An evaluation of the actual cost of the reports requested by section 13 should be required. Every effort should be made to reduce the number of reports an employer has to file with an agency of the government.

CONCLUSION

Federal standards for state workers' compensation programs is a concept which the Alliance of Metalworking Industries must oppose. Inadequacies and inequities do exist in the workers' compensation laws in several states. But problems exist in the federal Longshore and District of Columbia programs as well.

The mistakes of federal programs which have provided disincentives to return to work, caused a dramatic increase in the number of claims filed, and spawned skyrocketing cost increases, must be avoided at the state level.

Interested parties must work together to continue meaningful reform on the state level. As this is undertaken, they must bear in mind that workers' compensation is not a pension system. It is a program intended to compensate for wages lost and medical care required by injuries and disabilities caused by workplace accidents.

State reform, which adheres to the fundamental objectives of workers' compensation programs, will help insure that we avoid new federal initiatives which are expensive, accomplish little and squander resources. No one needs to be reminded that current inflation rates have created monstrous burdens for individuals and businesses alike.

New federal programs, such as the one proposed by H.R. 5482, are a prime cause of inflationary pressures. They increase costs without increasing productivity. The consumer is the one who suffers.

The concerns expressed in the occupational disease section of this bill are valid, but federal action, as proposed, is inappropriate. We must proceed cautiously so we can avoid the expensive pitfalls of programs such as the $1 billion per year black lung program.

Finally, AMI believes that the time has come to re-evaluate the federal government's role in solving the problems of this Nation. The extremely poor benefit/ cost return from the estimated 325 billion spent by industry to comply with OSHA immediately comes to mind. Billions have been spent on regulations and compliance-yet the problem of occupational injuries continues to grow, seemingly unabated.

In the area of workers' compensation, AMI believes it is time to return to the basics, and work with state systems to provide necessary medical, rehabilitation and income protection services.

Mr. Chairman, thank you for the opportunity to testify this morning. I would be happy to try to answer any questions you might have.

Mr. BEARD. Thank you for your testimony and for the time you took to prepare the statement. Mr. Erlenborn.

Mr. ERLENBORN. Mr. Chairman, I am afraid that, with the bells having rung not only once but twice already because of a malfunction of the bell system, we have only 3 minutes to get to the floor. I wish we had time to get into questions. Let me thank you for your testimony.

Mr. BEARD. Thank you very much.

Mr. SHOFF. Thank you.

Mr. BEARD. The subcommittee stands adjourned.

[Whereupon, at 11:05 a.m. the subcommittee adjourned.]

NATIONAL WORKERS' COMPENSATION STANDARDS

ACT OF 1979

THURSDAY, MAY 15, 1980

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON LABOR STANDARDS,
COMMITTEE ON EDUCATION AND LABOR,

Washington, D.C.

The subcommittee met, pursuant to notice, at 9:55 a.m., in room 2257, Rayburn House Office Building, the Hon. Edward P. Beard (chairman of the subcommittee) presiding.

Members present: Representatives Beard and Erlenborn.

Staff present: Earl F. Pasbach, staff director; James M. Stephens, associate minority counsel for labor; John J. Smollins, special counsel; Edie Baum, minority counsel for labor; and Mary Lou Granahan, research assistant.

Mr. BEARD. Good morning, ladies and gentlemen. I am Edward Beard of Rhode Island, chairman of the Subcommittee on Labor Standards.

Today we will have one of the last hearings on H.R. 5482, to provide Federal standards for workmens' compensation.

We have Dr. James A. Merchant, Director of the Division of Respiratory Disease Studies at the National Institute for Occupational Safety and Health. Doctor, welcome to the committee.

Do you have any prepared statement?

Dr. MERCHANT. Yes; I do.

Mr. BEARD. All right. That will be incorporated into the record and you may proceed.

[Prepared statement of James Merchant follows:]

PREPARED STATEMENT OF JAMES A. MERCHANT, M.D., DR.P.H., DIRECTOR, DIVISION OF RESPIRATORY DISEASE STUDIES, NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH, CENTER FOR DISEASE CONTROL, DEPARTMENT OF HEALTH AND HUMAN SERVICES

Mr. Chairman, I am pleased to be invited to testify before this subcommittee on the use of epidemiological data in the assessment of occupational respiratory diseases. In my capacity with NIOSH, I direct the unit with principal Federal government responsibility for research on the many occupational respiratory diseases. This has given me a good deal of experience with these diseases which I will touch on today. My personal research interest has focused on respiratory disease arising from exposure to cotton dust, which I will address in more detail.

However, before discussing respiratory disease arising from cotton dust exposure, I would like to highlight the NIOSH Report prepared for the Department of Labor as mandated in Section 112 of the Black Lung Benefits Reform Act of 1977. This section of the Act required the Department of Labor, in cooperation

with the Director of NIOSH, to conduct a comprehensive study of all occupational respiratory and pulmonary diseases. In our contribution (interim report) submitted to the Department of Labor in July of 1979, four broad areas were reviewed:

(1) Scope of these diseases in American industry;

(2) estimation of population at risk;

(3) methods for evaluation of lung dysfunction and disease; and (4) analysis of research into the etiology of occupational diseases. Because I previously testified before this committee on May 16, 1979, about the scope of these diseases. I will not repeat the long list of individual diseases and the information compiled on them by NIOSH. Rather, I would like to concentrate on what is known about the causes of these diseases, as this has important ramifications regarding presumptions in assessing certain categories of occupational lung disease.

Disease definition

Critical to epidemiological studies, and compensation programs which deal with the results of such investigations, is definition of the diseases in question. The disease must be identified reliably (different investigators or physicans arriving at the same conclusion using the same terms of reference in a high proportion of cases); and the definition must be valid (have meaning based on an external and preferably objective measure such as pulmonary function testing or pulmonary pathology). The sensitivity and specificity needed to identify a disease depends upon a study's objective. Screening programs are designed to have high sensitivity to identify cases in the early stages of disease such as grade 2 byssinosis or radiographic category 1/0 pneumoconiosis. Programs designed to assess impairment or disability place greater emphasis on specificity which include only advanced cases associated with impairment. Application of differing definitions, or stages of the same classification, can result in widely diverging estimates of the frequency or severity of a given disease in a given occupational population.

Lack of meaningful, uniform disease definitions remains a problem in respiratory disease studies and programs. This is reflected in the variability in diagnostic habits of practicing physicians and exemplified by the following occupational airways diseases: asthma, chronic bronchitis, emphysema, and byssinosis. Although there are standard definitions for these diseases (all of which have been studied extensively), they are not entirely satisfactory for evaluation of the impaired worker. Emphysema is best diagnosed by examining whole lung sections. It is much more difficult to make a diagnosis on a living person. The importance of cough and phlegm-the hallmarks of chronic bronchitis-in terms of prognosis based on prospective studies are now in question. Although there have been many definitions of asthma, none have fully accounted for all of its aspects. These difficulties are in large part because these diseases have similar signs and symptoms and because they are caused by more than one factor.

Causality (etiology)

For some occupational respiratory diseases, single agents or exposures are clearly responsible for the respiratory disease. These include the infectious diseases and the immunological diseases hypersensitivity pneumonitis and occupational rhinitis or asthma). The linkage of these exposures to industrial exposures is, however, usually dependent upon epidemiological studies. The vast majority of occupational respiratory diseases are caused by more than one risk factor. Particularly when a large proportion of the population at risk is exposed to a second powerful risk factor, such as cigarette smoking it is important to have good epidemiological data which establish the link between exposure and disease. Chronic airways obstruction arising from occupational exposure is clearly the most complex and difficult occupational respiratory disease category. This relates to (1) overlapping disease definitions; (2) the multiple causes of these diseases; (3) often lack of adequate occupational exposure data on concentration and duration; and (4) lack of adequate assessment of other important risk factors. Serious consideration must be given to all of these points before drawing conclusions from epidemiological studies.

In addition to occupational exposure, cigarette smoking is an important risk factor in causing respiratory disease among workers. Smoking causes lung cancer, chronic bronchitis, emphysema, and heart disease. Smoking increases lung deposi

tion and retards clearance of toxic materials from the lung. Any of the occupational respiratory diseases may present in combination with pathology caused by cigarette smoking; hence, mixed patterns of respiratory disease are the rule. Smoking acts as an additive or synergistic risk factor in contributing to respiratory impairment. Smoking may interact with occupational exposures to produce more frequent and more severe disease at lower exposures (such as in byssinosis), or act as an important co-risk factor interacting with the occupational exposure to greatly multiply the frequency of disease (such as in lung cancer from exposure to asbestos).

A number of other risk factors may contribute to the effects of these two primary risk factors. In airways diseases, risk factors which have been studied are social class, air pollution, urban-rural location, genetic constitution and immunestatus. However, little epidemiological attention has been focused in these areas; therefore, their relative importance is not well defined. Available evidence, however, suggsts that they usually do not play a major role in causing diseases associated with workplace exposures.

Diagnosis and prognosis

The question is (1) whether adequate criteria exist to make reliable and valid respiratory disease diagnoses and (2) whether these diagnoses may be linked to an occupational origin. Although some diagnostic criteria exist for all known occupational respiratory diseases, they alone may be inadequate for use in evaluating disability. Some may be unacceptable for disability evaluation because they are completely subjective or unavailable to the practicing physican.

The diagnostic criteria for byssinosis, which have proven reliable and valid for epidemiological use, are not completely suitable for disability evaluation because they are subjective (based on a pattern of symptoms) and detect only part of the vegetable dust's biological effect. Testing pulmonary function over a workshift, widely used in epidemiological studies and surveillance programs in the textile industry, is unavailable to practicing physicians who often evaluate workers who have left the industry. In addition, although risk factors may be elicited by occupational history, clinical, and laboratory examination, it is virtually impos sible for a physician to know their importance in causing a given disease in an individual patient.

Allocation of risk may be assessed only from epidemiological data gathered on a reference population reasonably representative of the subject's exposure. The probability the subject's airways disease is affected by his or her exposure, therefore, depends very much on the strength of the epidemiological data inferring causality. Reasonable causal inferences or presumptions could, for instance, be made that occupational exposure helped cause lung cancer in a worker who worked many years topside of a coking battery where epidemiological data has revealed a tenfold excess of lung cancer. Epidemiological data must therefore provide information on both exposure and specific disease outcome to serve as frames of reference to assess probabilities (presumptions).

Finally, apart from assessment of the specific diagnosis and its associations with industrial exposure, is assessment of impairment. With few exceptions, all of the occupational respiratory diseases may lead to permanent impairment or death. In life, impairment is best judged by a thorough clinical and laboratory assessment of lung function. The single best prognostic test for those with severe airways obstruction is spirometry and specifically FEV1 (Forced Expiratory Volume). Arterial blood gases are also important and may be particularly useful to assess the severity of pulmonary impairments in patients with fibrotic or infiltrative diseases, such as far advanced pneumoconiosis or hypersensitivity pneumonitis. In order to judge impairment, laboratory evaluations must be done care fully and well-documented, meaningful prognostic standards must be applied. Such standards are available for spirometry and arterial blood gases.

As discussed previously, epidemiological studies allow drawing reasonable inferences about the role of occupational exposures and smoking in a number of occupational respiratory diseases that are caused by more than one factor. Chronic obstructive lung disease arising from significant exposure to cotton dust is an important example where the use of reasonable presumptions based on epidemiological data could be used.

The evidence implicating cotton dust exposure and cigarette smoking in causing chronic obstructive lung disease may be summarized as follows:

1. Pathological studies reveal significantly more chronic bronchitis among cotton dust exposed workers than controls. Smoking appears to increase the frequency and severity of emphysema and chronic bronchitis.