Document 4v2Vxo8QBY58jX54xdnKoEode

HEALTH Health Policy Advisory Center, Volume 14, Number 3 PAC Breath of Death The Asbestos Disaster BULLETIN BULLETIN Comes Home to Roost THE P :, " n] THST INSIDE The Politics of Health Planning P. 3 Watch Your Mouth! P. 27 Peer Review To the Editor: Please give my Strelnick sincerest thanks to Hal Strelnick for his outstanding " Maggie Kuhn " article. It warmed my heart and it will be passed around to many others. She said it all about " Reaganomics. " A new member of the " International Giraffe Appreciation Society. " Jack Guberman P.S. I am so glad I sent sub- scriptions to my daughters. This one article is worth many times the subscription cost. Keep up your fine work! Health / PAC Bulletin May - June, 1983 Board of Editors Tony Bale Howard Berliner Carl Blumenthal Pamela Brier Robb Burlage Michael E. Clark Barbara Ehrenreich Sally Guttmacher Louanne Kennedy David Kotelchuck Ronda Kotelchuck Arthur Levin Steven Meister Patricia Moccia Kate Pfordresher Marlene Price Virginia Reath Hila Richardson David Rosner Hal Strelnick Sarah Santana Richard Younge Richard Zall Editor: Jon Steinberg Staff: Roxanne Cruiz, Debra De Palma, Loretta Wavra, Mona Lee Yousef. Associates: Des Callan, Madge Cohen, Kathy Conway, Doug Dorman, Cindy Driver, Dan Feshbach, Marsha Hurst, Mark Kleiman, Thomas Leventhal, Alan Levine, Joanne Lukomnik, Peter Medoff, Robin Omata, Doreen Rappaport, Susan Reverby, Len Rodberg, Alex Rosen, Ken Rosen- berg, Gel Stevenson, Rick Surpin, Ann Umemoto. To the Editor: I write to thank you for your efforts this year on behalf of municipal health programs. As a result of concerns expressed by the public and local elected officials alike, there were im- portant restorations and addi- tions to the City's public health budget for the coming fiscal year. Funding was restored at the Department of Health to con- tinue three district health sta- tions and ten child health sta- tions which the Department had proposed by closed or con- solidated. Moreover, an addi- tional $ 700,000 was earmarked for school health to expand case finding and follow - up services, equip dental clinics with before the Board of Esti- mate and the City Council adopted a budget on June 3, we added $ 260,000 to hire 42 den- tal assistants. This appropria- tion will allow the school den- tal program to provide 11,000 MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR AND SUBSCRIPTION ORDERS should be addressed to Health / PAC, 17 Murray St., New York, N.Y. 10007. Subscription rates are $ 15 for individuals, $ 30 for institutions. ISSN 0017-9051 1983 Health / PAC. The Health / PAC Bulletin is published bimonthly. Second class postage paid at New York, N.Y. and at additional mailing offices. Design: Three to Make Ready Graphics / 1983 Cover by W.H.O., Scientific American, 1875. Articles in the Bulletin are indexed in the Health Planning and Administration data base of the National Library of Medicine and the Alternative Press Index. children with high priority dental services. As I am sure you know, many people, including myself, have characterized the AIDS epi- demic as public health enemy # 1. In addition to supporting efforts to convert the old Food and Maritime High School building into an AIDS health services services center center,, I I supported supported an an additional $ 175,000 to the De- partment of Health for AIDS- related activities which was in- cluded in the final City budget. At the Health and Hospitals Corporation, we were able to fund two programmatic initia- tives which I believe are par- ticularly important to munici- pal hospital patients. Five mil- lion dollars was earmarked for ambulatory care reorganization to convert traditional outpatient lion dollars was earmarked for ambulatory care reorganization to convert traditional outpatient departments to primary care programs at Harlem, Queens, continued to p. 32 Health / PAC Bulletin Vital Signs Child Labor While the boom in babies born to college educated - wo- men in their 30's is attracting considerable media attention, a more ominous birth rate has been surging almost unnoticed in a less upscale population. According to Teenage Preg- nancy: A Critical Family Issue, a new study by the Charles Stewart Mott Foundation, every year 1.2 million American teen- agers are pregnant. In the 15- 19 age group this breaks down to one in every ten women every year; if the present pat- tern continues, this means that between three and four of every ten will be pregnant before they celebrate their twentieth birth- day. Data from 1979 used in the study reveal that 60 percent of these pregnancies involve wo- men 18 and 19 years old, 37 percent occur in the 15-17 age group, and three percent among those under 15. The Foundation, which funds programs attempting to ame- liorate " the negative conse- quences of teenage pregnancy once it occurs and the mother has opted for delivery, " points out in the study that although the proportion of teenage preg- nancies which result in live birth has dipped slightly, half still do. Currently another 38 percent are terminated by abor- tion tion,, while while the the rest rest end end in in mis- mis- carriage or stillbirth. Those 15 and under, among whom pregnancy has been ris- ing, are in the highest health risk risk group group.. They They are are more more likely likely to " suffer from medical com- plications in pregnancy and childbirth without good pre- natal care and nutrition, " says the study, " more likely to die from toxemia, anemia, and complications from premature births... and have a higher incidence of prolonged labor, prenatal and postnatal infec- tions. Furthermore, notes the re- port, " Six in ten teen mothers who deliver before they are 17 become pregnant again before they turn 19. " The younger the mother at first delivery, the more children she is statisti- cally likely to bear and the closer together they are likely tdbe. The Reagan Administration may have hoped to bring fami- lies closer together with its " squeal rule " requiring notifi- cation of parents when teen- agers request contraception aid, but one would hope siblings born ten or twelve months apart is not an aspect of what they had in mind. This would, however, be the effect of the squeal rule should it be upheld Letter from the Editor " You mean you print those notices in your'Bulletin Board'free? " someone asked in- credulously, " Now those people I know could pay. " We do accept paid display ads though - not from chemical, pharmaceutical, cigarette, and various other manufacturers whose products and philosophy might be injurious to your health. But all notices in the " Bulletin Board " are indeed published free of charge. No doubt some of those who send us notices could pay for an ad, but we are not the Reagan Administration. We don't believe in means tests. We don't believe that everything available to the public should either be profit making - or the largesse of some corporation or wealthy individual. On the contrary, we believe that items mentioned in our Bulletin Board will be more valuable to our readers because they are the products of people who worked hard without thought of profit to provide what people need, not what they can pay for. Most such enterprises, unlike Mobil Oil, the Pharmaceutical Manufacturers Association, and NBC, don't have large advertising budgets. If for nothing else, we can thank the Reagan Administration for its fashion show of the Empire's New Clothes. Now that we've seen Capital naked we know better than ever that if we can't help others, we can't help ourselves. / on Steinberg Health / PAC Bulletin 3 in the courts. The Administration philoso- phy appears to be that the prospect of suffering is the best deterrent to early sexual activ- ity. This is reminiscent of the 1950's joke about the dean of women who tells entering stu- dents, " Remember, girls, an hour of pleasure can bring a lifetime of pain, " and one of the students yells out, " Dean, how do you make it last an hour? " The appalling statistics pre- sented in the Mott Foundation study show that the suffering is already here, and it clearly hasn't discouraged sex. Perhaps it is time to try a new approach, like making birth control free- ly available. Southern Standard Time Cotton dust has been identi- fied as a serious health hazard for at least a century. Workers exposed to it develop byssino- sis, commonly called Brown Lung disease, a chronic, incur- able condition that severely hampers breathing. The current victims of this condition are the 95,000 tex- tile workers in Southern tex- tile mills. They and others have fought hard to get the industry to clean up its act. In most states, the Depart- ment of Labor or Health is re- sponsible for inspecting plants, but due to a bizarre decision by South Carolina's Department of Labor, the state's 45,000 tex- tile workers have not seen any inspectors for over six months. The Department says it called them off because Reagan's Oc- cupational Safety and Health Administration was studying proposals to change the 1978 cotton dust standard that re- quired the installation of ven- tilation equipment to replace face masks. " Until the new cot- ton dust standards come out, we have unclear guidelines to follow in high health hazard inspections, " a spokesperson for the Department of Labor advised. Using the old (and possibly more stringent) stan- dards, the spokesperson de- clared, would be " somewhat unfair to the mills. ' No doubt. The millowners might have been forced to in- vest in effective ventilation equipment. If new, less strin- gent, standards were to emerge from OSHA, this money might be spent money unnecessarily. " Our members are very up- set that [the State] would take a position like this, " commented Sam McWater of the Brown Lung Association of South Carolina. " Our membership feels that very little was being done before, and now nothing will be done. Our greatest fear is that cotton mills will return to the old ways of doing things, and the workers will suffer even more. " After long very long study - , the Reagan Administration has decided to continue the 1978 standard that forced industry to develop sophisticated ven- tilation equipment, for overly dusty plants. Apparently Rea- gan's OSHA officials were worried that " workers would spend much of their time away from the job so they could take off the masks. " As of late June, there was no word from the South Carolina State Department of Labor on its mill inspection plans. The Death is Yours, the Coal Mine In June the Labor Department finally got around to publish- ing regulations for carrying out the 1981 amendments to the Black Lung Benefits Act. It appears the Department's officials believe the bill was really the Black Lung Cost / Benefits Act, and you know who should pay the costs. The new Reagan regulations make it much harder for coal miners and their survivors to qualify for benefits by eliminating two presumptions formerly applied in determining awards: 1. If a deceased miner was employed for ten years or more in coal mines and died from respirable disease, it would be presumed, subject to rebuttal, that death was due to black lung. 2. A miner with 15 years of coal mine employment could get benefits if he or she had any totally disabling respira- tory impairment, unless it was proven that this was not black lung and was not caused by coal mine employment. With these gone, the burden of proof is on miners and their survivors. The only presump- tion they have left is that the Reagan Administration doesn't care if they die hungry. 1985 Revisited Hospital management has often been defeated in its effort to control the policies of the major nursing organizations, but enough is always at stake for another try to seem worth- while. This year the major burden was on the eager shoulders of the Hospital Association of Pennsylvania (HAP). The Na- tional League of Nursing was holding its convention in Phil- adelphia in June, and NLN by- laws extend voting privileges to any nurse who attends. Early in 1983 HAP's Execu- 4 Health / PAC Bulletin tive Committee of the Council of Hospitals with Diploma Schools of Nursing sent a let- ter to all diploma schools in Pennsylvania. It announced HAP's intention to obtain a resolution at the NLN conven- tion rescinding the organiza- tion's 1981 Executive Commit- tee policy statement in favor of a baccalaureate degree in nurs- ing (BSN) requirement for en- try into practice. HAP followed this up with form letters to all diploma graduates (who don't get BSN's) in the state advocating that they enroll in the NLN to ob- tain voting privileges at the convention and offering re- duced rates for transportation and housing there. Supporters of the BSN re- quirement in the NLN began their own informal but inten- sive get vote - out - the - campaign. Nurses flocked to Philadelphia either in direct support of the Executive Committee's policy statement or to oppose what was generally seen as a crude attempt by an outside organi- zation to pack the convention. Attendance was at a near record. Rumors were flying that nurses with 20 years'ex- perience but no BSN would be on the unemployment lines, that the organization would split into factions and die, that " the end of nursing " would swiftly follow a pro BSN - vote. The debate grew heated. Nurses were scared. Some were crying. Supporters of the BSN re- quirement commented that a battery of physicians, attorneys, and sociologists, each with a postgraduate degree, was try- ing to convince " the girls " that they really didn't need an ol ' BSN to be considered their professional colleagues. When the vote finally came, the Hospital Association - sup- ported resolution was rejected by a large margin. Nursing organizations and individual nurses have strug- gled with the issue of the prop- er educational preparation for registered nurses for at least 50 years. In 1923, the Goldmark Report recommended collegi- ate nursing education for " nursing leaders. " In 1947, the more democratic Brown Report extended the recommendation to include all professional nurses. The introduction of as- sociate degree education in nursing 1951 was specifically intended to answer to " soci- ety's needs " for a " semi - pro- fessional nurse " or a " nursing technician. " Making the BSN a prerequi- site for professional nursing practice was advocated in a 1965 Position Paper by the American Nurses'Association; in 1974 legislation supported by the New York State Nurses Association, commonly known as the " 1985 Proposal "; and, most recently, in the NLN's 1981 Position Paper on Entry into Practice. Neither the American Hos- pital Association (AHA) nor the American Medical Associ- ation (AMA) has ever been happy with these attempts at upward mobility. Both benefit directly from the diploma train- ing schools, in which the turn- of the - century apprenticeship model has provided hospital administrators and physicians with a cheap, controllable nursing workforce. Both the AHA and the AMA have at- tacked the BSN requirement in editorials, at public meetings nad conventions, and through intense, well funded - lobbying efforts HAP this June followed a long tradition. Individual nurses experience this conflict at a painfully per- sonal level when they must make their choice between a WORKBOOK and SELF RELIANCE - JOURNAL Each issue of this bimonthly magazine includes: 16 page * devoted to one important consumer topic. 20 pages of small press book reviews, plus news items from social action groups and notices of address changes. i7V SM.JRH.IANCF. JOVKNAI. cam be purchased as a separate publication Jar use as a classroom text or reference material. Prtces of the SHJ sold as a separate publication are: % m \. It M, t.ntm ** , i.fqlm i.fqlm tl mMI. IMIIII HIM - I tmtati MM < (. I. Subscribe to The Workbook! S8.SO sr. citizens, students; $ 12.00 individuals, 25.00 $ institutions Uitke check payable to: \ tmihwest Kelcurch A Informotinn Center. It) Httx <, VJ. Alhiu iienpic / , NMM71tm Health / PAC Bulletin 510 diploma school, or pursuing an associate or baccalaurate degree with little, if any, accu- rate information about the real differences in work career / possibilities. Minorities and the working class are general- ly tracked into hospital schools and community college nurs- ing programs, which is not surprising in a health care sys- tem that reflects the racial and class discrimination of the larger society. Equally predictable is the subsequent experience of these nurses, who find their mobility within the health care hierarchy restricted by their lack of a BSN. They must then resolve the larger politi- cal struggle at the personal level, juggling personal and professional commitments to find time for analytical work, collective organizations, and educational advancement. Punitive Misconduct Governor John D. Rockefel- ler IV of West Virginia has just signed into law a bill revoking workers'right to sue their em- ployers for punitive damages in cases of gross employer mis- conduct. In so doing, the Governor re- pealed a right won by workers in 1978 when the West Virginia Supreme Court ruled that work- ers could sue their employers for injuries and illnesses caused by " willful, wanton and reck- less " employer misconduct. Previously, this had been pro- hibited based on interpretation of the state's workers'compen- sation law which, like most state laws, makes compensation the sole remedy for injured workers. Industry groups campaigned hard for the legislature and state house to overturn the court decision because, they said, it damaged the state's industrial climate. However, under the new law workers still retain the right to sue for compensatory damages in cases of serious employer misconduct. ADVERTISEMENT The School of Public Health of The University of Texas Health Science Center at Houston invites applications for positions as Post Doctoral Fellow or Research Assistant Professor to join a newly established research program in Health Policy and Workforce Analysis. Persons with a doctoral degree in epidemiology and experience or special interest in health services research are preferred. Applicants with other relevant qualifications, e.g., doctoral degrees in demography, economics, statistics, will also be considered. The research will concentrate primarily but not exclusively on policy issues (affecting Texas) related to supply, demand, and distribution, of health professions workforces; and costs, availability, utilization and efficacy of health and medical care. Candidates should have capability in data collection, analysis, and evaluation. If you are interested, please send a resume to: Frank I. Moore, Ph.D. Associate Dean for Administration University of Texas School of Public Health P.O. Box 20186 Houston, Texas 77025 THE UNIVERSITY OF TEXAS IS AN EQUAL OPPORTUNITY EMPLOYER; WOMEN AND MINORITIES ARE ENCOURAGED TO APPLY. Health / PAC Bulletin Breath of Death The Asbestos Disaster Comes Home to Roost by Tony Bale Xiow much asbestos will you breathe in today? If you are exposed at the level of the permis- sible OSHA standard at work, over ten mil- lion large fibers and several times that num- ber possibly more dangerous small ones. Liv- ing in the same house as one of these workers you may be at even greater risk from dust carried home. Over the past 40 years some 21 million workers in the United States have inhaled significant potentially dangerous amounts of asbestos. At an office or school you may be breathing fibers from peeling insulation material circu- lating in the indoor air and through ventila- tion systems. Asbestos is also found in the outdoor air, emanating from sources such as automobile brake linings. Objects of everyday life hair- - dryers, for example - can undergo a Hitch- kockian transformation into lethal agents. Of- ten you can't be quite sure if you are being exposed; once you have been, there is no way to get the fibers out. Parents must live with the anxiety that they may be unwittingly transmitting an asbestos - related disease to their children; for some, this fear becomes a devastating certainty. And if asbestos exposure leads to your death from cancer, will anybody recognize the connection? Will anybody care enough to help your family weather the financial blows of this manufactured plague? Will the terrible injustice of your death be balanced, slightly, by a financial " recovery " from asbestos com- panies, employers, and insurers who might Tony Bale worked on the Mount Sinai as- bestos related - disease assessment project and is a member of the Health /? AC Board. have prevented it? Your death could have no meaning. Or it could, now, contribute in some small way to preventing the same tra- gedy from striking others. Asbestos was an integral part of the America created during and after World War II. It found its way into construction projects, in- dustries using high temperatures, hundreds of products, and our lungs. The widespread use of asbestos, along with its capacity in both high and low doses for causing cancer after long latency periods, set the stage for a major disaster reaching well into the next century. The bills are coming due. Thirty million tons of asbestos spread throughout our goods, machinery, and walls must be maintained and / or removed. Hun- dreds of thousands of lives have been or will be lost, as well as billions of dollars of output. The moral fiber of society shreds as it faces the victims but not their needs, and fails to see justice done. Much human - made suffering manifested in disease is thought by victims and physi- cians to lie in " nature "; things just happen because of good or bad fortune. In the as- bestos tragedy, medicine has pulled the veil off many related diseases to reveal their social roots. Applying this information, plaintiffs and their attorneys are shifting the blame and the financial burden from the victims to the asbestos industry which inflicted the damage. Through their victories in the courts, as- bestos victims have effectively put a lien on the assets of the industry. Their litigation and other actions have compelled society to con- front the issues of how far an industry can go in contributing to the death of its employees, users of its products, and the general public and remain in business. In immediate practi- cal terms, the questions are how best to deal Health / PAC Bulletin with the future financial losses of victims and how best to use the resources of the industry and of government to prevent future diseases to the extent possible. The full scope of the asbestos disaster in the United States became undeniably apparent in the mid 1960's, when Dr. Irving J. Selikoff of the Mount Sinai School of Medicine in New York wrote a series of historic publications. Selikoff had found that a group using asbestos products, insulation workers, had developed highly elevated rates of asbestosis, mesotheli- oma, and lung cancer. Smoking and asbestos exposure interacted to multiply the risks of lung cancer to many times the rate either caused individually. Those who studied these conclusions im- mediately realized that if they were extrapo- lated to other occupations with similar en- vironmental exposures the number of people endangered was staggering. Further research soon began to confirm these fears as details of the pernicious effects of various types of fibers, the risks of various occupations, and other damage emerged. It was this evidence- and these individuals - out of epidemiologi- cal tables that the asbestos victims took into the courts and the media as well as their own organizations. Following the enactment of the Black Lung Amendments of 1977, which provided some relief for coal miners, the U.S. Department of Labor awarded a contract to Dr. Selikoff to assess the extent of the asbestos disaster, costs of asbestos - related diseases, and adequacy of compensation. This ambitious project (which I worked on) administered by Donald Spatz has provided the best available information about asbestos- related diseases and their consequences, a subject where conclusions are often skewed by both emotion and the billions of dollars at stake. The Department of Labor released the Mount Sinai group's report, Disability Compensation for Asbestos Associated - Disease in the United States, in mid 1982 - . Like many presentations of scientific data, this did not reach a broad audience. What it says, however, deserves to be retrieved for the public. It would not be an exaggeration to say that everyone in the coun- try will be affected by the issues it raises. This article presents some of the key find- ings which illuminate the asbestos compen- sation debate. (The policy recommendations are my own; except where explicitly stated they do not necessarily represent positions taken in the report.) The report begins by reviewing widely known medical facts as well as recent find- ings to bring the disaster into focus. Asbestos insulation workers, it notes, die from cancer at over three times the normal rate. More than one out of every five dies from lung cancer; among those who smoke the proportion jumps to five times the already high rate for other smokers and over fifty times that of non- smoking blue collar workers. Higher rates of gastrointestinal, esophogeal, larynx, and other cancers have been observed. Tumors of the lining of the lung (pleura) and abdomen (peritoneum) called mesotheli- oma serve as a " signal " for asbestos exposure. " Most patients with mesothelioma die of the disease within a year, " according to Dr. Seli- koff. Formerly very rare, mesotheliomas are now appearing in rapidly growing numbers, the product of past asbestos exposure. They already cause almost ten percent of deaths among insulation workers. Perhaps even more frightening, mesotheli- oma was found to account for over one per- cent of the deaths among family contacts of workers in a New Jersey asbestos factory 30 years or more after the worker was first ex- posed no victims would be expected in a comparable population without asbestos ex- posure. And the danger reaches far beyond the factories; the well publicized - death of 13 year old John Carson, son of a Denver brake mechanic, from mesothelioma brought this home to millions. Worse could be in store. Exposure levels in schools with damaged asbestos surfaces are comparable to levels in asbestos workers ' homes, and mesotheliomas have already ap- peared in the full gamut of asbestos exposure situations, often when they were light and short term. Risk of mesothelioma is not raised by smok- ing, the study noted. On the other hand, some people contract it after asbestos exposure too low to cause asbestosis. This high lethality coupled with the widespread use of asbestos means that people in many walks of life are dying from casual exposure. Because these tumors are otherwise so rare, this conclusion can be affirmed with a high degree of cer- tainty. It is hard to know who among us is safe. Mesothelioma incidence peaks 30-35 years after first exposure; the earliest expo- sures do the most harm. 8 Health / PAC Bulletin Studies in the New Jersey asbestos plant also revealed that only two years'work with heavy exposure seemed to be a " saturation dose " there; further exposure does not seem to have raised the risk of contracting lung cancer, but even among those exposed less than one month the cancer rate climbed. Asbestos cancers typically have long latency periods, but the effect of significant exposure is soon grimly evident. ".. the effect of an exposure to asbestos is to multiply the pre- existing risk of cancer in the exposed popula- tion, " concludes William}. Nicholson of Mount Sinai, " and... the multiplied risk becomes manifest in a relatively short time. " It may be apparent five to ten years after asbestos exposure begins. Workers in their 40's and 50's don't have 30 or 40 years of grace; the likelihood they they will be struck by cancer, already much greater than it is among younger people, multiplies in as little as five years. Asbestos doesn't just start cancers; it seems to speed up the development of those already in progress. This deadly acceleration effect helps explain why asbestos insulation work- ers live six years less on average than other blue collar workers with the same smoking habits. Canadian Revolution How Many Will Die Based on calculations by George Perkel of the yearly numbers in working popula- peak in 1987, when they will cause about a third of asbestos - related deaths. After tions significantly exposed to asbestos, that, the construction trades (exclusive of William J. Nicholson developed projec- tions of the numbers of deaths from as- bestos related - diseases for occupational insulators) will be heaviest hit, account- ing for well over a third of the deaths. Many of the workers who die will be those exposures occurring in the last 40 years. His work provides the best current risk exposed to sprayed asbestos fireproofing materials between 1958 and 1972. estimate of the order of magnitude of the danger and its impact on different occu- Lung cancer currently causes more than half the excess cancer deaths, mesotheli- pational groups. oma less than a fourth. However Meso- Overall, the study estimates an astound- thelioma victims will climb steadily until ing 27.5 million Americans were signifi- they almost equal those from lung cancer cantly exposed to asbestos at work over in 2012. Stationary engineers and fire- the 40 years ending in 1981. More than 21 million of them are still alive. Nicholson fighters, chemical plant and refinery main- tenance workers, and automobile main- projects over 200,000 excess deaths from this exposure by the end of the century, tenance workers are among those who will succumb in numbers far above the with another 50,000 deaths reaching into norm. the second quarter of the next century. He estimates the number felled in 1982 at 8,206 and predicts the toll will peak in 1992 at 9,653. Frightening as these figures are, they are misleadingly low when the question of compensation arises. Suppose someone dies from lung cancer after working in These ballpark figures do not count cur- an occupation where asbestos exposure rent exposures or environmental contacts. doubles the likelihood of contracting it. Many people believe the asbestos epidemic There is no way to tell if his or her death is primarily a leftover problem from World War II and assume that once the wartime was one of the " excess " group. (Obviously for mesothelioma, where the expected rate shipyard employees die off few further asbestos - related deaths will occur. Nichol- is normally effectively zero, this issue of origin does not appear.) son, however, estimates that these will Health / PAC Bulletin 9 None of the widows of insulation work- ers interviewed in the Mount Sinai study was " typical "; each had a unique story to tell. Few were passive victims.Most com- municated strong character in putting their lives together after experiencing extraor- dinary hardship. A little emphasized - part of the story of the widows of asbestos workers has been their lawsuits, including the non financial - aspects of their motivation for going to court. Mrs. T. was one of many who em- phasized her desire to see justice done and help others through her lawsuit. " My hus- band went into the hospital with stomach pains, cramps and frequent throwing up, ' she related, " Less than two weeks later he was dead. " Her husband died at age 49 of peritoneal mesothelioma, leaving her with two teenage children. The union told her she might be eligible for workers'compensation. Her case was settled for $ 18,000, with $ 5,000 of that go- ing to the lawyer. " I don't understand why it took so long, " she commented, " I only had my salary and not much else to keep us going. It was about tiiree ydhrs till I collected from the time of his death. Some women with smaller children would have found it extremely hard to wait that long. " After weighing the issue further, Mrs. T. filed a lawsuit. " My husband had made a good living working with asbestos and I didn't want to go along with the trouble of a lawsuit, " she explained, but the lawyer finally convinced her " that people should know about it and I was entitled to the money. " Several smaller companies settled for $ 15,000 but Manville Johns - went to trial- the first such trial in her state. " The trial against Manville Johns - went on for a week, " she said, " It was quite an experience. By then my husband had been dead five years. They brought out that Johns Manville - provided no protection for him. By the time they put warnings on the bags it was too late for my husband. The testimony went through the time he was sick, to the time he passed away and the autopsy. What came out in the trial was interesting to me, but also upsetting be- cause I had been so personally affected. Most was new to me. It was quite an ex- perience listening to all the things the oompany had done. It was worth it, but I'd never go to court again. " She won the case, but the jury awarded her only $ 18,000. Legal fees for the settle- ments and trial came to $ 24,000 so she got to keep only $ 9,000. " The money came in handy, but that's not what made it worth it, " she said. Johns- Manville is a big company and people had to do something about his. Now it's on record that the company was at fault. It may make people aware. " When my husband worked with asbes- tos there was no protection. Late in his worklife they started to wear little masks with no protection. The ones he got just before he passed away were a little better. At the bank where I work they just did some remodelling and the men had metal masks that protected their nose and mouth. Some of the young boys were wetting it- that's good protection. " The idea is to keep people from getting this. My oldest boy worked with his dad summers. Some wives washed their hus- band's clothes. I hate to see other people go through what I went through. I hope my case had some effect on the other men who worked with my husband. " My son went into hospital work. He's a respiratory therapist - because he was in- terested in his father's illness. Workmen's compensation needs to get money to widows faster. Some of these people are hurting bad. The court case was too long and drawn out. " BANGEROUS The Mount Sinai survey stimulated a few widows to contact attorneys in the hope of filing a lawsuit. Most were stymied by statutes of limitations. One such case, decided by a state supreme court, illus- trates many of the uncertainties of asbes- tos compensation. Napoleon DeCosse was 76 years old when he died of a heart attack in 1976 in Arizona. For most of his working life he had been a member of the International Association of Heat and Frost Insulators & Asbestos Workers in Minnesota. His physical condition had deteriorated rapid- Health / PAC Bulletin ly before his death and one of the doctors mentioned to his widow that he might have had cancer. Mrs. DeCosse discounted this; she knew smokers in her husband's trade were more likely to get cancer, and he had never smoked. In 1980 Dr. Selikoff had written the DeCosse family that he had determined the underlying cause of her husband's death was peritoneal mesothelioma. She then contacted an attorney, who filed a suit under the Minnesota Wrongful Death Act. This statute stipulates that claims must be filed within three years after death, and lower courts disallowed her suit on this grounds. However, the Min- nesota Supreme Court ruled in May, 1982, (319 N.W.2d. 45) that she should be al- lowed to bring her suit. The court reasoned that the wrongful death law did not supercede a common law principle that said that in cases of possible " fraudulent concealment " the statute should be effective from the time the concealment is uncovered. It cited a 1931 decision in a malpractice case ex- pressing a moral sense that many people still find compelling: " .a person should not be permitted to shield himself behind the statute of limita- tions where his own fraud has placed him. He should not be permitted to profit by his own wrong, and it would strike the moral sense strangely to permit him to do so. Fraud is bad, it should not be permitted to go unchecked anywhere, and justice should always be able to penetrate its armor. " The Minnesota Supreme Court sent the case back to the lower court to determine whether fraudulent concealment had ac- tually taken place, commenting, " The as- bestos related - case law and commentaries make it clear to this court that appellant may be able to establish that respondents have been less than candid in disclosing to those exposed to their products the poten- tially deleterious effects of that exposure. " Whatever bars on third party suits the asbestos industry tries to erect, it is un- likely that the moral sense of most Ameri- cans and many judges would accept a situation where claimants able to prove their case on theories such as " fraudulent concealment " and " intentional tort " could not get their day in court. If plaintiffs can prevail in court on such theories, involv- ing higher levels of intentionality and negligence than the duty to warn theory that has been the basis for most asbestos suits up to now, most Americans would probably strongly support the idea that all the assets of the asbestos industry should go to compensate the thousands of victims. GLAMMARIF ' I'was happy with what happened with compensation, " said a widow who had to wait two and a half years after her hus- band's death for the first installment of her state's maximum award of $ 18,000- of which her lawyer got a third. " When that first check came, I really needed the money. I didn't have a whole lot of insur- ance or savings. I didn't have money for heating bills. And Compensation got rid of those medical bills that were hanging over me. That $ 3,000 really helped. I was close to begging in the streets. " She had a longer wait for her court set- tlement. " The lawsuit was nerve wracking - as long as I had to wait to collect it. Every day you're waiting for a call or try to find out what's happening. I wasn't feeling good at the time. I really needed the money. This thing can go on and on. You're here today and gone tomorrow. It took six years, but it seemed about 30. " Finally I got a check for $ 42,000; the lawyer received $ 28,000 in the settlement. The full amount was $ 70,000. It was like a million dollars when I got it. Just the same, my husband would have worked six more years. Wages were high and going up; it didn't even replace lost wages. " CALORIE Navigating the bureaucracy can often prove agonizing: " It was a strain not knowing where money was coming from. The government agencies didn't want to accept the fact. Workmen's Compensation said go to Disa- bility and Disability said go to Compensa- tion. I think the state of California sent us some papers to sign. We put in an applica- tion for disability and they rejected it. We Health / PAC Bulletin could have * hung on financially, but we were worried. Then we went to his boss, who was usually good about compensa- tion. It was not satisfactory. They didn't want to accept responsibility; they were probably afraid of a lawsuit. It was a very nervous period in my life. Fortunately, the lawyer was able to do'it for us. The lawyer came to our rescue. The (lawyer filed a successful disability claim, death claim, and third party suit.) For some new widows, these difficulties with the system are compounded by se- vere depression. A just compensation sys- tem must be prepared to deal compassion- ately witji claimants such as this: " I had signed over power attorney - of - to the lawyer because my health was - bad from my breakdowns. One month after I was in the Mayo Clinic, a check came from the lawyer for $ 9,000. I was in a wheel- chair at the time because of my nerves. The doctor said my nerves had taken over Ary ivhole body. I came out of it fine. A friend had told me it was supposed to be $ 25,000 (the state maximum), but I only got $ 9,000. I never knew how much the lawyer got or how.much the medical bills were * \ felt very passive. I had no parents to consult wttn, r wasn't aware of my rights and the laws. I wasn't in a mental position to think about these things. I was grateful for.the money. With three kids, anything I got I was grateful for. I just wanted to get the case over with. The less the chance of going to court, the better for me. I took their word and didn't fight the lawyer or anybody. I agreed with every- thing that was put in front of my face. " Widows often lose their workers'com- pensation benefits if they remarry. This may lead to a continuation of cat and mouse games with the insurer: The insurance company is very sneaky. Soon after we won, my attorney called me and said Aetna offered to settle the rest of the claim for $ 19,000 (rather than pay on a monthly basis). He said he didn't think I should take it, but it was his duty to report the offer. They were willing to bet I'd remarry within six months. I haven't mar- ried yet (it was ten years after her hus- band's death) and so far I've collected $ 38,000 from them. They've been out here every couple of years to see if I've remar- ried. They look in from outside to see who comes in and out. Except for the long time delay, compensationAvorked out pretty well for me. " J oe < #oisop > An award of benefits doesn't mean wid- ows receive them; in some states it can simply force the widow into a painful choice: " My mother has been awarded 100 per- cent benefits, but the company has offered to make a settlement or go to an appeal that can take another two or three years. Nobody's getting any younger. We have to decide whether to take the offer or go through another two or three years ap- peal. The medical facts have already been decided in our favor so I think we'd win. Who knows how much time she has re- maining (she was 61 years old.) It's been five years already. The company has offered one third of what she was awarded- $ 35,000. A quar- ter of that goes back to the attorney. She was awarded by the court a maximum of $ 95,000 payable at the rate of $ 95 a week. She would get cash of about $ 28,000 and then $ 95 per week until it reached $ 95,000. " I always thought workmen's compen- sation was the law, but the way it came down we expended a lot of time and effort, but still can't get it. I'm not saying we won't get it, but so far we haven't. It's a lot of psychological pressure. Think of the mental depression: a husband passing away and then not to know if or when compensation is coming or what to do next. " ' / \ \ < 3MMftCTNp > The State of Washington received the most favorable comments from the widows for its workers'compensation program. A high percentage of widows filed death claims in this state with an exclusive state insurance fund and receive cost of living increases on benefits: " I was fortunate in my workmen's com- pensation claim. A relative advised me to Health / PAC Bulletin file and how to do it. He said I've got it coming. I followed his advice and filed a claim against Owens Corning - and some other private insulation contractors. Five months after filing, I got my first check. The widows'pension was awarded for asbestosis without any contest (the cause of death was peritoneal mesothelioma.) Payments were $ 185 per month in 1971 and they are now up to $ 540 per month. The Industrial Commission accepted the evidence I provided. They didn't give me any trouble. It would have been different from an emotional point of view if I had had to go through a long case. I had no need for a lawyer. " m 11% #i Health / PAC Bulletin 13 Nicholson's projections (see box) say that in 1982 there will be 5,000 excess deaths from lung cancer out of a total of 30,000 lung cancer deaths in asbestos exposed - occupa- tions. But for compensation purposes, there were 30,000 potentially asbestos - caused deaths. And that is for one year alone. It is easy to see that the Manville Corporation's estimate of 32,000 future lawsuits against it as the largest asbestos manufacturer may be wildly optimistic. One of the biggest problems in designing a compensation program is where to draw the line between who is eligible and who is cut out. Even though the diseases are often clear- cut, the low exposures in some occupations or industries may make it difficult to prove a causal connection with work. Of workers with significant asbestos exposure, a third are at lower risk because their exposure was rela- tively low or of short duration. Nevertheless, considerations of equity de- mand that any compensation program cast a wide net to include most of the asbestos- related deaths. Even those with low expo- sures are at elevated risk, and their lung can- cer or gastrointestinal cancer may well have had an asbestos component. The consequences of this are staggering. Instead of the ten thousand excess deaths a year often cited in the media since the Mount Sinai report came out, the number potentially compensable soars to more than four times that amount. It may go higher still. Early this year Nicholson reported that recent govern- ment figures show mesothelioma cases shoot- ing up even more rapidly than he had pro- jected. Since 1969 they have climbed 400 percent; in 1980 the annual rate jumped 30 percent. This probably means that other as- bestos related - diseases are also felling more people than projected. Compensation Potentially compensable is a long way from getting adequate compensation in the Ameri- can system. The Mount Sinai study surveyed the next of kin of 1,000 deceased insulation workers in 1980. All had been members of the International Association of Heat and Frost Insulation and Asbestos Workers (commonly known as the Asbestos Workers Union) who died of an asbestos - related disease between 1967 and 1976. They had lived in 48 states and Canada. This was the " best case " group. If any occu- pational disease victims had a chance to do well in the state workers'compensation sys- tems, it was this one: * Each case had been given a medical re- view by the staff at Mount Sinai and been found to involve an asbestos - related disease. * Dr. Selikoff had sent letters to the vic- tim's Asbestos Workers local and the interna- tional informing them of this relationship. * The Union had an active occupational health program and some locals had screen- ing programs. * A solid body of epidemiological research connected the diseases with this trade. * Several of the diseases, among them me- sothelioma and asbestosis, are only found in conjunction with asbestos exposure. * Most of these men (there were no wo- men) worked continuously with asbestos un- til they became totally disabled. The survey found that the 84 percent of the victims who stopped work because of their terminal illness lived an average of 20.5 months. A quarter of them were disabled for six to 11 months; fully 30 percent were dis- abled two years or longer. Amazingly, even in this " best case " group only 29 percent applied for workers'compen- sation disability benefits. Among those dis- abled a year or more only 43 percent filed claims. Even in cases of asbestosis, which often leads to long periods of disablement and is unambiguously caused by asbestos exposure, only 70 percent filed disability claims. Theoretically, under most state laws the vast majority of these workers and their sur- vivors would have been entitled to receive benefits. In fact, they did in 89 percent of the recorded decisions. But almost half the disa- bility claims were pending at death. Only 15 percent of the disabled workers received work- ers'compensation benefits before their death, with an average payment of $ 74 a week. Some states had much higher rates of fil- ings than others, and even within the same state there were substantial differences in rates among the union locals - the successful ones seem to be those which developed sup- portive networks to identify cases and guide them through the system. In the words of the report: For a disabled worker to file a claim for workers'compensation, he must be aware that his illness is linked to his work, that he Health / PAC Bulletin has legal rights to benefits and that the state law is at least reasonably likely to be suppor- tive. All of this requires considerable infor- mation that many workers may not have. Such networks can increase the likelihood that disabled workers will be aware of the compensability of their condition and increase the likelihood that a claim will be filed. Some local unions have health surveillance pro- grams that help identify asbestos - related dis- eases. In some locals, union officials actively sought out cases and helped shepherd them through the system. Successful claims can breed more claims as members hear of the outcomes. Attorneys in some localities develop ex- pertise in asbestos cases and become known to the union members. Many widows recalled that their husbands were advised to contact " the lawyer for the union. " This lawyer usu- ally did not work directly for the union, but was known among the members as the per- son who handled asbestos cases. Close ties can develop between the union, one or two law firms, and a handful of physicians in a particular locality. These persons identify those disabled from asbestos associated - dis- ease and may lead them to the workers'com- pensation system. So far most locals in other asbestos - exposed occupations have not begun to develop such networks, so many workers'compensation claims which could be filed and won are never initiated. Although it is true that most other occupational groups will have a tougher time meeting the entry requirements to the system, their unions could learn a great deal from the experience of the insulators'fami- lies, particularly the positive role a union can play. The evidence is overwhelming. Survivors aware that they could file a death claim cited the union as their source of information more frequently than any other. Among widows who knew their husband's death was asbes- tos related - , 86 percent of those who had been advised they might be eligible for a death benefit filed a claim. Of the 36 percent who filed a death claim, only one in twenty - five was turned down or dropped the claim; all the rest got some money. In other words, those who received no money from workers'compensation Jost out mainly because they did not know they had a right to it. As these findings show, any effective and fair asbestos compensation program must ac- tively seek out potential claimants, make sure they know their legal rights, and make sure Maria Mattola, The Mobilizer legal assistance is available to them. Other- wise the result is less a compensation pro- gram than a reward system for being lucky enough to somehow be aware of your rights and be able to act on that knowledge. Right now, when the majority of the bereaved learn years later that they might have had a com- pensable claim, it's just chalked off as their hard luck. Smokers may have a harder time proving their case, and this may make them more likely to accept a lower settlement offer, but employers'" smoking defense " does not keep workers out of the system. Most of the lung cancer victims and many of those who died from other asbestos - related diseases were smokers, yet only a negligible percentage were denied benefits. Their success was based on the premise that the disease was related to as- bestos exposure at work, regardless of whether it struck in the absence of all other possible causes. Even when claims were made, the awards were rarely swift or sure. Employers contested most of them, with greater success than a superficial reading of the statistics would indicate. Although two thirds of the claim- ants were awarded benefits, almost half that many accepted a settlement. The long wait Health / PAC Bulletin 15 was a major factor. Only a third of the cases were concluded within a year; 30 percent of the widows had to wait two years or more before they got a penny. For many these de- lays proved intolerable; the younger widows particularly were more likely to take settle- ments than wait for awards, even though the mean value of the lump sum payments was only $ 18,900. Swift payment would give a small measure of security to pieople whose world has sud- denly become insecure. Adequate payments would also be a wel- come innovation. A study by Donald Spatz in the Mount Sinai report shows that the large number of death claims filed in New Jersey between 1967 and 1976 were usually com- pensated at less than their full statutory value. For several lung cancer deaths this meant small posthumous permanent disability awards for conditions such as " residuals of chronic bronchitis with pulmonary fibrosis. " Lewis W. Hine The New Jersey system was also unable to compensate mesothelioma as mesothelioma to the full extent of the law. Only one of the six cases received a full death benefit award; the rest received lesser benefits or came to settlements for something such as " exposure to deleterious substances which caused a pulmonary condition. " In the one mesotheli- oma * case which did merit full benefits in the state's opinion, the worker had received par- tial disability benefits for asbestosis and was awarded death benefits for " death occasioned by exposure to asbestos, " rather than meso- thelioma. Similarly, asbestos cancers seem to be a difficult problem for the workers'compensa- tion system. Awards in many states refer to them as a consequence of asbestosis rather than recognizing cancer itself as the occupa- tional disease. If such (classification mis) continues, it would ensure that many workers who might 16 Health / PAC Bulletin receive money if they had enough informa- tion about the system and were part of a network would get considerably less than they are entitled to by statute. And they would be the lucky ones: Spatz also found that a recency of exposure rule in New Jersey has barred most of the potential claims from a local asbestos factory that closed in the 1950's. Asbestos victims have another avenue for pressing claims, the courts. Many members of the Asbestos Workers Union and their survi- vors have been pioneers in filing third party suits in their states. (These are called third party suits because the defendant is not the employer of the plaintiff, but the manufacturer of the asbestos products, such as insulation material.) those Of surveyed in the Mount Sinai study, 16 percent filed. The proportion had doubled to 32 percent in cases of 1975-76 deaths, perhaps in part because word of successes began to spread. In the eight cases that went to a jury only one plaintiff lost; 59 widows received out of court settlements averaging $ 72,000; another 38 cases were still pending. It should be noted, however, that when the plaintiffs won attorney fees ate up almost 40 percent of the money on average. Overall, some nine percent of the widows filed both a workers'compensation death claim and a lawsuit. An extraordinary 58 percent filed neither. Peter Barth tersely summarized the perfor- mance of the various support programs (again, this is for the " best case " group): How well have the programs operated? First, the most striking characteristic seems to be the lack of usage of these various sup- port schemes. Over 40 percent of these work- ers received neither Social Security benefits (old age or disability) nor a pension at the time of their death. For those who stopped working due to their terminal illness (84 per- cent of the cohort), two of every three did not file a disability claim for workers'compensa- tion. Even among those disabled two years or more, such claims did not materialize for over one half - of the workers. Where there was a surviving widow, death claims were filed by less than one half - of the cohort. Relatively few third party lawsuits have oc- curred as well. For those workers or survivors seeking compensation, the process is a very extended one. The typical disability claim is often still pending at the time the- worker dies. The death claim process is also very prolonged and settlement is a common way to termi- nate it. However, hardly any workers'com- pensation claims for disability or death and tdheniiradl .p arty lawsuits result in an ultimate Usage of some of the programs increased in the final years covered by the study as infor- mation became more widely disseminated. but even in the last year in this " best case " a majority of the victims didn't enter the work- ers'compensation system, and many of those who did were rewarded with low benefits after long delays. Few felt that the system was in keeping with what I take to be the moral consensus of most Americans: that these peo- ple were disabled and killed by their work B Canadian Revolution Health / PAC Bulletin 17 and corporate negligence; they and their de- pendents deserve a compensation system that makes sure people are aware of and exercise their rights a system that provides adequate benefits swiftly with a minimum of litigation in an atmosphere which preserves the dignity of the claimants. Some were lucky enough to be in the right place, the right union local, with the right asbestos - related disease, the right lawyer, etc., and made out financially. Many found the compensation system came up with too little too late. More came up with nothing at all. Financial Loss Asbestos insulation workers make a good wage compared to most blue collar workers; free market ideologues would suggest that this includes a substantial risk premium for working with a lethal substance. However according to Peter Barth's calculations for the Mount Sinai report, from the late 1960's, when the hazard became widely recognized, this risk premium might have amounted to $ 600 a year hardly a bargain that insulation work- ers would have struck for six years of their lives. Well, says the fallback argument, the greater access to workers'compensation and tort law recoveries by insulation workers, along with other transfer payments related to death, al- low the survivors to maintain their standard of living. The evidence was examined by William Johnson and Edward Heler for the Mount Sinai study. They attempted to estimate the average " social costs " (primarily the value of the lost output of the worker) and " private costs " (primarily lost spendable income). Their conclusions, in 1981 dollars: * For the small group of living insulation workers, asbestos factory workers, and ship- yard workers with asbestosis who left work before retirement because of their disease- private cost, $ 127,151; social cost, $ 172,213. * For insulation workers who were dis- abled from all asbestos - related diseases (aver- age disability period, 18.5 months -private) cost, $ 35,963; social cost, $ 45,855. * For deceased insulation workers who succumbed to asbestos - related disease - pri- vate cost, $ 163,236; social cost, $ 346,392. To estimate how much of the personal loss was made up by transfer payment programs, the study obtained detailed financial infor- mation from 195 widows whose husbands would have been 65 or younger. Roughly a quarter received no payments at all attributable to their husband's death. Al- most three quarters did obtain some transfer income, from programs such as workers'com- pensation, Social Security, pensions, veter- ans'widows'benefits, and public assistance. The average total received made up 40 per- cent of lost income. Put another way, their disposable income dropped $ 8,000 a year. Adding the lump sum tort settlements into this group's income nudged the replacement rate up to 42 percent. A fortunate few were able to make up 92 percent by combining tort settlement money with transfer payments. Johnson and Heler concluded that most of the costs of asbestos - related diseases were borne through private losses and by society at large through lost output and social programs. Their estimates did not attempt to measure the cost in medical care, pain and suffering, and the quality of life of surviving household members. Almost a third of the disabled workers queried in the detailed insulation workers survey discussed in the preceding paragraphs received benefits from Social Security Dis- ability Insurance before their death. This pro- gram, which has a five month waiting period, represents a Federal contribution to disabled asbestos workers that would be unnecessary iLindustry paid into a sufficiently generous compensation scheme. Similarly, health pay- ments could be made through workers'com- pensation instead of Medicare among those surveyed, workers'compensation paid most of the medical bills for only four percent. In addition, over ten percent of these workers. had out of pocket medical expenses of more than $ 5,000. In this light, the " free market " turns out to be subsidized by the suffering and money of asbestos victims. The manufacturers sell as- bestos at a price well below its true cost. As Johnson and Heler conclude, " It is difficult to find a rationale on either equity or efficiency criteria that suggests that consumers of prod- ucts that contain asbestos should benefit at the expense of the disability and death of their fellow citizens who are employed in the manufacture or use of such products. " Disaster Compensation The asbestos victims have a powerful case, and enough of them have already made it in Health / PAC Bulletin the courts to threaten all the assets of the asbestos industry and a good chunk of the massive property and casualty insurance in- dustry as well. Using the media and public protest as well as the courts, victims have sounded a compelling appeal for compensa- tion. Their success in winning public support has spurred a national debate. The industry response, most prominently the Manville Corporation's 1982 filing for bankruptcy, has further heightened the sense of urgency. Even now, however, the issue is more noted than understood. Despite the Mount Sinai report, most people think of asbestos - related diseases as simply an " occupational disease " problem which can be resolved through im- proved workers'compensation programs. Yet the lawyer who worked one summer on a construction site, the office worker in a ship- yard, the college professor son of an asbestos worker, the passerby at a sprayed asbestos construction site, Steve McQueen, have all succumbed mesothelioma reaches where people never expect it. Those responsible include not only employ- ers financially liable under workers'compen- sation, but the asbestos industry, the insur- ance industry, and the government. All these interests recklessly failed to act on knowledge they either had or should have had. Built into this disaster are situations that give this suf- fering a special poignancy: that workers and the public weren't warned of the lethal risk they faced; the fear engendered by carrying a toxic time bomb in your body; the incurable nature of most of the diseases; the fear of inadvertently spreading it to wife and children. What Should Be Done This toxic time bomb demands a concerted national response to ensure that the limited assets available from asbestos manufacturers, employers, and insurers are used to compen- sate victims efficiently, swiftly, equitably, and adequately. This is not beyond the realm of possibility. Because potential victims include large sec- tions of the general public, a massive, disaster- oriented compensation and cleanup program could win a broad base of labor and com- munity support. This requires, of course, let- ting the people know what has been done to them. Most journalistic accounts have de- scribed the plight of victims of severe as- bestosis, workers with a history of high expo- sure. Many future victims will develop mild asbestosis, which causes a permanent partial disability but does not make it impossible to work. Often they, like the majority afflicted by asbestos - related diseases, will die of can- cer. Most will have a hard time proving their exposure was the cause, since their body will show few signs of asbestosis. Nonetheless, they will be part of groups that experience higher than expected rates of cancer. Recognition of their plight requires shift- ing the emphasis of compensation programs from proof of individual exposure to proof of membership in an occupational group that has significant exposure and / or elevated rates of asbestos - related diseases. As the Mount Sinai study shows, the asbestos victims and their attorneys have already established, in the workers'compensation system in most states, the causal relationship of the disease to their work. Corporate interests have suggested that eliminating product liability suits would be a fair exchange of an improved workers'com- pensation system. This is absurd. The estab- lishment of a strong Federal system based on irrebutable presumptions simply requires making good nationally on a promise - ad- mittedly only partially honored - central to state workers'compensation laws: fair com- pensation for occupational diseases. Workers shouldn't have to give up an important legal right to get something already owed them. A fairer system would allow claimants to choose not to exercise their right to third party suits in exchange for benefit levels sub- stantially higher than the two thirds of lost wages typically the maximum now. This new award would be based on a multiple of the state average given for all workers'compen- sation cases. This would save the huge sums currently drained off in litigation which might well result in the same award - and allow victims to maintain or even improve their standard of living. These benefits would incorporate recognition of pain and suffering and failure to meet the duty to warn that now can be won only through third party suits. In some states, asbestos victims have done fairly well with civil suits. In others, notably New York, lawsuits for asbestos - related dis- eases have been effectively barred by restric- tive court interpretations of statutes of limita- tions. Most third party suits bring the victims disappointingly small, but greatly needed, amounts after a long and anxious wait. Yet Health / PAC Bulletin 19 in theory each state has a workers'compen- sation system which covers occupationally- related diseases. The Mount Sinai study, which showed the importance of information and supportive networks in gaining entry to the system and the crucial role a union plays, point up the need for intensified efforts to bring more people into the existing state pro- grams as well as to improve them. The wait for a decent Federal system may be long. Other urgent and evident needs include: * a special compensation fund for envi- ronmental mesothelioma victims. * an outreach program to inform the as- bestos exposed - both of their potential risk status and of measures such as giving up smoking which can dramatically reduce the danger to their health. * a program to identify people with possi- ble claims and notify them of their legal rights. * a program funded by the asbestos in- dustry for the maintenance and removal of asbestos already in place. * A disaster of this magnitude requires a coordinated governmental response. This means replacing the many comatose bureauc- racies now involved with the asbestos prob- lem with a special agency able to mobilize and target resources for areas of greatest need. * Serious consideration should be given to criminal prosecution of corporate offenders, and to allowing the public and workers a substantial role in corporate risk benefit / de- cision making - . Right now it's often our risk and their benefit. Would such measures give asbestos vic- tims some special, privileged status? Not really. When the dioxin and flood disaster hit Times Beach, Missouri, most Americans sup- ported government efforts to meet the vic- tims'needs and see that they didn't suffer severe financial losses. True, and regrettably, this is an exceptional case. Our society cus- tomarily addresses needs only after a com- plex process of proving the aid recipients belong to a special class of worthy claimants that is somehow deserving of special help. Nevertheless, each courtroom success of asbestos victims pressing claims against as- bestos manufacturers has created a public spectacle of the moral bankruptcy of Corpo- rate America as well as the failure of our soci- ety to aid people in need. For capital, the situation has become an open sore, badly in need of a remedy that preserves popular faith in the basic fairness of the system and con- tains the potentially disruptive financial con- sequences of the asbestos disaster. Because it has become a problem for capital as well as the victims, the way is open to a governmen- tally mediated reform solution. What form this will take will be largely determined by the ability of asbestos victims to move beyond individual legal actions, scat- tered local groups, and a handful of activist unions into a cohesive national force able to exert pressure on Congress. The various national compensation bills intended to change the rules of the game will certainly speed this process. On the state and local levels, legislative action and mutual support coalitions can be built around the issues of workers'compensation and threats to third party suit rights proposed in the name of " tort reform. " Two national organizations, the White Lung Association and Asbestos Victims of America, are already developing a national presence. The asbestos plaintiffs'attorneys have also organized, under the name Asbestos Litiga- tion Group. The direct beneficiaries of any success of this movement are likely to be asbestos expo- sure victims. As in the past in the United States, the absence of a broader social frame- work for aiding all those in need leads each group of victims to seek its own rights through special relief measures. Other groups able to locate their suffering in social relations and assert their rights will be able to raise similar claims for redress. Ultimately, the revelation of the full extent of social causation of individual suffering man- ifested in diseases and other forms might help lead to a reorganization of society so that meeting people's needs is taken as a matter of right, and the people making life threatening - decisions and the people taking the risks are one and the same. Right behind asbestos victims are those afflicted by radiation, DES, benzene, formal- dehyde, herbicides, toxic dumps, and many more, ad nauseam. Each group is following the same course of development: recognizing the social, corporate roots of the disaster; forming support networks and victims'organi- zations; fighting for public support through the media; seeking compensation in the legal system; fighting to prevent future suffering. Together, they present a powerful claim that something is fundamentally wrong with the way production in this country has been 20 Health / PAC Bulletin organized, fundamentally wrong in the way rewards and pain from this production are parcelled out. Toxic victims don't have to read about exploitative social relations in books; they can read about them in their own bodies. But the asbestos disaster is not waiting for the good society where all needs are met. Each year thousands of people will become disabled and die from asbestos exposure; each year thousands of families will bear the finan- cial brunt of their misfortune; each year vic- tims will turn hopefully to compensation sys- tems that turn them away or deliver too little, too late; each year asbestos victims will use that most American of protest techniques- full assertion of their legal rights - to make sure the issue doesn't die, even if they do, and to press for simple justice. Resources The Mt. Sinai Report, Disability Com- pensation for Asbestos Associated - Disease in the United States is available from the Environmental Sciences Laboratory, Mt. Sinai School of Medicine, 1 Gustave Levy Place, New York, New York 10029. The best collection of useful information on all aspects of the asbestos problem is the 1982 publication Asbestos Alert avaiJ- abJe from the Public Media Center, 25 Scotland Street, San Francisco, California 94133. A livelier radical British counter- part Asbestos: Killer Dust can be ordered through the Trade Union Bookservice, 265 Seven Sisters Road, London, U.K. N4 2DE. Other useful general publications are the National Cancer Institute's Asbestos: An Information Resume DHEW (NIH) 78-168 and The Asbestos Hazard by Paul Brodeur, published by the New York Academy of Sciences, 2 East 63rd St., New York, New York 10021. More specialized information can be found in Irving /. Selikoff and Douglas H. K. Lee's Asbestos and Disease (Academic Press, 1978) and George and Barbara Peters ' Sourcebook on Asbestos Diseases (Garland STPM Press, 1980). The White Lung Association has several chapters throughout the country. Informa- tion on the chapters and asbestos matters can be obtained from their Technical Re- source Center, 1114 Cathedral, Baltimore, Maryland 21201. Another national victims'group is As- bestos Victims of America, P.O. Box 559, Capitola, California: 95010. manomotola Maria Mattola Various viewpoints on the Miller Bill (see article which follows) can be found in the hearings held before the Subcommittee on Labor Standards of the House Commit- tee on Education and Labor Occupational Health Hazards Compensation Act of 1982 (G.P.0.1983). Paul Brodeur's Expendable Americans (Viking, 1973) continues to be the most vivid and gripping journalistic presenta- tion of the asbestos tragedy. Health / PAC Bulletin HEALTH PAC BULLETIN UP Octdoe + 1. THE HEALTH CARE HIERARCHY * * a a a * Sotofi/ * * * * The Health / PAC Bulletindoesn't have to boast that it's better than the competition; there is no competition. No one else offers independent analysis of health policy issues from prenatal care to hospices for the dying; covers medical carelessness for women and on the job poisoning; offers incisive international reports and lively briefs on domestic health developments. If you already know all this and have a subscription, why not do a friend a favor and fill in his or her name on the form below before you run out of 20 $ stamps? Remember, nine out of ten radical doctors recommend the Health / PAC Bulletin for fast relief of health care policy mystification. Please enter i six (issues) j Check: * Individuals $ 15.00 * Institutions $ 30.00 Name Address .subscription ^) for the Health / PAC Bulletin City. State. Zip. D Bill me (plus postage and handling) D Charge: D Visa D Master Expiration date No. .Signature Send your check or money order to Health / PAC Bulletin, 17 Murray St., New York, N. Y. 10007 22 Health / PAC Bulletin Asbestos Compensation: Justice for Whom? by Dave Kotelchuck J. here are now two major asbestos disease compensation bills before Cbngress. Both are bailout bills for the asbestos industry. One, introduced by presidential candidate Senator Gary Hart (CO D -), establishes a dis- ease compensation system for asbestos vic- tims run by the individual states. Costs would be split between government and industry as determined by special state compensation panels. The Hart system would cover asbes- tos victims only. The other bill, proposed by Representative George Miller (CA D -), establishes a Federally- run compensation system for asbestos work- ers and includes a trigger mechanism allow- ing other diseases to be added later. Under this bill, the entire cost of compensation pay- ments would be paid by the responsible in- dustries. The differences between these bills are real and significant, but they are identical in one crucial respect: both effectively eliminate the right of workers and their families to sue cor- porations for negligence when asbestos expo- sure on the job causes illness and death. This transforms both bills into industry bailouts; with it, the relative merits for working people of the Miller bill seem very much smaller. This feature also, not coincidentally, makes both bills potentially acceptable to industry and thus to Congress. As veteran Health / PAC readers know, workers long ago lost their rights to sue their immediate employers for an injury or illness on the job (see Bulletin 71, July Aug -. 1976). This provision was included in all state worker compensation bills in exchange for a Dave Kotelchuck is an occupational health specialist and a member of the Health / PAC Board. - <? \ promise - never fulfilled of prompt, adequate no fault - compensation for workplace acci- dents. But there was an escape hatch. Workers have been able to file so called - " party third - ' suits against manufacturers arid distributors who had sold the dangerous materials and machinery to their immediate employers. This has been of little value to asbestos workers at Johns Manville - Corporation, the giant of the asbestos industry, since it extracts asbestos from its own mines in Canada and then processes and manufactures it in the U.S. However the corporation has been hauled. into court many times. Some former employ- ees and their families have filed suit with the argument that compensation laws were not meant to shield criminal conduct by employ- ers which they say Manville was guilty of by willfully hiding medical and hazard infor- mation from workers (see Bulletin 61, Nov.- Dec. 1974). Several such suits are now in state courts and in at least one California case (Rudkin vs. Johns Manville - ) the right to sue the company for negligence has been granted. In addition, thousands of other asbestos workers and their families have filed third party suits against Manville, among them employees of other asbestos companies which bought its raw asbestos, Federal shipyard workers, and building construction workers who sprayed asbestos insulation bought from Manville. By the time Manville filed its bankruptcy claim last year - a novel ploy in corporate legal history, since the company is in fine financial shape (see Bulletin Vol. 13, No. 5 -over) 16,000 suits had been brought against it. Manville consultants estimated that another 32,000 might follow by the end of the cen- tury. As noted in the previous article, experts such as Dr. William Nicholson of Mount Sinai Health / PAC Bulletin Medical Center believe the number of poten- tial suits is far larger. The Hart bill would eliminate this possibil- ity overnight by flatly banning third party suits by asbestos workers and their families against any corporation which supplies as- bestos material to employers. Aside from de- priving asbestos workers and their families of the right to see justice done, this would be a dangerous precedent in a very real sense for all workers, since it offers legal protection for corporations which have killed or maimed workers on the job. The Miller bill's analogous provision is slightly better. It bans third party suits only if a worker's compensation claim is not decided within 18 months. If it is decided sooner, the worker must accept the verdict. By in effect punishing companies which endlessly con- test and delay settlements, this would assure prompt action on worker claims, virtually eliminating third party suits. The original compensation laws, most of them passed in the second and third decades of this century, were championed by the ma- jor U.S. corporations precisely because they took away workers'rights to sue their (im- mediate) employers. Predictable, no fault - costs for worker compensation seemed preferable to growing worker anger over carnage in the workplace, the bad publicity, and the grow- ing and unpredictable costs of negligence suits. For similar reasons, many labor unions and socialist political parties of the day initially opposed these laws. Workers were finally starting to win their suits in court and the loss of the right to sue was deemed more signifi- cant than the gains to be achieved from the no fault - accident compensation (see Bulletin, 71, July Aug -. 1976). The will of the big corporations prevailed. Eventually the outright opposition of work- ing class groups gave way to efforts to amend and improve the laws. In the 1930's, after the Gauley Bridge scan- dal (see Bulletin 79, Nov. - Dec. 1977), when workers began winning direct suits against their employers for silicosis occupational - diseases were rarely covered in the old state compensation laws corporations - suddenly became " good citizens, " supporting limited occupational disease coverage in the states. This again took away workers'rights to sue their immediate employers without provid- ing adequate compensation for them or their families, as the accompanying article in this issue explains. Once again history is repeating itself. The asbestos industry finds its profits and perhaps even its future existence threatened by an upsurge of third party suits. At no time has any of these companies, least of all Johns- Manville, admitted or apologized for its shame- ful half century of scientific coverup of asbestos hazard and withholding of medical informa- tion from sick and dying asbestos workers (see Bulletin 50, March 1973; and Vol. 11, No. 5, May June - 1980). On the contrary, the in- dustry is following the old patterns of seeking legislation to choke off third party suits, even as the asbestos dust is choking off the victims ' lives. So far other corporations have been muted in their response to the asbestos compensa- tion bills. They are, nevertheless, watching the response with great interest since many of them may face similar cases in the future. Consumers and consumer groups are already slapping companies with product liability lawsuits for harm caused by products which workers in the plants are exposed to daily for almost all of their adult lives. Compensating Benefits? Most workers and labor unions oppose any ban on third party suits. AFL - CIO leaders have taken this position in testimony before Representative Miller's Congressional sub- committee. But it is clear that this is the essential quid pro quo for corporate acqui- escence to a job disease compensation bill. What labor will do if it can't eliminate the third party suit ban is not clear. Although it severely restricts their rights to sue, many workers and their unions may still support the Miller bill or a modified version of it. If they do, it will be for two basic reasons: the immediate financial needs of ill workers and their families are great, and the benefit levels provided by the bill are a major im- provement over current benefits. Prognosis Most factory workers are well aware that the " world just isn't fair, " to quote among the few memorable words of former President Jimmy Carter. They know that management takes basic economic and social rights away from them day - in, day - out when they enter the plant gate, simply because it has the power and the motivation. In this real, unjust world, workers and their unions may decide that Congressional com- 24 Health / PAC Bulletin pensation legislation like the Miller bill (see box) improves their situations on balance and support its passage. Many of their friends in public health and elsewhere will approve of this choice, without abandoning efforts to eliminate the ban on third party - suits from this and any future compensation bills. As in many other labor and social issues, the bottom line here is not how much the program costs, but whether or not it is just and serves a pressing social need. For multi- billion dollar corporations in a country rich enough to waste billions on conspicuous military consumption, the cost of such com- pensation programs would be modest. The failure to establish a proper disease compen- sation system further victimizes sick and dy- ing workers, their families, and the general public for decades of corporate crime. The Miller Bill (HR3175) The most recent version of Representa- tive Miller's bill is officially entitled " The Occupational Disease Compensation Act of 1983 /'It was introduced this June with the co sponsorship - of all the other Demo- cratic members of the House Labor Stan- dards Subcommittee. Aside from the third party provisions, its notable features include: Coverage: Compulsory for all those- except Federal, state, and local employ- ees exposed - to asbestos on the job. Eligibility for Compensation: Includes all, except government employees, who are disabled or die from diseases caused by exposure to asbestos on the job. Standards for Compensation: How the compensation panels are to determine whether or not a particular worker's ill- ness or death was caused by asbestos ex- posure is a key element in any bill, and the Miller bill's standards are one of its best elements. They effectively shift the burden of proof to the employer. Specifically, if a person exposed to asbestos on the job de- velops mesothelioma or asbestosis, he or she is automatically and irrebutably pre- sumed to have developed the disease on the job and thus be eligible for compensa- tion. If lung cancer develops in an asbestos worker ten or more years after first expo- sure, it is presumed to be job related - . This can be disputed on a case - by - case basis by the employer (it is, therefore, a rebutable presumption). Amount of Compensation - Compensa- tion for total disability is 80 percent of the national average weekly manufacturing wage, except for construction workers, who receive 80 percent of the national average weekly construction wage. For the permanently disabled, either total or partial, payment continues for the rest of the worker's life. If the worker dies from asbestos disease, the surviving family receives a full five years of total disability benefits. Thus the surviving family of an asbestos manufac- turing worker would now receive $ 7 2,867, based on a national average manufactur- ing wage of $ 350.32 in May 1983. The surviving family of an asbestos construction worker would similarly receive $ 92,676. Both figures are less than the death benefits under most state worker compen- sation laws. Compensation for partial disability is based on lost income if the person is able to continue working and finds a job. In this case the diseased worker receives two thirds of the difference between the weekly pay on his or her current job and that in the last job during the year before disabil- ity. If the worker remains on the same job or finds a job with higher pay, he or she receives no compensation at all even -, for example, if he or she has an advanced case of asbestosis. If the partially disabled worker is not employed, then he or she receives a fraction of the total disability benefits corresponding to his or her de- gree of disability, e.g. a worker who is 30 percent disabled would receive 30 percent of the benefits of a totally disabled person. Payment of Compensation Costs: Indus- try pays all compensation costs through compulsory payments to the Toxic Sub- stance Employee Compensation Insurance Pool. This pool would be run by a group of private insurance companies and would provide an amount of coverage for asbestos victims set annually by the Secretary of Labor. Under this bill the pool - not the employer would be legally responsible for all payments to asbestos victims and could contest worker claims on behalf of the asbestos companies. The Pool would thus be set up as a third party between worker and employer, which could act on Health / PAC Bulletin behalf of the companies while shielding them from direct responsibility, for exam- ple, in contesting worker claims. Additional Coverage of Occupational Diseases: The Secretary of Health and Human Services is required to survey an- nually new information about occupation- al diseases. Based on her (at this time) report, the Secretary of Labor is empow- ered to set new standards covering other occupational diseases. The Secretary's decisions are subject to congressional veto. Also one percent of the payments to the Insurance Pool are earmarked for research into occupational diseases and for medi- cal surveillance of exposed workers. The Hart Bill (S1643) In comparison to the Miller bill, the Hart bill has much less to offer asbestos or other workers, and much more for the asbestos industry especially - Manville, now headquartered in Hart's state of Colo- rado. The Hart bill covers asbestos diseases, and asbestos diseases only. It establishes asbestosis, mesothelioma and lung cancer as compensable diseases for asbestos - ex- posed workers and sets Federal benefit schedules quite similar to those in the Miller bill. But the actual decisions as to whether workers receive benefits or not are made by state compensation agencies, and the bill does not establish presump- tive standards, rebutable or irrebutable, to guide these decisions, although it does give the U.S. Department of Labor power to set such standards as it sees fit. The bill also sets up state Apportion- ment Criteria Committees which decide (again with no guidelines written into the bill) how much of the benefit payment each employer of the ill or dead worker is responsible for, including Federal and state employers. Thus depending on cir- cumstances and the whims of 50 different state boards, taxpayers could be left hold- ing the compensation bag for much of the asbestos'industry's corporate crime. In addition, the state boards can cut down benefit levels to individual workers and their families in proportion to the " degree of responsibility " of the employ- er for - example, they can limit payments for lung cancer if a victim smoked. This is hardly a no fault - insurance system! Finally, the Hart bill speaks not at all to prevention of disease or medical surveil- lance of exposed workers. I AM A SINCLAIR REFINERY WORKER You hired me with no experience or training to oversee your multi million - dollar refinery, then you ridicule me when I say I don't understand. You hired me to tell you of things not working right but then you slap me in the face when I do if it is not to your liking. You hired me to operate a complex operation, but paperboys receive more training than I do. You hired me to work in unusual conditions and hazardous environments but when I stumble you say I'm shiftless and don't care. Now you have spat upon me in the worst possible way: You've attempted to strip me of my pride and self esteem, You've brought tears to the eyes of my friends, You've torn at the heart of my wife, You've marred my memory to my children. You've destroyed my loved ones'faith in the community I work in You've left unpunished and unmentioned the perpetrator of these wrongs, for he is really you. You will call on me soon but I will not hear in the way I once did. -Name withheld by request (from the Oil, Chemical and Atomic Union News) 26 Health / PAC Bulletin Bulletin Board * Medicine Show The Slide Archive of Historical Medical Photographs at Stony Brook has recently an- nounced the development of an archive of slide reproductions of photographs pertain- ing to the history of medical care in America. The collection, created by the Center for Photographic Images of Medicine and Health Care with funding from the National Endow- ment for the Humanities, contains over 3000 images, representing a wide range of medical and public health activities from the 1850's to the 1950's. Slide reproductions of photographs are avail- able at cost for educational purposes. An il- lustrated catalogue, to be published in 1984 by Greenwood Press, will provide a detailed description of the collection and of various other published and unpublished sources of photographs in the history of medicine. Per- sons interested in information about the ar- chive and with requests for particular images may contact the Archive at Health Sciences Library State University of New York at Stony Brook P.O. Box 66 East Setauket, New York 11733 Doctor Yes Health USA," a new PAC established by physicians and dentists " dedicated to better health care in America, " intends to present a perspective somewhat to the left of the AMA on issues such as cost containment; Medicare and Medicaid reform; adequate nutrition; ma- ternal and child care; preventive medicine; and environmental, safety, and nuclear haz- ards. The board of directors includes Drs. Ber- nard E. Filner, Victor Sidel, Jack Geiger, Jean Baker Miller and Neal D. Kaufman. ' it is a PAC in the public interest, " declared Dr. Filner, " We want to disprove a miscon- ception that doctors are only interested in protecting their economic welfare. " Well, Dr. Filner, to paraphrase Henry Kis- singer, there are doctors and there are doctors. Health USA can be contacted at 7910 Wood- mont Avenue, Suite 915, Bethesda, MD 20814. .Telephone (301) 656-7900. Our Patients, Ourselves The Nurses'Environmental Health Watch / New York is sponsoring an all day - conference October 12 on health and safety in the nurse's workplace. The program will address the nurse's role in assessment, prevention, and correction of workplace hazards. Speakers include Patricia Moccia, Ph.D., RN, of the Health / PAC Board and Michael Mattia, safety director at Jackson Memorial Hospital, Miami, and author of a series of articles on hazards in the hospital environ- ment published in the American Journal of Nursing. Fear of Flying Fear at Work: Job Blackmail, Labor, and the Environment, by Richard Kazis and Richard L. Grossman, published by Pilgrim Press, is the first comprehensive study of how job blackmail works; the impact of environmental regulations on jobs, inflation, productivity, and inflation; and many other related issues of immediate concern to environmentalists and workers throughout the country. The book can be ordered from Environmen- talists for Full Employment, 1536 Sixteenth St., NW, Washington, DC 20036. Single copies of this 320 page paperback are $ 10.95, two to five are $ 8.95 each. There are special discounts for non profit - organizations. Planned Parenthood The Midwives'Alliance of North America (MANA) will hold its first international con- vention in Milwaukee, Wisconsin, October 7-9. MANA was recently founded to unite both streams of midwifery in the United States and Canada. There will be workshops on grassroots or- ganizing, legislative strategies, and priorities for the development of the profession of mid- wifery. For further information, contact Carole Leonard, 30 South Main, Concord, NH 03301. Health / PAC Bulletin 22277 Watch Your Mouth! by Arthur A. Levin This is the final column on teeth and dentistry, although probably not the last word. In it I would like to discuss some of the controversies that sur- round certain public and per- sonal dental health practices. As mentioned in the last col- umn, fluoride is generally cre- dited for reducing dental caries among the exposed population substantially. Its dissemination has largely been accomplished by politically mandating treat- ed municipal water. As with other public health measures, such as inoculation of school age children, the de- cision has been made that the health benefits to the larger community of citizens out weighs any impingement upon individual freedom of choice. In many areas individuals and groups have actively fought against fluoridation of public water supplies, arguing that it poses substantial risks. Some claim it is carcinogenic; others have seen the hand of " subver- sives " poised on the water tap. These charges are not all of equal merit. Evidence for the efficacy of fluoride treatment is substantial. However, despite the dental profession's repeated assurances of safety, there is Arthur A. Levin is Director of the Center for Medical Con- sumers and Health Care Infor- mation, Inc., and a member of the Health / PAC Board. Body English new scientific concern about excessive exposure to fluoride. A recent article in the British publication New Scientist (May 5,1983) points out that the use of fluoride in drinking water supplies was hailed over 40 years ago as a cheap way of reducing (perhaps even elimi- nating) the costly and discom- forting effects of dental caries. Now, it says, with the addi- tional experience that only time can bring, there is reason to re examine - its cumulative effects. The New Scientist article points to two factors. First, be- sides the increasing exposure to fluoride through dental public health efforts, (promot- ing use of fluoride toothpastes, mouthwashes and profession- ally administered fluoride treat- ments) people are absorbing it in food, medicine, pesticides, insecticides and air they breathe. Thus, the notion of controlling the dosage at levels that are " ac- ceptably " safe (as envisioned in 1945 when the first water fluoridation experiments began in Grand Rapids, Michigan and Newburgh, New York) may not be practically achievable. Second, in 1976-77 scientists at Sweden's Karolinska Insti- tute discovered a simple and accurate method for measuring the blood level of fluorides. This test allowed researchers to determine that even very small doses of fluoride could boost levels in the blood from " normal " to potentially harm- ful. Proponents of fluoride have long defended its safety by pointing to a study published in a 1960 issue of the Journal of Applied Physiology. This pur- ported to show that blood levels of ionic fluoride remained stable no matter what the in- take. However the National Research Council National Academy of Sciences pointed out in 1977 that the study was faulty in design and its conclu- sions were therefore question- able. The first sign of fluoride tox- icity is usually mottling of tooth enamel. White some dental professionals make light of this initial overt symptom, others assert this is unwise. They warn that it quite possi- bly indicates other cells besides those involved in tooth forma- tion have been injured. Until this scientific contro- versy is resolved, and more is understood about the health effects of excess fluoride, it would probably be wise to limit your intake. This can be done by substituting bottled water for tap, a chic but costly and somewhat inconvenient solution. It can also be accom- plished by reducing use of commercial toothpastes and mouthwash (a mixture of bak- ing soda and peroxide will clean your teeth better and al- low you to remain at least as kissable) and refusing fluoride treatments. This does not mean it is wise to eliminate all fluoride intake, since it does prevent cavities and filling them (known in the trade as restoration) may pose even greater risks to your health beyond - the stress of making a dental appointment. Although gold is the mate- rial of choice in restoration be- cause of its strength and dura- bility, its increased value and expenses of casting have led to the use of less costly amalgams. (We cannot refrain from not- ing an irony of history here. In our last column we mentioned the connection between the Health / PAC Bulletin slave trade and the rise of cavi- ties; now we see that the best known treatment would long have been prohibitively expen- sive were it not for the low wages of black miners in South Africa.) Known to most people as a " silver " filling, amalgam is actually a mixture of silver, copper, zinc, tin, and mercury. It is soft when first mixed, al- lowing the dentist to compress it into the cavity easily; it be- gins to harden very quickly, and reaches maximum hard- ness within 24 hours. It also however, has many disadvan- tages both to the dental profes- sional and the person on the receiving end. The principal risks of amal- gams stem from one key ingre- dient, mercury. As long ago as 300 B.C. scientists observed the toxic effects of mercury and mercury compounds. Ob- servations on harmful effects of exposure to workers in mer- cury mines were made in 1553 (perhaps one of the earliest ex- amples of occupational health research). Nineteeth century researchers developed a large literature on the toxicity of mercury, and the use of amal- gams in dentistry was very controversial from the time it was first introduced in the mid- 1800's. The practice neverthe- less became widespread by 1900. Amalgam fillings over- came a brief flurry of concern and debate in the latter half of the 1920's based on an attack by a German professor of chemis- try named Stock, and its for- tunes rose with those of the gold bugs in the 1970's. Now the debate is heating up once again. Unfortunately there is little past or present research into the effects of mercury amalgams on human health, despite the headstart given in 300 B.C. The number of den- tal professionals who are con- cerned with this problem is still small, although it does ap- pear to be growing. This renewed controversy is of interest to the profession for personal as well as ethical rea- sons, since ambient mercury vapor has been found to be above acceptable levels in ten to 22 percent of dentists offices. This airborne vapor is at its highest level when the filling is being mixed and inserted. Once inhaled, it is rapidly ab- sorbed into the bloodstream and and can can find find its its way way to to the the brain. How high blood levels of mercury must be to cause brain and central nervous system damage is still debated. In any case, because mercury easily finds its way across the pla- cental barrier and into the de- veloping fetus, women are ad- vised not to undergo dental work during pregnancy. Be- sides what they get by inhal- ing vapors, patients who get amalgam fillings are endan- gered according to some ex- perts because mercury leaches out out of of the the restoration restoration and and is is absorbed in the oral cavity. Studies have shown that chew- ing releases mercury from the fillings, but the effects of such long term, chronic low level - exposure have not yet been scientifically determined. Mercury can also be ingested at the time restoration is done, or when a filling is removed, however it is not clear whether any is absorbed before it is passed as waste. A study of mercury levels in the blood of medical students found that they were directly related to the number of amalgam fillings; students with none had less mercury in their blood. Other than possible toxicity, mercury amalgams have other disadvantages which include: -they fracture easily. -they may conduct heat and cold more effectively than natural tooth material, caus- ing sensitivity to temperature changes. Lthey work very well only in small cavities where there is support from surrounding healthy tooth structure. -they often erode over time and need replacing. Unfortunately, other than gold there is little alternative. Composite (plastic) material is often used to restore front teeth. since it is white in color and thus more attractive. However, it has two major disadvantages. It cannot withstand pressure as well as the metallic mate- rials and therefore may not last as long; and it expands and contracts with temperature changes, allowing more decay to occur beneath. New materials are being de- veloped which may mitigate these two problems. Some ex- perts believe these advances combined with new techniques for bonding (a process by which plastic tooth colored - material is attached to the existing ena- mel surface of the tooth) may be an effective solution. Dentistry presents a paradox of sorts to the consumer. Its approach is much more primary prevention - oriented than medi- cine's. Yet, the benefit of many of its curative practices has been poorly researched - if it was at all. For some proce- dures and materials, the risks have been almost casually dis- counted without any support- ing evidence; in some cases (mercury and fluorides) the evidence clearly seems to dic- tate a more cautious approach. As with all health care, con- sumers are well advised to educate themselves rather than accept a given preventive or restorative program on faith. Health / PAC Bulletin 29 i Media Scan MEDIA SCAN Health Facts: A Critical Evalu- ation of the Major Problems, Treatments, and Alternatives Facing Medical Consumers, by Maryann Napoli. Woodstock, NY: Overlook Press, 1982. 385 pages. (16.95 $) Health Facts, the monthly pub- lication of the Center for Medi- cal Consumers & Health Care Information, 237 Thompson. Street, New York, NY 10012. (18 $ / year) by HaJStrelnick The signature of Sergeant Joe Friday, the detective im- mortalized by Jack Webb on TV's Dragnet, was a telegraphic line repeated in almost every episode, " Just the facts, ma'm, just the facts. " Maryann Napoli, has focused a similar no nonsense - , critical eye, sharpened by the prag- matic empiricism of the best of American science, on the health care available for American " medical consumers. " She and her colleagues at the Center for Medical Consumers and Health Care Information in New York produce Health Facts, the most consistent and trustworthy health newsletter that I know, Hal Streinick is a physician with the Social Medicine pro- gram at Montefiore Hospital in the Bronx and a member of the Health /? AC Board. and out of this she has com- piled 20 issues into a quite readable and quite disturbing book with the same name. Most bookstores now have entire sections of health and self care - books, and there is a growing number of health newsletters and magazines that try to help their readers navi- gate the treacherous and con- fusing currents of the health care system. Health Facts is different from most most of of these these.. It It offers offers no no hype hype,, no promises, no miracle cures, no vitamin panaceas, no thera- py or personality cults- " just the facts. " But these are not limited to the biological and clinical; they extend to politi- cal and economic facts that shape and determine the pri- orities of practice and research and illuminate the market forces that govern the health care sys- tem. Unlike Dragnet's, the facts relevant here are often contra- dictory or unavailable, but the author is not intimidated. She presses on, explaining what we do and don't know. The book begins by laying out the scientific principles on which all medical practice should be based - the prospec- tive, randomized clinical trial or the " gold standard " of clini- cal evidence. It then proceeds to hold all practices - both tra- ditional medical therapies and holistic alternatives to this same standard. Napoli's exam- ination exposes the disturbing degree to which both tradition- al medicine and holistic alter- natives are practiced without valid proof of the efficacy of their therapies. She examines the placebo effect, the ethics of research, and the role of the FDA Food and Drug Administration (al- though she only begins to ex- plore why more ideal, prospec- tive studies are not performed). Where definitive proof is lack- ing, her preference is for holis- tic approaches such as nutri- tion, exercise, and meditationL an appropriate bias, since even when they have not been proven effective scientifically, none of these have the serious negative side effects of drugs or surgery. The book next reviews the controversy surrounding the annual physical exam, describ- ing its usual components, em- phasizing the value of the medical history, periodic blood pressure measurement, breast examination, the Pap test, and glaucoma screening. The fol- lowing chapter discusses three controversial surgical proce- dures, tonsillectomy and ade- noidectomy; hysterectomy; and coronary by pass - surgery; and finds each wanting in scientific support in all too many cases. Two chapters each are then devoted to reviewing the risks and benefits of medical and dental x rays - in general and mammography in particular; cancer therapies and their poli- tics; hypertension and heart disease; psychotropic and an- tibiotic drugs; and alternative, non medical - therapies. There are individual chapters on the common yet neglected prob- lems of depression, lower back pain, and prostate disease. The chapters on eyes and teeth will be valuable even to the profes- sional, since this information is too often left only to special- ists. The book also contains a re- strained chapter on the bene- fits of exercise - an oasis of ra- tionality in the mania of mara- thons and fitness freaks. Like the others, it concludes with 30 Health / PAC Bulletin specific recommendations on " What You Can Do " and sug- gested readings and references. Only someone as compulsive as I am will complain that the references seem to follow no logical order. A book like Health Facts is bound to have a couple of facts wrong in its 385 pages. In one instance, it gets caught on a common misconception that every medical student is guilty of at least once, how nitroglyc- erin relieves the heart pain of angina pectoris. {Nitroglycerin relieves angina not by dilating the coronary arteries but by re- ducing the work of the heart and its demand for oxygen through pooling blood in the body's veins.) More depression is treated by internists and family and general practition- ers than by psychiatrists, yet they are omitted in the discus- sion on its treatment. This is a minor oversight. When reading the book, I wondered if the au- thor, like the porcelain makers of Dresden, intentionally in- troduced occasional flaws to show that this was the work of a human being, not a machine or " infallible " physician. The complementary relation- ship between the book and the newsletter, also largely written by Napoli, is one that has become a necessity. What is known and what is practiced in orthodox medicine, as well as the emerging alternatives, is always changing. A book like Health Facts can quickly be- come dated, but it provides the foundation upon which to read the Health Facts newsletter (Health / PAC's " Body English " column is based on it). A recent issue, for example, covers " Saving Your Teeth, " an updated and expanded ad- dition to a chapter in the book. The most recent issue covers a wide variety of topics, includ- ing the AMA's drug informa- tion program called " patient medication instructions " or PMIs, temporomandibular joint disorders, medical uses of Vi- tamin E, and the drug interac- tions of the nation's most fre- quently quently prescribed prescribed medication medication.. It factually answers a reader's question, " Is honey better for you than sugar? " (No.) Follow- ing ing the the Health Health Facts Facts model model., Scientific American has re- cently introduced a textbook of medicine that is updated each month rather than reprint- ed in new editions every three or four years. If I would criticize the author of Health Facts, it would only be be to to suggest suggest greater greater attention attention to the illnesses of children and to the potential power of illus- trations. Most health care pro- viders agree that while indivi- duals may neglect their own health, they will actively care for their children. And why - try to improve on an apt cli- che -a? picture is worth a thousand words. Books Received Levy, Barry S. and David H. Wegman (Eds) Occupational Health: Recognizing and Pre- venting Work Related - Disease (Boston: Little, Brown & Co., 1983) $ 26.95 Karpel, Mark, A. and Eric S. Strauss, Family Evaluation (New York: Gardner Press, Inc., 1983) $ 26.95 Carter, Elizabeth A. and Moni- ca McGoldrick (Eds), The Fam- ily Ldfe Cycle: A Framework for Family Therapy (New York: Gardner Press, Inc., 1983) $ 26.50 McNulty, Elizabeth Gilman and Robert A. Holderby, Hospice: A Caring Challenge (Spring- field, II: Charles C. Thomas, Publisher, 1983) Navarro, Vicente and Daniel M. Berman, Health and Work under Capitalism: An Interna- tional Perspective (Farming- dale, N.Y.: Baywood Publish- ing Co., Inc., 1981) Together, Health Facts - the book and the newsletter - stand as a powerful indictment against the practice - now, study - later approach taken by our pseudo- scientific health system whose business - as - usual makes us all guinea pigs. They educate even the professional, since our train- ing too often ignores the lack of supporting evidence for many current practices and follows the dictum primum non nocere- " above all do no harm more " in its breech than in its practice. It is not difficult to imagine Sgt. Friday finishing Health Facts, looking into the camera as the " Dragnet " theme builds in the background, and saying, " Thanks, ma'm, now we've got the facts. " Abrams, Natalie and Michael D. Buckner (Eds), Medical Ethics: A Clinical Textbook and Reference for the Health Care Professions (Cambridge, MIT Press, 1983) $ 25.00 Ziegenfuss, James T. Jr., Pa- tients Rights and Professional Practice (New York: Van Nos- trand Reinhold Co., 1983) $ 19.95 The Hospital Research & Edu- cational Trust, The HospitaJ's Hole in Caring for the Elderly: Leadership Issues (Chicago: An Affiliate of the A. H. A., 1981) Tabb, William K., The Long Default: New York City and the Urban Fiscal Crisis (New York: Monthly Review Press, 1982) paperback $ 6.95 Health / PAC Bulletin 31 continued from p. 2 Bronx Municipal, North Cen- tral Bronx, Elmhurst and Coney Island Hospitals. An additional $ 1.9 million was also appro- priated for improvements in medical records. Together, these initiatives should en- hance the quality of services to large numbers of municipal tinuing to work with you to outpatients. improve the quality of health There were, of course, some care in our City. worthwhile public health pro- grams that we could not afford to fund this year. I know you will continue your efforts on behalf of these programs and Sincerely, Carol Bellamy President. New York City Council the New Yorkers whom they serve. I look forward to con- Hecdth / PAC Health Policy Advisory Center 17 Murray Street New York, New York 10007 2nd Class Postage Paid at New York, N.Y. X 523 -