Document V3e1QwZdRmvypQzK38bZ1d46o

FILE NAME: Pennsylvania (PA) DATE: 1961 May DOC#: PA024 DOCUMENT DESCRIPTION: Johns Hopkins University Report - Pennsylvania Health PENNS YL h REPORT OF A STUDY OF HEALTH NEEDS AND RESOURCES OF PENNSYLVANIA BY THE SCHOOL OF HYGIENE AND PUBLIC HEALTH OF THE JOHNS HOPKINS UNIVERSITY v\ M AY 1961 TABLE OF CONTENTS Chapter 1. Sunanary, C o n clu sio n s, and M ajor Recommendations .................................. 1 - 19 2. S ta te and L o ca l R e la tio n sh ip s . . .................... - ...................................................... 21 - 32 3. Environm ental H e a l t h .............. .............................................................................................. 33 - 68 4 . M aternal and C h ild H e a l t h ................................................................................................. 69 - 99 5* Communicable D isease and T u b e rc u lo sis ........................................................... ... 101 - 123 6 . M ental H ealth ..................................................................................................................................125 - 157 7. C hron ic D iseases and State-Owned G en eralH o sp ita ls ............................. 159 - 212 8. D en tal H ealth ..................................................................................................................................... 213 - 215 9 . O ccu p atio n al H e a lth ....................................................................................................................217 - 228 10. N ursing Resources and P u b lic H e a lth N ursing ............................................. 229 - 257 11. H e a lth Education ........................................................................ 259 - 309 12. In terd ep artm en tal R e la tio n sh ip s and A d m in istra tio n .......................... 311 - 317 13. P lan nin g and Research ......................................................................................... 319 - 327 FLU 1b '62 |(|t I'rrdoy CARNEGIE NiTIIIlit ui lEMi&jSt Mim , PENNSYLV HEALTH REPORT OF A STUDY OF HEALTH NEEDS AND RESOURCES OF PENNSYLVANIA BY THE SCHOOL OF HYGIEVE AND PUBLIC HEALTH OF THE JOHNS HOPKINS UNIVERSITY 'I M AY 1961 TABLE OF CONTENTS Chapter A1- G iia n a m P / in r ln d / ir t i nnH Mb 4a f Pa a /i - J b ^*4b b i ____ ___ .................. i - 19 \ 2- G hB h jiti/l T^w*b 1 Rp 1b F 1n n f l h i n i .............................................................. .................. 21 - 32 *1 .................. 33 - 6 8 4. .................. 69 - 99 * 101 - 123 ................. 125 - 157 7r Pv Kll 1r/VuM%l4X.pb UO lfBBCBdBoBCBBB IaIrIwQl CJ LOaBl Cp --s1U^V-U--CU puacnl lAc|>I d*1l D11aDbV|u1IAFLAb AI Bb *___*__* .................. 159 - 21 2 fl .............. 213 - 215 o .............. 217 - 228 il nv 11 1U7o 13. .............. 22 9 - 257 .............. 259 - 309 i n c c r u s p a r L K Q C d i n e x a c i o n s a i p s a n a A a m i n i B L i a v i o i i * .............. 311 - 117 .............. 319 - 327 FLU 1b '62 TH? H'.'VT L'^ 'P Y CARNEGIE IKSTirulc Of lECiiSSU Slf 217 OCCUPATIONAL HEALTH Scope ot Study The purpose o f t h i s stu d y as o r i g i n a l l y d e fin e d was to determ ine a) the needs o f the .,,smonwealth w ith r e s p e c t to an o c c u p a tio n a l h e a lth program w ith in th e Department o f H e a lth , 1 the adequacy w ith which th e se needs are m et, and c) such changes t h a t m ight be n e c e ssa ry bring about a match between the two. I t is p o s s ib le w ith in the tim e and s t a f f lim it a t io n s : th is s e c tio n o f the .study to determine the f i r s t p o in t, need, on ly in a general way; hence, :-.e d e fin e d g o a l has been a ch ie v e d o n ly in p a r t . C o n c lu s io n s have been reached and recommenda tions developed by ap p lyin g the c r i t e r i a o f good in d u s tr ia l h e a lth p r a c tic e to the lim ite d -b servatio n a made in th e s tu d y . A. Methods Employed in the Study l . P erso n el In terview s and co n feren ces were h eld w ith; * A d m in istra to rs and p r o fe s s io n a ls in th e Bureau o f Environm ental H ealth and i t s D iv is io n o f O ccu p a tio n a l H e a lth , a t H a rrisb u rg . b . A d m in istrato rs and s p e c ia lis t s in oth er departments o f the s ta te government; 1) Labor and In d u s tr y 2) Mines and M ineral Industry c . R egion al o f fic e s at P h ila d e lp h ia and P ittsb u rg h . 2. Reports o f the D iv isio n have been review ed. 3. Case re c o r d s in o c c u p a tio n a l d is e a s e c la im s on f i l e a t th e Workmen's Compensa tio n Bureau have been review ed. 4 . Conferences have been h eld w ith the C itiz e n s Committee, and in d iv id u a lly with some o f i t s members. B. L im ita tio n . The scope o f the study is lim ite d to a development o f good judgements as to th e b e st o c c u p a tio n a l h e a lt h program fo r the Commonwealth a t t h i s tim e , w ith o n ly g e n e ra l co n sid e ra tio n s o f the a d m in istra tiv e machinery needed fo r it s acco m p lish ment. I I . P ro g re ss S in c e 1948 The 1948 Su rvey s p o t - li g h t e d c e r t a in problem s w ith r e s p e c t to a) the d if f ic u lt y of fit t in g occupational h ealth a c tiv ity in to the standard public h e a lt h fram ew ork, and b) the d i f f i c u l t y o f draw ing lin e s around th e a c t i v i t y so t h a t i t does not become an Independent p u b lic h e a lth e ff o r t . T h u s, in K ey ston es o f P u b lic H e a lth o f P e n n s y lv a n ia we fin d d is c u s s io n s o f th e a c t i v i t i e s the D iv is io n o f I n d u s t r ia l H ygiene under A d u lt H e a lth , and a g a in under E n viro n m en tal S a n i` at io n ; and we fin d co m p la in ts o f the d r iv e fo r an autonomous, o c c u p a tio n a l h e a lth o p e r a tio n 'Trplete w ith i t s own p h y s ic ia n s , e n g in e e r s , s a n i t a r i a n s , n u rs e s , d e n t i s t s , h e a lth e d u c a t o r s , la b o r a to ry . E s s e n t i a l l y , two id eas seem to be in c o n f l i c t h e r e . On the one hand, o c c u p a tio n a l health '? c o n sid e re d a m an -cen tered s p e c i a l t y where p r a c t i t i o n e r s use any d i s c i p l i n e they c o n s id e r -ce f u l fo r th e s o lu t io n o f a g iv e n problem ; a n d , on th e o th e r hand, o c c u p a tio n a l h e a lth is la s s ifie d as a s u b -d is c ip lin e o f environm ental sc ie n c e . 218 A . Admi n L* t ra t ive L o c a tio n t)f O ccu p a tio n a I H ealth A c t i v i t y The c o n s u lta n ts who con ducted the lO-'ih Survey e v id e n tly lean ed toward the v ! in d u s t r ia l hygiene is nan-centered . They found the D iv is io n o f In d u s tr ia l Hygl the Bureau of Health C onservation (o rgan iatio n c h a rt, p. 32, Keystones) ; they I t s c o n tin u a tio n there in the In te rim O rg a n iz a tio n ch art (p. 34 ); and they l e f t t h i s lo c a tio n in the recommended U ltim a te O rg a n iz a tio n c h a rt (p . 35). T h is re was not fo llo w e d . We now fin d the D iv is io n o f O c c u p a tio n a l H e a lth In the Bureau.^ Environmental Health. Each s o lu t io n has ad v a n ta g e s and d is a d v a n ta g e s . The o c c u p a tio n a l h e a lth aejt Is p a r t i a l l y a t home in e i t h e r p la c e , and p a r t i a l l y a m i s f i t in e it h e r p la c e , d e s p it e th e f a c t t h a t the f i r s t m ajor recom mendation In KeyBtones was not a c c o u p ll th is fa ilu r e is not o f i t s e l f c r i t i c a l . ft. P erso n n el o f the D iv is io n The changes In numbers and c la s s i f i c a t i o n s o f personnel s in c e the Keys to -- are shown below. 1948 1961 Bureau o f In d u stria l Hygiene p h y s ic ia n s - 3 1, C h ie f o f Bureau 2, Heads o f D is t r ic t O ffic e s D iv isio n o f O ccupational Health Physicians l , Chief of D ivision 3, Central O ffic e l , Employee H ealth S e r v ic e 12, C e n tra l o ffic e 12, D is t r ic t O ffic e s Laboratory Technicians - 6 4 , C en tral Laboratory 2, F ie ld X-Ray T echn ician s Nurse, Consultants - 2 S a n ita ria n s - 20 Home O f f i c e and D istrict O ffices Laboratory S ta ff 10, C e n tra l Laboratory 5, F ie ld X-Ray T echnicians Nurse Consultants Employee H ealth S e r v ic e Nurses T otal professionals 55 Total p rofessionals 61 The bare a o r.oc t e l l see tv j;. it o i lowing the Keys tones re p o rt, th e r e was a stea d y d e t e r io r a t i o n o f p e rso n n e l q u a l i t y in th e Bureau o f I n d u s t r ia l Byglaaa The S t a t e ' s s a l a r i e s , low b u t c o m p e titiv e d u rin g the war b e ca u se o f wage and p r ic e r e g u l a t i o n s , became u n r e a l i s t i c a9 i n d u s t r i a l s a l a r i e s In c r e a s e d in the p o st-w a r y e a rs. The tr a in e d in d u s t r ia l h y g ie n is ts o f the B u r e a u --e s p e c la lly th e b e tte r o n e s - - le f t the s t a t e s e r v ic e fo r job s in p r iv a t e in d u s t r y . The r e s id u e , th e le s s c o m p e titiv e among the t r a in e d in d u s t r ia l h y g ie n is t s and th e corp s o f u n tr a in e d s a n i t a r i a n s , c a r r ie d on the B u reau 's work in a d e c r e a s in g ly s a t is f a c t o r y fa s h io n . The m erit system p r in c ip le s o f c i v i l s e r v ic e were a v a i l a b l e ; b ut in c o n s id e r a tio n o f the p r a c t i c a l problem s t h a t could not be surmounted, these p r in c ip le s were not. ap p lie d by the Bureau C h ie f then in o fflflfc When, because o f o u tsid e p r e s s u r e , the c i v i l s e r v ic e p r in c ip le s were a p p lie d , a suceosal** o f personnel changes fo llow ed . The Bureau became a D i v i s i o n , th e p re se n t D ir e c to r was a p p o in te d in 1955, c i v i l * s e r v ic e exam in ation s became a req u irem en t o f em ploym ent, and th e s a la r y s c a le s wer* subsequently raised s u b s ta n tia lly . fg' 219 In s p ite o f Che fa c t th a t.C h e g ro ss number o f employees in in d u s t r ia l h e a lth op era tio n has not changed m a t e r ia lly (55 in 1948 as compared w ith 61 in 1961) c e r t a in program changes have re su lte d in a s u b s ta n tia l net gain in terms o in t e n s ity o f a p p lic a tio n o f in d u s tr ia l hygiene ta le n t to the D iv is io n 's work. In 1948, the o ld Bureau ca rrie d f u l l r e s p o n s ib il it y fo r the atm osp h eric p o llu t io n c o n tr o l program, whereas now the a d m in istra t iv e component o f t h is program has been s e t up in d e p e n d e n tly ; and the I n d u s t r ia l hygiene work o f P h ila d e lp h ia County is now shared w ith the C o u n ty 's H e a lth Departm ent. Of the 30 In d u s t r ia l hygiene e n g in e e r s , e ig h t have m asters degrees in t h is f i e l d and a l l are co lle g e graduates w ith in te n siv e in -s e rv ic e tr a in in g . Of the three p hysicians in the o ld o r g a n iz a tio n , two were r e t ir e e s from p reviou s c a r e e r s . Today th e re ere f i v e p h y sic ia n : Four o f these are b o a rd -ce rtifie d or b o a rd -e lig ib le in occupational m edicine, re la tiv e ly young, and in t h e ir most p ro d u c tiv e y e a r s . The rem ain in g one la a young man w ith good g a n e r a l t r a in in g in m ed icin e. The c e n t r a l la b o r a to ry haa a c h ie f who competed s u c c e s s f u l l y fo r h is post in c i v i l s e r v ic e exam in atio n s. With him are s ix w e ll-q u a lifie d graduate chem ists and four lab o rato ry te c h n ic ia n s . C onsequently, altho ugh the q u a n tita t iv e ci. >nge from 1948 to 1961 has been m inor, th e upgradin g o f q u a lit y haa been im p ressive . C . Program Changes A lthough th e p resen t program o f th e D iv is io n o f O ccupation H ealth is summarized eleew here in t h i s re p o rt ( S e c t io n I I I , B) i t i s a p p ro p ria te here to p o in t out d iffe r e n c e s between the program o f th e o ld Bureau ai re p o rte d in 1948 (K ey sto n es) and tha a c t i v i t i e s o f the present-D ivision. The gross d iffe r e n c e s c o n sist o f: 1. T ran sfer o f the atm ospheric p o llu tio n c o n tro l program out o f the D iv isio n 2. Development o f an a c t iv e program o f r a d ia tio n h e a lth , p a r t ic u la r ly aa th is re la te s to use o f ra d ia tio n in the h ealin g a r ts . 3. Development o f an employee h e a lth s e rv ic e fo r the Connonwealth employees. D iffe r e n c e s in wa^s o f o p e r a tin g s in c e .1948 may be summarized as fo llo w s : 1. G reater emphasis has been g iv e n to p h y s ic ia n -p a r tic ip a tio n In the D iv is io n 's a c t iv it ie s , a t the c lin ic a l and epidem iological le v e ls . 2. I n d u s t r ia l h y g ie n is t s and ch em ists stan d on t h e ir own p r o fe s s io n a l f e e t . Each group has a c h i e f , r e s p o n s ib le fo r p r o fe s s io n a l q u a l it y . The common e f f o r t Is served by co o p e ra tio n r a th e r than by d i r e c t io n . 3. A lth o u gh .th e g o al o f o p e ra tin g through the re g io n a l h e a lth o rg a n iza tio n s has not been f u l l y a c h ie v e d , a way to do t h i s has been found. G iven a good r e g io n a l h e a lth o f f ic e r , a good In d u s tria l hygiene engineer is assigned to h is s t a ff They work to g e th e r as p h y s ic ia n and e n g in e e r . T h e ir most t e c h n ic a l problems are a tta c k e d by b r in g in g in a d d itio n a l s p e c i a l i s t s from the c e n t r a l s t a f f , and the support o f the la rg e , ce n tra l laboratory Is brought in as needed. This scheme rep resen ts a h e a rte n in g breakthrough in the e f f o r t to in te g r a te occupa tio n a l health a c t iv it ie s in the to ta l p u b lic h ealth program, a goal repeatedly c a lle d for in Keystones. 4 . There has been a t ig h t e n in g o f the c o n tr o l e f f o r t once p la n t problems come co l i g h t . Where a su rvey once ended in p ious recommendations th a t were f i l e d and fo r g o t te n , th ere now is c a r e f u l fo llo w -u p and In s is t e n c e upon com pliance w ith req u ests fo r improvement in environm ental co n d itio n s and/or in d u s tr ia l p ra ctice s. 5. The g en eral le v e l o f p erform an ce, d i f f i c u l t to compare a t two d i f f e r e n t p o in ts in tim e by two d i f f e r e n t o b s e r v e r s , is n o n e -th e -le s s co n sid e re d to be much 220 z&urn. h ig h e r now. C e r ta in e u p h o ric language appears in K eystones (p. 2 4 6 ), revM lfag th ac th e in v e s t ig a t o r s o f th a t tim e may have been "ta k e n in " a b i t . A watt s o p h is tic a te d g r o u p w o u l d have looked tw ice before a cce p tin g the follow ing se If-a p p ra isa l of their hosts. "1 . The c o n tro l o f the environm ental fa c to r s o f in d u s tr ia l h e a lth . Ib is goes fa r beyond the n e g a tiv e phase o f p r o t e c t io n from h arm fu l cooil- tio n s and attem p ts to a ch ie v e th e most h e a lt h f u l environm ent poatihl* "2. A tte n tio n to m edical se rv ice s w ith regard to those causes o f dlaial**. e f f ic ie n c y , absenteeism , i ll n e s s , or death due to in d u s tr ia l factor*. "3 . A tten tion to the general health o f the in d u stria l workers, relating to such fa c to r s as n u t r it io n , mental h e a lth , and those i l ln e s s M which atta ck any group o f people o f sim ila r age gro u p s." 0. S p e c ific Keystones Reconmendations The fa t * " o f s ix recommendations c a r e fu lly s p e lle d out in Keystones Is sunmarls l! be low. 1. L o c a tio n o f the o ccu p a tio n a l h e a lth a c t i v i t y in a separate bureau under an a s s is t a n t s e c r e ta r y o f h e a lth con servation (p. 35). Wot done. 2. That th e p r in c ip a l s t a f f p o s itio n s be supported by Commonwealth appropriations, th ereby fre e in g fe d eral funds for program extension o f p ilo t-p r o je c t bases (p. 259). Done. 3. That w r itte n agreements be developed w ith the Department o f Labor and In A s g lJf, s p e llin g out in d e t a il a working arrangement for occupational d isease con tm f (p. 260). Wot done. 4 . That p o lic y and procedure be c l a r i f i e d as regards in d u s t r ia l hygiene a c t iv it ie s (b ro ad ly con sidered) o f the s e v e r a l components o f the H ealth Department. Doan. 5. T hat s a la r y sch ed u les be brought Into lin e w ith r e s p o n s ib ilit ie s fp . 261). T h is was done o n ce , but needs r e -d o in g . 6. That "a system atic com pilation o f inform ation concerning in d u s tria l plants fo r the purpose o f e v a lu a tin g the in d u s t r ia l hygiene problems o f the s ta te " be acco m p lish e d . Done. C e r ta in recom mendations e x is t by im p lic a tio n ra th e r than d ir e c t s t a t e ment in K ey sto n e (p . 271). The s ta tu s o f th ese is summarized h e re . a . That p la n t in s p e c tio n s be c a r r ie d on by f u l l y tr a in e d p r o fe s s io n a ls ra th e r than by s a n it a r ia n s . Done. b . That c lo s e r in te g r a tio n be ach iev ed w ith the Department as a whole. Done. c . That the o ld Bureau should d iv e s t i t s e l f o f c e rta in h e a lth education and p u b lic h e a lth n ursing fu n c tio n s . Done. I I I . E v a lu a tio n o f E x is tin g Programs A. Background con sid eration s There is a d isp e rsio n of o ccu p a tio n a l h ealth a c t i v i t ie s through three major depart ments o f th e S t a t e governm ent: H e a lth , M ines and M in e ra l I n d u s t r ie s , and Labor and In d u stry . 221 D isp e rsio n o f In d u s t r ia l h e a lth a c t i v i t i e s tak e s the form o f a m u lt ilo c a tio n of function rather than transfer o f appropriations. R esp o n sib ility for occupational disease co n tro l has been lumped w ith in d u s t r ia l a c c id e n t p re v e n tio n as a fu n c tio n o f the D ep art ment o f Labor and In d u s tr y ; and a s im ila r p a ir in g o f r e s p o n s i b i l i t i e s has occu rred in the program o f the Department o f Mines and M ineral In d u s tr ie s . There is a d iscern ab le power s t r u g g le among the persons in v o lv e d in t h i s s i t u a t i o n , and i t is t h is which may present a fin a l o b stacle to e ffe c tiv e in d u stria l health a c tiv ity in the S ta te . In a ll f a ir n e s s , i t sh ou ld be p oin ted out th a t power s t r u g g le s o f t h i s s o r t are not unique to the pres< it gro u p ; they a re to be found in o th e r s t a t e governm ents, the F e d e ra l government, in the m i l i t a r y , in in d u s tr y , and in d e e d , may be s a id to be a fundamental c h a r a c t e r ! t i c o f a l l o rg a n ize d human a c t i v i t y . We s h a l l d e a l h e r e , th e n , w ith a s o c ia l r a th e r than a nersonal problem and attem pt to keep d iscu ssio n s 'ilear o f p e r s o n a litie s . The best ad m in istrativ e lo catio n o f the S t a t e 's in d u s tr ia l hygiene program can be lo g ic a lly determined only when there is agreement as to the o b je c tiv e s o f the program. I f the o b je c tiv e is lim ited to the co n tro l o f o ccu pational d isea a es, the program can be located in the Department o f Labor and Industry q u ite as w a ll as in t in Department o f Wealth. This i s th e p r a c tic e e f four major in d u s tr ia l s ta te s s t the (arasant t i n s , as w ell as in c e rta in other cou n tries that are considered to have problems o f t h is kind under reasonable c o n tr o l. Z f , on the other hand, the o b je c tiv e s ere to include some broad ideas o f h e alth improvement o f persons o f working a g e , then the best lo ca tio n o f ' the a c t i v i t y is in the H ealth Department. Ir re sp e c tiv e o f how broad the program's o b je c tiv e s u ltim a te ly might be, there is a fir s t obligation to achieve e ffe ctiv e control of occupational diseaaes. This ca lls for s e ttin g standards o f in d u s tr ia l operation , in sp ectio n o f work p laces to ie< th a t standards are a l l m aintained, and a good system o f occupational d ise a se reporting th ^t w ill serve as a continuous a u d it o f the program's e ffe c t iv e n e s s . The weakest le g o f th is tripod is the la s t , reportin g. The D i v i s i o n 's D ir e c to r i s ab le to g e t r e p o rts o f some 1600 c a se s o f o c c u p a tio n a l d is e a s e per y e a r . These come by v a r io u s ch a n n e ls: c e r t a in com pensation r e c o r d s , p la n t in s p e c tio n s , d eath c e r t i f i c a t e s , and l e t t e r s from workmen. By re a so n a b le a p p lic a t io n o f good r e p o r tin g d a ta from o th er s t a t e s , i t seems l i k e l y t h a t th e tru e in c id e n c e o f occu p a t io n a l d is e a s e s in-. P e n n s y lv a n ia -ie . a t le a s t.. 10., 000. c a s e s per y e a r , about s i x tim es the p r e s e n tly re c o g n iz e d number. An in d ic a t io n o f the k in d o f tro u b le t h i s s it u a t io n can lead to i s th e sudden r e v e la t io n , as a r e s u lt o f f i e l d s tu d y , o f a g r e a t number o f casesof s i l i c o s i s in the bitum inous Industry around Johnstown, d e sp ite the fa c t th at a l l have been sure that s i l i c o s i s is no problem in any bitum inous d i s t r i c t in th is cou n try. S u rely cases have been diagnosed from tim e to time by p r iv a te m edical p r a c titio n e r s or in d u s tr ia l p h y sicia n s In th e Johnstown a re a . A fa ilu r e to r e g is te r discovered cases at a c e n t r a l p o in t h as served t o mask most e f f e c t i v e l y t h i s m ajor ep id e m ic. O c c a s io n a lly o ccu p a tio n a l d isease problems get d efin e d by form al ep id e m io lo g ica l s tu d ie s th a t make use o f advanced p u b lic h e a lth m e th o d o lo g ie s. In t h is s it u a t io n th ere is comfort in fin d in g the occupational disease co n tro l fu n ctio n located in a h ealth departm ent. An i l l u s t r a t i o n in p o in t is a re c e n t stu d y by the D iv is io n o f O c c u p a tio n a l H ealth , o f the p o s s ib le occurrences o f b e ry lliu m d ise a se a t a p la n t. The b est understanding o f t h i s problem depended upon fin d in g s among r e s id e n ts in the neighborhood o f the p la n t as w ell as the em ployees, in volvin g procedures well-known to p u b lic h ealth s p e c ia lis t s . An e s s e n t i a l requ irem en t o f o c c u p a tio n a l d is e a s e c o n t r o l i s th a t the employer must be h e ld f i n a n c i a l l y r e s p o n s ib le fo r f a i l u r e s . T h is means th a t com pensation fo r d i s a b i l i t y must be f u l l y borne by him , which is not the p r a c t ic e in P e n n sy lv a n ia . I t i s im p o ssib le to fin d a su b stitu te fo r c o st-co n tro l as a m otivating in te re st in occupational disease p re v e n tio n . N oth in g e ls e works seven days a week, 24 hours a day, and in the absence or presence o f in s p e c to r s . Along w ith t h is must go a b s o lu te ly f i r s t - c l a s s a d m in istra tio n of the workmen's com pensation law s, w ith d e c is io n s based upon s c i e n t i f i c fa c t s ra th e r than the need to so lv e socio-econom ic problems o f a gen eral n atu re. 223 3. Actions on Comp'aints, Cases, or Inspections: a . I n d u s t r ia l d ise a se in v e s t ig a t io n . Upon r e c e ip t o f in fo rm a tio n co n cern in g a case o f occupational d isease--su sp ected or e sta b lish e d --a n in v e stig a tio n is made by one o f the D iv is io n 's p h y s ic ia n s . The p a tie n t is v i s i t e d and p o s s ib ly examined, the work p la c e is in v e s tig a te d , and the employer i n t e r v ie w e d . b. Measurement o f atm ospheric p o llu tio n problems, p rio r to co rre c tiv e actio n s by the A ir P o llu tio n C o n tro l D iv is io n ( in t h i s same Bureau). c . Hazards c o rre ctio n recommendation ( s p e c ific a tio n s and/or a c tu a l d e sig n ). 4 . S e rv ic e Program Promotion a. P lant H ealth S e r v ic e s . Various o p p o rtu n ities afford ed by the a c t iv it ie s o f the D iv isio n are e x p lo ite d to persuade employers to provide form al, in -p lan t in d u strial health services. b. S t a t e employee h e a lth s e r v ic e . The D iv is io n has in development an ont h e - jo b h e a lth s e r v ic e fo r the S t a t e ' s employees who work in H a rris b u rg . 5. Research a . Su rvey o f c o a l m iners fo r s i l i c o s i s . The r e s p o n s ib il it y fo r co n d u ctin g an e p id e m io lo g ic a l stud y to determ ine th e p re va le n ce o f ch e st d i s e a ' > among c o a l m iners is shared v f* v - t"' -- >* v* - ^ 5,,.^ "-1 In d u s tr ie s - M-.-ls sr (X .i. o f the stud y which In clu d e che talcin g o f 14" x 17" ch e st x -ra y o f m in ers, in te rp re ta tio n of the x-rays film s , recording o f occupational h is to r ie s , and making measurements o f v i t a l c a p a c ity . C o r r e la tio n o f x -ra y fin d in g s i s made w ith d u st count d a te o b ta in e d d u rin g su rv eys o f m ines. The Department o f Mines and M in eral In d u strie s is resp o n sib le fo r co n d u ctin g su rv ey s o f c o e l mines and fo r making th e n e cessary d u st count:a. Personnel o f the D iv isio n o f O ccupational Health have provided tra in in g in the techniques used in th is work. b. B e ry lliu m c l i n i c . Following an in la .-.t and cocm unity stud y the D iv is io n o f O ccupational Health has e sta b lish e d a berylliu m c lin ic In Reading. This has the approval o f the Berks County M edical S o c ie ty . The purpose o f the c l i n i c i s to assem ble a group o f b e r y lliu m c a se s t o t e s t new methods o f treatment to evaluate dl re treatm ent, to provide consultation oa reqi.es . , i i< c-u: -p a t ie n t care Co persons unable to affo rd the serv ices a ..a n . Laboratory services are performed in accordance w ith the needs o f any p a r tic u la r c a s e . Funds fo r o p e r a tio n o f the c l i n i c a re p rovid ed by a re se a rch g ra n t from the t). S . P u b lic H ealth Se rv ice . C. O ccupational Health Act iv i t ie s in Other S ta te Departments O c c u p a tio n a l h e a lth a c t i v i t i e s have developed w ith in the hegenomies o f two o th e r major departm ents o f S t a t e government: Labor and In d u s tr y , and Mines and M in e ra l I n d u s t r ie s . The circu m sta n ce r e s u lt s from a l o g i c a l development o f the con cern fo r a c c id e n t p re v e n tio n , and fo llo w e d c lo s e ly upon passage o f e a r ly workmen's com pensation laws alm ost SO years ago. The -e f fo r t s a lo n g a c c id e n t p re v e n tio n lin e s as c a r r ie d ou t In these two departm ents were e n o rsn u sly s u c c e s s fu l, as they have been g e n e r a lly throughout American in d u stry . Threa stan d ard in stru sie n ts were used: 1) a workmen's coippensation law th a t made em ployers 222 H earings before the Workmen's Compensation Board should be at a te c h n ic a l le v e l which is adequate to determine the fa c ts of- d ia g n o sis and d i s a b i l i t y in a given occupation d ise a se c a s e . P h y sicia n s and e n g in e e rs, and perhaps r e fe r e e s as w e ll, vary in th e ir c a p a c ity to develop these f a c t s . Every p r a c t ic a l e f f o r t should be made to use the beet ta le n t a v a ila b le . A fin d in g of l i a b i l i t y in the fa c e o f a w e ll-r u n c o n tr o l program bee im p lica tio n s beyond the case at hand: the co n tro l program I t s e l f Is brought under c h a lle n g e , and there may even be a le g itim a te doubt th at the in volved in d u stry can be operated s a fe ly . Among the broader purposes o f o c c u p a tio n a l h e a lth is the use o f employed population* to study one or another ch ron ic d ise a se . Examples o f th is are beginning to appear in tb* lit e r a t u r e , the stu d ies fo r the most part being conducted by the m edical departments of la rg e in d u s t r ia l fir m s . R e p re se n ta tiv e p a y r o ll groups can be brought under observation in such a way as to support g e n e r a liz a tio n s re g a rd in g the h e a lth problems o f the working p o p u la tio n s: m o rb id ity and m o r ta lity r a te s by a g e , s e x , r a c e , type o f employment, and income le v e l; and fu r th e r g e n e r a liz a tio n s regard in g the socio-econom ic im p lica tio n s (for both employer and employee) o f these h e a lth problm e. A c t i v i t i e s o f t h is kind should bn reserved fo r the fu tu re as fa r as the s t a t e 's occu p atio nal h e a lth program ia concerned. > On thn b a s is o f f i r s t th in g s f i r s t , the urgent need is to fin d and prevent o ccu p atio n al diseases. B. E x is tin g Programs The D iv is io n c a r r ie s on an im pressive le v e l o f a c t i v i t y . From t h is i t is p ossib le to sep arate out about a dozen program s, two o f w hich a re j u s t i f i a b l y c a lle d research p r o je c ts . The judgement is o ffe re d th at each o f these is a r e a l n e c e s s ity . A ll program are s l i g h t l y u n d e r s ta ffe d . W ithin l i m i t s , t h is probably is a good way o f o p e ra tin g , th ere bein g a p o in t o f d im in ish in g re tu rn s in th e economy o f cap ab le p erso n n el. The programs are lis te d below, arranged in an organized fash io n . 1. In d u stry In v e n to ry . The in d u s t r ia l e sta b lish m e n ts o f the s t a t e are sy ste m a tic a l! v i s i t e d by tr a in e d in d u s t r ia l hygiene e n g in e e rs . Records a re made o f the naturt o f the e n te r p r is e , the p o te n tia lly hazardous m a te ria ls and processes in use, and the c o n tr o l measures found as w e ll as those recomnended. When considered necessary or u se fu l fo r fu tu re use, samples are c o lle c te d fo r subsequent analysis in th e la b o r a to ry a t H a rrisb u rg . A l l in form atio n i s en tered on rap id so rt cards which are re v ise d from time to tim e. 2. Hazards Search and Case F in d in g : a . R a d ia tio n exposure to o p e ra tiv e s a n d 'th e g e n e ra l p u b lic by p h y sicia n s and d e n t is t s , and to th o se employed where r a d ia tio n i s used com m ercially. The concern is w ith both h igh energy sources and r a d io a c tiv e iso to p e r. b. Exposure to microwaves at radar s ta tio n s . Microwave exposure in connection with in duction welding is a point o f sp e cia l a tte n tio n in the industry Inventory ( 1, above). c . O ccupation al exposure to n o ise , both impact and steady s t a t e . d. Chest su rv ey . A m obile u n it which can produce 70 mm. ch est roentgenograms is in constant u se, booked a year iq advance- -u su a 1 ly in response to s p e c i f i c req u ests by in d u s t r ia l management and/or labor groups. For the sake o f o p eratin g e ff ic ie n c y , the s e rv ic e is r e s t r ic t e d to p lan ts employing 50 or more p eo ple. e . Exposures to a g r ic u l t u r a l d ise a se h azard s: n itro g e n o xid es in s i l o s , pesticide sprays. 225 c . In s p e c tio n . In sp e cts a l l b u ild in g s where labor is performed and Issu e s L icen ses fo r movie p r o je c t io n is t and p r iv a te employment a g e n c ie s . In sp e cts b o i le r s , e le v a t o r s , m ines, and q u a rrie s fo r s a fe t y . A lso r e g u la te s the s to r a g e , use and h a n d lin g o f. e x p lo s iv e s . R e g u la te s m a n u fa ctu re 'o f hedding and u p h o ls te ry . d. R esearch and S t a t i s t i c s . Prepares re p o rts o f in d u s tr ia l in ju r ie s , co st o f l i v i n g , and makes wage su rveys fo r Minimum Wage Boards. e . Workmen's Com pensation Board. D e cid e s on a p p eals o f workmen's com pensation cases. f. , - Workmen's Com pensation Bureau. Approves e l l workmen's com pensation p aid to in ju red workers. R ecently th is bureau has accepted r e s p o n s ib ility fo r adm inis t r a t i o n o f o c c u p a tio n a l d is e a s e c la im s a g a in s t th e Comm onwealth's fu n d s. An a t to r n e y was engaged to d i r e c t s ta n d a r d , fo rm al d e fe n se m e asu res. H is e a r ly e f f o r t s hove sto p p e d many c la im s t h a t would o th e r w ise have been r o u t in e ly s e t t le d . I t ia f e l t th a t the sp le n d id defen se perform ance would be fu rth e r enhanced by exp ert m edical a a a lsta n ce from s p e c ia lis ts on the s t a f f o f the D i v i s io n at O c c u p a tio n a l- H e a lth . T h is a c t i o n i s one o f th e recoranendations of th is report. fc. S t a t e W orkmen'* In s u r a n c e Fund. " S e l l s Workmen's Com pensation In su ra n c e to Em ployers. Works c lo s e ly w ith the Bureau o f R e h a b ilit a tio n on o c c u p a tio n a l i n j u r i e s ." A c t u a ll y , t h is is an In su ran ce company w ith a d ir e c t o r a t e spread through the s ta te government. I t In su res the sm all firm s th a t coimnercial insurance firm s w ill not berry because o f th e ir sm ell s iz e or p o o r-risk ra tin g s. h . R e h a b ilit a t io n . A s s is t s d isa b le d to become s e lf-s u p p o r tin g through r e t r a in in g ; provides m edical tre a tm e n t, p r o s th e tic a p p lia n ce s and m aintenance during tra in in g period. I t may be se e n from th e fo r e g o in g t h a t th e Department o f Labor and In d u s tr y i s empowered to s e t r e g u la tio n s and stan d ard s fo r the purpose o f p re v e n tin g o c c u p a tio n a l d i s e a s e , c a r r y o u t in s p e c t io n s to e n fo r c e th e r e g u la tio n s -, s i t in judgem ent on d i s a b i l i t y c la im s b ro u gh t b e fo r e I t , pay out awards when th e judgem ent fa v o r s '.ha cla im a n t, submit evidence to support the cla im a n t's ca se , organize a defense again st the claim an t, and, fin a lly , see that the claim ant is re h a b ilita te d . As m ight be e x p e c te d , th e r e i s much c o m p a rtm e n ta llz a tlo n o f in fo r m a tio n and o f p la n n in g . No one p erso n in te rv ie w e d had an o v e r a l l p ic t u r e o f th e o c c u p a tio n a l d is e a s e p roblem , nor e x p re s s e d any hope o f e v e r g e t t in g th e p i c t u r e . No one has an y id e a o f a s im p le b i t o f in fo r m a tio n upon w hich e f f e c t i v e programming must be b a se d : th e number and k in d s o f o c c u p a tio n a l d is e a s e s t h a t o c c u r In th e s t a t e . In th is s itu a tio n i t has been p o ssib le fo r the D iv isio n o f O ccupational Health to develop and c a rry on a program o f o c c u p a tio n a l d ise a se p re v e n tio n as a r e s u lt o f a g g re ssiv e a c tio n ra th e r than because o f top le v e l agreement or terms o f referen ce in the s t a t e law . L e g a l a u th o r it y a c t u a l ly r e s t s w ith the Departm ent o f Labor and In d u stry ; whereas a c tio n has been assumed by the D iv isio n o f O ccu p a tio n a l H ealth s im p ly b ecu ase i t has th e p eo p le who know how to do the jo b . I t i s n e c e s s a r y to resolve th is c o n flic t. Department o f Mines and M in eral In d u s tr ie s T his Department has as one o f it s p r in c ip le concerns the m aintenance o f sa fe w orking co n d itio n s in co a l m ines. A g a in , th is go al has been ach ieved most Im pres s iv e ly w ith resp ect to red u ction of the accid en t ra te . A corps of e x p e r ie n c e d , r e l i a b l e mine in s p e c to r s has been d ev e lo p e d o v e r th e y e a r s . These men are s p e c i a l i s t s Ln a f i e l d c l o s e l y r e la t e d to b ut not e x a c t l y in o c c u p a tio n a l d is e a s e p r e v e n tio n . 224 f i n a n c i a l l y lia b le fo r in d u s t r ia l 1v su sta in e d d i s a b i l i t i e s and the r e la te d s u r g ic a l and h o s p ita l c a re ; 2) a system o f workmen's compensation a d m in istra tio n th a t a rriv e d at d e c is io n s q u ic k ly , and tended to in te r p r e t fa c t s L ib e r a lly in favor o f the in ju re d worker to the p o in t th a t the workmen's com pensation law is now considered a m o d ified form o f s o c ia l in su ran ce ra th e r than a m o d ific a tio n o f the law o f t o r t s ; and 3) o r g a n iz a tio n s o f fa c t o r y and mine in s p e c to r s w ith a u th o r ity to en force s a fe ty m easures. T h is has been a stand ard approach a cro ss the c o u n tr y , and i t has worked un ifo rm ly w e ll in a l l s t a t e s . In the la t e 1 9 3 0 's, the workmen's com pensation law was en larged to cover a l i s t of o c c u p a tio n a l d ise a s e s ( s o - c a lle d "sc h e d u le a c t " ) . About 20 years la t e r t h is was enlarged fu r th e r to cover any and a l l o cc u p a tio n a l d is e a s e s . A lso In the la t e 1930's the Bureau o f I n d u s t r ia l Hygiene was t r a n s fe r r e d to the Department o f H e a lth as a t e c h n ic a l and lab orato ry a c t i v i t y . The le g a l underpinning fo r th is a c t i v i t y , however, is in the Cenera S a fe ty Law which remained in the Department o f Labor and In d u stry . \ There was su b se q u e n tly passed an "O c c u p a tio n a l D iseases A c t " , which was se p a ra te from th e orkmen's com pensation law and w hich, d e sp ite i t s t i t l e , d e a lt o n ly w ith a ilic o - a ll it h r a c o s llic o r a . With t h i s came a s e t o f .concepts unique to the Commonwealth To our .kn ow ledge,th ey e re a pure in v e n tio n and have no precedent anywhere e ls e in the world. These points are: a; An o ccu p a tio n a l d is e a s e covered by t h is a ct is one which by d e fin it io n takes fi y e a rs or more o f .a n in d u s t r ia l exposure fo r i t s developm ent. b . To q u a lif y under the law , the c la im a n t must have su sta in e d th e exposure fo r two ou t o f th e p a s t 10 y e a rs through employment in P en n sy lv a n ia . ( In p r a c tic e , th ese two y ears need o n ly be in the in d u stry and not a t a p a r t ic u l a r kind o f work. c . I f the cla im a n t was employed by a s in g le employer in P en n sylvan ia d u rin g the exposure y e a r s , the Commonwealth pays 40 per cen t o f the com pensation award and the em ployer, 60 per c e n t. d. I f the cla im a n t worked fo r more than one employer du rin g the exposure y e a rs, the Commonwealth pays 100 per ce n t o f the com pensation award. Tha la s t requirem ent is s a t i s f i e d by v i r t u a l l y a l l claim ants for com pensation for d i s a b i l i t y fo r s i l i c o s i s and a n t h r a c o s ilic o s is , corp orate maneuvers having been devised to en su re in t e r r u p tio n o f co n tin u o u s l i f e o f c o a l mining com panies. The amount o f com p e n s a tio n p a id out o f the s t a t e tr e a s u r y to c la im a n ts under t h is law now exceeds $ 1 , 000, 0 ' per month. A p e r f e c t ly sound con cept o f s o c i a l l e g i s l a t i o n - workmen's com pensation for occup ational d is a b ility for the u ltim ate purpose o f occupational disease prevention was c y n i c a l l y p e r v e r te d -to a d o le in an attem p t to- a l l e v i a t e the economic re p e rc u ssio n s o f a f a l l i n g In d u s try . O nly r e c e n t ly has an a c t i v i t y been s ta r te d to b rin g sc .e s = V ' ar o f responsible adm inistration into th is p ictu re. 1. Department o f Labor and Ind u stry The t o t a l impingement o f the Department o f Labor and In d u stry upon the o ccu p a ti' d ise a se problem is f a n t a s t ic a lly com plicated. A t o t a l o f eigh t Bureaus have a c tiv ity in th is f i e ld , as fo llo w s :* a . I n d u s t r ia l Board. C o n sid e rs a p p e a ls o f laws a f f e c t i n g lab or and a pproves a ll safety devices requiring approval. b. I n d u s t r ia l S ta n d a rd s. Develops in d u s t r ia l s a f e t y r e g u la tio n s and r e v is io n s and recommends a c tio n fo r ap proval o f s a f e t y d e v ic e s and equipm ent. *From th e d ir e c t o r y o f the Department o f Labor and In d u s tr y , cu rre n t as o f the s p rin g o f 1961. 227 rep resen tative of a given industry (or, a lte r n a tiv e ly , harboring rep resen ta t iv e exposure t o 'a g iv e n su b sta n ce w ith in th a t in d u stry ) should be s e le c te d fo r s tu d y . C o r r e la tio n s sh ou ld be sought between e n viron m en tal c h a r a c t e r i s t ic s and s e le c te d h e a lth param eters, v i z . , in cid en ce and s e v e r ity rates o f i ll n e s s by d ia g n o s is , ab sen teeism , and c l i n i c a l fin d in g s a t tim es o f the p e r io d ic h e a lth exam in ation s o r d in a r ily provided by In d u s tr ia l m edical d ep artm en ts. A s e a rc h s h o u ld be made fo r known a s w e ll as p r e v io u s ly unsuspected r e la t io n s h ip s between c h ro n ic d ise a se and the n atu re o f em ploym ent, to p ro v id e a b e t t e r b a s is th an we now have fo r e s t a b l is h in g safe lim its o f exposure. b . H e a lth o f th e Work F o r c e . R e p r e s e n t a tiv e p a y r o ll group s sh o u ld be brought under o b se rv a tio n in such a way as to support g e n e r a liz a tio n s regard in g the h e a lth problems o f the w orking p o p u la tio n s: m o rb id ity and m o rta lity r a te s o f il l n e s s e s by a g e , s e x , r a c e , type o f employment, and income le v e l; and fu r th e r 'g e n e r a lis a tio n s regard in g the socio -econ om ic problems ( fo r both th e em ployer and th e em ployee) r e s u lt in g from the h e a lth problem s. 3. The D iv is io n should assume le a d e r s h ip in th e development o f fu r th e r le g is la t io n in th e o c c u p a tio n a l h e a lt h f i e l d a s may be found n e c e s s a r y th ro u g h i t s c o n t in u in g , b ro a d -g a u g e d s t u d i e s . Recomm endations f o r new l e g i s l a t i o n s h o u ld be su pp orted by c a r e fu lly an alyzed d a ta . The D iv is io n 's ta rg e t in this regard should be a h igh le v e l o f h e a lth fo r the work fo r c e . A p p lic a b le to o th e r departm ents under e x is t in g law 4 . A p h y s ic ia n o f the D iv is io n o f O c cu p a tio n a l H ealth should be a tta c h e d to the s t a f f o f th e D ir e c to r th e Workmen's Com pensation B u reau , Departm ent o f Labor and In d u s tr y . T h is should be an ad hoc assignm ent to a s s is t in th e dev elo p ment o f m ed ical f a c t s needed in the a d m in istra tio n o f cla im s fo r d i s a b i li t y from s i l i c o s i s among m in ers. The D i v i s io n 's p h y s ic ia n sh o u ld work as a c o n s u l ta n t t o th e Workmen's Com pensation B u re a u 's d e fe n se c o u n s e l. A u s e fu l by product o f t h is s e r v ic e would be the o p p o rtu n ity fo r fir s t -h a n d o b se rv a tio n s by the D iv is io n 's p h y s ic ia n on a la r g e number o f c a se s o f s i l i c o s i s . 5. An i n d u s t r i a l h y g i e n is t o f th e D i v i s io n o t O c c u p a tio n a l H e a lth sh o u ld be a tta c h e d to the mine su rvey group employed by the Department o f Mines and M in eral In dus t r ie s to a s s e s s the a i r borne d u st in c o a l m ines. T h is sh ou ld be an ad hoc assignm ent fo r the d u ration o f the p resen t research p ro je c t which seeks to c o rr e la te le v e ls o f d u stin e ss w ith the occurrence o f In d u s tr ia l lung d isease among c o a l m in e r s . The r e s p o n s i b i l i t y o f th e I n d u s t r i a l h y g i e n is t s would be to make su re t h a t th e a i r sa m p lin g and d u st c o u n tin g o f th e m ines group Is c o n sta n tly in lin e w ith what is needed in the research p r o je c t. 6. The reso u rces o f the D iv is io n o f O ccu p a tio n a l H ealth should be used by tue S t a t e Workmen's In su ra n ce Fund to red u ce I t s lo s s e s . The Fund e x i s t s to p ro v id e in su ra n ce co v erage fo r h ig h - r is k a cco u n ts which the com m ercial in su ra n ce com p a n ie s w i l l n ot c a r r y . U s u a lly th e in su re d p a r t ie s a re s m a ll em ployers whose r i s k cannot be e stim a te d a c t u a r i a lly because o f the sm a ll number o f people in vo lved ; and, a l l too fr e q u e n tly , they a c tu a lly are poor r is k because ot the hazardous nature o f th e ir b u sin e ss. In th is s it u a tio n , a commercial c a rr ie r would employ com petent personnel to conduct an a g g re ssiv e lo s s -p r e v e n tio n program . The S t a t e Workmen's In su ra n ce Fund has a v a i l a b l e to i t a high-quality s e r v ic e o f t h i s typ e fo r th e a s k in g . A g a in , a u s e fu l b y -p ro d u c t would be f i r s t - h a n d in fo r m a tio n on h i g h - r i s k i n d u s t r i a l e s t a b lis h m e n t s , f o r more g e n e r a l a p p lic a tio n elsew here in the a c t iv it ie s o f the D iv isio n o f O ccu pation al H ealth. 226 The d is c o v e r y o f a g r e a t manv ca>*e- >' j i i i c M - i s among bf t urni nous miners a r e s u l t o f a f i e l d stu d y o f the D iv is io n o f O c c u p a t i o n a l H ealth has broken wide op*th e whole q u e stio n o f th e need o f more s t r in g e n t dust c o n tr o l in the bitum inous in d u s t r y . A stan d ard way to study t h is c a l ' s f o r c o r r e la t io n s between the work environm ent and d e g ree s o f lung In volvem en t. When t h i s r e la t io n s h ip is understood i t w i l l be p o s s ib le to recommend th e most p r a c t i c a l methods o f p r e v e n tio n . An in v e s t i g a t io n o f t h i s k in d must be c l o s e l y su p e r v is e d in e v e ry d e t a i l by the prln< p al in v e s t i g a t o r . I t tu rn s out th a t the mine o p e ra to rs do not want to adm it the D iv is io n 's in d u s t r ia l h y g ie n is ts underground, as a r e s u lt o f which the Department o f Mines and M in e ra l In d u s t r ie s h ir e d e x p e rie n c e d mine forem en, e n r o lle d them in a s h o rt co u rse o f t r a in in g in du st c o u n tin g , and made them r e s p o n s ib le fo r the qua-' ta tiv e asp ects o f the dust counts needed in th is stud y. Trained in d u s tria l h ygieneo f the D iv is io n should be read m itted to th e mines to work c lo s e ly w ith the employe*i o f the Department o f Mines and M ineral In d u s tr ie s on t h is p r o je c t. T h e r e a fte r, th e r e sh o u ld be th e c l o s e s t c o o p e ra tio n >r>twgen th e Departm ent and th e D iv is io n tv en su re w orking c o n d it io n s t h a t w i l l produce no new ce es o f s i l i c o s i s . In d u s tr ia l h y g ie n e a t t h i s le v e l o f perform ance is a s p e c i a l i z e d p r o f e s s io n , and not a sim p!* s k i l l ....J t can be p icked up as a s id e -lin e and p ra c tic e d as a p art-tim e endeavor. IV . Summary The body o f s t a t e law p e r ta in in g to o c c u p a tio n a l h e a lth in P en n sy lv an ia has grown p ie c e meal in response to the pressu res and needs a t given tim es. O ccu p ation al h e a lth a c t iv it ie s a re sp read th ro u gh th e s t a t e govern m en t, accom m odations h a v in g been made h ere and th e re for the a d d it io n o f new f u n c t io n s , a u t h o r it y and r e s p o n s i b i l i t y , a l l adap ted to e x i s t i n g admlnls t r a t iv e s tr u c tu r e in a pragm atic wav. One sees r e s u lt s o f p r a c t ic a l compromise between th* need on one hand to p r o t e c t the work fo r c e from e x c e s s iv e s o c i a l and h e a lt h c o s ts o f in duf-tr, a liz a t io n and on the o th e r , the need o f b u sin ess to meet com p etition in the p ric e o f it s p r o d u c ts . W ith each m ajor problem approached on an ad hoc b a s is i t was n a tu r a l t h a t an l l l o g i a d m in is tr a tiv e scheme should r e s u lt . The D iv isio n o f O ccupational H ealth , sta rte d as a s p e cia liz e d a c t iv it y under federal a u s p ic e s some 25 y e a rs a g o , has become a m ajor o p e r a tio n w ith in th e S t a t e H e a lth Department. The D i v i s io n i s now im p r e s s iv e ly s t a f f e d w ith f u l l y t r a in e d s p e c i a l i s t s , and has e x c e lle n t physical f a c i lit ie s . P e n n s y lv a n ia 's most u rgen t o c c u p a tio n a l h e a lth problem s can be so lv e d by b r in g in g the te c h n ic a l reso urces o f the D iv is io n o f O ccu p ation al H ealth to bear upon c e r ta in occu p atio nal h e a lth a c t i v i t i e s now lo c a te d else w h e re in the s t a t e governm ent. Some le s s u rgen t problem s, fo r the most p art those alread y w ith in the d ire c t ju r is d ic t io n o f the D iv is io n , have th e ir s o lu t io n in e x te n s io n s o f a c t i v i t i e s a lr e a d y under way w ith in the D i v i s io n . S t i l l o th e r problem s can be s o lv e o n ly w ith e n t i r e l y new approaches w h ich , in tu r n , w i l l depend upon new leg islatIo n s. V. Reconxnendat ions A . A p p lic a b le to the D i v i s io n under e x i s t i n g law 1. A b la n k e t recom m endation is su b m itte d , t h a t a l l o f th e e x i s t i n g programs o f the D iv is io n be c o n tin u e d . Sim p ly b ecau se th e re may be a tendency fo r I t to be overshadowed by th e o th e r a c t i v i t i e s o f the D i v i s io n , s p e c i a l em phasis should be p la ce d on fu r th e r development o f the employee h e a lth program, exterd it s b e n e fits as w idely as p o ssib le to s ta te employees. 2. The D iv is io n sh o u ld embark on lo n g -te rm e p id e m io lo g ic a l s t u d ie s th a t have related but d iffe r e n t o b je ctiv e s: d e fin itio n s of risk o f occupational disease and b a s ic h e a lth s tu d ie s o f P e n n s y lv a n ia 's work fo r c e . a. O c c u p a tio n a l D is e a s e R is k . One in d u s tr y a f t e r a n o th e r sh ou ld he stu d ie d to d is c o v e r p o s s ib le r e la t io n s h ip s between fa c t o r s o f the work environnwr and the h e a lth o f workers exposed to th at environm ent. A group o f p lan ts 228 7 . A f t e r same e x p e r i e n c e has been g a i n e d under recommendation 4 , t he resource'; o f the D iv is io n should be used fo r d e v e lo p in g the te c h n ic a l fa c t s o f a l l work m e n compenst ion claim s fo r o c c u p a tio n a l d is e a s e . In many eases the D iv is a w ill a lr e a d y have u s e fu l background in fo rm a tio n on the in d u stry and perhaps even on the p a r tic u la r p la n t concerned. In o th e r s , the D iv is io n should condo environm ental stu d ie s and perhaps c l i n i c a l exam inations o f the claim an t as w e ll as o th er members o f the work fo r c e , to develop the d e t a ils needed fo r a rr iv in g at the best d e cisio n . Again, a u sefu l by-product of th is service would be the fir s t - h a n d o b se r v a tio n s on a g iv e n p la n t and i t s work fo r c e ' n the r e a l - l i f e circum stances o f so lv in g an acute problem. C . A p p lic a b le w ith new l e g i s l a t i o n 8. A r e p o r t in g system should be developed which makes known to the D iv is io n everproved or suspected case o f o c c u p a tio ia l d isease soon a fte r such a case is recognized or suspected. \ ' -> : ... 9. E it h e r by a new law or by a- b in d in g , w r it t e n , in t e r iep artm en tal agrec-r.ier.t, th ere must be produced*, a p o lic y wh) H d e fin e s the respon a b i l i t i e s o f the tb- departm ents - - H ealth , H ines and M inerai in d u s tr ie s , and labor and In d u stry -- w ith r e s p e c t to the c o n tr o l o f o c c u p a tio n a l d is e a s e s . teco m en d aticn No. 18 in gem stones (p . 260) i s h erew ith re -a u b m itte d , to g e th e r w ith an endorsement o f the ad vice to fo llo w the then e x is t in g agreement in C a lifo r n ia (Appendix X , p. 318, Ke y sto n e s) .