Indeed, the history of occupational medicine is replete with examples of occupational diseases first identified by workers and later confirmed by physicians. Sometimes, however, workers will not be correct in attributing their symptoms to the workplace. The result of this error is that the DOE facility may be falsely targeted as the source of a spectrum of diverse and quite unrelated illnesses. We cannot blame people who make this judgment: they do so in a vacuum. The underlying problem is the structural lack of a system that can authoritatively and credibly confirm or refute workers' suspicions about workplace exposures as the source of their ill health.
Let me turn to a second core problem in occupational health at the gaseous diffusion plants: the lack of proper, accurate information about exposures that have occurred at the gaseous diffusion plants over the past four or five decades. Ultimately, in occupational medicine, we are called upon to make a judgment about whether a health problem of a particular individual is work-related. The equation that rules this decision is quite simple. On the one side is information about the exposure or workplace factor. On the other side of the equation is the delineation of the illness. The latter is usually straightforward given the armamentarium of medical tools that we now have to conduct medical investigations.
The weak link in this equation is often the level and quality of knowledge about the workplace exposures. Chronic occupational illness today results from exposures that occurred in the past. We are therefore subject to whatever actions that people who were responsible for the workplace did or did not take to measure those exposures. In 1996-1997, as part of the Worker Health Protection Program, we conducted a one year needs assessment of workplace exposures and the rationale for medical screening at the gaseous diffusion plants. We concluded, as have others, that workplace exposures have been poorly documented in general at the gaseous diffusion plants, either through failure to measure properly, or through failure to document measurements in a manner that can be properly interpreted. This applies to radiation measurements, but even more so to assessment of hazardous chemical agents such as asbestos, silica, and beryllium.
One important consequence of this failure is that it makes the decision-making about causality between workplace exposures and health problems that occur many years later difficult and complex. When a gaseous diffusion plant worker, or more likely, retiree, develops lung cancer, the likelihood that his prior occupational exposures to asbestos contributed to the development of the lung cancer depends very much on the intensity, duration, and timing of his exposures to asbestos. If information on this exposure does not exist, the amount of judgment that must be used to decide on work-relatedness of that lung cancer increases. And, so too does room for disagreement in formulating that judgment.
A cynical means to "eliminate" occupational disease now becomes apparent. First, on a prospective basis, fail to document exposures in a thorough, reliable, and interpretable manner. Second, overlook communicating meaningful information about those exposures to workers. Finally, decades later, when chronic occupational diseases of long latency appear, claim retrospectively that insufficient data on exposure preclude proper assessment of the causal role of such exposures in the development of the extant illnesses. Note that the premature deaths and diseases suffered by workers do not disappear under such a scheme. But the occupational attribution vanishes.
Let me provide an example relevant to the "discovery" of plutonium, neptunium, and other transuranics at the Paducah gaseous diffusion plant. The same lesson applies to the Oak Ridge and Portsmouth gaseous diffusion plants. A memorandum from 1960 has been discovered, entitled "Neptunium237 Contamination Problem, Paducah, Kentucky, February 4, 1960." It was written by Dr. C. L. Dunham, a physician who directed the Division of Biology and Medicine of the Atomic Energy Commission (AEC), the predecessor to DOE, and a physician colleague from the same Division (Attachment A). Dr. Dunham was therefore the chief physician of the AEC and presumably took the same Hippocratic Oath that every physician takes upon entering the profession. In this memo, they discuss in some detail how neptunium arrives in Paducah, how it deposits on the inner barrier tubes that are the central component of the gaseous diffusion process, and how workers are exposed to the neptunium. They then refer to urine neptunium levels taken in some workers. These physicians further specify that up to 300 Paducah workers should be tested but that, referring to management personnel "they hesitate to proceed to intensive studies because of the union's use of this as an excuse for hazard pay (p. 3)." Dr. Dunham and colleague further argue in favor of the need to obtain post mortem tissue samples, but state that this was difficult due to "unfavorable public relations." Dr. Dunham and colleague conclude: "Thus, it appears that Paducah has a neptunium problem but we don't have the data to tell them how serious it is." There is a striking absence of any formulation of a plan of how to collect those data and how to reduce neptunium exposure at Paducah.
And now, forty years later, we are asked to judge how significant that exposure might have been, who was the population at risk, and whether a retiree's cancer was caused by that unquantified and, presumably, uninvestigated exposure to neptunium, plutonium, and other materials. And at the end of the current spate of urgent investigations, news reports and hearings, there will be some who will conclude ruefully that "we simply do not have the data to tell them how serious it is" and will thereby be paralyzed by this ignorance. I cannot think of a better way to make occupational disease "disappear."
I. Conclusion
Clearly, our present obligations to workers who built and maintained our nuclear weapons stockpile require that we move beyond paralysis. Through our Worker Health Protection Program, Congress has provided an immediate response to the need of gaseous diffusion plant workers for appropriate and timely medical screening for work-related disease. It is now time for Congress to take the next step: establishing a simple and effective system that will meet the need and right of DOE workers for just compensation. For the past decade, Congress has supported a sustained and costly program to clean-up the environment at the gaseous diffusion plants and through the DOE complex in general. Are DOE workers who served us for decades worth any less?
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