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What’s next for OSHA’s crane rule?

The Pump HandleMon, 06/22/2009 – 20:31

Friday (6/19) was the final day for participants from  OSHA’s public hearing on its proposed cranes and derricks  rule to submit comments to the agency;  by my count, seven  organizations responded.   The  Edison Electric Institute    offered the lengthiest document (94 pages), and it was peppered with provocative language, such as

“…these and many other vexing questions arise from OSHA’s convulated proposed regulatory scheme.”

the rule “…would de-stabilize  settled principles [and] would be highly ill-advised….could stimulate more litigation…and [create] an avalanche of state and local laws.”

 What is EEI’s objection?

EEI is the association of U.S. shareholder owned electric companies, and they want   [I think] OSHA to exempt  the work of and equipment used by power line crews from the cranes and derricks rule.   But, that’s not all they want.   They want OSHA to insist that its rule  preempt any state or local laws governing cranes and derricks.   They assert that the U.S. Supreme Court ruled in  Goode v. National Solid Wastes Management Ass’ n (1992) that the OSH Act

“‘precludes any state regulation of an occupational safety and health issue with respect to which a federal standard has been established unless a state plan has been submitted and approved pursuant to Section 18(b).”  

The City of New York’s Department of Buildings disagrees.   In their comments to OSHA, they remind us:

“New York City has more skyscrapers over 500 feet tall and is more densely populated than any other city in the United States.   The cranes that build these skyscrapers tower over occupied buildings, streets and sidewalks.   Because of the obvious danger that improper cranes and derrick assembly and use pose to public safety, New York City has for decades regulated this segment of the construction industry.”

“The City licenses riggers who oversee crane and derrick assembly; it licenses the operators who lift the concrete, steel and building materials and equipment into those skyscrapers; and it reviews the plans submitted by engineers for crane and derrick erection and use.  

In NY City’s letter to OSHA, the Commissioner urges the agency to revise its statement of “federalism” to explicitly declare that the rule:

“…does not preempt state and local public safety laws where cranes and derricks pose a risk to public safety as long as such laws do not conflict with OSHA standards.”  

They judiciously offer OSHA specific language to insert in the rule, and provide several examples where OSHA rules co-exist with state and local laws (e.g., fire protection stnadards, means of egress.)

EEI disagrees.   They write:

it is understood “…that in a state that does not have an [OSHA State Plan], the state cannot regulate an occupational safety and health issue that is addressed by a federal OSHA standard.”

EEI adds:

“EEI appreciates that localities have responded to the recent spate of serious crane accidents by investing considerable expertise and resources in developing regulation of cranes and derricks.   Nonetheless, nothing that OSHA could say, or forbear from saying in the preamble to a final rule would change the principle…that the OSH Act ‘precludes any state regulation of an occupational safety and health issue with respect to which a federal standard has been established unless a state plan has been submitted and approved pursuant to Section 18(b).  [505 U.S. 88, 100 (1992).  ]

 The City of New York’s Building Department interprets that 1992 U.S. Supreme Court ruling differently, noting:

“…state and local public safety laws have incidental positive impact on worker safety—whether seat belt laws, local speed limits, or as here, local building codes—provides no logical or legal basis for preemption.   OSHA itself has implicitly acknowledged continued validity of various state and local laws that address the same issues as related federal standards and should do so in this proceeding.    As stated [in the ruling]..’state laws of general applicability (such as laws regarding traffic safety or fire safety) that do not conflict with OSHA standards and that regulate the conduct of workers and nonworkers alike would generally not be pre-empted.” ”

When I read NY City’s arguments, they make a strong case:

“…The erection, dismantling and operation of cranes and derricks pose a substantial risk to public safety in dense urban areas.   OSHA should not preempt state and local regulations that do not interfere with OSHA’s federal regulatory objectives when preemption will leave the public exposed to unacceptable risks.”

“…In the tight confines of New York City, mobile cranes are forced to park on and operate from the street, leaving no room for error.   …OSHA has an extremely limited inspector staff to police the construction industry.   In New York, OSHA employs only a handful of inspectors for the metro-politan area, and these must oversee all OSHA-covered industries, and not just the 300 cranes operating in the City or the thousands of active construction sites that are at work in the City on any particular day.

“…City inspectors have uncovered bent crane struts, improper foundations and foundation supports, improper lifting and rigging practices, and jerry-rigged repairs…     Clearly, preempting public safety officers from performing their duties in connection with crane operations in a large municipality would be extraordinarily unwise.

So it goes in  our system of  worker health and safety rulemaking.   Interested parties have  their chance(s) to  share their  expertise and perspective on  a proposed  rule.   But ultimately, it is up to  OSHA’s Asst. Secretary (usually in consultation with the Secretary of Labor and her advisors) to  decide:   issue a rule or  wait.  

In this last (hopefully) go-around on the crane rule, other commenters included the Int” l Union of Operating Engineers (IUOE) (59-pages), the  AFL-CIO Building  Trades Department, the National Commission for the  Certification of Crane Operators (NCCCO), and the National Organization  for  Competency Assurance.   The IUOE says it  supports the rule, but  recommends  revisions to provisions covering  universal voice commands, pre-erection inspection,  retention of the current rule prohibiting the suspension of unmanned loads, among others.    IUOE notes its:

“…primary concern throughout this process has been to ensure that the certification standards in proposed 1926.1427 do not permit employers to bypass true third party verification; that training of non-certified operators during the pre-certification is safe; that training mills that teach to the test do not undermine the integrity of certification testing; and that effective state and local licensing is not derailed by the establishment of national minimum certification standards.”

What’s next for OSHA’s crane rule?    Ultimately, it is OSHA’s duty to develop a final rule  that is “reasonably necessary and appropriate.”    This means a  final rule  that

  1. substantially reduces a signficant risk of material harm
  2. is technologically and economically feasible for the affected industry as a whole
  3. employs the most cost-effective means of achieving its goal, and
  4. is supported by the evidence in the rulemaking record.

When I break down the steps this way, the task doesn’tseem so daunting.    Certainly with this last round of comments,  as well as issues raised during the March 2009 public hearings, there are decisions that OSHA officials  need to make.  

  • What is an appropriate phase-in period for operator certification?
  • What should be the minimum standards for certification?
  • How to distinguish between training and certification?
  • Should exemptions be granted for cranes used in power line work?
  • Should OSHA adopt NY City’s language ‘federalism”  language?
  • Etc., etc., etc.

 The next steps are OSHA’s.   It needs to make decisions on remaining issues,  prepare the final rule and  be prepared to defend   its decisions in the Court of Appeals.     (The  OSH Act offers affected persons or parties an opportunity for judicial review.)    

Lawsuits challenging OSHA rules are  typical and it is  something the agency  expects.   The real challenge for OSHA leaders in this new Administration is  to avoid the trap of over-thinking, over-writing, over-analyzing the  final rule, especially the preamble.      If you can answer 1-4 above, and you can demonstrate that the final rule is a logical outgrowth of the proposed rule, dots the i’s and cross the t’s and issue it as a final rule.   I know a special family in St. Louis who are eager to attend the signing ceremony.   I hope they have that opportunity before the end of 2009.

Celeste Monforton, MPH, DrPH received a comment from Mr. Rick Power on March 26, 2009 (10:12 pm) in response to  her blog post  “More delays on OSHA’s crane rule”.   He wrote: “On Tuesday February 3rd, 2009 my nephew was fatally injured while dismantling a 100 ton crane at a construction site located in St. Louis, MO.   He was a 21 year old apprentice.”   His nephew was Steven Lillicrap.   Celeste is grateful that her blog  connects her with family-member victims of workplace hazards, and that she had the opportunity to meet Diane Lillicrap and Rick Power on Worker Memorial Day 2009.

Occupational Health News Roundup

The Pump HandleMon, 06/22/2009 – 14:17

In Texas, a construction worker dies every two and a half days. In the Texas Observer, Melissa Del Bosque explains that it’s because of “lax enforcement of labor and safety regulations, too many overtime hours without rest breaks and a lack of safety training and equipment.” The Austin-based nonprofit Workers Defense Project, which helps construction workers seek restitution for injuries, spent three months visiting construction sites to interview workers about these issues. Del Bosque summarizes their findings:

Researchers found that Austin construction workers—whether they” re legal immigrants, undocumented workers or seventh-generation Anglos—have plenty in common: Most work long hours without overtime. Few receive adequate safety training. And few get basic safety equipment when they” re hired for a job.

“Texas has failed to guarantee even basic safety and labor protections,” [Workers Defense Project’s Cristina] Tzintzún says.

At least 45 percent of the workers surveyed earned poverty-level wages. One in five had been injured on the job. Sixty-four percent said they had not gotten basic safety or health training. Many reported that they” d had to bring their own hard hats and safety belts to both government-funded and private-job sites.

In other news:

Washington Post: Virginia trucker Arthur Pierce fell into a coma while on the job (evidently from a fall), but his wife wasn’table to collect workers’ compensation benefits- although she probably would have received benefits if he” d died immediately, rather than dying after 16 months in a coma. Now, Claire Pierce is working to change the Virginia’s workers’ compensation law.

Associated Press: Moderate-income, non-disabled veterans had been denied enrollment into the Veterans Administration healthcare system; now, the VA is expanding eligibility to an estimated 266,000 veterans who meet that description.

Washington Post: Obama has signed a presidential memorandum extending some benefits to the same-sex partners of federal workers- although extending health benefits to those partners will require the passage of legislation that’s currently before Congress.

Canadian Broadcasting Corporation: Canada is spending millions to remove asbestos from government buildings- but, unlike other developed countries, it still exports asbestos to India (40 million tons last year), where many workers are exposed to asbestos without safeguards or trainings.

New York Times: Italy has one of the worst job-safety records in Europe, but recent deadly workplace disasters have spurred an effort to toughen sanctions for companies that fail to address workplace hazards.

Views of a CalOSHA Inspector

The Pump HandleFri, 06/19/2009 – 20:23

As we learned  this week,  Cal/OSHA and the  OSH Appeals Board are in a state of disarray.    A daring group of state employees have raised their voices in protest (see “CalOSHA inspectors demand change”)  reminding us that dysfunction  in  their agency can  translate  into  more  injuries and illnesses for California’s workers.   The collective action of these inspectors and staff is  vital.   So too is the  sole voice of individuals who share their experience and insight.  

Meet  Jack Oudiz, who joined  Cal/OSHA in 1985.    Mr. Oudiz is retiring from Cal/OSHA and  shares the following:

My statement is compelled by a sense of sadness and disappointment at leaving an organization that is in many ways much less effective than I found it nearly 25 years ago.   The Division I leave today has veered so far away from its mission that it has begun to redefine that mission to justify its actions.  

Who is Jack  Oudiz?     In the 1970’s Mr. Oudiz  worked as a machinist in the San Francisco Bay area, and was a  member of the Steelworkers and then the International Molders and Allied Workers.     He  discovered the field of industrial hygiene and in 1980 went to the University of Cincinnati to get an Masters degree in the field.   In Cincy, he  worked for the Molders Union,  and with the support of  OSHA’s (Asst. Secretary Eula Bingham)  New Directions  grant program, they were able to  establish  a H&S Dept.   Jack eventually became director of it and  engaged  their  locals around the country in OH&S.   In 1985, he went to work for Cal/OSHA in  its Sacramento District Office as a compliance industrial hygienist.  

More on his career of public service later; he offers us his  unique perspective as  a   long-term Cal/OSHA inspector, in the form of an  open-letter exit-interview.     In it he writes:

“The  history of the enactment of the Occupational Safety and Health Act of 1970 shows that the governmental role in regulating safety and health conditions in workplaces was the direct result of many years of political struggle by workers and their unions.   While the Act was far from perfect in its scope and construct, it did establish the fundamental principle, in law, that all workers have the right to a workplace that does not endanger their safety and health, the “General Duty Clause” as the Federal agency calls it.”  

“This principle was codified in the California Labor Code as a statement of responsibility of all employers.   A national regulatory bureaucracy was created by this Act to assure that this principle was in place and enforced in all workplaces.    The Division [Cal/OSHA] is the branch of that bureaucracy in California.   It derives its mission and reason for being from that principle.   That is, to assure, to the best of its ability, that workers in California are afforded the protection required to keep them safe and healthy at work.
That one clear message has never been articulated by anyone in a leadership role while I have worked in the Division.”  

“Consequently, each person who comes to work in the Division  is left to define for his or herself what is their role and what is their purpose within this bureaucracy.   Since ‘production”  measures have always been given the most outspoken emphasis by Division leadership, some come to see the mission as defined by the number of inspections and citations amassed.   Others come to the Division with prejudices and biases regarding workers, unions, employers and, absent any clear guidance and emphasis from above, continue to express those leanings in their daily work. The result, as I have consistently observed it, is a workforce with a wide divergence of commitment to the agency’s mission led by many managers whose success is evaluated and measured by statistics rather than by their level of dedication and ability to create common cause in pursuit of the mission.”

“…California continues to trail both Federal OSHA as well all other state staffing levels with respect to the proportion of enforcement inspectors to the state workforce.   This staffing shortage was the focus of recent legislative oversight scrutiny.   When given the chance to affirm the need for more staff, the current DOSH Chief buckled to political pressure and declared that ‘efficiencies’ in operation would counter the need for additional personnel.   This statement was so ludicrous and the needs are so glaring that even he has now finally had to publically pronounce that the Division is in sore need of more resources and staffing.   In the meantime, the present Chief just created and filled a high level staff service manager position with an ‘efficiency” expert while a Deputy Chief for Occupational Health position remains unfilled for the 10th consecutive year.

“The consequences of chronic staffing deficiencies in enforcement district offices are numerous and have a huge impact on the work and morale of Division staff.   When workloads are too great for offices and inspectors, inspections and accident investigations are rushed, witnesses are not interviewed, evidence is not collected, citations are not issued or are given away to avoid time consuming appeals, inspections are conducted by letter rather than in person, some accidents even fall through the cracks and never get investigated.   Mentoring of inexperienced inspectors seldom occurs and they are often left to fend for themselves in complicated inspections or investigations.”

“…The historical decline in the strength and influence of the labor movement in California (as well as nationally) in the past 25 years has had a devastating impact on the effectiveness of the Division and its commitment to its mission.   It is hard to conceive that at one time the Chairman of the Cal/OSHA Appeals Board was a former union rank and file member and shop steward.   The imbalance of power between labor and employers has been reflected in the regulatory process, in the appointments to critical positions on the CalOSHA Appeals and Standards Boards, in the hiring of and decisions rendered by the Appeals Board and its judges and in every other facet of DOSH policies and procedures.”

“The universal use by the Division of advisory committees and the development of regulation by consent, on its face, may have the appeal of fairness and balance, but in reality it has slanted rulemaking power overwhelmingly to employers.   It is not unusual for a regulatory advisory body to have a 10 to 1 ratio of representation in favor of employers.   Even when labor representation is present, it is customarily severely outgunned in expertise, experience and assertiveness.   The outcome, in the case of landmark regulations such as the ergonomics standard and the heat illness prevention standard, clearly reflects this imbalance of power.   These two regulations have given DOSH an undeserved reputation as a leader in progressive health and safety rulemaking. The truth is that these regulations were grudgingly enacted only after vociferous labor action (and heat related worker deaths that drew public outcry) and were weaker versions of what was needed.”

“DOSH’s role is intended as an advocate for worker health and safety.   The OSHAct did not intend nor require consensus or agreement between the regulated community and those that the agency is intended to protect.   The OSHAct did not intend nor require the balancing of worker safety and health with industry profits.   Rather, the law requires the agency to protect a worker, to the extent feasible, from ‘material impairment of health or functional capacity even if such employee has regular exposure to a hazard regulated by such standard for the period of his working life.”  [emphasis added]

“When the Division assumes the role of an impartial party in the development of regulation, it abdicates its responsibilities as an advocate for worker health and safety.   Because of emphatic employer opposition to the ergonomics standard, the compromise regulation that was passed ignored much of the scientific evidence and has remained essentially unenforceable.   The “Noah’s Ark” approach that requires a minimum of two of each type of injury to trigger the requirements of the regulation has meant that many exposed or injured workers lack any protection simply because there may not be any injured co-workers.   Consequently, the negligible incidence of cited DOSH ergonomics cases does not begin to reflect the scope of the actual hazard in workplaces.”

“…In recent years, perhaps nothing has had a more deleterious impact on the daily activities and morale of the Division’s enforcement staff than the practices of the Cal/OSHA Appeals Board.   The attitudes and decisions of many of the Board’s administrative law judges have been widely perceived by enforcement inspectors and many of their managers as anti-Division and strongly biased in favor of employers.”

“The Board itself has reinforced this perception by capriciously dismissing important citations based on frivolous technicalities such as partially inaccurate company names or downgrading citation classifications without reasonable cause.   These decisions and actions have a widespread chilling effect on Division’s staff.   Both managers and inspectors are more reluctant to classify serious citations in the expectation of a negative outcome on appeal. ‘Why bother?” is how many feel.”

“In other cases, staff has begun to reinterpret DOSH regulations based on what they have seen in ALJ decisions.   This negative impact has been compounded by practices of the Appeals Board such as overbooking of hearings, arbitrary denial of continuances and expecting worker witnesses to travel great distances for hearings.    …The Division leadership has done little to protest or challenge these actions by the Board.”

“…Until there is the political will in California to take seriously the principle established in law by the OSHAct, I don’texpect that the Division will become any more effective in carrying out its mission.   We will continue to have leadership beholden to the Chamber of Commerce rather than the working men and women of California and unwilling to address the structural deficiencies of the Division.   Those deficiencies have the net result of less effective enforcement of ever weaker regulations and a dispirited workforce in search of inspiration and leadership.”

“Without pressure from below, there is little incentive for change. The OSHAct was in many ways a revolutionary act.   For the first time, the dictatorial power of the employer over the workplace was challenged.   Government inspectors were given the unprecedented power to not only inspect all workplaces but to shut workplaces or work activities down.”

“It is not surprising that employers and their elected representatives fought the Act tooth and nail.   It is also not surprising that these same forces have continued to fight at every opportunity to diminish the Act and the effective enforcement of its intent.   What has not been achieved through legislation has been essentially accomplished through sabotage, undermining, and resource starvation.   If there has to be an OSHA bureaucracy, then every measure has been taken to see that it cannot effectively function.   The more demoralized the workforce, the more complacent the leadership, the less accountability in the organization, the less competent the managers and inspectors, the better for those opposed to the achievement of the Act’s goals.”

“Only a grassroots effort by workers, unions and those who support social justice and human rights can exert the political pressure necessary to correct the institutional problems that have overwhelmed the agency given the duty and responsibility to protect worker safety and health rights.”

Read the complete  open-letter exit-interview  written by Jack Oudiz.    

Jack Oudiz is retiring as a senior safety engineer with Cal/OSHA.   His Cal/OSHA service includes  district manage of the  Modesto office, regional senior IH,  designer and manager of the agency’s  Professional Development and Training Unit.    He led a contingent of Cal/OSHA staff-volunteers to assist at the World Trade Center disaster recovery site in October 2001.   Following that, he  successully (but not with a struggle)  integrated Cal/OSHA into California’s Emergency Response system, leading to the agency’s  full  integration  into the local and State Incident Command System.    

 

Swine flu in health care workers: a first look

The Pump HandleFri, 06/19/2009 – 08:25

by revere, cross-posted from Effect Measure

Swine flu infection of health care workers (or as CDC refers to them, health care personnel or HCP) was of interest early in the pre-pandemic phase for at last two reasons. One was the obvious goal of estimating the risk to front line workers and devising best practices for their protection. Another was the belief, reinforced by the SARS outbreak in 2003, that spread to HCP was an early warning that the virus was easily transmissible from person to person. SARS is a disease where patients are most infectious in the later stages when they are extremely ill, and HCP were among the hardest hit groups. Most flu is transmitted in the community, but the SARS model still seems appropriate for flu viruses like H5N1 (”bird flu”) where transmission is rare. Any report that a health care worker has been infected from a bird flu patient is viewed with alarm, possibly suggesting that the probability of transmission has increased. And bird flu was the template upon which pandemic planning was based. So within a few weeks of the outbreak (the first case of novel H1N1 was diagnosed in mid-April), CDC asked state health departments to report any cases of novel H1N1 among HCP. Yesterday they reported the first results in CDC’s Morbidity and Mortality Weekly Reports (MMWR):

As of May 13, CDC had received 48 reports of confirmed or probable infections with novel influenza A (H1N1) virus; of these, 26 reports included detailed case reports with information regarding risk factors that might have led to infection. Of the 26 cases, 13 (50%) HCP were deemed to have acquired infection in a health-care setting, including one instance of probable HCP to HCP transmission and 12 instances of probable or possible patient to HCP transmission. Eleven HCP had probable or possible acquisition in the community, and two had no reported exposures in either health-care or community settings. Among 11 HCP with probable or possible patient to HCP acquisition and available information on PPE [Personal Protective Equipment] use, only three reported always using either a surgical mask or an N95 respirator. (CDC, MMWR [cites omitted])

This is information from 18 states during the earliest phase of the outbreak, with illnesses that had onset between April 23 and May 4. Additional information was available for only 26 of the 48 HCP cases, so this is a small sample making generalizations risky. The HCP reporting was of special interest and not representative of all cases and we know many cases were missed in the general population. On the basis of this evidence, however, HCP don’tseem to have been a greater proportion of the cases than their percentage in the general population (”Among confirmed and probable cases in adults aged 18-64 years and reported to CDC as of May 13, approximately 4% have occurred in HCP; approximately 9% of working adults in the United States are employed in health-care settings”). In other words, infection of HCW was not a good sentinel for transmissibility in general for this virus.

What do we learn from the 26 cases with detailed information on risk factors? 50% appear to have contracted their disease in a health care setting, with at least 5 directly from a patient. In the early weeks of the outbreak hospitalizations were uncommon, so most of the HCP contracted their disease in outpatient settings. Only 3 had used a surgical or N95 mask, but of these, one, a physician used an N95 mask all the time but it had not been fit tested. In general, CDC’s recommendations for PPE during this outbreak were not followed, although masks and gloves were worn sometimes.

Like anyone else, HCP also contracted their infections in community settings. So they are a possible vector between health care and the community in both directions. CDC emphasized in its Thursday press briefing that ongoing investigations of HPC clusters was suggesting two things related to this: (a) infectious patients should be identified as soon after they come in the door as possible so that HCP can use the necessary protective measures; and, (b) HCPs should not come to work sick. At least one of the cases was a probable HCP to HCP transmission and a sick HCP can infect vulnerable patients. We can expect to see additional guidance and better data as more data is collected and analyzed.

It is perhaps somewhat counterintuitive that HCP, with a high potential for exposure, have no higher risk. Perhaps we will revise this judgment as more reliable and larger amounts of data come available. At this point it seems that when there is lots of this virus in the community, you are as likely to get it outside of as inside a health care institution. That would seem to apply both to patients there for other reasons and to people who work there.

We” ll have to see if this holds as we learn more.

EPA Declares Public Health Emergency in Libby

The Pump HandleThu, 06/18/2009 – 15:03

It might seem obvious that having an entire town heavily contaminated with asbestos and hundreds of residents sickened by asbestos-related illnesses would constitute a public health emergency. Getting the federal government- specifically, the EPA- to actually declare a public health emergency in Libby, Montana took years of effort, though. Yesterday, EPA Administrator Lisa Jackson finally announced that a public health emergency exists at the Libby asbestos site,  and the declaration  will allow it to get more resources for cleanup and healthcare.

Andrew Schneider (who’s now blogging at Cold Truth- update your bookmarks and RSS feeds!) wrote last month about the need for this declaration:

However, [Senator Max Baucus] says that major help may be on the way as he believes he can get a Public Health Emergency declared for Libby.

Battles had been fought throughout the Bush Administration, by OMB and EPA for years over those three little words.

Paul Peronard, Chris Weis and Aubrey Miller- the trio of EPA emergency response and public health specialists who were the first to arrive in Libby a decade ago-   had their careers threatened repeatedly because they saw the need to declare the emergency.

They fought for the designation because it would permit EPA to do the complex cleanup the unique tremolite asbestos demanded, the town needed and would make the government responsible for ensuring the delivery of adequate health care.

The Bush Administration fought the effort because it was trying to force an industry-sponsored asbestos litigation reform act through Congress and wanted no attention brought to the devastation asbestos could impart.

The Democratic lawmaker lambasted the decision to not declare a public health emergency at the time, calling it an “outrage.”

Baucus said a public health emergency would authorize cleanup work in homes and other structures as well as require the federal government to provide screenings and health care for Libby residents with asbestos-related disease.

This is the first time that a public health emergency has been declared under the 1980 Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), which is also known as Superfund.

It’s not until the last paragraph of the EPA announcement that we get a brief mention of W.R. Grace, the company that continued running the asbestos-contaminated vermiculite mine for decades after the harms of asbestos were widely known. Last year, the company agreed to pay the government $250 million for cleanup costs, even though the eventual tab was likely to be closer to double that amount.

It’s much harder to put a figure on the human toll of this public health disaster. In his excellent Seattle Post-Intelligencer series on Libby and in his book, An Air That Kills, Andrew Schneider chronicles the struggles of Libby residents, many of whom spend the last months or years of their too-short lives tethered to oxygen tanks and unable to do simple household chores. Former mine workers also struggle with feelings of guilt, knowing that the asbestos fibers they brought home in their clothes probably sickened their family members.

EPA’s declaration of a public health emergency in Libby doesn’taddress the terrible loss of life the town has already suffered, but we can hope that it will ensure proper medical care for those who get sick and prevent further exposures to asbestos.

Scientists Fault Report on Camp Lejeune Contamination

The Pump HandleThu, 06/18/2009 – 12:57

We wrote last month about the Agency for Toxic Substances and Disease Control’s withdrawal of a report that omitted important information about the contamination of the Camp Lejeune military base in North Carolina – a move that seemed to indicate better prospects for the hundreds of former base residents who used contaminated water and are seeking damages for health problems. On Saturday, however, the National Research Council released a report (commissioned by the U.S. Navy at the direction of Congress) that concludes it may be impossible to know whether contaminants can be linked definitively to diseases like birth defects, childhood leukemia, liver damage, and breast cancer.

Now,  five scientists who have served on committees advising ATSDR about how to move forward with Camp Lejeune health studies have come out with a statement saying the NRC report “reached puzzling and in some cases erroneous conclusions.” Here is their complete statement:

We are disappointed and dismayed at the report titled, “Contaminated Water Supplies at Camp Lejeune- Assessing Potential Health Effects,” released by the National Research Council (NRC) on Saturday, June 13, 2009. This report was two years in preparation by scientists, many of whom we know and respect, that reached puzzling and in some cases erroneous conclusions. We are aware of the complex situation regarding availability and access to data, and each of us has participated in committees advising the Agency for Toxic Substances and Disease Registry (ATSDR) about how to move forward with health studies. It is our view that the Marines and their families who were exposed to dangerous chemicals in the Camp Lejeune drinking water over several decades deserve to know if this exposure has had an effect on their health. The most direct way to assess this is to conduct valid epidemiologic studies of those who lived or worked there, and we urge ATSDR to continue their efforts to carry these to conclusion. The overall judgment about the impact of the chemicals on health can then be informed both by the general scientific literature the NRC reviewed, plus findings from directly relevant studies of the exposed population.

Specific areas where we disagree with the NRC report include their assessment of the water distribution modeling, their assessment of the risk caused by exposure to two of the principal contaminants (TCE and PCE), and the likelihood of conducting meaningful epidemiologic studies in this setting. We view the water modeling undertaken by ATSDR and its consultants as “state-of-the-art” and worth carrying through to completion so that it can be used in the on-going and proposed health studies. There may be uncertainties about specific levels of exposure for individual households or people, but these can be described in the study results. We also agree with the National Toxicology Program that TCE and PCE are “reasonably anticipated to be human carcinogens” and reject the characterization of the evidence as “limited/suggestive” as presented in the NRC report. We note that this characterization of solvent mixtures actually steps back from previous work done by the National Academy of Sciences Institute of Medicine in 2003. Finally, we disagree with the thrust of the NRC report that it is unlikely that scientifically informative epidemiologic studies of the Camp Lejeune population can be done. The NRC doubts that “definitive” answers can come from any study, but this sets the bar too high- no one study can provide definitive answers, and all studies must be considered in the light of other scientific evidence. From our experience in other settings, we believe that useful studies of the Camp Lejeune population are possible and furthermore that the Marines and their families deserve our government’s best efforts to carry them out.

For these reasons, we urge the ATSDR to consider this particular NRC report in the context of other expert advice they have received during the past decade and the competent work already done by agency staff. Since the NRC report is at such variance with the recommendations of other water modeling and epidemiologic experts, we believe it should not stand as the final word.

Sincerely,

Ann Aschengrau, Sc.D., Professor, Associate Chair of the Department of Epidemiology, Boston University School of Public Health

Richard Clapp, D.Sc., MPH, Professor, Boston University School of Public Health

David Ozonoff, MD, MPH, Professor and Chair Emeritus of the Department of Environmental Health, Boston University School of Public Health

Daniel Wartenberg, Ph.D., Professor, Environmental and Occupational Medicine, Robert Wood Johnson Medical School

Sandra Steingraber, Ph.D., Scholar in Residence, Ithaca College

Senator Kay Hagan of North Carolina (where Camp Lejeune is located) also issued a press release stating that she “cannot stand behind the validity” of the study. She also said, “The resolution of this issue cannot be held hostage to additional scientific studies that may not tell us anything more than we already know.”

CalOSHA inspectors demand change

The Pump HandleWed, 06/17/2009 – 18:36

A group of 47 H&S inspectors, supervisors and managers from California OSHA (Cal/OSHA) sent a pointed letter to the three-person OSH Appeals Board demanding they “cease and desist” their destructive practices.   This Appeals Board is equivalent to the OSH and MSH Review Commissions; it exists because California is one of the 23 States that operates its own OSHA program.    

The CalOSHA employees  wrote, we:

 ”strongly protest Board policies and practices that have significantly undermined our ability to do our job of protecting the lives, health and safety of California’s workers.”

It’s amazing to me (and refreshing)  in these dire economic times,  with Governor Schwarzenegger slashing the state budget, that these state employees are willing to act collectively and speak up.   Their outrage stems from a practices that started four years ago by the OSHAB to reduce a backlog of 4,000 cases.    

Some cases were taking 2-3 years for a hearing by an administrative law judge.   (We know that under the OSH Act,  an employer can’tbe compelled to correct  hazards until the company’s appeals are exhausted—not a good way to prevent  injuries and illnesses.)    The California OSHAB’s brilliant scheme for “resolving”  the backlog was…..get this…..over-booking the ALJ’s schedule.     The judge will be given three or four cases to be heard at exactly the same date and the same time.   The result:  the Cal/OSHA  managers and attorneys have to  pick a small subset of cases to go to hearing and “settle” the rest of them.

The Cal/OSHA employees write:

“How can we…prepare exhibits, witnesses and arguments for three separate cases all scheduled for the same time?   How can we convince worker witnesses to travel long distances, and then to come back after they have been sent home because their case wasn’theard?   The simple answer is that we can” t.”

“The Board has continued to refuse to even indicate which case will be heard first.   The Board has continued to hold hearings at distant locations where worker witnesses have great difficulty in appearing.   The Board has continued to deny, or simply ignore, legitimate requests for continuances.”

“That’s why there have been hundreds more ‘settlements’ over the last four years, many with drastic reductions in final penalties.   These policies are in addition to the recent practice of the Board to dismiss cases, even those with serious injuries, on minor technicalities; and to unilaterally ‘interpret” legislation and ignore court rulings, so as to restrict the Division’s ability to enforce the law.”

The CalOSHA employees go on:

“As you must know, those of us representing the Division at appeal hearings are frequently ‘out-gunned” by the employers’ corporate attorneys who have more resources, personnel and time—even before we have been tripled booked with hearings, often in places where worker witnesses find it difficult to appear.   …We know that not all citations are ‘open and shut” cases and we believe everyone, including employers, should have the right to a speedy appeal and an impartial review of the facts.   All we want is a level playing field.”

Over the last year, I” ve heard a number of very troubling complaints about abuse of power and/or substandard peformance by some of the OSHA State-Plan States: Nevada, North Carolina, and Minnesota come to mind.   I wonder if its time for some oversight of OSHA’s oversight of them?

Identifying Lead-poisoned Adults

The Pump HandleWed, 06/17/2009 – 14:32

The 1,050 State public health experts who make up the Council of State and Territorial Epidemiologists (CSTE) is urging the  States and CDC  to adopt a new case definition for adults of elevated blood-lead levels (BLL) and to require laboratories to report ALL blood lead test results to NIOSH’s  Adult Blood Lead and Epidemiology (ABLES) Program.   CSTE recommends the  definition of   an “elevated BLL” change from  25 ug/dl and greater, to  10 ug/dl and greater.  

The CSTE’s policy statement is grounded on the growing body of evidence linking “low” levels of lead in adults with decreased  kidney function, cardiovascular disease and cognitive impairment.   A mini-monograph published  in 2007 in Environmental Health Perspectives  provides some of the most recent evidence cited by CSTE to support its recommendation.   The  group identified  a number of occupations for which workers are at particular risk of lead poisoning such as  construction involving  paint removal; demolition and maintenance of outdoor metal structures (e.g.,  bridges,  water towers);  and battery manufacturing and recycling.   (I” ve written previously about mine workers with lead poisoning.)    

 In CSTE’s news release  announcing the policy recommendation, the group noted:

“…only a fraction of known occupational cases are included in national health statistics, which currently only include counts of individuals with blood lead levels 25 ug/dl and greater.     …The result is a significant underestimation of the health impact of elevated blood lead levels in the population of the United States.     …With more complete reporting, we will have a clearer picture of the true scope of the problem to guide our efforts to prevent lead poisoning.”

The CSTE’s policy recommendation for an improved evidence-based definition of an elevated blood-lead level compelled me to look at a few of OSHA’s requirements related to lead exposure, surveillance and prevention.  

OSHA’s lead standard for general industry workers took effect (mostly) in 1981, and in 1993 for construction workers.   Both health standards include provisions for medical removal protection for lead-exposed workers (at no loss of pay) when  

  1. their blood-lead level (BLL) is at  or exceed 50 ug/dL, or
  2. there is a medical determination that “the employee has a detected medical condition which places the employee at increased risk of material impairment to health from exposure to lead.” [Section (k)(1) in 1910.1025 and 1926.62]

Under OSHA’s standards, a worker may return to work when their BLL is at or below 40 ug/dL, and  an employer is required to record  cases that the  medical removal criteria  on the worksite’s log of injuries and illnesses.   The disparity between OSHA’s definition of a case of adult lead poisoning (i.e., 40 ug/dL) and the CSTE’s recommended new definition of an elevated  BLL in an adult (i.e., 10 ug/dL) raises interesting issues for public health policy:

  • CSTE notes the importance of  maintaining “adult BLLs less than 10 μg/dL to avoid long-term health risks,” but OSHA’s standard implies that a BLL of 40 ug/dL or less is not harmful.  
  • CSTE’s recommendation for laboratory reporting to the CDC/ABLES system  of BLL’s at 10 ug/dL or greater, but OSHA’s requirements for recording a poisoning-injury is trigger only at the medical removal stage (typically a 40 ug/dL BLL).
  • Should CSTE’s recommendation and other calls for a more protective lead standard  prompt OSHA to change its recording requirements for elevated BLLs?   Or would OSHA be able to ascertain easily using ABLES which employers’ work conditions are responsible for  elevated BLLs?
  • Should MSHA (which has NO standard to protect workers from exposure to lead) adopt a policy requiring mine operators to report cases BLLs above 10 ug/dL as part of the agency’s Part 50 reporting system.   Currently, mine operators’ responsibility to report to MSHA hinges on their   knowledge of an illness case or an award of compensation.

My curiosity about how CSTE’s recommendation jives with OSHA’s lead standard and recordkeeping requirements, led me to  several  OSHA policy interpretations.   On  the one hand, OSHA suggests that  its recordkeeping rule,  among other things,  is supposed to help employers (and the agency)  recognize trends and implement preventative measures.   With respect to  an elevated BLL, this  precautionary interpretative statement by OSHA  seems to apply:

“A  ” diagnosis of substantial impairment of a bodily function” is not required for a case to meet OSHA recordkeeping criteria, nor is it a limitation to recordability under the OSH Act.   Many injuries and illnesses meet the recording criteria of the Act but lack diagnosis of a substantial impairment of a bodily function.     ….The workers are being removed not only to prevent illness, but to prevent further damage beyond what has already been done.” [emphasis added.]

On the other hand, and in the same  document, OSHA explains the recording requirements in terms of medical removal provisions:  

“…The medical removal provisions of each standard were set using scientific evidence established in the record devoted to that rulemaking.   OSHA takes care when setting the medical removal provisions of standards to ensure that these provision reflect a material harm, i.e., the existence of an abnormal condition that is non-minor and thus worthy of entry in the OSHA injury and illness records.”

“OSHA finds that cases involving a mandatory medical removal are cases that involve serious, significant, disabling illnesses resulting in restriction of work and transfer to another job, or both. These medical restrictions result either in days away from work or days when the worker can work but is restricted from performing his or her customary duties…”   [emphasis added]

Neither the CSTE document nor the published literature suggest that a BLL of 10 ug/dL constitute a “disabling illness.”     Rather the evidence indicates that adults with elevated BLL are at risk of  kidney, cognitive and  cardiovascular impairment.   If OSHA wanted to amend its recordkeeping rule (1904) to require  employers to record  BLLs of 10 ug/dL,  what would the resource demand be to make that simple change?      Would OSHA  have to calculate the “paperwork” burden,  prepare a regulatory flexibility analysis? determine special burdens for small businesses?   Egads! all that and probably more to simply make OSHA’s recording requirement consistent with any new CDC case definition?  

I” m not sure  a rulemaking change  would be worth the effort.   The CSTE’s recommendation, however,  should invigorate between discussion at NIOSH, State-ABLE staff  and OSHA of how  BLLs at 10 ug/dL and above can be referred promptly for a  workplace  investigation and public disclosure of the employer(s) identity.

Law firm doing dirty work for coal industry?

The Pump HandleWed, 06/17/2009 – 08:42

The Charleston Gazette’s Ken Ward Jr. reports that  one of West Virginia’s oldest and largest law firms, Jackson Kelly PLLC, is being sued for hiding evidence of coal miners’ black lung disease.   Ward  writes:

“Earlier this year, an investigative panel of the state’s Lawyer Disciplinary Board filed misconduct charges against Douglas A. Smoot.   Smoot hid a key portion of coal miner Elmer Daugherty’s medical examination report during a 2001 case, a board investigative panel alleged.   A hearing on those allegations is scheduled to start June 18.   And two lawsuits filed last month in Raleigh Circuit Court accuse Jackson Kelly of a widespread pattern of trying to cheat miners out of black lung benefits.”

If these allegations are true—cheating  injured coal miners from due compensation—that’s some low-down dirty work  for their  coal industry clients.  

Ward explains:

“The cases allege instances where unidentified Jackson Kelly lawyers gave judges or the law firm’s own experts only portions of the medical test results, withholding other evidence that proved miners had black lung.   In some instances, Jackson Kelly attorneys allegedly withheld proof of black lung from miners who did not have lawyers helping with their benefits cases.   But once those miners obtained lawyers, and those lawyers sought complete copies of the medical evidence, Jackson Kelly tried to settle the cases and avoid revealing the fraudulent actions, the lawsuits allege.     …The allegations stem from Jackson Kelly’s representation of coal companies that opposed the granting of black lung benefits for miners.”

For readers of The Pump Handle with experience in or research on our workers’ compensation system, these allegations may not surprise you.

Ward reports that the  lawsuits against Jackson Kelly was filed by attorneys John C. Cline  and Allan N. Karlin who represent  a  coal miner named Norman Dale Eller and the estate of deceased  miner Gary Fox; the attorneys assert evidence of misconduct from four additional black lung cases.   Quoting from one of the official complaints:

“The pattern and practice of Jackson Kelly’s conduct in these cases demonstrates that the conduct is neither accidental nor negligent and that Jackson Kelly attorneys have knowingly misrepresented evidence to the [administrative law judges] who decide these cases as well as to the claimants.”

Read all of Ward’s reporting  to get a snapshot of how the black lung claims process works (or fails to work).   He also provides links to the  misconduct charges, and the two lawsuits.

Under the Coal Mine Health and Safety Act of 1969 (amended by Mine Act of 1977) coal miners who become totally disabled due to pneumoconiosis are eligible to receive federal black lung benefits.   The burden of proof-total disability-is steep, and depends on physicians’ interpretations of x-rays and CT scans.   Typically, it’s the opinions of dueling experts (employer’s vs. worker’s)  that are assessed by an administrative law judge working for the U.S. Department of Labor.     It is anything but the non-adversarial system I interpret in the statute (see Mine Act Title IV).

We can count on Ken Ward to continue his coverage of these misconduct charges.   Can we count on Secretary of Labor Solis’ MSHA to take regulatory action to PREVENT workers from developing illnesses from exposure to coal mine dust and silica???    

Thirty years from now we shouldn’tneed a system to provide just compensation for middle-aged miners disabled by CWP, if our nation makes a  vigorous commitment NOW  to END coal workers’ pneumoconiosis (CWP) and silicosis.   But, it  was with sincere disappointment that I reviewed the Labor Secretary’s regulatory agenda issued in May, which did not mention respirable coal dust or silica.   In the related on-line agency rule list, DOL leadership indicated a plan to  propose a new regulation on these airborne toxins in April 2011 (here and here).

When  MSHA officials were asked  by the Courier-Journal’s Jim Carroll to explain  the two-year timeframe to  merely propose a rule on these exposure limits,  the agency’s spokesperson responded  that setting new health standards:

“requires a significant amount of up-front time” and “since the regulatory requirements for health standards are, by their very nature, complex.   MSHA’s  agenda projects what the agency considers to be a reasonable timetable to develop these proposals.”

I disagree.   The basic questions that MSHA must answer are:

  1. Is there evidence that  miners face a significant risk of material impairment from exposure to coal mine dust and silica.
  2. Is the evidence sufficient to demonstrate that MSHA’s decision is not arbitrary and capricious?
  3. Is the proposed lower exposure limit feasible for the mining industry as a whole?

 The answers are YES, YES, and YES.  

There is nothing particularly complicated or complex about the health science, the engineering,  the economics, or the law.     The “complications” are value-laden political choices.   Let’s call it as it is.

Raising Revenue for Healthcare Reform

The Pump HandleTue, 06/16/2009 – 15:35

When discussing the costs of various healthcare reform proposals, it’s crucial to keep one thing in mind: doing nothing would be a financial disaster. If we don’tchange the rate at which healthcare costs are growing, total health spending is projected to double over the next 11 years, from an expected $2.6 trillion this year to $5.2 trillion in 2020. Medicare and Medicaid will eat up a growing share of the federal budget; employers will stop offering insurance as premiums become harder to afford; and families will struggle to pay for needed healthcare. These problems all exist today, and they” ll only get worse if we don’t“bend the curve”- that is, do something to slow the rate of healthcare-cost growth.

President Obama doesn’tjust want to control healthcare costs, though. He wants to make insurance coverage universal, and that will cost even more money. Expanding coverage can save some money over the long term- for instance, people can get health problems treated early, instead of putting off care until they end up in the emergency room. Such savings won’tcome close to covering the cost of coverage expansion, though, and they certainly won’tshow up in the 10-year horizon that Congress is considering. Really, the main reason to expand coverage is that it’s simply not right for 46 million people in the world’s richest nation to lack healthcare coverage.

Due to Congressional pay-as-you-go rules, new proposals must be either offset with savings or funded through increased revenues. (Although the amount to be saved and raised will vary depending on the specifics of each healthcare proposal, $1 trillion is a good ballpark figure to keep in mind.) Here are some of the ways to raise more money for health reform:

Raise taxes– In his budget blueprint, Obama proposed bringing in more than $300 billion by reducing tax deduction opportunities for taxpayers in the highest tax brackets. Taxes on soft drinks, alcohol, and other substances that can contribute to health problems would raise revenue while discouraging unhealthy behaviors. A New York Times article suggests that a value-added tax, which is collected at each stage of the production and sale of consumer goods, might be considered, but Ezra Klein points out that such a tax is palatable in European countries that use it to fund healthcare only because the people who are paying it are getting something in exchange (namely, healthcare). Although all of us will benefit in some way from seeing the rate of uninsurance fall, those who already have insurance coverage might resent paying more taxes in order to extend it to the other 15% of the population.
 
Limit favorable tax treatment of health benefits– Right now, the government foregoes $125 billion in revenue each year by allowing employer-provided health benefits to go untaxed. (This helps employers, who don’tpay payroll taxes on the money they use to give health benefits to employees, as well as the employees receiving the benefits.) This is actually a regressive tax policy, because higher-income taxpayers gain the most from it. During the campaign, Obama criticized McCain for proposing to eliminate the tax exclusions and deductions for health benefits, but he now seems to be open to the idea. AFSCME (the American Federation of State, County, and Municipal Employees) opposes this idea, and has already run ads attacking Senator Ron Wyden of Oregon, who proposed replacing the current tax exclusion with a progressive tax deduction for all.

The tax could be limited to employees whose insurance premiums top a certain amount, or to taxpayers with incomes above a certain level. Since employers’ insurance premiums currently vary widely depending on location, firm size, and the age, sex, and health status of the firm’s employees, it would be hard to set a dollar limit on premiums. Employees of a big Midwestern firm with many young, healthy employees might get extensive coverage for $5,000 a year per individual, while a small Northeastern company with several older employees suffering from chronic health conditions could spend the same amount on premiums but get far fewer benefits for it. If healthcare reform prohibits insurers from varying premiums based on these kinds of characteristics, it will be much easier to cap the tax exclusion for health benefits in an equitable way. The more people who get to keep their tax exclusion, though, the less revenue it raises for healthcare reform.

Impose fines for noncompliance with mandates– Healthcare reform will likely include an individual mandate, requiring all U.S. residents who can afford it to have health insurance, and may also require employers to provide health insurance to their employees. Fining those who don’tmeet the requirements will improve compliance and raise revenue at the same time. Fines will likely vary based on the size of an employer’s payroll, and businesses below a certain size may be exempt.  

All of these options will be politically difficult- and I haven’teven gotten into the proposed cuts to healthcare spending that would take money away from powerful interest groups. But Congress has to find the money somewhere if healthcare reform legislation is going to move forward.

Occupational Health News Roundup

The Pump HandleMon, 06/15/2009 – 10:19

Home health workers who care for the elderly and disabled are an indispensable part of our healthcare workforce- but the Bush Administration’s Department of Labor decided that they shouldn’tbe covered by the same wage and hour laws that protect most workers. The Associated Press’s Sam Hananel explains that the administration based this determination on their interpretation of the Fair Labor Standards Act that was amended in 1974 to exempt babysitters and companions to the elderly and sick. Earlier this week, a group of 15 Democratic Senators, headed by Senator Tom Harkin of Iowa, urged Labor Secretary Hilda Solis to interpret the FLSA as applying to home health workers.

To get a sense of just how important this issue is, everyone should read Paula Span’s terrific article about home-care aides from the Washington Post Magazine. The piece focuses on Marilyn Daniel, a 63-year old home-care aide who has become a trusted and essential caregiver for the senior clients she serves. Daniel is often gone from home for 12 hours, catching buses to travel between clients’ homes and lacking any time off for meals. She’s lucky to work for a nonprofit agency located in DC, which has a living wage law; the average wage among Daniel’s co-workers is $12.40 an hour, and Span reports that many home-care aides don’tdo that well. An agency that charges clients $20 an hour will likely pass less than half of that along to the worker, and not provide benefits; working on the “gray market,” an aide might earn $15 an hour, but she won’tbe covered by workers’ compensation and she may be unemployed for stretches of time between clients.

As Baby Boomers age and require more assistance with activities of daily living, we” ll have an even greater need for home health workers. We should make sure they have adequate protections- and that they themselves can get healthcare, too.

In other news:

Associated Press: OSHA proposes fining Wal-Mart the maximum allowed amount of $7,000 for inadequate crowd management in connection with the death of temporary employee Jdimytai Damour, who was crushed by crowds at a Black Friday sale in a Long Island Wal-Mart store (via The Fine Print).

Charleston Gazette/Coal Tattoo: The family of Chad Cook, who was killed while driving a coal truck, fought to have the Mine Safety and Health Agency investigate his death. As a result, MSHA and state officials might eventually have to do a better job of investigating all mining deaths, and providing more information about how they decide whether a death is mining-related or not.

San Antonio Express-News: Six Texans who exhibited symptoms after exposure to burn pits at US military sites in Iraq in Afghanistan are suing contractors KBR and Halliburton. According to a plaintiffs’ attorney, 34 suits involving the burn pits have been filed or are expected to be filed in 34 states.

Las Vegas Review-Journal: Nevada Governor Jim Gibbons has signed into law a bill requiring construction workers and supervisors to attend health and safety course training within 15 days after they” re hired.

The Australian: Following a ruling by Britain’s high court that allows more than 1,000 British veterans to pursue class-action claims for health problems following their exposure to nuclear tests, Australian veterans exposed to nuclear testing in the 1950s have stated that they will lodge a class-action suit of their own if their government does not agree to award compensation and benefits by the end of the month.

Revolutionary medicine

The Pump HandleMon, 06/15/2009 – 08:59

by revere, cross-posted from Effect Measure

One of the premier and earliest flu bloggers and co-founder of Flu Wiki, DemFromCT is also a doctor. Not a young doctor, either, although somewhat younger than I am (most people seem to be, these days). In our young professional days, the American Medical Association was a real political power. When it spoke, politicians listened. Hell, everyone listened. Now? Well, who cares? Dem has a really excellent post up at DailyKos looking at the AMA’s opposition to the “public option” in the Obama health care plan. I” m not so crazy about a public option either. If there’s an option, it should be a “private option.” I want a public system. But that’s not what this post is about. I want to add some personal observations about the AMA to Dem’s post.

I” ve lived through two periods of medicine in this country. The earlier one, before 1964 and third party payers like Medicare and Blue Cross, was quite different than the one most of us are familiar with. My father was a “physician and surgeon” in those days and in his best year never made more then $10,000 dollars. He went to the office 7 days a week (the Sunday visit I suspect was to get some peace and quiet and do paper work), rounded at the hospital every day, made house calls, took out appendixes, delivered babies, treated diabetes, sewed up the lacerations of the cook at White Towers at 3 am, etc. I used to go to the office with him and he would let me go in the dark room with him while he developed the x-ray he just took, or I watched him make a sputum smear, stain it and then look at it through his microscope (which now sits on a chest in my dining room under a bell jar). His patients paid him a buck or two if they had it; if they didn’twe got a present of some kind at Christmas time. For some reason bottles of booze were popular. We had a very well stocked liquor closet for a family who didn’tdrink. No one had insurance, to speak of. So he, and many other doctors, worked hard and made an OK, but not a great, living. He died in 1957, shortly after making a house call. I remember him saying the person tried to push some money on him he wouldn’ttake. A couple hours after that he was dead. Seven years later, when I was a second year medical student, Medicare came on the scene, bitterly opposed by organized medicine. And the result? Doctors got rich.

The AMA started in 1847 as a small group of doctors intent on improving the economic condition of medicine. In the 19th century there were all sorts of practitioners — Thomsonian Botanicalists, homeopaths, bleeders and purgers )those were the regular practitioners — and lots of ways you could become a doctor. You could go to a medical school, of course. There were lots of them and they made money. Or you could apprentice to a practicing doctor. After two years or so you could hang out your own shingle. Licensing? Nope. The result was ruinous competition. The founders of the AMA hoped to do something about it. They didn” t. For over 50 years hardly anyone belonged to the AMA. It was an irrelevant social club for a few. But in 1900 in re-organized politically and began an era of spectacular growth and success. The AMA didn’tfocus on a national organization but a grassroots one. The basic unit was the country medical society. The county society belonged to a state society and the states to the national AMA. Every legislator had a doctor and therefore a personal lobbyist. The first objective was licensing laws and brining medical education to heel. The Flexner Report (1907) about medical school reform was part and parcel of the effort to both bring standards to the profession and stop anybody and his brother from starting a medical school. Country societies brought pressure on hospitals not to let a doctor have hospital privileges unless they were a member, and if you were a member of the country society you were automatically a member of the state and national AMA. Membership grew rapidly. By the end of the progressive era the AMA had an iron grip on medical education and licensing in almost every state. And also effective opponents of any government health insurance as a form of contract medicine.

The AME was bitterly opposed to any form of contract medicine because they had found that companies that offered free or very low cost health care benefits to employees did it at the expense of doctors, paying them very little per capita and providing a new kind of competition to the newly organized AMA rank and file. This opposition to anything but fee-for-service was a consequence of the effort to control low cost competition and became a reflex of AMA policy. For all of my father’s life as a doctor the AMA was a major political power, and it was doctors like my father that were its main beneficiaries (although he was a member, I don’tthink he cared much about it. He just paid dues and was a member of the country society like most doctors.). While Medicare and private health insurers made doctors rich beyond their wildest dreams, the AMA understood it would eventually threaten its power. Doctors would become proletarianized. As salaried workers they are very well paid, but they are salaried workers nonetheless, and the AMA has little to offer them except the usual guild-like behavior of fighting for higher reimbursements. As Dem points out, most doctors don’teven belong to it anymore. The AMA represents less than one in five practitioners.

So now we are rapidly moving into a new era of medical practice. No one is quite sure what is on the other side of this transitional period, but whatever it is and however long it takes, it won’tbe the same as before, just as the last 50 years were very different than the days when my father practiced (days which no one remembers any more). Like the revolution at the turn of the 20th century and the next one in the 1960s the change came because the old ways were broken, unsustainable.

That’s where we are again. Welcome to the revolution.

Swine Flu: Officially a Pandemic

The Pump HandleFri, 06/12/2009 – 14:50

The World Health Organization has officially declared that we” re at the start of an influenza pandemic. Nearly 30,000 cases of swine flu/H1N1 have been confirmed in 74 countries, and the virus is spreading easily among people in multiple regions of the world. North America has had the highest number of cases so far- 13,217 in the US, 6,241 in Mexico, and 2,978 in Canada- and new cases are still being reported. (In fact, CDC’s count for the US, which tends to run ahead of WHO’s, is now at 17,855.)

Countries in the Southern Hemisphere are just entering flu season, and large numbers of cases have been confirmed in Chile (1,694) and Australia (1,307). The Washington Post’s David Brown quotes WHO Director General Margaret Chan explaining that H1N1 is crowding out the seasonal influenza virus, which is a typical feature of past pandemics.

Chan also emphasizes an important unknown about this virus: how it will behave in conditions typically found in the developing world. So far, swine flu has killed only 145 victims, but in her public statement Chan said, “It is prudent to anticipate a bleaker picture as the virus spreads to areas with limited resources, poor health care, and a high prevalence of underlying medical problems.”

We don’tknow what will happen with this virus or how bad the pandemic will get. Keep washing your hands, covering your cough, and limiting your contact with others if you” re sick- and Revere also recommends getting a pneumococcal vaccine to prevent one of the serious common complications of influenza. This pandemic is also a good reminder that our politicians need to hear from us about the importance of a strong public health infrastructure, because our current facilities will be severely overtaxed if this virus comes back and wallops us in the fall.

Ideologically Motivated Killings and Fear at Work

The Pump HandleThu, 06/11/2009 – 10:57

Less than two weeks ago, Dr. George Tiller, one of the few health providers who would still perform late-term abortions, was murdered. (Judith Warner’s column on Dr. Tiller’s important work is well worth a read.) Police arrested Scott Roeder of Kansas City, and the office manager of a Kansas City women’s clinic says that Roeder matches the description of a man found vandalizing the clinic on two recent occasions, including the day before Tiller’s murder. The office manager filed police reports after both incidents and gave details to the FBI, including the suspect’s license plate number. Could a swift response by police or the FBI have prevented Tiller’s death?

Yesterday, another ideologically motivated killer struck. The attacker shot Stephen T. Johns, 39, of Temple Hills, Maryland, a security guard at the Holocaust Memorial Museum. Police arrested James von Brunn of Annapolis, who is said to be a leading writer in the white supremacist movement.

This kind of terrorism aims to instill fear in people who work for organizations targeted by extremist groups. Employees at women’s clinics nationwide are increasing security measures, and the Anti-Defamation League is encouraging Jewish institutions to review security protocols and use increased alert statuses. While law-enforcement patrols at these types of sites have evidently increased in the wake of these shootings, there are also questions about what kinds of larger efforts the government should be making to prevent such acts of terrorism.

Alex Kingsbury at U.S. News & World Report notes that the Department of Homeland Security has been warning about just these sorts of events:

A month before a suspected white supremacist walked into the Holocaust Memorial Museum in downtown Washington and opened fire, the Department of Homeland Security warned that domestic right-wing extremism was the most pressing domestic terrorist threat that the country faced.

Conservatives were outraged that the DHS analysts had singled out antiabortion and antitax radicals for scrutiny. But the report was part of a series that DHS compiles on domestic dangers from all sides of the political spectrum, an area that’s taken a back seat to overseas threats.

A series of recent incidents shows the prescience of those reports and illustrates the worrying reality that terrorism often comes from inside the homeland. Worse still, the reports caution that such attacks are likely to happen again.

Congress and the White House must make sure that national security officials devote appropriate resources to addressing domestic terrorist threats- and stand up to any conservative complaints about domestic anti-terrorism and law-enforcement activities.

At The American Prospect, Ann Friedman explains some of the measures that can help protect health clinics specifically:

From the immediate post-Roe years to the mid-1990s, clinic violence and blockades were a constant threat. After Dr. David Gunn was assassinated in 1993, Congress passed the Freedom of Access to Clinic Entrances (FACE) Act, which specifically banned such acts as blocking clinic doors, trespassing, making violent threats, arson, vandalism, stalking clinic employees, and other forms of violence. Many of these acts were illegal already, but the law made clear that targeting a clinic with these crimes merited a federal response.

While FACE improved the situation (the number of clinics experiencing severe violence dropped from 52 percent in 1994 to 20 percent in 2000), it didn’tsucceed in ending the violence. Attacks against women’s health clinics — both those that provide abortions and those that do not — continued throughout the Bush years. According to the National Abortion Federation, since 2000 abortion providers have reported 14 arsons, 78 death threats, 66 incidents of assault and battery, 117 anthrax threats, 128 bomb threats, 109 incidents of stalking, 541 acts of vandalism, one bombing, and one attempted murder.

Add one murder to that list.

The last time an abortion provider was murdered, when Dr. Barnett Slepian was killed in 1998, it was a wake-up call to the fact that passing the FACE Act wasn’tenough. Attorney General Janet Reno established the National Task Force on Violence against Health Care Providers, which committed the Department of Justice to enforcing FACE, coordinating information on national anti-abortion extremist groups, funding clinic safety efforts, and training local law enforcement. The following year, the White House budget requested $4.5 million to beef up security at abortion clinics. But other than finally bringing James Kopp, Slepian’s killer, to justice in 2003, the task force was largely dormant for eight years under the Bush administration.

Friedman notes that  statements following Tiller’s murder from Obama and Attorney General Eric Holder didn’tmention FACE or reviving the task force, and she urges that we have some means of accountability (either an active task force or something else) to ensure that existing laws against clinic violence are fully enforced.

In the meantime, many of the people going to work at facilities that have been threatened by extremist groups are probably feeling worried. Officials should take the necessary steps so that they don’thave to fear going to work.

Swine flu: are we there, yet?

The Pump HandleWed, 06/10/2009 – 12:28

by revere, cross-posted from Effect Measure

Listening to yesterday’s press briefing with WHO’s Dr. Keiji Fukuda (audio file here), several things seemed clear to me. The first is that everyone, WHO included, thinks a pandemic is well underway. Second, WHO’s efforts to explain why they are not making it “official” by going to phase 6 are becoming increasingly awkward and the explanations manifestly tortured. Essentially what Fukuda said was that WHO was waiting for its member nations to signal they knew it was a pandemic and then WHO would say it was a pandemic. It was reminiscent of the cries of one of the principals of the revolution of 1848 as he chased the mob into Paris’s Jardin du Luxembourg: “I” m their leader! I must follow them!” Third, despite Fukuda’s calm and measured tone, there was an undercurrent of worry. The severity of the not-yet-called-a-pandemic pandemic is now being termed “moderate” (which seems accurate to me). Fukuda explicitly declined to characterize it as “mild.” He also called attention to reports of “disproportionate numbers of serious cases occurring” in Canada’s First Nation (indigenous) community. From the Winnipeg Free Press:

There has been a “surge” in the number of people requiring intensive care in Manitoba hospitals with flu-like illnesses, the province said Monday.As of Sunday night, there were 26 such people in hospital — more than half of them aboriginal. All were or had been on ventilators due to influenza or of an influenza-like illness. Eight persons with severe cases required hospitalization in the past week alone.
Joel Kettner, chief provincial public health officer, said Monday “most if not all” of the cases are expected to be confirmed as the new H1N1 influenza.

[snip]

Kettner said the 26 people on ventilators in hospital are “very ill.”

“Some of them have been on ventilators for several weeks… The pattern has been so far that many of these patients have required several weeks of intensive care before they have recovered.”

He said that in the first week of June, the rate at which people became severely ill with what is suspected as H1N1 was far higher than it was in April or May.

More than half of those in intensive care are First Nations people — status or non-status as well as Inuit.

[snip]

Jan Currie, vice-president of the Winnipeg Regional Health Authority, said there are normally 30 to 35 people on ventilators in Winnipeg hospitals at any one time for a variety of reasons.

The 26 listed by Kettner are in addition to that, she said. The WRHA has acquired 15 extra ventilators and may defer non-urgent procedures that would normally require ICU care. It is also taking steps to provide enough support in intensive-care units and prioritizing patients for personal care home beds.(Larry Kusch, Winnipeg Free Press)

 

As Fukuda points out, influenza took a heavy toll in isolated and disadvantaged communities in earlier pandemics. This is part of a picture of a well transmitted novel influenza virus, circulating out of season and hitting younger age groups differentially, just what one expects from a pandemic strain based on past experience.

The on-again-now-off-again inclusion of severity as a criterion for a pandemic is currently being spun as a descriptor to give member nation’s the best information on the nature of the pandemic they are dealing with. I think that’s a sensible attitude, and I don’tfault WHO. The politics of any intergovernmental agency, especially in the UN system, produce a difficult and treacherous landscape to negotiate. If you” ve never seen it close up, it’s hard to appreciate the labyrinthine and counter-to-common sense ways of the international community. This is not the UN’s fault and certainly not WHO’s. It is the system they (and we) are forced to work within, as mandated by the nations of the world. If the space program becomes robust enough, someday you may be able to opt out for another planet. Until then, it’s no use complaining.

Meanwhile we now have the long predicted influenza pandemic. It’s neither so scary nor so benign that we can afford to either hide under the bed or ignore it. What we must do is roll up our sleeves and manage the consequences.

Explosion at NC ConAgra meat plant

The Pump HandleTue, 06/09/2009 – 16:19

Updated below (6/13/09)

The Associated Press and other news sources are reporting on an explosion today at a meat processing facility in Garner, NC.   Four workers are missing, at least 41 are injured, including several with very severe burns.   One worker reports:

“I was picking up a piece of meat off the line and I felt it, the percussion [force of explosion] in my chest.    One of the guys I was working with got blown back, he flew backwards.”

A local news source WRAL.com reports  the explosion:

“…caved in parts of the roof, sparked fires and caused an ammonia leak.   …Many [workers] suffered from exposure to toxic fumes from ammonia leaks, and some also suffered chemical burns.”

This report quotes another worker:

“‘ “What I saw (and) heard was this boom, and the ceiling start coming down, and we all start running.    Everyone was trying to get to the exit door. … I was just trying to get out…” ”

And adds a bit of information about what happened to the ammonia after the initial explosion, offering information from a spokesperson from the NC Dept of Environment and Natural Resources:

“ConAgra implemented its emergency plan immediately after the explosion, dumping the ammonia from lines in the plant into a settling pond.      The state Division of Air Quality and the EPA sent managers to the plant to ensure emergency response plans and protocols for storing hazardous materials were being followed.”

The U.S. Chemical Safety Board is on the scene, with Don Holmstrom serving as the lead investigator.   Workers at the plant are members of Local 204 of the United Food and Commercial Workers Union.

Senator Kay Hagen (D-NC) issued a statement concerning the explosion:

“Like many North Carolinians, I was extremely concerned to hear the news of today’s building collapse in Garner.   My thoughts and prayers are with the families and loved ones of the injured and missing workers from this tragic accident.   First responders from across the Triangle are working together at the scene to administer aid, and I hope their efforts to find those still unaccounted for are successful.”

North Carolina is one of the States that runs its own occupational health and safety enforcement program.   It will be their responsibility  to conduct the catastrophe investigation.

Updated (6/10/09):   a Pump Handle reader shared this  from “bizjournals.com”  with a note:  ”Slim Jims OK.   Workers… not so much.”     Indeed.

“The Garner plant is the only facility in the United States that makes Slim Jims. The company has an inventory of Slim Jims off site, so ConAgra does not expect there to be a supply disruption. Jackson did not know how large a supply of Slim Jims were available.”

Updated 6/13/09:     The names of the workers killed by the explosion are:   Barbara McLean Spears, 43,  Rachel Mae Poston Pulley, 67, and Lewis Junior Watson, 33.    

Local 204 of the UFCW has established a  disaster relief fund to aid victims.    Donations can be made out to:

UFCW Local 204 ConAgra Disaster Relief Fund
PO Box 466
Clemmons, NC 27012

Healthcare Reform Proposals Taking Shape

The Pump HandleTue, 06/09/2009 – 08:12

The last time we had a major health reform proposal was the Clinton administration, and it didn’tgo well. Ezra Klein explains the reasons: Instead of bringing members of Congress and stakeholders into the process early, the administration drafted a detailed proposal and then presented it to Congress. Those in favor of reform failed to mount a coordinated campaign for it, while the Republicans, guided by a memo from William Kristol, united in opposition against it and ruled out compromise. And even before the administration presented its plan, the health-insurance industry was spreading fear to the public with the notorious “Harry and Louise” ad.

Things are different this time around. Public support for some kind of healthcare fix is strong, as the recession leaves even more people struggling to afford the healthcare they need. And, explains CQ Politics’ Rebecca Adams, the insurance industry knows it’s not in a good position for bargaining:

After a decade in which the image of managed-care companies has been marred by stories about denied coverage and hassles for patients, health insurers have a 40 percent favorability rating with the public, according to a 2008 USA Today/Kaiser Family Foundation/Harvard School of Public Health poll. That number was lower than the ratings for banks, airlines and drug companies, and about half the approval rating of doctors.

Insurance companies and other segments of the healthcare industry (doctors, hospitals, pharmaceutical companies, etc) have evidently realized that spiraling healthcare costs and growing rates of uninsurance and underinsurance have predisposed both the public and politicians to favor a fix, so they might as well try to make the legislation as favorable to their industries as they can. The insurance industry in particular has made some impressive announcements- but it’s still not clear whether it’s possible to arrive at a compromise that’s acceptable to them and to reformers.

The insurance industry has promised to stop charging higher premiums to people with histories of health problems if there’s an individual mandate- that is, if everyone is required to have health insurance. They” re still opposed to having a public plan as one insurance option, though. (More on these issues here.)

According to Ezra Klein (who’s now a Washington Post blogger and gets given internal Senate committee memos), the two Senate committees involved in healthcare reform legislation- the Finance Committee and the Health, Education, Labor and Pensions Committee- is to have legislation on the floor of the Senate by the last two weeks of July. The overall goal is to have legislation on President Obama’s desk by October 1st. This timetable means that we should be seeing specific proposals very soon- and we” re already starting to hear specifics from Senators and the President:

  • The bill from the HELP Committee, chaired by Senator Edward Kennedy, will reportedly include a public plan, and the government will subsidize premiums for people with incomes of up to 500% of the poverty level. The plan would pay doctors and hospitals set fees, equal to 110% of what Medicare pays. There will be an individual mandate, with exemptions for those who can’tobtain affordable coverage.
  • Senator Max Baucus, chair of the Finance Committee, is now saying that he expects the Senate’s proposal to include a public plan. (Baucus works closely with Ranking Member Charles Grassley and had long stated his preference for a bipartisan bill, so his support for a public plan was never a foregone conclusion.) Modern Healthcare reports that Baucus expects this plan to “look and feel more like a private plan, adhering to open-market principles and ” where the government’s thumb is very, very light.” ”
  • In  a letter to Senators Kennedy and Baucus, President Obama stated his support for a public plan and indicated that he would be open to an individual mandate, provided that those who couldn’tafford coverage would be exempted. Obama had remained quiet on the details of healthcare until now, evidently preferring to let Congress create a plan for which they could muster enough votes. As a candidate, Obama criticized Hillary Clinton’s proposed mandate.
  • Blue Dog Democrats, a coalition of fiscally conservative House Democrats, will only back a public plan if it’s restricted to operating as public insurance does, and Senate Republicans generally oppose it.

A public plan is starting to look like a real possibility. How will the insurance industry respond? Will they accept a public plan if it’s required to operate like a private plan (not setting provider rates the way Medicare does)? We” re sure to hear more from them over the next few weeks.

Praise for Kathryn Mahaffey’s Work

The Pump HandleMon, 06/08/2009 – 11:12

As the public health community mourns the loss of a great scientist and colleague, The Pump Handle would like to share some of what has been written about Kate Mahaffey.   Please leave your own remembrances in the comments section below.

“I have known Kathryn as a colleague for more than a decade, but most recently have been impressed with her steadfast scientific integrity while at the U.S. Environmental Protection Agency.   She always managed to honestly communicate scientific findings that while unpopular with some, were critically important to protecting public health.     …Kathryn is a role model for the next generation of environmental public health practitioners.     [The skills she developed were] often learned through ‘trial by fire” and Kathryn has certainly experienced that, but has always maintained her scientific integrity grounded in the best science available.”   Henry A. Anderson, MD, chief medical officer, state environmental and occupational disease epidemiologist, Wisconsin Division of Public Health.

 

“Kate has been a role model for the use of science in the service of public health.   She has demonstrated the ability to conduct world-class scientific research and translate scientific knowledge into health-protective actions, even in an environment that is sometimes highly policitized.   This is an art that can be learned only through experience, and Kathryn is remarkably effective at it.”     Vincent James Cogliano, PhD, chief of IARC Monographs Programme

It was just about 1 year ago that I met Kate Mahaffey for the first time.   She was wrapping up her final weeks at the EPA, looking forward to the flexibility of retirement, and  excited about the opportunity to teach a toxicology course for our masters-level public health students.     She spoke modestly about her  early  training in nutritional sciences (PhD) with specialties in biochemistry and physiology, and post-doctoral training in neuro-endocrine pharmacology and epidemiology.   Her first job in federal service was as a research chemist in FDA’s Bureau  of Foods (Cincinnati, OH) which evolved into an  amazing array of science-based policy positions at FDA, NIOSH, NIEHS, and EPA.   In 1994, she was selected as the  lead scientists  for the  Mercury Study Report to Congress  (1997) as required by the 1990 amendments to the Clean Air Act.     Her early (1970’s) research on lead contamination of foods from lead-containing food cans was enough to satisfy me that Kate Mahaffey was a remarkable public health scientist.

Some of Kate’s most recent published work includes:

Tan SW, Meiller JC, Mahaffey KR. The endocrine effects of mercury in humans and wildlife. Crit Rev Toxicol. 2009;39(3):228-69.

Mahaffey KR, Clickner RP, Jeffries RA.   Adult women’s blood mercury concentrations vary regionally in the United States: association with patterns of fish consumption (NHANES 1999-2004).   Environ Health Perspect. 2009 Jan;117(1):47-53.

Mahaffey KR, Clickner RP, Jeffries RA. Methylmercury and omega-3 fatty acids: co-occurrence of dietary sources with emphasis on fish and shellfish. Environ Res. 2008 May;107(1):20-9.   [abstract]

Mahaffey KR, Schoeny R. Maternal seafood consumption and children’s development. Lancet. 2007 Jul 21;370(9583):216-7.

Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR.   Serum TSH and total T4 in the United States population and their association with participant characteristics: (NHANES 1999-2002). Thyroid. 2007 Dec;17(12):1211-23.

Mergler D, Anderson HA, Chan LH, Mahaffey KR, et al.  (The Panel on Health Risks and Toxicological Effects of Methylmercury.) Methylmercury exposure and health effects in humans: a worldwide concern.   Ambio. 2007 Feb;36(1):3-11.

Mahaffey KR. Mercury exposure: medical and public health issues. Trans Am Clin Climatol Assoc. 2005;116:127-53; discussion 153-4.

Her list of research publications is awesome and inspiring.   Some of her earliest work is:

Mahaffey KR, Corneliussen PE, Jelinek CF, Fiorino JA. Heavy metal exposure from foods. Environ Health Perspect. 1975 Dec;12:63-9.

Mahaffey KR. Nutritional factors and susceptibility to lead toxicity. Environ Health Perspect. 1974 May;7:107-12.

Kolbye AC Jr, Mahaffey KR, Fiorino JA, Corneliussen PC, Jelinek CF. Food exposures to lead.   Environ Health Perspect. 1974 May;7:65-74.

Goyer RA, Mahaffey KR. Susceptibility to lead toxicity. Environ Health Perspect. 1972 Oct;2:73-80.

Please leave your own remembrances of Kate in the comments section below.

Swine flu comes home

The Pump HandleMon, 06/08/2009 – 08:53

by revere, cross-posted from Effect Measure

There is no reason why a flu blogger-epidemiologist-physician’s family should be immune to flu in the community. And it appears my family is not. My daughter has had a cough for the last few days and Friday night was suddenly seized by nausea, vomiting and fever. Her HMO’s urgent care directed her to the Emergency Room of the local hospital where a rapid flu test was positive. While waiting to be seen at the ER, her 10 month old, who had a croupy cough, also started vomiting and was warm to the touch. His (slightly) older brother (2 years) was also coughing. Her husband has a cough, too, and is overwhelmed by being the healthiest one in the family. Daughter says she feels awful with headache and muscle aches and pains the usual analgesics (including some opiates) don’tseem to touch. She told me she was talking to a co-worker recently who asked her if she ever had the flu and she said she didn’tknow. Her friend then said, “If you had it, you” d know.” She now says she understands what that means. So much for the “mild illness.”

Meanwhile, for the last 3 days Mrs. R. and I have felt like we were rolled over by a truck, and Mrs. R. had a sore throat. Maybe our age is keeping us from worse effects from this one, or maybe we don’thave flu. We” ll probably never know.

So am I justified in thinking my daughter and family have swine flu? I think the answer is “yes.” She had sudden onset of symptoms — she had a cough but I” d seen her just hours before she got acutely ill with fever and vomiting and she had seemed fine — all symptoms typically described with this virus. She had a positive test for flu antigen with a rapid test. And virologic surveillance is showing virtually all of laboratory confirmed influenza A in the CDC NREVSS surveillance system is swine flu. Here’s the latest bar graph:

Source

The data show that only 2.8% of specimens were other flu viruses (seasonal flu A or flu B). Of the remaining 97%, most were either novel H1N1 (75%), not sub-typed (15%) or unsubtypable (7%). So the overwhelming probability is that this is swine flu, especially considering the symptoms (swine flu has an unusual prevalence of nausea and vomiting associated with it).

As for the two children, one at least (the 10 month old) has the same symptoms as their mother and the brother and Dad both have respiratory symptoms. Mrs. R.’s and my feeling of enervation is less sure. We spend a lot of time with the grandchildren and their mother, so it’s plausible.

My daughter was offered Tamiflu at the hospital but also told that at best it would lessen her symptoms by a day or so (true) and that many people were saying it made them feel worse (nausea is a side effect). Since nausea and vomiting are towards the top of the list of things my daughter hates, she decided to decline the Tamiflu offer. I wasn’twith her, or I might have counseled otherwise, but it’s an interesting insight into the behavior of both health care workers and patients.I did (re)send her some of the blog post of the other day, however, where CDC’s Dr. Anne Schuchat summarizes what to look for to tell if someone with (swine)flu is going sour. I told her to keep an eye on the kids. Here it is again:

In children, signs that need urgent medical attention include fast breathing or trouble breathing; blueish or gray skin color; not drinking enough fluids; severe, persistent vomiting; not waking up or not interacting.; being so irritable that the child doesn’twant to be held; and flu-like symptoms improve, but then return later with a fever and a worse cough. Those are warning signs we physicians think about all the time, with respiratory infections. And they” re good to have in mind with this new influenza-like illness caused by the novel H1N1 strain. Just good things for parents to have in the back of their mind.In adults, we look at another set of warning signs that suggest the need for urgent medical attention: difficulty breathing or shortness of breath; pain or pressure in the chest or abdomen; sudden dizziness, confusion, persistent or severe vomiting that doesn’tgo away; and flu-like symptoms that improve, but then come back again with a fever or worsening of cough. (Statement by Dr. Anne Schuchat, CDC Press Briefing, May 28, 2009)

 

Vomiting and fever have also swept through the grandchildren’s day care center, although my daughter reports children were often back in school after a day or two. Since we know children shed virus longer than adults, the day care center was probably a flu incubator. This is a direct consequence of the inadequate child care and sick leave policies this country has. These are often considered social policies, but they have very direct public health consequences.

Since the only viruses that travel over the internet are the benign kind that wreck your hard drive, destroy your thesis or term paper or latest legal brief or all your email, you don’thave to worry reading this will give you flu. I won’tmake any guarantees about your children, grandchildren, spouses/partners or workmates, however. You take your own chances there.

Tribute to Kathryn R. Mahaffey, PhD

The Pump HandleFri, 06/05/2009 – 13:36

It is with deep sadness we inform you of the sudden passing of  Kathyrn R Mahaffey, PhD.      Kate  had an exceptional and diverse career, with  appointments at FDA, NIOSH, NIEHS and EPA.     Most recently, Kate served as a Professorial Lecturer at the George Washington University School of Public Health.

Her husband, David Jacobs offers the following remembrance and tribute to her significant contributions to the public’s health.     Information about a  memorial service appears at the end of this post.

Kathryn R. Mahaffey passed away peacefully in her sleep June 2, 2009 after decades of work that advanced the nation’s health and environment.   She is remembered as a beloved wife, mother, scientist and community member who served as a source of inspiration with her principled and tireless intellect.   She was the rare scientist who knew how to apply the lessons from academic research to protect the public heath.   Her work changed the face of epidemic heavy metal poisoning, endocrine disruptors and many other environmental pollutants that afflict children, pregnant women and at-risk populations. Literally millions of children have avoided the tragedy of lead and mercury poisoning as a consequence of her work.  

Dr. Mahaffey was the first to ensure that the number of lead poisoned children in the US was determined accurately through the National Health and Nutrition Examination Survey in the 1970s, an action that enabled the nation to track a more than 90% reduction in children’s blood lead levels.

Dr. Mahaffey conducted path-breaking scholarship on mercury poisoning, helping to disentangle the web of bioaccumulation that had stymied previous efforts to seriously address the problem. She was a principal author of the eight-volume Mercury Study Report to Congress that broke new scientific ground while focusing national attention on mercury exposure in the U.S.   Most recently, she helped organize an international conference in Japan on reducing exposure to mercury from eating contaminated fish, while balancing key nutrients such as omega-3-fatty acids.   As a public health activist, her work won cheers from children’s health scientists and attacks from those who considered the facts to be injurious to their interests.

Dr. Mahaffey joined the public service in 1972, working first at the Food and Drug Administration, followed by the National Institute for Occupational Safety and Health, the National Institute of Environmental Health Sciences and numerous positions at the Environmental Protection Agency.   Most recently she was a distinguished professorial lecturer at George Washington University, where she taught toxicology.   She was also engaged in helping to design new studies, such as the National Children’s Study.

The recipient of numerous awards from government and academe, she received the prestigious Arthur Lehman Award for regulatory toxicology from the Society of Toxicology and the Bronze Medal for Commendable Service from EPA for her work on mercury.   She was also appointed to many panels by the National Academy of Sciences. She most recently filed a scientific critique of a government report on risks and benefits of fish consumption; in her comments she demonstrated that an attempt to abandon fish advisories, which have helped reduce mercury exposure, was without scientific foundation.

A prolific writer, Dr. Mahaffey published over a hundred manuscripts in the peer-reviewed scientific literature, eight reports to Congress, fifteen book chapters, and seven books.  

Her personal life was brimming with the same intensity she brought to science, with achievements in music, sewing, knitting, furniture and interior design.   A love of cooking and people made her parties special and memorable. S he was a loving friend and family member who endeared people with her unique blend of intellect and tenderness.

She founded and led the Green Group at the Westmoreland Congregational United Church of Christ, Bethesda, Maryland where she also served as a trustee.   As a gifted volunteer math tutor and leader of the math club at the Marie Reed Elementary School (one of the poorest elementary schools in Washington DC) she invested many hours with underachieving students.

A native of Mahaffey, Pennsylvania, she graduated from Penn State University and held a doctorate in nutrition, physiology and biochemistry from Rutgers University. Her upbringing in rural Pennsylvania significantly shaped her beliefs that people and the earth are part of an interconnected system requiring essential protection.

Kate Mahaffey is survived by her husband, David Jacobs, her daughter, Harriet Meehan, her son, Bert Kramer, her mother, Harriet Mahaffey, her two sisters, Rebecca Latimer and Deborah Westover, her two step-children, Paul and Robin Jacobs, and her two grandchildren, Lillian Meehan and Evalyn Meehan.

A memorial service will be held on Tuesday evening, June 9, 2009, 7:00 PM at Westmoreland Congregational United Church of Christ, 1 Westmoreland Circle, Bethesda, Maryland. In lieu of flowers, contributions can be made to the Kathryn R. Mahaffey Memorial Scholarship Fund, which will enable students to pursue careers in science and public service. Checks can be made out to the Westmoreland Congrega-tional United Church of Christ, with a notation on the check stating “Kathryn Mahaffey Foundation Fund.”

This tribute and remembrance was provided by David Jacobs, Kate Mahaffey’s husband.

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