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a .-,.-, , /' i"// 4lr. 'T/ October 11, 1956 D r. W illiam U. G iessel The Navigation Clinic 215 Milby Street ' Houston, Texas Dear Doctor G iessel: I have not been able to find tim e to go over the m aterial which you cent m e with your letter of August 9 until today, and even now I m ust give it a priority over a number of other m atters that would be given prior attention but for the u ses of professional courtesy and your request for my advice on a sp ecific problem . I shall do m y b est to respond to the latter. ' I shall omit any discussion of the sim ilarities or differences in our view points and m ethods in our approach to preventive m edicine and industrial hygiene in the lead trad es. The only basis for any real discussion of th ese m atters lie s in: the fa cts of life , a s th ese relate to the so c ia l, econom ic, physiological and clinical backgrounds concerned. That is why l offered to spend som e tim e with you, which if you w ere here in m y office, I could give you, but which, for a number of reasons, I cannot spend, in anything like equivalent quantity or effectiveness, in correspondence. I turn then to your p ractical problem . You begin by asking me to make certain assum ptions which I dare not m ake, although I shall go along with them as far as I can. For example, you give me data obtained by the analysis of certain sam ples of a ir. Am I to assum e that there w ere only fiv e a n alyses ? 3f so , th e se , with th eir high variab ility, give m e v ery little idea of the general le v e l of the lead hazard involved in the work of this plant. And how about the men in other parts of the plant, or those who m ove about as they work? A ll I can conclu ded m these wholly inadequate data, is that the ventilation, regardless of the "competence" of the persons who installed it, is not maintaining the kind of cleanliness of the air, with respect to lead compounds, that is n ecessary for the safety of the m en. ^ ` The foregoing conclusion is amply confirm ed by the analytical results on the urine erf certain of the e m p lo y e e s. The la tter item s of data, lik e those referred to above, are not sufficient in number or in their spread over the various occupations, or in relation to the duration of the exposure of the individuals, to show anything about the sp ecific hazards of the specific 0001497 D r. W illiam U. G iessel - (2) - October 11, 1956 occupations and work areas of the plant, except that the plant, apparently as a whole, is dangerous. Two pipe press m en, two truck drivers and one furnace operator have yielded som e results that are within the upper normal range. A ll of the others are excreting lead at a rate that is d e a r ly indica tive of hazardous absorption* The arithm etic average value for this entire group of resu lts is 0,17+ m g, of lead per lite r . If these m en w ere repre sentative of the jobs in this plant, and if these sam ples w ere representative of the general lev el of their urinary excretion, this plant is indeed unsafe, and regardless of who has done the industrial hygiene engineering, the m ea su res of environm ental c o n tr o la r e sadly in need of im provem ent. What is needed is a thoroughgoing investigation of the o v er-a ll situation and a revamping o the system of controls. . - .. New a s to th ese m an. If they continue in work of this type, in such an environm ent, there w ill he severe ca ses of lead poisoning among them. You wish, to a v ert such c a se s of poisoning. Thera a re certain procedures that can be employed with som e hope of benefit. 1. On the assum ption that a plant so poorly equipped with fa c ilitie s for atm ospheric hygiene, is probably as poorly equipped otherw ise,, and on the evidence of the high lev els of lead absorption, Xconsider it lik ely that th ese m en are ingesting appreciable quantities of lea d . What are the con ditions with resp ect to lock er rooms,, changing of cloth es, wash room s and show er equipm ent, and ^fclean lunch room ? I am fu lly aware that resp ired lead is important, but there are many industrial situations in which it is by no m eans so p reponderant as to justify any degree of die regard of the opportunities for ingeation. The lead that men swallow (except for that trapped in the upper resp iratory tract and that in their norm al food and beverages), can be avoided by careful and not unduly co sily attention to the prevention of ingestion. This often m akes the difference between serious and borderline hazard. Such sourcas of lead absorption . can be elim inated by,m eans of p rop erfa c ilitie s and a,sound program for the.training of the p ersonn el unde-r good su p erv isio n . It is m uch le s s c o stly than certain types of ventilation, and the establishm ent of such a regim en is actu ally a requisite . for the developm ent of .real understanding on the part of both workm en and m anagem ent. - ,. - 2. The plant can be surveyed econom ically, but adequately for initial purposes, either by a carefully planned se r ie s of a ir analyses, or by a carefully considered program of analyses of the Mood or urine (or both) of representative personnel,; so as to define the loci and severity of the hazard. It is ad visab le, if p o s sib le , to apply both of th ese p roced u res, but if only one is chosen, the biological procedure is much the b est. Either of them can be done quickly, and if they are/in telii gently, they need not be prohibi- 0001498 Di*. W illiam U. G ie sse l - (3) - O ctober 11, 1936 tively expensive, 3 , On the b a sis of sound evid en ce, the needs o f the situation, from the asp ect of control, can be established, and the w orst situations corrected first. By concentrated attention to the latter, the o v er-a ll expense can be greatly reduced, -* While the plans are being made and the appropriate step s are being taken {after the survey indicated above), the men who are in danger/' can be partially protected by a number of d evices. / a , Respirato!**/p roiection can be provided to individual men, and, with proper education and supervision, this can be made fairly effective for a tim e . It should not be counted on a s m ore than a stop -gap , w hile appropriate equipment to control the exposure is being installed, but, I repeat, it can be made to work beneficially, b. Unduly exposed man can be moved from the m ore dangerous jobs to those le s s dangerous. Those in im m ediate danger of developing illn ess should be rem oved from exposure, tem porarily, Sound criteria for such action, and for the return of th ese m en to their jobs, have been developed and published, and are in su ccessfu l operation in quite a number of industrial plants. If the plant is such that som e jobs are available in safe a rea s, this is fairly easy to do. If no such jobs ex ist, or if the plant as a whole is involved in highly variable and insufficiently controlled exposure, it is very difficult. The d ism issal of men who are in a situation of this type, is , I agree, alm ost unthinkable. Indeed it is an act of utter irrespon sibility and barbarity on the part of the management, . In m y opinion, the physician operates against the proper approach to thi3 situation, if he resorts to the m easures of "prophylaxis" that'are represented in the u s e of S D A , The procedure m ight be used with som e propriety, if we knew enough to Use it with complete safety and with the assurance of a sa tisfa cto ry Outcome for the! m an (which w e do hot), if It w ere u sed , tem p orarily . and rarely* tp deal v/ifh a sp ecific clin ica l and personal problem during the period required to achieve sa fety by proper m eans. That is , if the situation as a whole were fully understood by management, faced by them honestly and Intelligently, and proper steps initiated to solve it, one could help men who a r e in danger but not'Hi!, t o hang- on to'iseir jobs and livelihood, and thereby help indirectly to keep the industry out of avoidable trouble. If, however, one is m erely trying to work against the inevitable* with no real understanding on the part of the m en and'no sound and inform ed attitude and effort on the part of the- m anagem ent, the doctor has no choice but to hew to the straight m ed ica l lin e and let-the chips fa ll w here th ey m ay, A maP wbo is ill, in consequence b lea<^ absorption, no m atter how slig h tly , is a candidate for enforced retirem ent from work with com pensation. He should not return to his job until it Is safe for him to resum e exposure. I agree that the m edical sem antics hbre have been deplorably m isguided and obscure. It is plainly true that there is a w ell defined zone of lead absorption, w ell D r. W illiam U. G ie ss e l - (4) - O ctober 11 i 1956 above the norm al le v e l, -within which m en do not guer any illn e s s at a ll at any tim e. There is a zone, also fairly w ell defined now, at which danger begins and is revealed by a low incidence of m ild {call it "incipient" or "latent" or anything you like,, but it is clin ical lead intoxication, as defined by deviations from the physiological state) lead poisoning. Above this zone, the incidence of poisoning increases as does the severity of the d isea se, Within the zone of danger, we should act to reduce or elim inate exposure before illness develops, . Exposure and absorption can be reduced in a number of;wayss (a) by shortening the tim e of exposure per day, per week or per year, A period of freedom from exposure, regardless of when it:com es, reduces the body burden of lead, and if such periods are properly spaced,, they can be em ployed to prevent lead poisoning: fb) by alternating the sev erity of exposure through scheduled changes in work and location; (c) by specific and instructed effo rts, on the part of workman, to avoid undue exposure, through achieving an understanding of how it occurs {avoiding the plume of fume that follows a moving pot or escapes from an open furnace, avoiding crude acts that d isp erse clouds of dust in the a ir, and keeping on the off aide of sources of dust and fume so far as possible* while carefully avoiding all ingestion of lead by reason of dirty hands, food and beverages. The foregoing m ea su res m ay sound a bit lik e "gilding the lily " in the e a rs of the novice o r the "hard boiled , " but having had the d irect r esp o n sib ility over many years for the safety of m en who work in the m ost dangerous (potentially) of a ll of the lead trades, I have been able to hives tigate and m easure the influence of several of these factors, They are of practical, and not academ ic, sign ifican ce. M oreover, in th is, the m ost in trin sically hazardous of the lead-using industries, we do not have ca ses of lead poisoning. It has taken a long tim e to achieve the understanding of the p rob lem , in fixe ter m s of p racticai'p erform an ce, but the criteria fo r safety are now clear, having been tested by tim e and experience. You may say, at this point, that the situation referred to above is ell very w ell for a large and wealthy industrial organization, but that it cannot be achieved by a sm all company or owner with lim ited resou rces. To this frequently stated bit of trip e, 1 reply that this sam e thing has been accom plished by certain sm all organizations and ow ners, who, whether or not they are socially sen sitive, have learned by their own o r, if they are really in telligen t, by the experience of others, that the financial jeopardy associated with the operation of a frankly dangerous plant is too great to be endured by a prudent m anager. This is a m atter of w ise management based upon an understanding o f the problem , aud it is the function of a physician who has appropriate a c c e ss to / management, to see that such under standing is a rriv ed a t. The ro le of the physician is a gracious and beneficent one, so far he the endangered personnel are concerned, but it is that of the insistent instructor, stern critic and judge, with reference to the hygienic "c.~C.: M r. M anfred B ow ditcti C 0001500 J D r. William U. G ie sse l - (5> - O ctober 11, 1956 re8ponsibilii:ies ow ner. It ia ra re indeed that th ere is any so cia l justification for the p ersisten ce of an industry that rem ains actually unsafe for any considerable period of tim e. If a m aterial o r a process cannot be handled or operated safely, it is a so cia l liab ility, and w e, as the responsible . .jiaators of the health of the people, should be the la s t to stave off the just ,,a-.^iinent of so c ie ty a s e x p r essed in its m ed ical and hygienic knowledge, ^gufations and la w s, This f-s-.s turned out to be a long le tte r , a s I feared it would when I fin ally jot around to it. The fact is that this is one cf the oldest and m ost troubleuorne problem s of industry and industrial m ed icin e. It is fa r from sim p le, and its m ed ical and Social im plications a r e confused because they have gone ao long without' suificiei.it exam ination and elucidation, N eith er we a s doctors :ior the resp onsib le people in industry have com e right down to ana faced the r ea l is s u e s , except o cca sio n a lly and under exceptional c ircu m sta n ces, 'We have hidden under the -obscurity-of "unusual uus c ep tib ility'` and 'lie alleged unpredictability of the effects of lead absorption, and have failed to direct the thinking of in d u strial m anagem ent when indeed w e have not actually m isle d it by our ignorance and our lack of so cia l w isdom . T/e no longer have our ignorance of cith er fcae danger or the uncertainties of the d isea se to ju stify our inaction. M oreover, I look to the new e ra of occupational medicine,, in which the resp on sib ilities of the industrial physician are being defined and cla rified , to stam p out the backw&rdauaa of our approach to this and other somevdiat comparable proolemo of industrial health. Sincerc-ly yours, .Robert A . A shoe, id. A, 3AE ef C. C .: M r. Manfred Bowditch (Blind) ^ 0001501