Document RE6B4KwVQ23mja4N10Oj8eVk

*V '4' 4\ \ /. -:/: rf. ;i ; 1 v-v> .;7^ . S?, fi-- Jy'-iT?li'*'^v'^i' -` : - ,w > &&Zi?s* '}&%} '^ ' ^ \ V' ` ', ,' fe'v '- , 1 4 . wrtrfwflW ftmrrn IF r.ffi. . and look what's not .''jv"'j'^-'" \' " ' 'V -vbv''''"'1' v ,' ~'{r " .4?/ iif%S^sr?S S&4? INDUSTRIAL MEDICINE Is f A< .IT*.. *- t ?! A/eiv materials--and When Assistant Secretary of Labor perhaps some old John H. Stender, head of the Occupa tional Safety and Health Adminis ones--harbor new dangers tration, ordered a review of work place hazards and accidents several months ago, he wasn't prepared, he conceded, for some of the "gruesome exam ples" of electrocutions, suffocations, bums, and fatal falls the agency's regional offices turned up. "The hazards that working men and women are facing today as they go about their work are as unnecessary as the damage I suffered working on boil ers 30 years ago," declares Assistant Secretary Stender, who has a hearing loss to remind him of his years as a factory worker. But a menace not included in those reports was about to surface. The widely used industrial chemical vinyl chloride (VC) was linked unmistakably early this year with the rare--or previously rare--angiosarcoma of the liver. Once considered for use as an anesthetic, the gaseous substance now has awakened deep concern in physicians, and members of labor, industry, and government. The 11 cases confirmed in the U.S. (and a 12th in England) had harsh implications for thousands of workers, for industry facing the immediate need to change production methods, and for public health officials. VC's carcinogenic potential was conceded early by John O'Neill, chief of the division of health standards in the Occupational Safety and Health Adminis tration (OSHA), the Department of Labor's agency responsible for setting and enforcing safety codes. "There is no use denying it," he says. "We are faced with a new occupational disease." The public announcement of the VC hazard came in January after officials of the B. F. Goodrich plant in Louisville, Ky., alerted by plant physician John L. Creech, informed government officials that four liver angiosarcoma deaths had occurred among former employees involved in producing polyvinyl chloride continued MEDICAL WORLD NEWS/May 3, 1974 EC 2890 33 (PVC) from VC. Physical examinations and a search of medical records there and at other plants soon gave the to tal: live deaths and two workers with the disease but still alive at Louisville; three deaths at the Goodyear plant in Niagara Falls, N.Y.; and one death at the Union Carbide plant in South Charleston, W.Va. In mid-February, at a standing-room-only OSHA hear ing in Washington, D.C., a 43-year-old Italian researcher, Dr. Cesare Maltoni, director of Bologna's Institute of On cology, presented results of his animal studies that showed-for the first time-that VC produced angiosar coma of the liver in rats. Moreover, it did so at levels (250 ppm) many had considered safe. Although Dr. Maltoni's research did not prove VC caused the liver cancer in hu man beings, it did provide strong circumstantial evidence. Also testifying was Dr. Irving J. Selikoff, director of the environmental sciences laboratory at Mount Sinai School of Medicine in New York, who found the hearing some thing of a paradox. Although it appeared that a new prob lem had been identified and steps taken to meet it, he said: "It is equally true that there has been evidence of poten tially serious disease among vinyl chloride-polyvinyl chlo ride (VC/PVC) workers for 25 years that has been incom pletely appreciated and inadequately approached by medical scientists and by regulatory authorities." The first four cases of angiosarcoma of the liver from Louisville were confirmed at the National Cancer Insti tute by Dr. Louis Thomas, chief of pathology, and Dr. Hans Popper, former Mount Sinai dean and now a Fo garty scholar at NIH. They also have come up with a clue that potentially, at least, holds out hope for reversing or retarding the disease process. Shortly before the disclosures about VC were made at the OSHA hearing, Dr. Popper received a report from col leagues at the University of Bonn in West Germany of a peculiar liver lesion seen in some 50 VC workers there. Early in February, during a visit to Bonn on another med ical matter, he obtained slides and photos of "this peculiar fibrosis-chronic toxic fibrosing liver lesions." Studying these at the NCI, Drs. Thomas and Popper noted similar ities between the liver lesions in the German VC workers and liver biopsy material taken from one of the Louisville victims before the angiosarcoma had developed. "This has increased our suspicions that exposure to VC will lead to this lesion, which will lead to angiosarcoma," says Dr. Popper. "This is not yet proved but is highly suspicious-and very important. Why? Because if we can catch it at that stage, perhaps we can prevent develop ment of the cancer by removing a worker from exposure." But at the Goodyear plant in Niagara Falls, where a team of environmental scientists from Mount Sinai Medi cal School spent three days doing intensive mass medical 34 EC ?891 4 v^',",'."''".,-wc^. *7**-*V*'V,,'.''-,i` &*$ SftraWS f S*%1 ,, #;?5v 'A.:lsu ' ^':- ` \V v; v' V'"/"'1 , '"V * ~ ' .-#'*{-.> ``,.V'T*'< r.''*t^r''1,V% ^,: 4U'" '' .Vv, - ';^v^:t>-^v.f' *- ' 1 ' i.7' ' K >, ^ - ;,'C-;:'; ;*' ./* `.> ' ntw w^cover aMB'^>>) If* lot of trouble spots i Instant hfea)ttast can help in so many cases. ; "I Mixed with milk, it provides 1655 gms. protein t| to proi^otetapid healing. 25% MDR or more amins and minerals. 290 delicious ? lories. (Milk contributes substantial 4 ';'4\#--k..!,..-nutr*tion, read the label.) ^ f'V"vtt-ut >!& iff.*IP? Sf 't;r\ Send for iw professional sample of Carnation insrapt breakfast arid these free diet plans Rsheck the ones you'd :Y:^ like): Residue Controlled ; *%:.:k<C3Pu*tneRestricted Uberal ; f:.&; ^7:41 Bland ., Q1M Protein. Mail this coupon to: , '' Carnation Spany- , P-O. Box 550, DepMQ6, ! , Pico Rivera, Calif.ftrtkXA1 I Name. " 4-' ' "'?IIs CPwtwr* taeWHtw^iwt, : ' '^OtriWtiBnCampw*T. U* EC 2892 17/7' DUSTRIAL MEDICINE continued 'rganization, estimates that more than 2.4 million work ers suffered disabling injuries on the job, resulting in lost work days, in 1972. Preliminary BLS data for that year, based on different criteria, show 5.6 million recordable in juries and illnesses, whether or not work time was lost. But some are convinced the "standard estimate" of 14.000 job-related deaths and two million injuries each year falls far short of reality. Dr. Lorin E. Kerr, president of the American Public Health Association, cites a feder ally financed report that indicates 20 to 25 million injuries and 25,000 deaths a year are closer to the true figures. Oth ers, including some government officials, have estimated 100.000 deaths-but nobody really knows. Health hazards peculiar to certain occupations and in- was little pressure for strong occupational health and safety legislation. "Industry was happy with the voluntary approach to oc cupational hazards," says Dr. Marcus M. Key, NIOSH di rector. "Labor was more interested in hazard pay than in the prevention and control of hazards. And we in the Pub lic Health Service were satisfied with the holy trinity of research, training, and technical assistance to states." Sheldon W. Samuels, director of health, safety, and en vironmental affairs for the AFL-CIO's Industrial Union Department, notes that in one Midwestern industrial state, "not a single case of occupational cancer was re ported for the entire year of 1970 and the first three months of 1971," despite widespread use of known.indus trial carcinogens. To him, this was "gross and obvious un derreporting." OCAW's Legislative Director Mazzocchi demands doctors who recognize occupational ills and yell about them. dustries have been recognized since well before the age of plastics. In 1546, miners in the Erz Mountains of Central Europe were known to have an unusually high frequency of fatal lung disease, determined four centuries later to be bronchogenic carcinoma associated with high radiation levels from uranium-bearing ore. The British Medical Journal (1:590, '74) cites the scrotal cancer found among chimney sweeps in the 18th century and the observations of bladder cancer induced by aro matic amines in the 19th. And in the early 20th century, radium poisoning considerably shortened the lives of women who painted luminous dials on watches and clocks. Dipping their brushes into the radium-containing paint, then moistening the brushes with their lips to make a fine tip was the modus mortis. Despite occasional outcries for reform, like those follow ing the 1911 Triangle Shirtwaist factory fire in New York City in which 146 women sweatshop workers died, there 36 ^Lnd the federal government's arm was hardly stronger, 'A 1970 report noted that Although inspectors discovered' hazards in more than 90% of factories entered, only about 1% of the companies were called to account and barely one in a thousand penalized. Labor Department records show that from 1963 to 1968, safety and health complaints were filed against 154 companies. The passage of the Occupational Safety and Health Act of 1970, which became effective April 28,1971, and estab lished the NIOSH as OSHA's research arm, was the culmi nation of many events. Key among them was passage of the Federal Coal Mine Health and Safety Act of 1969. That1 landmark legislation, stimulated by such mine cave-ins as the 1968 Farmington, W.Va., disaster in which 78 miners were killed and by the black lung scourge, marked the first federal "coming to grips" with an occupa tional disease. The 1969 coal mine act provided federal funds to in demnify some of its victims and their widows and set standards aimed at disease detection, prevention, and con trol. With 1972 amendments adding benefits averaging $300 a month for diseases resulting from coal dust inhala tion, some $1 billion a year is being paid to 235,000 totally disabled men and to 140,000 widows and dependents. Further, every working miner-some 100,000 under ground coal workers in 23 states-will be x-rayed regularly by NICjSH as part of a National Study of Coal Workers' Pneumoconiosis. This study is the first to assess the extent of anatomical disease in a national industry. Based on early findings, Dr. Kerr, also director of the Mine Workers of America's occupational health department, expects 18% to 20% to have x-ray evidence of pneumoconiosis. Dr. Kterr stresses that the law calls for-and that exist ing technology could achieve-elimination of this disease. "It can be wiped out in one generation. It can be made as rare as j typhoid. The way to do it is get rid of the dust, which vye've known how to do since at least 1948-you ven tilate and use water." Awareness of an industrial hazard by no means implies that something will be done about it. Dr. Joseph K. Wagoner, director of the division of field studies and clini cal investigations for NIOSH, notes that the first reports continued ;\ EC 2893  ^outside medical surveillance of asbestos workers and for . ' tough warning labels on asbestos products, f t Said an outraged Dr. Selikoff, whose long-term studies of asbestos workers have shown strikingly high incidences of asbestosis, lung cancer, and mesotheliomas: "My opin- V ^0n of that decision would have to be written on asbestos- i Dr. Homayoun Kazemi, director of the U.S. Beryllium 11 Case Registry, does not object so much to the standard for T* that metal, which has been in effect since 1949 (a max- imum average of 2 jig/m3 of particulate beryllium over f_. eight hours and a peak below 25 /ig/m3). But with more than 30,000 workers potentially exposed to beryllium fumes and dust in four major refineries and 8,000 process ing plants, Dr. Kazemi vigorously protests the failure of management at many plants to maintain that level-and the failure of OSHA to police them. "People are still being exposed to very high levels, and the plant owners know it," declares Dr. Kazemi, chief of the Massachusetts General Hospital pulmonary unit. In recent years, some new patients have been "neigh borhood cases," not beryllium workers but those living near a plant using the metal. And new beryllium hazards have been reported even more recently: It appears that the mantles of gas camping lanterns and dental alloys re lease potentially dangerous amounts of beryllium. The risks would extend not just to campers, dentists, arid den tal laboratory technicians but possibly to dental patients requiring extensive work. The U.S. Beryllium Case Registry, a voluntary listing, now stands at about 840 cases and increases slowly but steadily by two or three a month. Dr. Kazemi wonders about cases not reported and is even more concerned about those in whom berylliosis goes unrecognized. But diagnosing and dealing successfully with occupa tional ills can be negated by failure to probe deeply enough-or, occasionally, by probing too deeply. The APHA's Dr. Kerr tells the story of a 62-year-old bus driver with "hot belly" who underwent an exploratory lap arotomy in an unsuccessful effort to pinpoint the cause of his persistent abdominal pains. "Several days later, a member of the house staff who visited the patient learned he had been a bus driver only a few months," says Dr. Kerr. "For most of his working life he had done bridge demolition work. Using an acetylene torch, he cut through metal-and layer after layer of the red lead paint applied to prevent rusting. What he had was the lead colic that goes with severe lead poisoning. The unnecessary operation could have been avoided if someone had asked, 'How long have you been a bus driver?' A new idea? Hardly. Bernardino Ramazzini, the father of occupational health, urged that approach in 1700." Of all occupational hazards, dermatoses are not the most serious but they are the most common. NIOSH esti mates that skin disorders from chemical, mechanical, and biological causes account for 50% to 75% of all industrial diseases and affect from 600,000 to 750,000 people. But new forms of industrial cancer and other diseases are likely to be a recurrent problem until some way is found to screen the thousands of old substances now in in dustrial use and the thousands more that enter manufac turing processes, and the environment, each year. Faced with the massive task of dealing with the thou sands of substances handled, touched, or inhaled by work-' ers, OSHA-with recommendations from NIOSH-pulled together all existing federal health standards into one package covering some 500 toxic substances. Next, it set up the Target Health Hazards Program, directing en forcement first toward plants where workers are exposed to asbestos, lead, silica, cotton dust, and carbon monoxide. But admittedly, these standards-and the available in- spectors-are not enough. In March, OSHA announced a 30-month, $3.5-million project to speed the issuance of rules governing some 400 toxic substances. These rules will deal with plant monitoring, control methods, medical requirements, and other activities; they will not change the threshold limit values to which workers are exposed. But is there any way that the vast array of chemicals in use, and to come into use, can be checked for danger? To provide the necessary legislative machinery. Con gress is considering several versions of a toxic substances bill to cover agents now regulated by other laws. Still un clear is who pays for the testing of an existing chemical, how trade secrets will be protected, and who will be con sidered responsible for various misuses. While Congress debates, is anyone trying to pinpoint industrial dangers? "No one else is formally responsible, so we have taken the initiative," declares NCI's Dr. Umberto Saffiotti, asso ciate director for carcinogenesis, division of cancer cause and prevention. Of the $36 million allotted to the carci nogenesis program, some $7 million now is being used in a major bioassay program. As of March, he reports, some 450 chemicals were being screened for carcinogenicity. More than 20 laboratories are taking part in the pro gram and most chemicals are tested by a protocol that in cludes preliminary toxicity studies followed by lifetime tests on groups of 50 animals. In addition to long-term studies, the program now is testing the reliability of short-term bioassay systems based on chemical reactivity, such as DNA binding, mutagenic activity, and in vitro' neoplastic transformation. But despite all the investigations, despite standards being evolved and emergency rules issued, thousands of workers--assured by the Occupation Safety and Health Act of 1970 of "safe and healthful working conditions" and "no diminished health, functional capacity, or life ex pectancy as a result of his work experience"-are still all too often involuntary players in the game of industrial Russian roulette. Dr. Selikoff, noting that the government-medical-indus trial reaction to the VC threat was a response to an al ready present hazard, puts it this way: "It is sobering to realize that there may be other agents sitting in the wings, which we do not now suspect and which we still do not really know yet how to anticipate. We can't see thembut we hear them moving about in the forest." MEDICAL WORLD NEWS/May 3,7674 EC 7894 30 _**'&,, *?tr v*t,.-<'Ki*'* * r'x>`> ,;***,,. ,. *. --.-jj a'vv;- ' `' '* **'`--?i;*V`,.4`*-**** j. 'v'*:- .tA` ' .V k' * *;? -v j -,; " -* . , f . /' -v` v*' V ._- :.' ; .,. \;si V -. w, ^ St*!1*-' ' "' S ? > * * j' " *j*`A i ,, ` *' -* V'<fc -C * 'V *-, a # ? * * :. iL ,".*j .*'* ,, V-, V /I l' "Tv i i 't |.'l` ' i - " ^ j -,!, ' Ev/ -a .. - _f* r-/>v *1 >, ^ Wj * -Sf f '. > *!*,,*'*. VE. . >, * w'c ! ' - ' - ,'*<- ^ ^ -' ' : ?:.w * r . ', * * J*> /* -+ , --1. : -* .-v A..' ' <?:<", .-.l: 'Vv; s. t ' 'tt/' j*i*T i'.::*':,. >.. '*> vv". * `.,.v'. ' ."&' ', *<' .. *".., ',"-,7.- ' , ";'.A- a \-< fcr-xy^:V|-V%*'2^^ .'v'';*':. : - - tv -VJ - - '/ --^S ' -- ' ' ' - ' 1 f /, ^ `H v:'Vi ' j'.`: ' v"! 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