PROCESS OUTLINE

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Mr. FRANK. Mr. McKernan.

Mr. McKERNAN. Just to follow up a little bit on that, how much of the reason that we are 70 years behind would be due, in part at least, to physicians who are not adequately diagnosing some of these occupational illnesses?

Dr. MILLAR. I think that plays very considerably into the problem. There is a limited exposure of medical students to occupational issues. Dr. Landrigan and I provide the occupational-exposure training to one prominent medical school, and it amounts to a couple of hours a year; and that is a very good medical school. So a lot of physicians do not have a real awareness of occupational disease. One of the crucial benefits of that sentinel health event list that Mr. Frazier referred to is that it does, in fact, provide a handy reference, a quick reference for physicians of what conditions do we consider as part of the occupational disease problem.

Mr. McKERNAN. Would it be fair to say that most physicians' exposure to occupational illnesses would come by being in an area where there just happened to be a lot of illnesses because of exposure in certain workplaces in that community?

Dr. MILLAR. That, of course, is true, but also, I think it would need to be coupled with some interest among the medical school faculty, for instance, in pointing out to students that this is, in fact, an occupational problem. As you know, for things like pneumoniosis unless you have a real interest in what is going on in the lung, x ray findings could be any number of things, and unless one asks the right questions: What did this person do for a living; for how long what were the working conditions it is unlikely that the appropriate occupational relationships are going will be defined.

Mr. McKERNAN. What types of State laws are there on the gathering of data on occupational illnesses? Are there State laws requiring that physicians submit this type of information to State health agencies or is it all on a voluntary basis or is it regulatory? How does that work?

Dr. MILLAR. We are trying to find that out with some precision. We think there is a great variety of different approaches out there. Some States, in fact, may now have legislation in place that requires the reporting of occupational diseases, but this is not done carefully or hasn't been stimulated, or was set aside at the time OSHA was created, or whatever. Mr. Frazier is looking into that matter and we are indeed surveying the States now to find out exactly what is there and what needs to be done.

Todd, would you like to comment on that?

Mr. FRAZIER. We visited a few States and have some appreciation of the range of variation in the existing laws. For example, in the State of Virginia, they are required to report, as I understand it, all occupational-related diseases, however that is defined.

In the State of Maryland

Mr. McKERNAN. If I could just interrupt you for a minute.
Mr. FRAZIER. Yes.

Mr. McKERNAN. How is that defined?

Mr. FRAZIER. Well, I think it is left undefined; that is one of the problems. Because this is an old law and, of course, the recognition and knowledge of the extent of occupationally related diseases is a dynamic thing, it is poorly defined in that case.

In the State of Maryland, they have a discrete list of diseases and are considering adding new disease entities as our knowledge of etiology increases.

Mr. McKERNAN. Do you know of any other States-or is this part of your research-that have compiled a list through their own research of what is in that pretty much identified as occupational illnesses, and state therefore, are required to be reported by physicians as incidents of those illnesses?

Mr. FRAZIER. Only in general terms. This is the type of thing that will come out in our ongoing survey.

Mr. McKERNAN. And I take it that from the national activity you were talking about with CDC, that it is basically all voluntary from that standpoint as well for States to report what they found to a central clearinghouse nationally?

Dr. MILLAR. The reporting by the States to the Federal Government is voluntary, but this has not been a major problem. When we have gone to the States and made a reasonable case of how the data were going to be used and that it would be useful to them in developing preventive measures, they have quite readily accepted additions to that list.

Mr. McKERNAN. Are there any examples of occupational illnesses that you have given to the States as those which are of interest on a national basis that you haven't received the information back on?

Dr. MILLAR. Of occupational

Mr. McKERNAN. Yes, illnesses?

Dr. MILLAR. The only occupational one on the list now that I can think of readily is anthrax, a particular kind of infectious disease that appears in certain workers exposed to certain kinds of hides. It has been there for a long time.

I believe that silicosis is the first one we have actually attempted to get them to relate to and try to get nationally reportable. Phil, do you want to comment on that?

Dr. LANDRIGAN. Yes, that is quite correct. As a matter of fact, in the course of informal conversation at the meeting of the State epidemiologists yesterday we learned that somewhere between seven and nine States, at least, already have silicosis on the books as reportable. The issue before us is to get the States to work on that, to bring State health departments up to the necessary level of expertise so they can do some digging and find the cases exist within their borders.

Mr. McKERNAN. I guess what I am trying to determine is whether this is a national problem that ought to be addressed on a national basis, be it voluntary guidelines, mandatory, whatever, so that the people out there who are treating those who have illnesses that may be occupational in nature are forwarding that information, know what it is, that some central clearinghouse is looking for so that we are getting the kind of data we need to really do the analysis.

It seems to me as though whatever a physician decides is something that they ought to report to the State, they report, and whatever the State decides they ought to report to the national level, they report, and you may be getting the information from, perhaps, a quarter of the sources that really are seeing that illness and if

you got it from the other three-quarters, it might make a big difference in the research on a national basis.

Dr. LANDRIGAN. Yes.

Dr. MILLAR. I think we must continue to make a distinction between data that are useful for research and data that are useful for prevention and disease control. Many of the data that we get from all kinds of sources are quite useful for research but not in terms of surveillance. The test of the efficacy of surveillance is whether the data are useful and visibly used to provoke preventive intervention.

One reason we are keen on getting this implemented through the existing traditional public health structure is that we think important actions can be taken at the local and State level in addition to the actions that are taken by the Federal Government.

Mr. FRANK. Would the gentleman yield? Dr. Millar, I understand that, but you said earlier that one of the problems that we have here in trying to come up with intervention strategies is that we know so little. You use the analogy of an army not knowing anything.

Dr. MILLAR. Yes.

Mr. FRANK. That would seem to me to make the research in this case essential. I mean

Dr. MILLAR. Clearly

Mr. FRANK. You seem to be suggesting there that-well, that is the research, but we want to focus on the subject to help us fight it, but it seemed to me that you were suggesting earlier that we don't really know enough now to fight intelligently; so the research is an essential part of that.

Dr. MILLAR. I certainly didn't mean to imply that the research aspect is unimportant. The point I am trying to make is that although we use a lot of data and turn out good research that does, in fact, help us to understand these problems, the quality and nature of research data are different from those required on a concurrent basis to actually go out and do something about a problem right now. If, for instance, we get death data, for instance, that is 4 or 5 years out of date, it may be very useful for research, epidemiologic research, but it is not going to govern intervention at all.

Mr. FRANK. I understand that, but I don't think either Mr. McKernan or I were suggesting, or any of the other members, that you should do one to the exclusion of the other. I think we are accepting your view that we need a lot more research.

This may be a little role reversal for the Members of Congress to be saying, "Don't be so specific-oriented; understand the greater role of research," but I think that is what we are saying. We appreciate that you have inherited a situation where you didn't have the basics. We would hate to see it prejudiced by a kind of sense that you have got to do something right away.

Dr. MILLAR. We agree with you and we are proceeding on both lines.

Mr. McKERNAN. I have no further questions.
Mr. FRANK. Mr. Owens.

Mr. OWENS. No questions.

Mr. FRANK. Thank you very much, gentlemen.

Just a couple of last ones. I continue to be concerned about the budgetary impact. I understand that money is not the automatic solution to problems, but it has been my experience that the absence of money is rarely an automatic solution to problems either, and as between the presence of some money and the absence of some money, the presence is usually better than the absence in trying to get us a little step ahead.

There has been a very substantial reduction in the NIOSH budget and the problem here is that-as I said, through no one's fault-this is an area that has been neglected. I think if peoplethe average citizen-listen to these conversations, they would be shocked to know that with all the technological advances that we have made, the research advances, that we still know so little about occupational illnesses, and as I said, I think it is a reflection of kind of antiworking-people attitude in a lot of ways, but we are now trying to overcome that.

It has been our experience, I think, in government, that when you are in a period of budget cutbacks, it is precisely the new initiatives that suffer the most, that when you are trying to get into something new and there are substantial cutbacks, everybody is trying to worry about what has already been in effect, so I am very concerned about our ability to undertake some of these initiatives, which sound like very good ones, in this period of great cutbacks. So I would like to ask if you would send to me a breakdown of the budget this year and proposed for next year that NIOSH will be spending in the area of trying to improve our understanding of occupational illnesses and how we deal with it—that is, the kinds of things we are talking about, this research effort, trying to break out of this box and this catchup with the 70-year lag.

If you could give us some budget figures on those, that would be helpful and I am think it would be helpful to us in trying to push forward.

Dr. MILLAR. We will be pleased to provide that.

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