For 20 years, Ray Ballinger worked as a furnace operator at a foundry in Illinois. Around his 40th birthday, he noticed he was short of breath. He felt tired and his left side was weak. After a while, he couldn't keep up at work and was fired. He went from doctor to doctor, but none of them diagnosed any problem. A few prescribed antidepressants. Nothing helped.

Two years later, a friend of Ray's heard me talk about occupational health hazard, and suggested Ray come to see me. After two years and numerous doctors, Ray was skeptical and understandable upset. He said, "I can't understand what happened to my wind. I never even smoked and now I can't breathe." Along with his regular medial history, I took an extensive occupational and environmental health history. Because of his exposure to asbestos and silicon as a foundry worker, I suspected he might have an occupational lung disease called pneumoconosis. His chest x-rays showed scarring (fibrosis). His lung function test confirmed pneumoconiosis. Although I couldn't reverse the damage of years of exposure to silicon and asbestos, I was able to identify his illness and help him get worker's compensation.

Widespread Problem. Ray's story is all too common. Thousands of workers are literally dying to make a living through daily workplace exposure to toxic metals, chemicals, radiation, environmental and biological hazards, and psycho-social stresses. Occupational exposures are a factor in 39 percent of all cancers.(1)

Although scientists are slowly making progress in identifying a and controlling workplace hazards, the sheer number of potential hazards is staggering. Thirty thousand new chemical are introduced each year, but we only have detailed health-effects information on about 500 of them.

To make matters worse, emerging industries, particularly computer assembly and silicon chip manufactures, pose new problems. These workers are exposed to a cornucopia of chemicals used to produce semiconductors, the "brains" inside microcomputers. At first, little attention was paid to the occupational health of this so-called "clean industry." But a recent study of a Digital Equipment Corporation plant in Judson, Massachusetts, showed an increased incidence of miscarriages among computer production workers. The study rocked the semiconductor industry and led to the adoption by many companies of fetal protection policies (FPP). Some companies such as AT&T bar pregnant women from production lines. Others now require women employees to provide evidence of sterility as a condition of employment.

According to the National Institute of Occupational Safety and Health (NIOSH), the research arm of the Occupational Safety and Health Administration (OSHA), nine out of every 10 North American industrial workers are not adequately protected from exposure to hazardous substances. Even non-working family members may be subject to occupationally-related illnesses. One patient of mine, a 49-year-old woman who developed a type of lung cancer caused by asbestos (mesothelioma), was exposed during years of washing her pipefitter husband's contaminated clothing.

According the the Bureau of Labor Statistics, in 1985 3,750 workers died on the job. The job-related injury and illness rate that year was 7.9 per 100 full-time employees; nearly 50 percent of these incidents involved lost work time. While construction, mining, and manufacturing industries have the highest injury and illness rates, some service industries such as health care and dry cleaning have equally high rates of occupational illness and injuries.

Although these figures are startling, they represent a gross understatement of occupational illness and injuries. One estimate says that each year 150,000 people die from job-related causes, 500,000 suffer form occupational illnesses and 11.2 million are injured at work.(2)

Behind the Times. Perhaps even more disturbing is the fact that the United States is the only large, industrialized country without a national system for reporting occupational disease. A recent report of occupational health by the 99th Congress was entitled "Occupational Health Hazard Surveillance: 72 Years Behind and Counting." To assist in reporting efforts, some in Congress are pushing to include occupational information on death certificates and parental occupational information on all fetal deaths in order gather data on workplace reproductive hazards.

Occupational illnesses and deaths are also underreported because some companies alter their injury/illness reports to avoid OSHA inspections. Chrysler was recently fined $250,000, the largest OSHA fine in history, for altering injury/illness statistics at plant in Belvidere, Ill. (3)

Recently, work-related injuries have increased by 10 percent. The AFL-CIO blames the increase on lax OSHA enforcement by the Reagan Administration. The Administration denies this accusation and counters that it has been instrumental in the development of several new workplace safety standards such as the Hazard Communication Standard, a federal regulation requiring annual workplace hazard training for all employees. But the Reagan Administration's Office of management and Budget (OMB) was also responsible for limiting a NIOSH study on the health effects of VDT screens on telephone operators at Bell South Corporation by forcing NIOSH to eliminate questions on stress and fertility. Employee groups such as the Communication Workers of America and 9 to 5 protested this action. They contend it was "meddling by economists who have no health and safety expertise."

The Reagan Administration has also led the effort to black passage of the High-Risk Occupational Disease Notification and Prevention Act. This bill would identify workers at high risk of diseases as a result of past or current exposure to hazardous substances. It would also require at least 100,000 workers each year to be medically monitored and counseled about the occupational health risks.

Occupational injuries, illness, and deaths also go underreported because physicians often fail to recognize occupationally related problems. The sad fact is that the medical community isn't trained to handle occupational health concerns. There are fewer than 1,000 board-certified occupational health physicians nationally. Most medical schools devote only four hours of instruction to occupational health.

In practice, few physicians heed the advice of Ramazzini, the father of occupational medicine, who in 1700 told doctors to "First, ask of what trade are you?" Most physicians do not take adequate occupational health histories. Ray Ballinger told me none of his previous physicians had asked about his job history, although he worked in a high-risk occupation.

The long latency period for many occupational illnesses also impedes medical and labor attempts to make the workplace safer. Cancers related to asbestos and radiation, for example, may take 20 to 25 years to develop. This lag period allows employers to avoid the expense of preventing illnesses, since they are not likely to incur the costs of the health problems they help create.

The source of many occupational diseases is difficult to pinpoint because people react so differently to hazards. On person with long-term exposure to a hazardous material may become ill, while another may not. This and other factors (genetics and lifestyle) make proving occupational hazards almost impossible. Asbestos workers who smoke, for example, are 50 times more likely to develop lung cancer the nonsmokers. Some companies are trying to weed out individuals who are susceptible to occupational hazards by conducting genetic screening and be refusing to hire higher-risk workers such as smokers.

To receive workers' compensation for an occupational illness, the burden of proof rests with the worker. Victims of occupational illness receive only 40 percent of their lost wages compared to 60 percent for injury victims. The difficulty in proving occupational disease is illustrated by a patient of mine who had developed asthma and restrictive lung disease after being exposed for 12 years to the dusts and chemicals at an agribusiness chemical manufacturer. His workers' compensation claim was denied because there was no medical evidence that conclusively connected his disease to the company's chemicals. Although I'm convinced his disease was job-related, his lab test were inconclusive and we were unable to find other workers with the same problem. In court, company lawyers focused on the fact that the man was a smoker.

Protect Yourself. With so many workplace hazards, how can you stay healthy on the job? Here are a few ways to protect yourself and your family from occupational injury and illnesses:

• Educate yourself and your coworkers. What hazards are you exposed to? Read your employer's Material Safety Data Sheets. One of my patients, a 28-year-old woman who works for a dry cleaner, was shocked when she learned she was regularly exposed to trichloroethylene (TCE), a known carcinogen. She used the Illinois Right-to-Know law and forced her employer provide her and coworkers with training on safe handling of TCE.
• Once you know what you are exposed to, find out what levels are hazardous to your health. Workers need to become familiar with the alphabet soup of industrial hygienists, such as TVL, Threshold Value Limit, an old term which meant the maximum allowable safe exposure level to a hazard. TVL has been replace be PEL, Permissible Exposure Level. The PEL for lead, for example, is 50 micrograms per cubic meter of air. STEL means Short Term Exposure Level. Generally, high levels of short term exposures are more harmful than lower exposures over a longer period of time. AL is the action Level of which an employer must have a medical surveillance program. One patient of mine, a woman who worked in a hospital's sterilizing unit, was routinely exposed to ethyl oxide (EO), a potent carcinogen that can also cause birth defects. She wanted to become pregnant, but was concerned about her exposure level. Although air samples were occasionally taken near her workstations, she was never told the results. She asked her supervisor, who told her there was no danger. Not satisfied, she anonymously called OSHA. An OSHA investigation found the air levels of EO did not exceed the Permissible Exposure Level, but did exceed the Action Limit. Her inquiry resulted in a medical surveillance program to measure worker exposure to EO.
• Check your company's Occupational Injuries and Illness log. This OSHA document must be posted annually be February 1 at the worksite by all companies with 11 or more employees. Look for trends in the kinds of injuries or illnesses. Is the log accurate?
• Suggest that your company start a medical surveillance program. A program is required if your exposure to one of the 24 hazardous substances such as asbestos, lead, or ethylene oxide regulated by OSHA exceeds the Action Limit.
• Educate management through your union or via contract negotiations or other means. A healthy and safe workplace creates a stable workforce and saves your employers money over time. Under the 1970 OSHA Act, employers are required to maintain safe and healthy workplaces. If you identify problems, follow up to make sure management eliminates the hazards. If management won't dal with problems, contact your union, OSHA, or consider talking with the news media. You can call anonymously.
• Use protective equipment. Hard hats, goggles, earplugs, steel-toed shoes, and respirators really help. Employers are required to furnish suitable protective equipment where there is "reasonable probability" of injuries. However, like seatbelts, protective equipment only works when it's used. One study of 770 workers with facial injuries showed that only one percent were wearing face protection.
• Inform your personal physician of your workplace exposures. Don't forget to mention exposures from hobbies. One of my patients developed lead poisoning due to the glazes she used making pottery.
• Organize coworkers around safety issues. If you have a union, see if it has a health and safety committee. Many national union safety committees provide educational material on workplace hazards.
• Request an OSHA inspection if your company won't listen to employee concerns about hazard exposure. You cannot be disciplined or fired for requesting an OSHA inspection. If you are concerned, OSHA can protect your identity. Most major cities have federal OSHA offices. In 21 states, OSHA complaints are handled by state rather than federal inspectors. An alternative to OSHA is to file a NIOSH Health Hazards Evaluation Request or have your union do it. NIOSH investigates such request when there are a number or workers suffering form undiagnosed problems.
• As a last resort, you can refuse to work in an unsafe environment without fear of termination. Before you take such a drastic step, make sure you can document that you asked your employer to eliminate the hazard and that the employer refused. Most workers who take this step are fired and must prove in court that they had no other recourse. Refusal to work is usually easier for union than non-union employees.

Contributing Editor David Fletcher, MD, MPH., is the Medical Director of MedWork, a comprehensive occupational health clinic in Decatur, ILL.

References (1) "Leading Work-Related Diseases and Injuries," Morbidity and Mortality Weekly Report, Vol. 33, September 1984. (2) Healthy People, HEW, U.S. Government Printing Office, 20420, 1979. (3) Occupational Safety and Health Reporter, Aug. 23, 1986.