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UNITED STATES DEPARTMENT OF LABOR

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ADVISORY BOARD ON TOXIC SUBSTANCES AND WORKER

HEALTH

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MEETING

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FRIDAY,

NOVEMBER 17, 2017

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The Advisory Board met at The Lodge 

at Santa Fe, 750 N. St Francis Dr. Santa Fe, 

New Mexico, at 8:00 a.m. Mountain Time, Steven 

Markowitz, Chair, presiding.

MEMBERS

SCIENTIFIC COMMUNITY:

JOHN M. DEMENT

MARK GRIFFON

KENNETH Z. SILVER

GEORGE FRIEDMAN-JIMENEZ

LESLIE I. BODEN

MEDICAL COMMUNITY:

STEVEN MARKOWITZ, Chair

LAURA S. WELCH

ROSEMARY K SOKAS

CARRIE A. REDLICH

VICTORIA A. CASSANO
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CLAIMANT COMMUNITY:

DURONDA M. POPE

KIRK D. DOMINA

GARRY M. WHITLEY

JAMES H. TURNER

FAYE VLIEGER

DESIGNATED FEDERAL OFFICIAL:

DOUG FITZGERALD
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AGENDA

Welcome and Introductions by Douglas

Fitzgerald and Steven Markowitz ............... 4

Review of Recommendations .................... 11

Review of Recommendations to SEM Database .... 16

Review of the Occupational Health

Questionnaire ................................ 52

Part B Lung Disease Report ................... 89

Presumptions Working Group by Steven

Markowitz ................................... 106

Changes in Procedure Manual by Steven

Markowitz ................................... 109

Review Public Comments by Board ............. 112

Additional Board Topics by Board ............ 150

Close of Meeting by Douglas Fitzgerald

and Steven Markowitz ........................ 154

Adjourn ..................................... 154
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1 P-R-O-C-E-E-D-I-N-G-S

2 8:04 a.m.

3 MR. FITZGERALD: Good morning, 

4 everybody. I'm Doug Fitzgerald, the Designated 

5 Federal Official for the Advisory Board on 

6 Toxic Substances and Worker Health.

7 I'd like reconvene the Board Meeting 

8 for its second day. And, I'll turn it over to 

9 Dr. Markowitz.

10 Thank you.

11 CHAIR MARKOWITZ: Good morning. 

12 We're going to do just quick introductions for 

13 the benefit of the public, if there are any 

14 here or people on the phone.

15 I'm Steven Markowitz, City 

16 University of New York, Occupational Medicine 

17 Physician in epidemiology.

18 MEMBER SILVER: Ken Silver, 

19 Associate Professor, Environmental Health at 

20 East Tennessee State University.

21 Yesterday, you heard a statement 

22 from the daughter of Ben Ortiz, a gentleman I 
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1 worked with very closely and when I lived here 

2 in New Mexico.

3 You've been hearing a lot about 

4 presumptions, a big fancy word. When Ben was 

5 making his case like a voice in the wilderness 

6 about the lab having made him sick, he'd 

7 punctuate every statement, que no? Don't you 

8 agree?

9 And, that's a presumption. It 

10 doesn't he deserve the benefit of the doubt 

11 with these climates?

12 MEMBER POPE: Duronda Pope, United 

13 Steel Workers, also a former worker of Rocky 

14 Flats.

15 MEMBER REDLICH: I'm Dr. Carrie 

16 Redlich. I'm a Professor of Medicine at Yale 

17 and Director of the Yale Occupational 

18 Environmental Medicine Program. Also, a 

19 pulmonary and occupational medicine physician.

20 MEMBER CASSANO: Tori Cassano. I'm 

21 a Retired Navy Occupational Medicine Physician, 

22 Radiation Health Officer. And, now, I have my 
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1 own private consulting business.

2 I worked for many years at the VA 

3 dealing with Veterans issues that are very 

4 similar to the issues you're dealing with now.

5 MEMBER DEMENT: I'm John Dement, 

6 Duke University Medical Center, area of 

7 interest and expertise is industrial hygiene, 

8 exposure assessment and epidemiology.

9 And, I've worked with the BTMed 

10 program for construction workers for the last 

11 20 years.

12 MEMBER GRIFFON: Hi, I'm Mark 

13 Griffon. I'm an occupation safety health 

14 consultant.

15 MEMBER DOMINA: I'm Kirk Domina from 

16 the Hanford Atomic Metal Trades Council in 

17 Richland, Washington. HAMTAC represents about 

18 2,600 active workers through 14 affiliated 

19 unions.

20 I'm a current worker and have been 

21 out there going on 35 years.

22 MEMBER TURNER: I'm James Turner. I 
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1 worked at Rocky Flats Nuclear Weapons Plant for 

2 26 years. I was diagnosed with Chronic 

3 Beryllium Disease in 1990.

4 MEMBER SOKAS: Rosemary Sokas, I'm a 

5 Professor of Human Science and of Family 

6 Medicine at Georgetown. And, I'm an 

7 occupational physician.

8 MEMBER BODEN: Hi, I'm Les Boden. 

9 I'm a Professor of the Environmental Health 

10 Department at Boston University School of 

11 Public Health. And, have been involved at the 

12 Nevada Test Site for some time and the 

13 predecessor for this Board.

14 MEMBER VLIEGER: Good morning, Faye 

15 Vlieger, former work package planner at 

16 Hanford, injured in a chemical exposure in 

17 2002. I currently advocate for injured workers 

18 under this program.

19 MEMBER WELCH: Laura Welch. I'm an 

20 Occupational Physician. I'm currently the 

21 Medical Director for the Center for 

22 Construction Research and Training which is a 
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1 research institute devoted to improving health 

2 and safety for construction workers and the 

3 Medical Director for the Building Trades 

4 Medical Screening Program.

5 MEMBER WHITLEY: I'm Garry Whitley. 

6 I worked at Oak Ridge National Nuclear Complex 

7 for 42 years, was President of the Metal Trades 

8 Council there. I represent about 2,300 people.

9 I retired in 2011. I'm now working 

10 with Worker Health Protection Program in Oak 

11 Ridge and we have about 14,000 retirees.

12 MEMBER FRIEDMAN-JIMENEZ: I'm George 

13 Friedman-Jimenez. I'm an occupational 

14 physician, Medical Director of the Bellevue NYU 

15 Occupation Environmental Medicine Clinic. And, 

16 I'm also Assistant Professor of Epidemiology 

17 and Medicine in the Department of Population 

18 Health NYU School of Medicine.

19 CHAIR MARKOWITZ: So, who needs to 

20 leave before 11:00 a.m. this morning? I think 

21 Dr. Boden is what, 10:30 or so? 9:15?

22 MEMBER BODEN: About 10:00.
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1 CHAIR MARKOWITZ: 10:00?

2 So, we're going to review the agenda 

3 for this morning.

4 We're going to discuss the final 

5 recommendation we did not discuss yesterday 

6 regarding the occupation health questionnaire.

7 We're also going to hear the 

8 committee report or a discussion on the site 

9 exposure matrix in particular around the 

10 recommendation we had made previously regarding 

11 the use of the IOM recommendations.

12 We're going to have short reports 

13 from the Part B Subcommittee and from the 

14 Presumptions Working Group.

15 And then, we're going to deal with 

16 several miscellaneous topics first on changes 

17 in the procedure manuals where we, as the 

18 Board, can get a better understanding of what's 

19 happening -- with what's happened and is 

20 happening with the procedure manual and how we 

21 can stay up with those kinds of changes.

22 I think if we have the time, I'd 
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1 like to spend a few minutes reviewing some of 

2 the public comments from yesterday.

3 And, also addressing how the Board 

4 can better integrate public comments, written 

5 and oral comments, into our deliberations.

6 And then, finally, if we have time, 

7 we can discuss our ideas and recommendations on 

8 how the Board can function better in the 

9 future.

10 MEMBER SOKAS: I just have a 

11 question about whether we could also include an 

12 update on the solvent hearing loss 

13 recommendation that went forward, because that 

14 wasn't included yesterday.

15 CHAIR MARKOWITZ: Right, okay.

16 So, that, when Ms. Leiton comes, we 

17 can hear from her.

18 But, those are from June 2017. 

19 Those are still within DOL. They haven't 

20 returned to us responses yet. I expect we will 

21 have those responses before the next Board 

22 Meeting which is going to be by telephone 
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1 sometime in January. And, we'll happy to 

2 discuss it then.

3 I don't think we're going to have 

4 time to --

5 MEMBER SOKAS: That's fine.

6 CHAIR MARKOWITZ: -- be able to 

7 discuss it as a subcommittee report before that 

8 meeting.

9 One thing I forgot to do yesterday, 

10 which, Kevin, would you bring up the first set 

11 of recommendations from yesterday? I forgot to 

12 get writing assignments for these. Who wants 

13 to draft the -- our comments on DOL's 

14 responses?

15 And, I think we could do this pretty 

16 quickly.

17 If we go back to the first set of 

18 recommendations that we submitted, 

19 Recommendation 2, if you just go over to the 

20 next page, which had to do with the use of the 

21 IOM report and recommendations.

22 We're going to discuss that and 
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1 that's probably the kind of thing Dr. Welch 

2 might want to take on because you're dealing 

3 with that.

4 The third recommendation is about 

5 hiring former workers to administer the 

6 occupational health questionnaire.

7 That requires, I think, just a brief 

8 comment from us on their response. If someone 

9 wants to take that on, that's fine. Otherwise, 

10 I'd like to take care of that.

11 A fourth recommendation is at the 

12 bottom of the board, a process whereby the 

13 industrial hygienist may interview the 

14 claimants directly.

15 They basically -- my -- our 

16 interpretation of the response is that they 

17 agreed to do that. So, I don't really think it 

18 requires any comment from us unless someone 

19 disagrees.

20 Recommendation Number 5, DOL isn't 

21 interested in publishing its policy 

22 teleconference notes. We, obviously, disagree, 
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1 but does anyone feel that it's any need to 

2 comment on their response?

3 Dr. Sokas?

4 MEMBER SOKAS: I don't think we need 

5 to comment. I think we can handle it as a 

6 procedure for asking for updates for the Board 

7 in the future.

8 CHAIR MARKOWITZ: Recommendation 

9 Number 6, which has to do with making claim 

10 files available electronically to the 

11 claimants. DOL agrees with that.

12 Recommendation Number 8, this has to 

13 do with our notion of making the file available 

14 to the CMCs industrial hygienists and Dr. 

15 Cassano jumps right in there.

16 And then, Recommendation 7, which 

17 has to do with restructuring occupational 

18 medicine within DOL.

19 Dr. Sokas?

20 MEMBER SOKAS: Yes, I'll write with 

21 that.

22 CHAIR MARKOWITZ: So, you know, in 
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1 writing these up, we're going to probably need, 

2 Kevin, the transcripts or the minutes from 

3 this.

4 So, what's the timing of the 

5 minutes? I have to sign them, but what's the 

6 timing of production of the minutes and the 

7 transcript?

8 PARTICIPANT: Transcript, 30 days; 

9 minutes by 90 days.

10 CHAIR MARKOWITZ: Okay, okay.

11 So, yes, we'll have to speed up the 

12 minutes.

13 So, let's go to the second set of 

14 recommendations.

15 The first one is on asbestos related 

16 disease which I will prepare a response and we 

17 can get more input.

18 The next is work related asthma. 

19 And, Dr. Redlich is on, I give to her.

20 The next is COPD and, Dr. Welch, do 

21 you want to take that on?

22 MEMBER WELCH: Sure.
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1 CHAIR MARKOWITZ: We're going to 

2 discuss the revisions to the occupation health 

3 questionnaire recommendations, we haven't 

4 covered that yet.

5 The Recommendation Number 5 is 

6 enhancing the scientific and technical 

7 capacity. I'm not sure that there's much to 

8 respond to or for us to comment on, actually.

9 So, I've not -- I'll put my name 

10 down with a question mark about that.

11 Recommendation Number 6, 

12 interpretation of BeLPT. What did we decide? 

13 Did we decide that we had something to --

14 MEMBER WELCH: I'll do it.

15 CHAIR MARKOWITZ: Okay.

16 MEMBER REDLICH: So, I'll do it with 

17 Dr. Cassano.

18 MEMBER WELCH: Well, I have a -- you 

19 and I work good.

20 MEMBER REDLICH: Okay.

21 CHAIR MARKOWITZ: Dr. Redlich and 

22 Dr. Welch.
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1 And, then the quality assessment of 

2 contract medical consultants, Recommendation 

3 Number 7. I do think this deserves a comment.

4 MEMBER SOKAS: Yes. So, I'll do it 

5 with Dr. Cassano.

6 CHAIR MARKOWITZ: Okay.

7 MEMBER CASSANO: I have a question. 

8 Are we going to vote on the combining of the 

9 two individual -- for the two subcommittees or 

10 not?

11 CHAIR MARKOWITZ: At this point, I 

12 don't know if it requires a vote.

13 MEMBER CASSANO: Okay. So, do we 

14 consider ourselves combined now?

15 CHAIR MARKOWITZ: Sure.

16 (LAUGHTER)

17 MEMBER CASSANO: All right, then.

18 CHAIR MARKOWITZ: We're in the 

19 waning months of this Advisory Board. So, I 

20 don't -- and, again, our work agenda is laid 

21 out for us for the next couple of months.

22 Okay, so let's -- Dr. Welch can do 
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1 that. Dr. Welch, I don't if you want to do the 

2 SEM recommendation first or.

3 MEMBER WELCH: I can do that first.

4 CHAIR MARKOWITZ: Or the OHQ. Why 

5 don't you assign special interests?

6 MEMBER WELCH: Did you try that?

7 Okay, this is Laura Welch and I'm 

8 going to, as we discussed yesterday, we made 

9 recommendations to the Department about how to 

10 incorporate some of the recommendations in the 

11 IOM report by reviewing the 11 databases that 

12 IOM had in the table and incorporating the 

13 health effects of that into the SEM.

14 And, the response from the 

15 Department was that that was essentially too 

16 big a task and they needed more help.

17 So, I along with the SEM 

18 Subcommittee looked at the list and we would 

19 recommend that that the Department start by 

20 integrating the data from IARC, the 

21 International Agency for Research for Cancer 

22 and the EPA IRIS database.
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1 And so, what we have up here, I'm 

2 going to describe -- just describe how the IARC 

3 does their assessments and we have a slide 

4 about the -- yes, that's good -- about how EPA 

5 does their assessment.

6 Can people see that? Is that worth 

7 looking at? It's a little fuzzy. So, maybe 

8 it's not that helpful unless you can make it 

9 much -- quite a bit bigger.

10 The reason there's -- let me just 

11 explain -- the reasons that we're recommending 

12 those two databases is because it's the, in a 

13 way, the most bang for the buck, or the EPA 

14 IRIS one is.

15 The 11 data sources that IOM 

16 recommended, very comprehensive. They do 

17 overlap to some degree. It makes sense, it's 

18 different agencies looking at health 

19 assessments of toxic chemicals. So, it's going 

20 to make sense that ATSDR and EPA may have the 

21 document that addresses the same question.

22 It's very likely that they have the 
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1 same health effects and they're basing it on 

2 the same information.

3 But, our committee thought that 

4 since EPA is very thorough and ongoing and 

5 active in terms of the assessments of 

6 chemicals, that's a good place to start.

7 So, basically, EPA develops -- gets 

8 chemicals proposed to them by other agencies or 

9 by outside groups and they frame the scientific 

10 questions specific to the assessment, develop a 

11 draft. It's reviewed by health scientists 

12 within EPA and by interagency scientific 

13 consultation, so other federal agencies.

14 It's reviewed for public comment. 

15 It goes through an external peer review and 

16 those comments are incorporated into a final 

17 Agency -- an interagency science discussion.

18 I mean, it's about as much 

19 scientific input as you can get for government 

20 documents, both with experts that produce the 

21 document, both Agency, cross-agency and public 

22 comment review.
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1 It takes a long time. There's, for 

2 any one of these chemicals, there are 

3 organizations and individuals with strong 

4 opinions about what EPA should say. So, and 

5 it's all very public.

6 So, it's very -- I think, it's 

7 definitely a database that the Department of 

8 Labor can rely on. It's developed by a federal 

9 agency.

10 And, if one just pulls up and reads 

11 an IRIS assessment, it's very clear what health 

12 effects are caused by those chemicals, what the 

13 -- what the --

14 What they do and the most sensitive 

15 health effect. They calculate an acceptable 

16 exposure to the public. It's not focused on 

17 occupational standards, but the health effects 

18 are the same whether the exposure is in the 

19 environment or in the work environment.

20 And then, they focus it around the 

21 most sensitive end point. But, of the -- there 

22 are about 500 assessments within IRIS.
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1 And, of those, 110 have an 

2 assessment for oral -- or for inhalation 

3 exposure, which is probably the most relevant 

4 to the occupational exposures.

5 So, we're talking about 110 reviews 

6 that would identify health effects.

7 The IARC Group I carcinogens which 

8 are accepted as known human carcinogens are 

9 most likely already incorporated into SEM by 

10 SEM relying on Haz-Map.

11 But, since Haz-Map hasn't been 

12 updated, the new IARC monographs have probably 

13 not been added to the SEM except maybe in, you 

14 know, kind of high priority ones that someone 

15 noticed.

16 And, we would also recommend that 

17 the Department incorporate the Group II IARC 

18 carcinogens which are probably human 

19 carcinogens and that's really consistent with 

20 the statute, I think, and the intent of the law 

21 that compensation is for -- it's more likely 

22 than not that this compound contributed, caused 
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1 or aggravated the condition.

2 And, probably human carcinogens, 

3 using the IARC assessment, are way above that 

4 more likely than on standard.

5 So, again, it's not -- there's not a 

6 big number in the IARC documents. There's just 

7 one table on the IARC website that lists the 

8 chemical, the organ system where it causes 

9 cancer, the number of the monograph and we just 

10 need to incorporate that table.

11 The IARC peer review is similar to 

12 the EPA IRIS in terms of its scope, although 

13 they don't have a public comment. They don't 

14 incorporate public comments.

15 But, they do have, the Agency 

16 chooses the people to be on the panel, creates 

17 a working group for each chemical they assess. 

18 And, they invite additional specialists to 

19 report to the panel.

20 The staff puts together a document 

21 with all the information to give to the panel. 

22 And then, when the working group meets, which 
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1 is for seven or eight days to assess one 

2 particular chemical, they have representatives 

3 from national and international health agencies 

4 who are there and the IARC Secretariat.

5 Then, once the staff puts together 

6 this information and the working group develops 

7 a draft, they have specific subgroups that work 

8 on the areas within each IARC monograph. They 

9 reach a consensus.

10 And, also very importantly, there's 

11 a very strong conflict of interest review for 

12 people who are going to sit on this panel, sit 

13 on the IARC working groups because, you know, 

14 when IARC says something is a human carcinogen, 

15 it has impact for actions on the industrial 

16 level across the world.

17 So that they work really carefully 

18 to get the best scientists and people who don't 

19 have a conflict of interest.

20 It's a very impressive organization. 

21 Anybody who's worked with it would -- you can 

22 absolutely, totally rely on what they come out 
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1 with.

2 It's not -- we, as the Institute of 

3 Medicine said and as this Board has said, we're 

4 not -- we wouldn't expect the Department of 

5 Labor to conduct independent peer review of the 

6 relationship literature to come up with 

7 relationship between a toxic exposure and 

8 health effect.

9 But, what we're recommending is that 

10 the Department set up an internal process, 

11 either with the current staff they have or 

12 bringing in additional consultants.

13 And the Board would be happy to 

14 review what that process is. We have some 

15 ideas but we think it makes more sense for the 

16 Department to come up with a process and then 

17 we can -- the Board can help making sure that 

18 that's reasonable.

19 To look at the list of chemicals in 

20 IRIS and match it to the list of chemicals in 

21 the SEM. And, if there's a chemical in the 

22 SEM, then they should add that health effect 
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1 from that chemical that's identified by the EPA 

2 assessment or by IARC to the SEM.

3 And, you know, as I said, it's about 

4 110 chemicals in IRIS, so maybe 50, 100 at most 

5 in IARC that are known and probably human 

6 carcinogens. I think the number may be 110, 

7 something like that.

8 So, that's the overall 

9 recommendation. And, it's not that that would 

10 be the end of it, but it's a -- with those two 

11 data sources, with -- I think that the 

12 Department would be garnering maybe, you know, 

13 75 percent of the information that's in the ten 

14 data sources.

15 The National Toxicology Program is 

16 also something we could add. But, I think that 

17 it overlaps pretty significantly with IARC. 

18 Not completely, not completely, but it's -- but 

19 what we hear from the Department is that 11 

20 data sources is too much.

21 So, we could start with two, we 

22 could start with three. You know, the National 
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1 Toxicology Program is very similar in terms of 

2 its -- the robust transparent process experts, 

3 peer review, public comment.

4 So, you know, I wouldn't object to 

5 that, I just want to -- I want to recommend 

6 something that it's impossible to say it's too 

7 much work. That's my goal.

8 You can't -- the Department can't 

9 come back and say this is too much work. This 

10 is not too much work. And, I guess it's not 

11 impossible, right?

12 But, it's like, you know, if we look 

13 at what the IOM recommended and then we, you 

14 know, pull that one recommendation from that 

15 and elevate it even more feasible, then it's 

16 understandable these documents are -- they are 

17 technical, you need technical people to read 

18 them. But, there's not a lot of interpretation 

19 that needs to be provided.

20 It's going through the documents, 

21 finding the health effects and the chemicals 

22 and matching it into SEM. It's a fairly simple 
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1 process.

2 And then, once those are completed, 

3 the Board could then say, okay, well now, go on 

4 to others.

5 So, open for comment or discussion 

6 if people feel strongly we should add NTP, I 

7 don't mind at all. George does? Okay.

8 CHAIR MARKOWITZ: Dr. Friedman9 Jimenez?

10 MEMBER FRIEDMAN-JIMENEZ: Yes, I do 

11 feel strongly that we should add NTP. I think 

12 that they do overlap with IARC. In some ways, 

13 they're driven by the IARC evaluations, but it 

14 is fairly independent. And, I think it's an 

15 excellent group.

16 I served on the Board of Scientific 

17 Counselors Carcinogen Review Committee and 

18 Steven is serving now. And, I don't know if 

19 you agree with me, but I think that that does 

20 add, and I don't think it's a lot of additional 

21 work.

22 And, there is overlap but NTP has, I
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1 believe, a lot more substances that they've 

2 evaluated. And, they have a different 

3 classification system of known human 

4 carcinogen, reasonably anticipated to be a 

5 human carcinogen. And, it's somewhat different 

6 than IARC's.

7 So, I believe there is value added 

8 by including NTP as well.

9 CHAIR MARKOWITZ: So, Dr. Welch, I 

10 think you made -- there may be a slide at the 

11 end of the NTP review process.

12 MEMBER WELCH: There is.

13 CHAIR MARKOWITZ: But, anyway, we 

14 don't have to go through it, but maybe we 

15 should just put it up so we can look at it 

16 while we --

17 MEMBER WELCH: Yes, Kevin, if you 

18 can scroll down, I think it may be the last one 

19 in this slide. That -- yes, there it is.

20 So, that's the National Toxicology 

21 Program process.

22 CHAIR MARKOWITZ: Dr. Sokas?
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1 MEMBER SOKAS: And, just to support 

2 what everybody's been saying, NTP includes not 

3 just carcinogens, but other end points which is 

4 important.

5 CHAIR MARKOWITZ: Dr. Boden?

6 MEMBER BODEN: So, a question. Can 

7 you give an approximately amount of effort that 

8 it would take for the DOL to do this? Even 

9 though I understand we won't hold you to it, 

10 but it might be helpful for DOL to know if 

11 you're talking about a day, a month or a year 

12 of somebody's time.

13 MEMBER WELCH: This is Laura Welch.

14 Well, I tend to underestimate the 

15 amount of time things take for myself. But, 

16 you know, I would say, depending on -- it 

17 depends on how much the Department wants to 

18 assure itself that IARC is authoritative.

19 I think we can assure them IARC is 

20 authoritative.

21 So, to incorporate the IARC 

22 carcinogens, to decide which ones to 
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1 incorporate? Half an hour. I'm not kidding. 

2 There's a list.

3 (LAUGHTER)

4 MEMBER WELCH: There's a list, it's 

5 like here's the cancers, here's the organ 

6 systems. That's it. Then you have to do the 

7 work to get it into SEM.

8 IARC and NTP are a little more 

9 complicated because there's not a table. They 

10 haven't made a table that -- so, you have to 

11 read the documents and determine what the 

12 health effects are.

13 And, I think it would probably be 

14 reasonable for the Department to have two 

15 people do that and assure they, you know, be 

16 sure that people come up with the same end 

17 points as you read through the documents.

18 So, that's, I don't know, you know, 

19 a month full-time. I mean, I -- to do all 

20 those things, a month full-time. That would be 

21 my estimate because it did -- you don't have to 

22 read any scientific papers, just read through 
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1 the documents.

2 It could be less than that, but --

3 and then, to -- it's not a lot of time. That's 

4 what I would say.

5 CHAIR MARKOWITZ: Dr. Cassano?

6 MEMBER CASSANO: Yes, the one thing, 

7 I remember one of the concerns of the 

8 Department was the fact that they can -- some 

9 of them conflicted.

10 And, I think what, you know, 

11 obviously, different organizations put out 

12 their consensus documents at different times.

13 So, you know, if you tend -- if you 

14 see a conflict, then you should look at the one 

15 that is done most recently to determine what 

16 the more current science is, obviously, with 

17 backup with the others, if you're talking about 

18 the same chemical.

19 I mean, this is what I did at VA for 

20 years is turn scientific evidence into policy. 

21 And, if you're dealing with one chemical, it 

22 may take you a day or two if you have to 
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1 supplement -- if you want to supplement your 

2 knowledge.

3 But, of course, I went further in 

4 that. We did -- I would look at literature 

5 past the latest consensus document.

6 But, it doesn't really take that 

7 long because you've got it all laid out for you 

8 either in a table or just by reading the 

9 conclusions of the consensus document or the 

10 beginning of it. It's not hard.

11 CHAIR MARKOWITZ: Dr. Friedman12 Jimenez?

13 MEMBER FRIEDMAN-JIMENEZ: There's 

14 not a lot of conflict between IARC and NTP. 

15 They tend to agree in most cases.

16 Sometimes, one is more recent than 

17 the other, as you said.

18 I want to correct what I said, IARC 

19 has more -- has 114 Group I known human 

20 carcinogens, NTP has 62. So, there's a 

21 difference there.

22 And, there's a 2A and 2B under IARC 
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1 which is probably carcinogenic and possibly 

2 carcinogenic. And, that's a big distinction 

3 from our perspective.

4 So, IARC gives more information, 

5 whereas, NTP says reasonably anticipated to be 

6 human carcinogen.

7 But, I think there's value in both 

8 of them. And, as Rosie said, this opens the 

9 door to using NTP evaluations for non-cancer 

10 outcomes which could be very valuable because 

11 they do extraordinarily detailed reviews of 

12 neurotoxins, respiratory toxins, immunotoxins 

13 and a variety of other non-cancer causing 

14 chemicals.

15 CHAIR MARKOWITZ: So, just to be 

16 clear, when we refer to NTP then we're 

17 discussing two types of documents. One is 

18 their report on carcinogens which is parallel 

19 but doesn't completely overlap the IARC review.

20 And then, there's something called 

21 from Table 3.1 of the IOM report, the health 

22 assessment and translation evaluations which 
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1 are non-cancer outcomes of which there are deep 

2 evaluations, but a limited number, I think.

3 It's not -- we're not talking about 

4 dozens and hundreds the way we are with the 

5 carcinogens with these health assessments.

6 So, just to put it into perspective.

7 Dr. Dement?

8 MEMBER DEMENT: Well, the IRIS 

9 documents are going to get more to the non10 cancer influence. I mean, they look at cancer 

11 as well, but they look at non-cancer end 

12 points.

13 I think this probably will extend 

14 the NTP list considerably as well.

15 CHAIR MARKOWITZ: Dr. Silver?

16 MEMBER SILVER: So, there's this 

17 clause in DOL's response we found that some of 

18 the information is not relevant to occupational 

19 exposure. We know that.

20 In an environmental database, there 

21 might be some chemical where the most sensitive 

22 end point was observed in children through oral 
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1 ingestion of water, that's fine. But, it 

2 doesn't vitiate all the other valuable 

3 information in an environmental agency's 

4 database. So, get on with it.

5 CHAIR MARKOWITZ: So, you know, the 

6 comment was made that perhaps we'd heard from 

7 DOL that it was too much work to look at all 

8 the sources that the IOM recommended. That's 

9 not my interpretation of Mr. Steinberg's letter 

10 which, unfortunately, I don't have here.

11 But, I interpret that their response 

12 is assistance from us in triage and, you know, 

13 where we should start and how to proceed. And, 

14 I think we're responding to that.

15 But, we shouldn't, in any sense, 

16 convey that we believe that start -- by 

17 starting by, frankly, the easiest and most 

18 directed sources that it ends there. Because

19 the other sources that list them in Table 3-1 

20 in the IOM report are very important.

21 And, some of them are difficult to 

22 work with. You know, the pocket, the NIOSH 
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1 Pocket Guide. I don't know when the last time 

2 it was put out, but it's not necessarily the 

3 easiest thing to integrate.

4 So, DOL should get there and it 

5 needs to build the capacity to get to the rest 

6 of the sources.

7 But, moving ahead with those 

8 authoritative sources initially makes no sense.

9 George, did you -- is your card up 

10 because you wanted to say something?

11 Dr. Welch?

12 MEMBER WELCH: So, I was looking to 

13 see if I had the language, too. And, I think 

14 that your interpretation is more appropriate 

15 really.

16 And, I think it's a better way to 

17 say it, so it's sort of like -- and that's kind 

18 of in some ways what we're saying is, if you 

19 start with these two, one, they're relatively 

20 easy to use and because the information is 

21 formatted and it will -- and start with these 

22 three, with the three of them, it'll cover the 
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1 majority of what's going to be in the 

2 remainder, as you said.

3 Because some of them are updated, 

4 out of date.

5 And, I wanted to also follow up on 

6 what Dr. Silver said about not being relevant 

7 to occupational exposures.

8 The data within IRIS, and the reason 

9 the EPA develops it is to look at health 

10 effects to the general population to the 

11 environment. They're not setting regulations 

12 for occupational exposures.

13 But, the same chemicals, if they're 

14 used in occupational environment, can result in 

15 the same health effects.

16 So, it's a very broad picture, an

17 assessment done for environmental exposure is 

18 very relevant to occupational exposures.

19 Now, obviously, if the end point 

20 isn't one that we would see in this population, 

21 then you don't include that end point. And, a 

22 lot of the end points for -- in the IRIS 
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1 database are reproductive, so that's something 

2 that could be included, probably generally 

3 hasn't been included in the SEM because it's an 

4 effect on the unborn kids. That's a -- that 

5 would take another discussion.

6 But, the big picture that the 

7 assessments are done for the purpose of 

8 assessing environmental exposure that are 

9 really highly applicable to occupational 

10 environment.

11 CHAIR MARKOWITZ: Dr. Cassano?

12 MEMBER CASSANO: Yes, you know, 

13 usually it doesn't go the other way because, 

14 you know, see a lot in literature, well, those 

15 effects only occur in occupational 

16 environments. They don't occur, you know, in 

17 the general population in the environmental 

18 exposures because the exposure is so low.

19 But, when you go the other way from 

20 an environmental exposure to a higher level of 

21 exposure, if the end result occurs at a low 

22 level environmental exposure, it almost 
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1 definitely will occur at a higher occupational 

2 level exposure.

3 So, to continue what Laura said, 

4 they become very applicable to occupational 

5 health. And, the route of exposure is not 

6 necessarily always that important, in some 

7 instances, it is.

8 CHAIR MARKOWITZ: So, I'm very 

9 concerned about actually the DOL's capacity to 

10 do this work.

11 And, I think Mr. Steinberg's request 

12 letter to us about helping -- he's seeking help 

13 in triage and figuring out where to --

14 basically where to start, to me, reflects the 

15 insufficient expertise that the program 

16 currently has access to.

17 The Board, I think, just to reflect 

18 what Dr. Welch said, at least this Board is 

19 very happy to help with this process to 

20 monitor. We'd like to, I would say, monitor 

21 this.

22 This is a very important issue here. 
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1 But, to me, this is just added information, 

2 added evidence, really, that there needs to be 

3 an enhanced capacity of the program to have 

4 access to scientific and medical industrial 

5 hygiene, toxicological expertise in order to do 

6 this.

7 I don't know if that's needed in 

8 order to do the first set, the IRIS, NTP and 

9 IARC. But, it would be needed to move beyond 

10 that.

11 So, I would sort of reiterate that I 

12 know that's a different recommendation we made, 

13 but, to me, this is evidence that underlies our 

14 recommendation on that.

15 Dr. Sokas?

16 MEMBER SOKAS: And, just to be 

17 clear, I think the Board would also probably be 

18 happy to review, if the Department of Labor has 

19 a contract with someone to accomplish this, if 

20 the internal resources are already maxed out 

21 and not able to do this, that the Board would 

22 be happy to review the qualifications of the 
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1 contractor.

2 And, I would suggest that there are 

3 other agencies within DOL like OSHA that have 

4 these large contracts available with groups 

5 that may have more expertise than the ones 

6 currently under OWCP.

7 So, for example, you know, I 

8 wouldn't want to necessarily see Paragon do 

9 this if they haven't been capable of doing it

10 in the past with the SEM. So, it may be that 

11 there would be other organizations -- other 

12 contracts available across the Department that 

13 would be accessible.

14 CHAIR MARKOWITZ: Actually, Ms. 

15 Leiton, I have a quick question for you, just a 

16 factual question. Paragon, I know they work 

17 with you in terms of the SEM.

18 Do they also -- do they have 

19 epidemiologists? Do they have physicians? I 

20 imagine they have industrial hygienists, people 

21 whose area really is on the exposure side.

22 But, do they also have health 
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1 experts such as epidemiologists? Because 

2 that's really -- epidemiology is really key to 

3 interpreting these various databases and using 

4 them.

5 MS. LEITON: They have -- they 

6 definitely have IHs. They don't have a medical 

7 team there. But, everything that goes in in 

8 terms of health effects is reviewed by our team 

9 which includes doctors and toxicologists, not 

10 an epidemiologist, but a toxicologist.

11 We do use IARC already, but only the 

12 first group. We haven't gone on to the second 

13 group yet.

14 And, the clarification about not 

15 having the resources or the time to look at 

16 this stuff, it wasn't that. It was just that 

17 there's a lot of tables. Some of them were 

18 inherently inconsistent with each other when 

19 they did the review. Some of them were, as you 

20 indicated, not really related to occupational 

21 exposure.

22 And so, limiting it was helpful. 
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1 And, we do have the resources to look at these 

2 things. It's just that we didn't want to just 

3 kind of -- when you're looking at all those 

4 different tables and they did look at all of 

5 those different tables, they said, well, we 

6 didn't -- they didn't think that some of them 

7 were related to the work that we do, weren't 

8 sure that they were all actually consistent 

9 with each other.

10 So, the narrowing down you're going 

11 to do is going to be helpful.

12 We do look at them -- everything 

13 that we add in is looked at by a team which 

14 includes, as I said, doctors and toxicologists.

15 CHAIR MARKOWITZ: As you develop a 

16 plan to integrate these sources, make sure that 

17 they're in the SEM, can you provide us with a 

18 copy of that plan so we know sort of what's 

19 going to happen when and how things are 

20 happening?

21 MS. LEITON: Absolutely.

22 CHAIR MARKOWITZ: Thank you.
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1 Other comments, questions?

2 Mr. Whitley?

3 MEMBER WHITLEY: While we're dealing 

4 with the SEM, I know we talked a little bit 

5 about it here, are we going to deal with the 

6 job categories and the chemicals that those job 

7 categories use?

8 Because that's -- they use that in 

9 the -- when they're doing claims a lot. And, 

10 if a job category is not listed as using 

11 certain chemicals, then it's kind of like they 

12 don't -- they deny it.

13 Are we going to tackle that or are 

14 we going to make a recommendation?

15 CHAIR MARKOWITZ: Well, I have my 

16 own view of that. But, if anybody else wants 

17 to respond first?

18 I think that we need to re-look --

19 I'm not sure to the extent to which the Board 

20 has really critically looked at SEM beyond our 

21 initial look at its structure and its 

22 limitations and the IOM report on that.
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1 But, 18, 19 months have passed for 

2 this Board and I think we should at the next 

3 Board Meeting -- I think we should recommend 

4 they re-look at the issue of SEM, how it's 

5 updated, what's happened in the past 18, 20 

6 months as we learned about it.

7 What are they doing in the absence 

8 of contracting Dr. Brown? What's happened with 

9 Haz-Map with the connections between the 

10 exposures and the diseases and are those 

11 updated beyond what we've discussed so far?

12 So, I think I agree with you. I 

13 think it should stay on the agenda as an issue 

14 that needs to be examined.

15 Ms. Vlieger?

16 MEMBER VLIEGER: Again, while we're 

17 on the topic of SEM, there must be some 

18 rationale documents associated with each 

19 addition or subtraction from the SEM.

20 Is that database available to us or 

21 can we get a report from the contractor on 

22 those additions and subtractions to the SEM?
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1 CHAIR MARKOWITZ: I guess that's a 

2 question for Ms. Leiton.

3 MS. LEITON: So, you're asking us to 

4 provide you with a report of everything that's 

5 been added or subtracted in the SEM?

6 MEMBER VLIEGER: No, ma'am, there 

7 must be a rationale for -- I mean, they don't 

8 just add something and walk away. There must 

9 be some work done behind it. There must be 

10 some rationale.

11 Are there rationale documents for 

12 when they add and subtract things to the SEM?

13 MS. LEITON: They have a process, 

14 but maybe we can provide you with the process 

15 they go by when they do that. That would be 

16 easier than trying to give you a description 

17 and rationale behind every move they make in 

18 SEM.

19 So, I can probably provide a basis 

20 of the process for how they do that.

21 MEMBER VLIEGER: Okay. Well, but 

22 the actual question is, is I believe 
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1 rationally, there should be documents of how 

2 they do things.

3 So, when something's added, why it's 

4 added. I believe there should be a library of 

5 their work of their, you know, who decided what 

6 and on what basis.

7 So, I don't want names, I would just 

8 like to see the documents where they're adding 

9 and subtracting things, because, from my 

10 perspective, the rationale is not rational.

11 MS. LEITON: Okay. Well, I see what 

12 I can do contractually.

13 CHAIR MARKOWITZ: Yes, Mr. Whitley?

14 MEMBER WHITLEY: Hey, Rachel, the 

15 question I think I've got is, there was 

16 chemicals put in the SEM database and they 

17 removed chemicals. Why would you remove a 

18 chemical if you said, now, we use that chemical 

19 in 1975, why would you take it out of the 

20 database today? What rationale would there be 

21 to remove a chemical from the database?

22 MS. LEITON: I'm going to have to 
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1 get back to you. And, I can look at what they 

2 -- what their processes are. They have 

3 processes. I know they have rationale behind 

4 them. I'm going to have to look at what 

5 documentation they have and what we can provide 

6 within our contract.

7 CHAIR MARKOWITZ: Other comments?

8 Dr. Friedman-Jimenez?

9 MEMBER FRIEDMAN-JIMENEZ: I thought 

10 the discussion of IARC and NTP is very 

11 important and useful. And, I'd like to expand 

12 that and ask a question.

13 I don't really have an understanding 

14 of what the system is for ongoing updating of 

15 the SEM and exposure information and exposure 

16 health association information to reflect 

17 advances in science.

18 For example, COPD 20 years ago 

19 wasn't really thought of as an occupational 

20 disease and there's been a lot of science in 

21 the last 15 years that has changed our view of 

22 it.
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1 And, I saw in the manual a good 

2 number of sections that read more like 20th 

3 century science.

4 So, it seems to me there needs to be 

5 an ongoing process. And, I'm wondering what 

6 that is and if that's -- if we need to discuss 

7 that?

8 MS. LEITON: I think that that might 

9 have been a question for me.

10 What I'd like, if we can get back to 

11 you on these questions, this round of questions 

12 just so that I can make sure I give you a 

13 proper, thorough answer, that would be really 

14 helpful.

15 I mean, to our entire process for 

16 how we -- I mean, I can tell you that we have, 

17 you know, we have a process whereby our SEM 

18 team does research. We get documents from the 

19 public in our SEM mailbox.

20 When they, you know, they are 

21 constantly updating it based on the research 

22 they can do. Like, for example, they went to 
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1 DOE Record Center. They looked up a lot of 

2 records there to look for additional toxic 

3 substances.

4 When we get information from the 

5 public or we get documents from our claim files 

6 about toxic substance exposures that are links 

7 that we might be able to put in the SEM, that's 

8 when our team looks at the health effects and 

9 they add a document -- a toxic substance link 

10 into there with a particular health effect.

11 The SEM team itself, in terms of 

12 adding toxic substances, they will do the 

13 research. They'll say, oh, we found, you know, 

14 10,000 toxic substances at Santa Susana, for 

15 example. And, we have added those based on 

16 maybe members of the public or what we found in 

17 other records or what they've done in research.

18 And, they'll go and they'll say, we 

19 think these should be added. Here's why they 

20 give it to our government staff and policy.

21 We review it and consult with our 

22 toxicologist and our IH and then they'll add 
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1 them.

2 It's a pretty simple process for 

3 adding things.

4 Deleting things is a little bit 

5 different and it's rare that they do that, but 

6 if they do that, it's because they had found 

7 some conflicting evidence to say, this really 

8 wasn't there or, you know, there's various 

9 reasons and they always have a reason for it 

10 and I'm sure it's documented.

11 But, I -- that process is 

12 interactive with us. It's, as I said, very --

13 it's a lot easier to add things than to 

14 subtract things.

15 And, the health effects, since we 

16 don't contract with Dr. Brown anymore, is a 

17 little bit more challenging. He does -- there 

18 are things still added through in the LEM to 

19 that database which we will take.

20 But then, we do research with IARC 

21 and we do research that comes in through 

22 various sources.
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1 So, it's -- that's kind of the high 

2 level of how we do it.

3 CHAIR MARKOWITZ: Thank you, Ms. 

4 Leiton.

5 Dr. Silver?

6 MEMBER SILVER: Because of the 

7 ambiguity about the Board's future, you're 

8 probably already on this, but I wonder if our 

9 Chair is keeping a list of recommended issues 

10 for the next version of this Board to tackle.

11 And, I think, Garry, with these 

12 concerns about job categories and that aspect 

13 of the SEM, you know, it would be a big chunk 

14 of important issues for the next Board to bite 

15 off.

16 CHAIR MARKOWITZ: I would say that 

17 Mr. Whitley's concern is on the list.

18 We need to fill out that list over 

19 the next couple of months and that will be one 

20 of the agenda items on the next Board Meeting -

21 - the telephone Board Meeting is what issues 

22 that we think are a priority that we are still 
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1 working on, we haven't gotten to, whatever, 

2 that the next Board should take up.

3 Ms. Vlieger?

4 MEMBER VLIEGER: This is a question 

5 for Carrie. Carrie, are you keeping track of 

6 what we're putting forward here as ideas or is 

7 it just --

8 (OFF MICROPHONE COMMENTS)

9 MEMBER VLIEGER: -- in a minute's 

10 great, thank you.

11 CHAIR MARKOWITZ: And, Ms. Rhoads, 

12 are you keeping track of the things that the 

13 Department is saying that they're going to 

14 provide for us, a record of things?

15 MS. RHOADS: Yes.

16 CHAIR MARKOWITZ: Okay, thank you.

17 Other comments or questions on this 

18 topic?

19 (NO RESPONSE)

20 CHAIR MARKOWITZ: Okay, if not, 

21 let's move on.

22 MEMBER WELCH: Can I make one 
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1 clarification? So, I'll -- should I write this 

2 up as a recommendation that then we would 

3 consider more formally at the -- at our phone 

4 Board Meeting or do you think it doesn't need 

5 to be a recommendation?

6 CHAIR MARKOWITZ: What you should 

7 write up is a comment on their response which 

8 we will review in January in the Board Meeting 

9 and vote on.

10 Okay, let's move on to the 

11 occupational health questionnaire. This is the 

12 final recommendation that we haven't looked at 

13 yet. So, Kevin, if you can bring up the second 

14 set of recommendations?

15 And, I think Dr. Welch is going to 

16 lead this discussion. But I want -- let me 

17 just summarize this recommendation that 

18 everybody's oriented.

19 It has to do with enhancing the 

20 occupational health questionnaire. And, by way 

21 of background, the SEM really doesn't have 

22 information of frequency, duration, intensity 
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1 of exposure within the complex.

2 And, that's a problem for people who 

3 are trying to make a judgment about work 

4 related diseases and relevant exposures.

5 So, our recommendation was that --

6 and I'm just going to summarize, that the 

7 revised occupational questionnaire expand the 

8 current list of hazards and exposures and 

9 materials that are listed.

10 That, for those exposures, the 

11 workers should be asked how he or she was 

12 exposed, including getting text on their own 

13 description.

14 The frequency of exposure that the 

15 worker had. And then, if the worker used the 

16 material directly or was a bystander in the 

17 area where that chemical was used?

18 We further recommend that the 

19 occupational health questionnaire -- there 

20 could be the list of specific exposures, but 

21 also the opportunity for the worker to add 

22 additional exposures that they know about that 
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1 aren't on the routine questionnaire.

2 Then, we provide a list of some 

3 hazards. It's a limited list of -- but an 

4 additional list.

5 And then, we also recommend that the 

6 OHQ add the list of tasks that's currently used 

7 in the construction worker, former worker, 

8 project.

9 And, finally, or almost finally, the 

10 -- our recommendation was that a question be 

11 asked about -- specifically about vapors, gas, 

12 dust and fumes then that echoes our 

13 conversation yesterday about COPD, getting 

14 details about those exposures including 

15 frequency and the like.

16 And then, finally, then a new 

17 version of the occupational health 

18 questionnaire be tested and be piloted before 

19 put into use.

20 So, that's the summary of our 

21 recommendation.

22 Now, if someone wants to read the 
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1 response -- DOL's response. We had some 

2 excellent readers yesterday. You couldn't 

3 possibly be exhausted.

4 MEMBER WELCH: Can I ask a question 

5 --

6 CHAIR MARKOWITZ: Sure.

7 MEMBER WELCH: -- that shows my lack 

8 of preparation that the comments say that the 

9 draft OHQ is attached, but I don't have it.

10 MS. RHOADS: It was sent in an 

11 email.

12 MEMBER WELCH: Okay. And so, you 

13 know, I'm -- I can't -- so, I got up this 

14 morning trying to be ready to talk about it, I 

15 realize I don't have the draft, so I can't 

16 really respond. But, other people can probably 

17 help in terms of responding.

18 CHAIR MARKOWITZ: Let's read the 

19 response. I don't think the intent here was 

20 for us to go through line by line of their 

21 draft and see the extent to which it comports 

22 with our recommendations.
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1 That wouldn't be the kind of work 

2 we'd do. Wouldn't have time to do that as a 

3 Board. But, nonetheless, it would be useful to 

4 be able to access it.

5 But, let's start while I guess 

6 someone -- Carrie's sending it around -- if we 

7 can just start with reading the response.

8 MEMBER WELCH: Yes, I can start with 

9 that.

10 So, upon review of the Board's 

11 recommendations in Section A, OWCP agrees that 

12 claimants who provide detailed accounts of work 

13 processes, labor activities and other 

14 operational descriptions of an employee's work 

15 activity are the most reliable and substantive 

16 mechanism for assessing employee occupational 

17 exposures to toxic substances.

18 In fact, OWCP has revised the OHQ 

19 and the Board's recommendation that the worker 

20 be asked to describe how he/she was exposed to 

21 each material using free text is included.

22 The draft OHQ also provides more 
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1 room for a description of job tasks and 

2 requests that the claimant advise as to whether 

3 he/she was in a particular union or was part of 

4 the former worker program.

5 In the draft, OWCP reduces the list 

6 of toxic substances. And, instead, lists broad 

7 categories under which the claimant may provide 

8 specific toxic substances, for example, high 

9 explosives or metals.

10 Over the last 10 years of conducting 

11 OHQ's, OWCP has found that the ability of a 

12 claimant, particularly a survivor, to 

13 affirmatively self-select toxic substance 

14 exposures from a list, often times does not 

15 produce reliable or useful information.

16 With regard to the list used by 

17 BTMed, and it references a website, this list 

18 refers solely to construction and trade 

19 positions and, therefore, would not be 

20 applicable to a general OHQ that applies to 

21 employees in all occupations.

22 With regard to the Board's 
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1 recommendation in Section B that proposed to 

2 add a section on reported exposures to vapors, 

3 gases, dust and fumes, our concerns are 

4 contained in our response to Recommendation 

5 Number 3 regarding the use of this language.

6 If the Board develops a list of 

7 toxic substances that represents vapors, gases, 

8 dust and fumes, OWCP will consider how that 

9 list may be addressed in the OHQ.

10 OWCP agrees with the Board's 

11 recommendation in Section C that the new 

12 version of the OHQ be tested multiple times 

13 prior to becoming final and will have the 

14 resource centers conduct these tests.

15 Attached is a copy of the draft OHQ 

16 OWCP recommends, welcomes specific 

17 recommendations concerning modifications to the 

18 draft that the Board may have.

19 CHAIR MARKOWITZ: Okay, comments?

20 Dr. Dement?

21 MEMBER DEMENT: I think we, in 

22 principle, agree with the intent of the change 
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1 in the occupational history to allow more 

2 detailed description of tasks performed with 

3 the material.

4 And, I think the question that we 

5 were faced with is how to -- how best to get 

6 that information from workers who may or may 

7 not have a good level of recall.

8 I think what we found in the BTMed 

9 program, rather than saying, you worked with 

10 this material, we also say -- ask, you know, we 

11 ask the question, you worked with this material 

12 and then, based on that experience over the 

13 last 20 years, give them a list of common tasks 

14 that construction trade workers would have done 

15 with this material and ask them did they do and 

16 how frequently they did it.

17 And, I think what we found is that 

18 providing that list, and we acknowledge that 

19 the list is not complete for production workers 

20 and that's something that I think is subject of 

21 continuing development, but these general 

22 categories of tasks.
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1 But, we've found that by providing 

2 that list, it actually helps to stimulate 

3 recall of the worker to provide that 

4 information.

5 So, that's the intent of it all. 

6 And, I'd say from the outset, you know, we 

7 collect these types of data in the BTMed 

8 program. We know that we're missing lots of 

9 information with regard to exposures.

10 But, our intent is to at least to be 

11 able to identify individuals who had 

12 substantial exposure versus those who had 

13 lesser exposures.

14 And, I guess the final comment is, 

15 based on taking that information and relating 

16 it to specific outcomes -- health outcomes --

17 we found it to be a useful process in that type 

18 of separation of exposures and identification 

19 of higher and lower risk groups.

20 CHAIR MARKOWITZ: Ms. Vlieger?

21 MEMBER VLIEGER: I'd like to agree 

22 wholeheartedly with Dr. Dement. I have seen 
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1 the difference between the questionnaires that 

2 come from the worker medical programs versus 

3 the old OHQ and now this proposed OHQ.

4 I was a planner at the Hanford site. 

5 Our right to work station looked like two 

6 Gutenberg Bibles set edge to edge with pages in 

7 them.

8 At the time of my accident, when I 

9 said please tell me what happened to me, what 

10 was I exposed to? And, I was told, well, go 

11 look it up yourself at the right to know 

12 station.

13 For those of you who don't know what 

14 a right to know station is, that's an MSDS bank 

15 of records for everything you could possibly be 

16 exposed to.

17 Now, as a planner, I was supposed to 

18 know what my workers would be exposed to and I

19 took great diligence to figure that out.

20 But, after 20 years and retirement, 

21 no one is going to remember that list. So, 

22 without providing some guideline as Dr. Dement 
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1 has said, for the chemicals they were exposed 

2 to by labor category, this new form looks, to 

3 me, much more worker unfavorable than the 

4 previous one.

5 I know it's an attempt to fulfill 

6 our request, but without linking it to those 

7 groups of chemicals and most of the workers 

8 don't know how to use the SEM. Some of our 

9 workers don't have computers nor do they want 

10 to learn how to use them.

11 So, I think at the process, using 

12 the new form, if there's some way to attach a 

13 group of chemicals for their known labor 

14 category and then anything they'd like to add.

15 But, otherwise, I see this as an 

16 epic fail again.

17 CHAIR MARKOWITZ: Dr. Friedman18 Jimenez?

19 MEMBER FRIEDMAN-JIMENEZ: I want to 

20 strongly agree with Dr. Dement and his 

21 evidence-based comments about recall. Recall 

22 is certainly a major factor in identifying past 
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1 exposures.

2 But, in light of what Ms. Vlieger is 

3 saying, I think there's another problem which 

4 may be as important which is lack of knowledge 

5 of what the exposures are.

6 So, if someone doesn't know exactly 

7 what they were exposed to, they may not 

8 identify it on a specific list.

9 And, what I would not like to see, I 

10 agree with providing a list, but I'm really 

11 worried that if the list is provided and 

12 someone doesn't answer that they were exposed 

13 to a certain chemical but they say they were 

14 exposed to vapors, gas, dust or fumes, that 

15 they will be considered unexposed because they 

16 didn't answer yes to the specific toxin.

17 So, I would like to propose that it 

18 be either or. Either they answer yes to the 

19 vapors, gas, dust or fumes or they answer yes 

20 to a specific toxin. And, the specific toxins 

21 would then act to jog people's memory and 

22 identify specific exposures.
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1 But, I think that -- I've seen so 

2 many patients that just did not know what they 

3 were exposed to. And then, when we threw 

4 research and identifying products, identify it, 

5 we see that there's a clear relationship.

6 So, I just wanted to point out that 

7 possible issue.

8 CHAIR MARKOWITZ: Mr. Domina?

9 MEMBER DOMINA: Just a comment on 

10 some of the chemicals, like some of the ones 

11 that were used at Hanford are so exotic, there 

12 is no health studies. And also, I believe 

13 there's still some of them that aren't 

14 classified.

15 And so, that has to be dealt with 

16 also. And, that leaves people out on occasion.

17 And, I guess that's it.

18 CHAIR MARKOWITZ: Dr. Welch?

19 MEMBER WELCH: Laura Welch.

20 One of the things that we proposed 

21 when we proposed a list of hazards, we proposed 

22 both asking people about hazards and tasked. 
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1 And, we proposed if people describe that they 

2 were exposed to a particular chemical that then 

3 they asked to describe how they were exposed. 

4 What was the task?

5 Usually, I mean, when I am looking 

6 at, you know, our BTMed former worker 

7 questionnaires to determine if somebody had a 

8 particular exposure, if their exposure might --

9 their work might be related to the disease they 

10 have.

11 I find the task is the most useful 

12 to me because, not only is it I generally know 

13 what people were in the construction trades, if 

14 they did a particular task based on the year, I 

15 have some idea about what they were exposed to.

16 And, the task gives me some idea of 

17 the intensity of exposure, too.

18 So, the task information in, you 

19 know, sort of an expert assessment, not 

20 necessarily what the claims examiners would do, 

21 but what the industrial hygienist would do. 

22 The task is really, really important.
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1 And then, the task and the list of 

2 substances have to be integrated. Having just 

3 a list is not very helpful. I mean, Department 

4 of Labor and in their response, the Department 

5 in their response says that it's not -- just 

6 having people self-select toxic substances from 

7 a list often is not reliable or useful.

8 I think it's useful if it's then 

9 linked to the actual activities. So, if you 

10 think that people are just checking things off 

11 on a list, asking for more information when 

12 they check a particular agent, then how they 

13 used that agent would then allow someone 

14 reading it to say, that makes a lot of sense, 

15 yes that makes sense. We know that that 

16 particular agent would have been used in this 

17 activity.

18 But, as we know, many of the agents 

19 in this complex were -- they had numbers, they 

20 didn't have names. So, task is still going to 

21 be, I think, one of the most valuable ways to 

22 assess exposures.
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1 But, again, that has to be looked at 

2 by industrial hygienists to really interpret 

3 that task.

4 CHAIR MARKOWITZ: The -- Steven 

5 Markowitz.

6 The, you know, construction in large 

7 part does your work, yours and Dr. Dement's and 

8 others at the CPWR, is an identified and 

9 limited universe of tasks and hazards. You can 

10 capture most of them in a finite list.

11 You know, in our chores at the DOE 

12 complex, the heterogeneity of activities that 

13 are undertaken at DOE, we certainly couldn't 

14 describe ahead of time a list of tasks for 

15 production workers for the whole set of other 

16 types of workers, engineering workers, 

17 administrative service workers, et cetera.

18 And so, they can be asked about what 

19 their tasks are and they should be. The 

20 problem with the OHQ is that the interviewer 

21 probably has limited expertise and an ability 

22 to actually ask about them to get a relatively 
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1 complete set of tasks on those types of jobs.

2 So, it gets back to what we've 

3 discussed before, who's doing the interview?

4 Industrial hygienists clearly can do 

5 that, but theyaren’t administering the OHQ. 

6 So, there's a problem there.

7 I don't know who was next. Dr. 

8 Cassano?

9 MEMBER DEMENT: Just to follow up on 

10 Steven's comment.

11 You know, so, what we're trying to 

12 do in the OHQ is sort of as a hygienist would 

13 transmit, you know, what we would ask if we 

14 were sitting in front of this worker.

15 Okay, you tell me you worked with 

16 benzene. Then, the next obvious question is, 

17 describe how you worked with it.

18 So, really the task is what we're 

19 looking for. And, we can do better with 

20 construction workers. We have lists we can --

21 and they're reasonable.

22 We're missing that for production in 
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1 large part, you know, it varies by site so 

2 tremendously.

3 But, nonetheless, as a hygienist, if 

4 you can tell me what you did with benzene, even 

5 it if was at a different site, but the process 

6 itself, were you cleaning parts with benzene? 

7 Were you pouring -- transferring benzene from 

8 container to container? Those are the things 

9 that are so helpful.

10 The difficulty is trying to use a 

11 second party to collect that information.

12 So, there's two things that we 

13 thought were helpful.

14 One, former workers doing that work 

15 are in a better position to know some of that 

16 anyway. They may not have done that exact 

17 task, but they're familiar with the site and 

18 they are familiar with what I would call 

19 industrial work.

20 The second process we thought was 

21 useful would be to allow, even after that 

22 process is done and that information is there, 
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1 if the worker has a claim and it doesn't meet 

2 one of the presumptions a priority, then the 

3 hygienist has the ability to go back and ask 

4 more specific questions of the individual by 

5 direct discussion.

6 So, that was the thinking process 

7 beyond -- behind, you know, this version of the 

8 OHQ.

9 CHAIR MARKOWITZ: Mr. Domina?

10 MEMBER DOMINA: Yes, I agree with 

11 Dr. Dement and Dr. Welch.

12 And, you know, the production 

13 workers is a lot different. And, you know, 

14 like I said, the prime example is walking into 

15 that machine shop. As soon as they open the 

16 door, you can smell cutting oil.

17 That building's been there for 65 

18 years. And so, you can't leave out 

19 secretaries, clerks, anybody else because they 

20 are in the process production areas of any of 

21 these sites across the country.

22 Most of these areas vented to the 
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1 atmosphere and so the concentrations, day after 

2 day, year after year.

3 And, I, you know, I hope, you know, 

4 that we -- and, I know it's extremely difficult 

5 to do that, but you have to have somebody that 

6 has knowledge of those buildings, how many 

7 different air zones there may or may not have 

8 been, upset conditions, wind, all those things 

9 when they pressurize the building.

10 So, you may have supposed to be 

11 negative in your building, but when you have a 

12 lot of wind, as we do, it pressurizes the 

13 building and then all bets are off.

14 And, yes, the job categories I think 

15 for construction trades is a little bit easier. 

16 But then, we have construction then they go to 

17 the production side for us. And then, it's 

18 just all the different things you can't leave 

19 any stone unturned, in my opinion.

20 And, I know it's going to be 

21 inherently difficult, but I don't -- no one 

22 should be left behind.
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1 CHAIR MARKOWITZ: Well, I mean --

2 Steven Markowitz.

3 Say that in our recommendation, we 

4 did add a question about bystander exposure. 

5 And so, the OHQ should at least have the 

6 opportunity to collect that information that 

7 you're referring to as bystanders.

8 The problem there is, they won't 

9 know what they were exposed to, but, 

10 nonetheless, getting it down that they worked 

11 in that building and they were a bystander and 

12 there were some exposures is a start for the 

13 responses to the questionnaire.

14 MEMBER DOMINA: Just a quick 

15 comment. Sometimes, you know, there should be 

16 documentation for certain things because, like, 

17 you might have had a campaign for some certain 

18 deal that ran for a year, two years, or 

19 something. And then, another time, it may be 

20 routine.

21 But, I think that hopefully there's 

22 documentation for some of that.
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1 CHAIR MARKOWITZ: Dr. Cassano?

2 MEMBER CASSANO: A couple of 

3 comments.

4 First, on the OHQ, I mean, as far as 

5 the bystander problem, what we've done in the 

6 past many times is asked someone on a 

7 questionnaire to diagram the workplace and what 

8 processes were going on and where they were in

9 relationship to that.

10 And, sometimes, that's very helpful 

11 in determining what someone like a secretary or 

12 whatever would be -- would have been exposed 

13 to. They may not know what the process is, but 

14 they know that there was some chemical thing 

15 going on here.

16 And, that's been very helpful in 

17 some situations.

18 The other comment I had was about 

19 the BTMed questionnaire. It may not be 

20 relevant for all of the workers, but you should 

21 really audit the two questionnaires and, if 

22 there is something in that BTMed questionnaire 
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1 that is not in the OHQ, it should be added. 

2 Because, that's an additional piece of 

3 information that people that are very smart 

4 about this have developed.

5 CHAIR MARKOWITZ: Dr. Dement?

6 Yes, Mr. Whitley?

7 MEMBER WHITLEY: When I go look at 

8 the SEM and I look up a supervisor or I look up 

9 a secretary, it says no chemicals. I just 

10 looked up two or three just now, it says no 

11 chemicals.

12 But, as Kirk just said, the 

13 secretaries office was out in the middle of the 

14 machine shop. The supervisor of the machine 

15 shop is out there walking around where they're 

16 cutting bars all day long.

17 So, I don't think the SEM can be 

18 used to deny claims. So, I don't know how it's 

19 such a large thing, it's very useful. But, it 

20 can't be used to deny claims because, it's like 

21 saying, the supervisor or an engineer both says 

22 no chemicals.
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1 So, if you looked on the SEM and it 

2 says they didn't have any chemicals around 

3 them. All those, I just looked them all up.

4 CHAIR MARKOWITZ: So, you know, the 

5 strategy is that the OHQ should be able to 

6 capture enough information to overcome that 

7 deficit in the SEM.

8 Because it's specific to that 

9 individual and it should be able to capture 

10 more detail. That secretary may not know what 

11 those chemicals were, but at least it can be 

12 related that she or he worked in that location 

13 and, therefore, they have been exposed.

14 Dr. Dement?

15 MEMBER DEMENT: Yes, I agree with 

16 Garry. I think some of the more classic cases 

17 in the occupational literature actually 

18 occurred among non-production people.

19 There's some of the beryllium 

20 disease cases, I mean, they were clearly on the 

21 production. There were sometimes people 

22 working in the files in the offices.
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1 But, I think another point for the 

2 OHQ, it may not answer everything, it's an 

3 attempt to gather as much as you can in the 

4 limited time with a limited amount of recall.

5 But, the other thing is to allow the 

6 hygienist to have that total package of 

7 information.

8 In many cases, there were comments 

9 made about tasks. It may not give the final 

10 answer, but it will be a red flag for the 

11 hygienist.

12 I want to ask specifically about a 

13 few of these tasks that are listed or 

14 exposures.

15 So, hopefully, some of those 

16 individuals who have this bystander or non17 production exposure would be picked up in that 

18 process. And, we hope that by the process 

19 picked up in the overall process of 

20 adjudication in the IH evaluation.

21 CHAIR MARKOWITZ: Dr. Silver?

22 MEMBER SILVER: Did anybody see any 
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1 qualifying language in the boilerplate of the 

2 OHQ that tells the claimant that this is a 

3 start, it's only a start and it would be in 

4 your interest to supplement the record as your 

5 claim proceeds with additional information such 

6 as the questionnaire from the former worker 

7 programs, information provided by coworkers, oc 

8 docs you may be visiting?

9 And, your authorized representative 

10 often is a site specific advocate who knows a 

11 lot about the buildings and processes and 

12 materials.

13 I just feel that a lot of people go 

14 into this and they think they're going to be 

15 taken care of, kind of cruise control, fill out 

16 your 1040 and you'll get your refund down the 

17 road.

18 And, we should tell them up front 

19 that the OHQ is just a start.

20 CHAIR MARKOWITZ: Dr. Friedman21 Jimenez?

22 MEMBER FRIEDMAN-JIMENEZ: Just a 
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1 small point, but it may be important.

2 I'm looking at the OHQ section under 

3 PPE, personal protective equipment, and it 

4 seems to me it may not be explicitly enough 

5 asked when did the person start to use PPE.

6 Because a lot of PPE became more 

7 available in the '80s and '90s and wasn't used, 

8 even though it was the same process earlier 

9 than that. And the PPE can significantly 

10 modify the exposure.

11 So, I think it might be asked a 

12 little more explicitly, when did the PPE become 

13 available and when did they start using it?

14 It does ask question like when did 

15 you use the PPE, but not explicitly when did 

16 you start using it?

17 CHAIR MARKOWITZ: Mr. Domina?

18 MEMBER DOMINA: Yes, if we're going 

19 to get specific on PPE, and like we've 

20 discussed before, PPE was used for RAD. We 

21 didn't have chemical stuff available to us 

22 until late.
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1 And, basically, yes, if there's RAD 

2 in the area and you're going in with a chemical 

3 to clean something up, it's when you got a 

4 headache is when you come out. That's how it 

5 was done year after year.

6 So, you've got to be specific and 

7 then the same thing with what kind of clothing 

8 you may or may not have been wearing, you know, 

9 standing in primary water that's just gone 

10 through the reactor, all that stuff.

11 And so, we have to be specific on 

12 that.

13 CHAIR MARKOWITZ: Dr. Dement?

14 MEMBER DEMENT: I think as a 

15 hygienist, for me, PPE is at the absolute last 

16 line of defense. And so, you wish to have 

17 engineering controls in place to minimize 

18 exposures.

19 And so, PPE availability in the 

20 absence of a program to properly train, 

21 administer, make sure this is used properly, 

22 can actually be to the determent of workers.
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1 I've seen cases where workers were 

2 given an inadequate respirator, called a 

3 respirator, put into a high exposed asbestos 

4 situation. And, in my view, they thought they 

5 were protected. They did this work for hours 

6 and hours. They were given a great disservice 

7 by this PPE in the absence of a program to 

8 properly select the device, to make sure it's 

9 fitted appropriately and used appropriately.

10 CHAIR MARKOWITZ: Dr. Welch and Dr. 

11 Sokas?

12 MEMBER SOKAS: And, this is just to 

13 -- I think we've had this conversation in the 

14 past in this Board where the availability or 

15 the use of PPE is actually seen as a marker for 

16 exposure rather than a reason to say, oh, the 

17 person wasn't exposed.

18 CHAIR MARKOWITZ: Dr. Welch?

19 MEMBER WELCH: You know, my memory 

20 isn't what it used to be, but I think in our 

21 recommendations about the OHQ, we recommended 

22 they drop those PPE questions.
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1 Because, that's something that the 

2 industrial hygienist could go back and ask 

3 about, but as Kirk pointed out and John, that's 

4 very complicated. And, particularly, the 

5 individual.

6 So, I'm not sure that it adds much 

7 to have it on the OHQ.

8 CHAIR MARKOWITZ: I'm sorry, did you 

9 want to -- John, do you want to respond 

10 directly top that? Go ahead and then we'll go 

11 to Ms. Vlieger and Mr. Turner.

12 MEMBER DEMENT: Yes, I just, if 

13 we're limited in time and resources, I'd much 

14 rather see resources trying to look at and 

15 determine the exposures rather than trying to 

16 go through the mishmash of when PPE was or was 

17 not used.

18 CHAIR MARKOWITZ: Mr. Turner?

19 MEMBER TURNER: There are a lot of 

20 worker, former workers, that have moved across 

21 the country and they are really sick. They 

22 don't know what type of work that they did, 
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1 what, you know, where they worked.

2 So, they have a representative that 

3 they called, you know, and tried to find out 

4 from some of their coworkers or some other 

5 person that knew this person to try to find out 

6 what type of work and what type of exposures 

7 that they had.

8 CHAIR MARKOWITZ: Which raises an 

9 interesting question. When the OHQ is 

10 administered, the person from the resource 

11 center is doing it by phone, right?

12 But, presumably the worker is 

13 permitted to bring a coworker or bring someone 

14 else with them to assist in that. Or, if by 

15 phone, to have a coworker or someone available? 

16 Not usually?

17 Ms. Leiton, do you want to respond 

18 to that?

19 MS. LEITON: There's no restriction 

20 against it. They can bring whoever they want 

21 to.

22 CHAIR MARKOWITZ: Thank you.
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1 Ms. Vlieger?

2 MEMBER VLIEGER: For clarification, 

3 my point of not usually is normally these 

4 appointments are made at the claimant's 

5 leisure.

6 And so, the ability to bring lots of 

7 people with you is not normally accessible.

8 My experience with the OHQ, with any 

9 of the people that are starting a claim, I will 

10 give them a blank copy of the form and I say, 

11 put it next to your chair, think about it. I 

12 want you to mark it up like crazy before your 

13 appointment.

14 Because, a lot of times, there's 

15 brain freeze during the appointment and they 

16 can't remember things. And so, I give them 

17 advanced copies and I usually carry a few with 

18 me because people are starting claims.

19 I say, you know, this is really 

20 important because it will be used as part of 

21 your claim.

22 And, what I've found on the IH 
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1 reports is that they actually use the IHQ, but 

2 many times, they're misinterpreting when people 

3 say they often, always or infrequently used 

4 their PPE.

5 And, they apply that across their 

6 entire work history. And, as we discussed, PPE 

7 is mostly for radiological conditions at the 

8 sites. So, PPE is a broad spectrum of things 

9 and the list on the OHQ was adequate. But the 

10 use and the misuse of PPE is never addressed in 

11 the questionnaire because we know a lot of what 

12 has been used is improper.

13 So, I think if we're going to give 

14 the OHQ to them, give them some time to play 

15 with it before the appointment because the 

16 appointment can be mind blowing to them.

17 And, with the older claimants, 

18 especially, they're going into what they 

19 conceive to be a government office and they get 

20 a little what -- the equivalent of white-coat 

21 fever and they forget things.

22 So, I would recommend providing them 
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1 a blank copy well in advance that they can play 

2 with so that they know what's going on.

3 And then, I always tell them, think 

4 about, you know, what you were doing at the 

5 time of more like, what car were you driving? 

6 What house were you living in? To put a time 

7 frame on when things were happening.

8 But, to just give them it at the 

9 appointment, it freezes most of them up. And, 

10 when you are able to provide a supplemental OHQ 

11 when you remember things later, it's a little 

12 tougher to get it into the system, but you can 

13 always provide the supplemental information as 

14 well as coworker affidavits.

15 CHAIR MARKOWITZ: Dr. Cassano?

16 MEMBER CASSANO: I just want to go 

17 back to the question about PPE and add on to 

18 what Laura said as using it as a marker of 

19 exposure rather than a marker of protection 

20 against exposure.

21 A lot of people don't know what they 

22 were exposed to. They don't know what they 
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1 were doing. They don't remember what they were 

2 doing, but they darn well remember that 

3 somebody gave them a respirator at some point 

4 or told them to use one.

5 And then, it becomes incumbent upon 

6 whoever's doing the questionnaire or the 

7 industrial hygienist to be able to dig through 

8 that and say, okay, you know, what processes 

9 were you -- do you remember approximately what 

10 you were building or what you were working on 

11 and that becomes then a way to dig down into 

12 what their exposures might have been.

13 So, I think it is a useful question 

14 as a general question, not as a, okay, you used

15 PPE, you were protected, you weren't exposed.

16 CHAIR MARKOWITZ: Mr. Domina?

17 MEMBER DOMINA: Just a comment, and 

18 this is probably an extreme case, and I'm sure 

19 Garry may know that guy at Y-12 wearing PPE 

20 that wasn't flame retardant welding overhead on 

21 a ladder and he burned to death because he 

22 didn't have a spotter and it caught fire behind 
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1 him and he was in PPE but not flame retardant.

2 So, you also, like Dr. Dement said 

3 earlier, where sometimes that is -- can be a 

4 hazard in itself.

5 CHAIR MARKOWITZ: So, we're going to 

6 take a break in a couple minutes, but I want to 

7 close out this conversation.

8 So, we have our recommendation and 

9 we have the draft OHQ which we haven't really 

10 had time to go through systematically.

11 But, we've had the comments we've 

12 had today. How should we move forward on this? 

13 Should we collect our comments on their draft 

14 OHQ and assemble them and submit? Or should we 

15 do that and look at them together in a Board 

16 Meeting and agree on them and then submit them?

17 I'm looking for suggestions on that.

18 MEMBER WELCH: Well, we could have 

19 the SEM Subcommittee do a, you know, we could 

20 have a conference call to talk about the new 

21 draft in light of what, you know, our goals 

22 have been with our recommendations and then 
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1 make some proposal to the full Board about how 

2 to respond.

3 CHAIR MARKOWITZ: That sounds good.

4 Dr. Friedman-Jimenez?

5 MEMBER FRIEDMAN-JIMENEZ: Just a 

6 question. I have some comments on form, 

7 content and even some errors in the manual. 

8 I'm going to have to leave. Should I just 

9 write them up and send them in? How are we 

10 going to discuss the manual?

11 CHAIR MARKOWITZ: So, Ms. Leiton, 

12 I'm sorry, a question for you. What Dr. 

13 Friedman-Jimenez is saying is he's got some 

14 comments, corrections, factual issues in the 

15 procedure manual. Should he just make note of 

16 them and send them directly to you or how 

17 should we proceed on that?

18 MS. LEITON: I think, ultimately, 

19 it's going to be -- that's going to be the 

20 easiest way because we can actually go through 

21 the manual along with your comments, read 

22 through them and make corrects as we need to 
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1 make them.

2 CHAIR MARKOWITZ: Okay. Having said 

3 that, I just want to make it clear that the 

4 Board is not saying that it's systematically 

5 going through the 748 pages and making 

6 corrections.

7 Dr. Silver?

8 MEMBER SILVER: Our request to the 

9 SEM Subcommittee, when you work up our 

10 recommendations, we should also look at the 

11 script that supposedly accompanies the OHQ and 

12 ensure that, up front and at the conclusion of 

13 the interview, the claimant is informed that 

14 it's really important to supplement this 

15 record.

16 Once the brain freezes over, people 

17 go home, they run into their buddies from work 

18 and a bunch of light bulbs go off and they need 

19 to understand the OHQ is just the first step.

20 CHAIR MARKOWITZ: Okay, between 

21 brain freeze and white-coat fever, we may need 

22 to look at the Haz-Map again.
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1 Okay, so, we're going to -- next 

2 week, then, we're going to have to arrive on a 

3 common date for a meeting of that SEM 

4 Subcommittee.

5 So, when you get the request, that 

6 committee, when you get the request for good 

7 times, please respond rapidly.

8 We're going to take a 15 minute 

9 break and we'll resume at 9:45.

10 (Whereupon, the above-entitled 

11 matter went off the record at 9:30 a.m. and 

12 resumed at 9:48 a.m.)

13 CHAIR MARKOWITZ: Okay, let's get 

14 started.

15 MR. FITZGERALD: If everyone could 

16 please take their seats. We'd like to get 

17 started.

18 CHAIR MARKOWITZ: Okay, we're going 

19 to start with Part B Lung Disease Subcommittee 

20 Report which will be relatively brief. That's 

21 not a suggestion, Dr. Redlich, that's just a 

22 description to everybody else.
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1 MEMBER REDLICH: This is Dr. 

2 Redlich.

3 While we're waiting for the slides 

4 to come up, I have included some from some of 

5 the prior presentations just as a reminder for 

6 both us and the DOL. And, I'm not going to go 

7 through them all.

8 But, this is an update on our 

9 subcommittee and the members, John Dement, Kirk 

10 Domina, myself, Jim Turner and Laura Welch.

11 And, I'm very briefly going to go 

12 over what we have actually done over the last 

13 almost two years.

14 We -- John Dement reviewed data we 

15 had received. We've reviewed about 80 Part B 

16 cases. We've made three recommendations.

17 And, I think unlike some of the 

18 other subcommittees, we have a list of specific 

19 questions that the DOL gave us that we 

20 responded to.

21 And, I put this slide second so I 

22 wouldn't forget at the end, but I just really 
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1 thank the other members of the Part B 

2 Subcommittee.

3 I needed remedial help because they 

4 all actually had much more experience with this 

5 program and the complexity of it. And, even 

6 just what all the abbreviations were. So, they 

7 and others were extremely helpful, and Laura 

8 with her expertise and experience with the 

9 program. And, also John Dement similarly and 

10 his analysis of the data.

11 And, Kirk, as we heard, and Faye, 

12 yesterday were extremely helpful in reviewing 

13 my cases.

14 But, just to remind everyone, I'm 

15 not going to go through all the data. I just 

16 copied the data slides that we had used before 

17 that Kirk -- I mean, that Dr. Dement, the 

18 analysis he had done.

19 And, you know, I appreciate -- I 

20 would also wanted to just say that the requests 

21 that we made to the Department of Labor for 

22 both data and cases were, you know, supplied 
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1 and in a timely fashion. And, that was very 

2 helpful.

3 So, but, the major point of this was 

4 that I think reviewing the data was very 

5 helpful to target specific issues and where we 

6 focused our efforts, especially trying to 

7 understand the magnitude of this program and 

8 problems.

9 So, this isn't a prior presentation, 

10 as are the conclusions but, as just a reminder, 

11 I think that whatever imperfections there may 

12 be in the data, it remains helpful to review 

13 and John did a great job of that.

14 So, moving on, the Part B cases, I 

15 think we've reviewed, as we heard yesterday, 80 

16 of them. And, I think the point is that we did 

17 identify really some fixable problems. And, I 

18 think the problems that could be fixed in the 

19 short run.

20 And, the major things that we had 

21 identified were issues with CBD sarcoid cases 

22 that were denied both because the presumption 
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1 was not 94implemented or the clear beryllium

2 exposure appeared to have just been ignored or 

3 denied.

4 And then, we had mentioned some of 

5 the other issues that had come up that do seem 

6 to be fixable such as this problem with CMC.

7 We made -- this subcommittee made 

8 three recommendations. The first one, we 

9 discussed yesterday related to the blood 

10 proliferation test.

11 The second and the third, we are 

12 waiting the DOL response on.

13 The second is a more technical issue 

14 that we had been requested to provide a 

15 definition of chronic respiratory disorder.

16 The third is one that we also refer 

17 to as just issues with the procedure manual 

18 that we hope can be improved in the future.

19 And then, we responded to specific 

20 questions that the DOL asked us. I am not 

21 going to go through all these questions, except 

22 we did give a 13-page reply to these questions 
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1 that have numerous references in it.

2 And, was based on quite a bit of 

3 information, review of the cases, the data, our 

4 meetings, our site visits, our expertise and 

5 the medical literature.

6 So, we are just hoping that the DOL 

7 carefully reads our responses to our questions 

8 and implements them where possible.

9 I think in terms of future 

10 directions, we are awaiting, as are the other 

11 subcommittees, a response to the second and 

12 third recommendations from the Part B.

13 We're hoping that these 

14 recommendations can be implemented. And, as I 

15 mentioned, the specific questions that we were 

16 asked our expertise on and provided, we're 

17 hoping that those answers can get incorporated 

18 into the procedure manual, the training 

19 documents.

20 There were, I think, some small, 

21 short-term, you know, some fixes are longer 

22 term and would take more time to implement such 
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1 as, you know, revise procedures and 

2 questionnaires.

3 I think there's some shorter ones --

4 short-term ones that we identified that someone 

5 could look into that could really impact 

6 people's lives, one of which would, for 

7 example, would be the CMC that had reviewed 

8 half the cases that we had been selected and 

9 provided to us.

10 And, I do think that it shows that 

11 there's a value to reviewing the data and 

12 selected cases.

13 So, I'm going to end there and if 

14 anyone else on the committee wants to comment.

15 CHAIR MARKOWITZ: Okay, so, if you 

16 could --

17 MEMBER REDLICH: I'm sorry, I did 

18 talk quickly.

19 CHAIR MARKOWITZ: No, no, that's --

20 no, no, that -- no, no, that was great.

21 If you could leave that slide up, I 

22 have a question, Ms. Rhoads. Can we make that 
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1 available on our website -- on the Board's 

2 website because that contained a lot of very 

3 useful information that people might want to 

4 access.

5 So, it's a -- okay. So, if we could 

6 do that.

7 I have a question for Ms. Leiton. 

8 So, there's some observations that the Board 

9 has made as we've discussed it and done our 

10 research that here haven't been part of 

11 official recommendations, such as what Dr. 

12 Redlich is talking here about.

13 What the committee considers to be 

14 the problematic consulting physician or cases 

15 that were -- that the committee believes were 

16 incorrectly adjudicated.

17 So, what kind of follow up can, does 

18 DOL do from these kinds of observations?

19 MS. LEITON: I was going actually 

20 ask about that CMC and that list and that 

21 evaluation. Were we provided with that, 

22 Carrie?
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1 They did an evaluation of CMCs and 

2 they've -- we've been referring to the 

3 particular CMC. So, I don't know if that was 

4 actually submitted to us.

5 If we can get that, that would be 

6 helpful. We can review it. We can maybe 

7 follow up on some of the issues that have been 

8 identified.

9 I don't know that that needs to be a 

10 formal process. I'm not sure exactly the rules 

11 in terms of can you just provide us that, we 

12 can follow up on it and get back to you? Or, 

13 does it need to be published? I'm not really 

14 sure what the DFO rules on that are.

15 But, we're -- I would like to see 

16 it. I would like to be able to follow up on it 

17 however that needs to happen.

18 MEMBER REDLICH: Yes, that is 

19 correct. I did not mean to imply that you have 

20 not yet taken care it because that is -- we did 

21 not provide any specific names.

22 And, the cases were --
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1 MS. LEITON: I mean, again, it would 

2 have to be --

3 MEMBER REDLICH: -- and that we 

4 could provide a list of those based by the 

5 event or by identifier --

6 MS. LEITON: Right.

7 MEMBER REDLICH: -- where we thought 

8 there was an issue.

9 MS. LEITON: And, I think that would 

10 have to be done informally and not on the 

11 website just because of the nature of it.

12 CHAIR MARKOWITZ: Sure. Like where 

13 we're discussing both issue of the particular 

14 CMC, but also the issues of the cases the 

15 committee thought were incorrectly adjudicated. 

16 Right?

17 MS. LEITON: Correct.

18 CHAIR MARKOWITZ: All right, thank 

19 you.

20 MEMBER REDLICH: Thank you.

21 CHAIR MARKOWITZ: Dr. Silver?

22 MEMBER SILVER: I'm interested in 
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1 how this issue of the problem with CMC is being 

2 framed? You did 80 cases, a lot of work. Out 

3 of a population of how many Part B cases for 

4 that relevant time frame? Do we have an idea, 

5 80 was a sample of a much larger number, right?

6 So, using a poker metaphor, on the 

7 first deal, you got a royal straight flush 

8 recidivist CMC who had attitude, I think you 

9 said.

10 If you drew another sample of 80 

11 cases, it seems to me there's a possibility of 

12 CMC B, bad attitude coming up in those files.

13 So, I think we may have a systemic 

14 problem or it could just be one bad apple.

15 MS. LEITON: I mean, I'm assuming 

16 you're referring to the analysis that was 

17 conducted by this subcommittee. So, I wouldn't 

18 know the answers to the universe or any of that 

19 off the cuff.

20 We provided the data. They did the 

21 analysis.

22 CHAIR MARKOWITZ: All right, well, 
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1 just to get some clarity on this particular 

2 consulting physician, the issue was lack of 

3 objectivity? Because we were referring in the 

4 discussions about attitude and other 

5 adjectives. But, let's formalize it a little 

6 bit.

7 Was the issue lack of objectivity in 

8 their analysis? Was the issue perceived 

9 conflict of interest because the person had an 

10 ideological conflict of interest?

11 I think we should -- we don't have 

12 to do it right now here, but we should use 

13 other more specific words.

14 Dr. Cassano?

15 MEMBER CASSANO: I think Rosie's 

16 going to ask the same question. You found this 

17 sort of incidentally to your analysis.

18 But, our subcommittee should really 

19 be taking this over so it's where the CMC 

20 Subcommittee. So, if you want -- I mean, I 

21 don't know how to work that --

22 MEMBER REDLICH: I'd be happy for 
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1 you to take it over.

2 (Laughter.)

3 MEMBER REDLICH: And, thank you very 

4 much for offering.

5 MEMBER CASSANO: Yes, but that's 

6 just --

7 MEMBER REDLICH: It was just 

8 incidental observation on them as we heard by 

9 Kirk.

10 CHAIR MARKOWITZ: Dr. Sokas?

11 MEMBER SOKAS: And, when we had 

12 asked for charts, we actually, again, there was 

13 a little bit of confusion. So, we wound up 

14 sampling some of the charts that had been 

15 provided for other people.

16 So, I'm assuming we reviewed some of 

17 those same charts. And, as an example, there 

18 was a, you know, a CMC who clearly refused to 

19 consider COPD as a work related outcome citing 

20 old -- and included a cherry picked citation 

21 from the literature in order to do that.

22 So, I mean, again, you could 
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1 certainly include that in the, did the CMC 

2 follow the published guidelines, you know, from 

3 the program?

4 I mean, I think when we talk about 

5 the auditing, the changes in the audit form, we 

6 can address some of those issues.

7 I think it might be also useful, I 

8 mean, we can get back in touch with Carrie, to 

9 make sure that we haven't missed some other 

10 ways that we can formalize that language.

11 CHAIR MARKOWITZ: Mr. Domina?

12 MEMBER DOMINA: When we stumbled 

13 upon this issue, they were cases that were 

14 provided to us by Labor.

15 And, I think the whole process needs 

16 to be looked at, too. Because, I think one of 

17 the other issues that came into play is the way 

18 the questions were framed from the CE to the 

19 CMC also was problematic.

20 And so, that, you know, we needed to 

21 look at all of it as a whole. Because, like I 

22 said, I think I had six cases that Carrie 
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1 assigned to me and when I -- after a couple, 

2 then I had another one and then Faye and I got 

3 together.

4 And then, we ran the whole list that 

5 was provided by -- from Labor to us. And then, 

6 it got inherently worse. And, that's why, you 

7 know, because, I had to ask Mark and I picked 

8 stuff out of there, it's like, wow.

9 CHAIR MARKOWITZ: Some of us 

10 disagree with at least one of the statements 

11 you made there.

12 MEMBER REDLICH: I think also one of 

13 the reasons that I've been harping on the 

14 procedure manual on the training materials that

15 is the jurisdiction of the other subcommittee, 

16 is that, I think some of the adjudications 

17 which we did not agree with, it was probably 

18 multifactorial where things went wrong.

19 But, I think it just has to be a 

20 recognition that, you know, there could be a, 

21 quote, qualified CMC or the like that those 

22 positions are not going to be -- they 
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1 themselves may not be aware of the last 15 

2 years of research on, let's say, COPD 

3 causation.

4 And so, there is a lot of, you know, 

5 a lot of the instructions is based on the 

6 decision making and the rationale of the 

7 physician either, you know, the CMC or the 

8 treating physician.

9 And so, there's a lot of 

10 expectations on these physicians that I think 

11 all of us who know who these physicians are, 

12 are concerned about them.

13 CHAIR MARKOWITZ: Ms. Vlieger?

14 MEMBER VLIEGER: I think we could, 

15 not being on the committee but only being an 

16 advisor to the committee, I think we could come 

17 up with the areas that we would need to look at 

18 in total in some sort of questionnaire.

19 But, what I find very disconcerting 

20 in the CBD cases that we reviewed and that I 

21 have seen personally is that, the doctors are 

22 using the wrong criteria and not using the 
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1 programmatic criteria for a diagnosis of CBD.

2 And, many of them are using the 

3 beryllium case registry criteria which is much 

4 more stringent than the DOL criteria.

5 And, when pressed through the 

6 program and when I asked, you know, they're 

7 using the wrong criteria, does anyone tell them 

8 they're using the wrong criteria at the CMC 

9 level?

10 I'm told that the CMCs are trained 

11 and that's what they do. There's no corrective 

12 action for that error in use of programmatic 

13 guidelines.

14 CHAIR MARKOWITZ: So, but, you know, 

15 some of this conversation demonstrates the 

16 importance of one of our other recommendations 

17 about taking a look at a sizable number of 

18 claims and really identifying the systematic 

19 issues.

20 MEMBER REDLICH: And, yes, and I did 

21 get that incorrect. Faye is correct that I 

22 think there are some discrete fixable things 
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1 that are not, you know, either so complicated 

2 or endless that they can't be fixed.

3 CHAIR MARKOWITZ: Dr. Cassano?

4 MEMBER CASSANO: Just a couple of 

5 things, I think this kind of thing, and we'll 

6 come up more information later is, it supports 

7 the quasi-recommendation we made at this 

8 meeting that you do more of a peer review type 

9 CMC process so that these individuals can be, 

10 you know, can be noticed earlier rather than 

11 the general one or the random one.

12 And also, who is responsible for the 

13 training? I know in some situations with 

14 contractors, you know, the agency trains the 

15 trainer and then they're responsible for 

16 training their CMCs. How does it work at Labor 

17 for the CMCs?

18 MS. LEITON: The contractor will 

19 train their -- the contractors that work for 

20 them. We will review the material and go over 

21 the training with the contractor who trains.

22 MEMBER CASSANO: So, you provide the 
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1 training material for them?

2 MS. LEITON: We will -- yes.

3 MEMBER CASSANO: Okay.

4 CHAIR MARKOWITZ: We need to move 

5 on. So, are there any other comments?

6 (No response.)

7 CHAIR MARKOWITZ: So, thank you very 

8 much, Dr. Redlich and the committee.

9 So, the Presumptions Working Group, 

10 if I can just summarize, we had a meeting, I 

11 don't believe, since the last full Advisory 

12 Board Meeting.

13 We do have a presumption 

14 recommendation that's still outstanding 

15 relating to hearing loss that Dr. Welch drafted 

16 that we submitted. So, we're waiting to hear 

17 about that.

18 Actually, considering other disease 

19 entities for presumptions, it's going to be 

20 more challenging because the nature of those 

21 illness. You can think about neurologic 

22 illnesses or kidney disease or the like.
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1 And, we haven't really discussed 

2 those. Probably a good thing because we've 

3 learned a lot and about through the DOL 

4 responses about how presumptions are, I don't 

5 know how Dr. Boden expressed it exactly, but 

6 the importance of finding bridges between 

7 medicine administration and the law.

8 But, so, I think that's actually a 

9 good learning process for us in terms of 

10 developing additional presumptions.

11 But, we will recommend to the next 

12 Board that that work continue.

13 Dr. Sokas?

14 MEMBER SOKAS: And, I just want to 

15 quote Dr. Boden, again, that, in general, which 

16 is a big challenge, that the presumptions are 

17 positive, they're not construed to be negative. 

18 If you don't meet a presumption, it doesn't 

19 mean you're automatically excluded, it means 

20 you go to the industrial hygienist and you --

21 or, you know, you get further information 

22 developed.
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1 CHAIR MARKOWITZ: So --

2 MEMBER SOKAS: And, that was one of 

3 probably the most important comments I think 

4 out of this meeting.

5 CHAIR MARKOWITZ: I think we've said 

6 that at every meeting. I think DOL has agreed 

7 with us at every meeting and I think that we 

8 need -- one of the functions the Board should 

9 do is actually to monitor that to see what 

10 happens in practice.

11 Because, that's the only way we'll 

12 know whether the universal agreement on this 

13 issue is actually applied. But, I'm not sure 

14 which committee that goes to.

15 But, excellent, that goes to your 

16 committee.

17 Any other comments on presumptions 

18 or --

19 (No response.)

20 CHAIR MARKOWITZ: The -- I wanted to 

21 just spend a couple minutes on the changes in 

22 the procedure manual, in part, because a Board 
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1 member raised this issue.

2 I don't know whether -- I have a 

3 comment on it, but I can start with that, I 

4 guess.

5 So, new version of the -- the 

6 integrated procedure manual came out and there 

7 was a transmittal letter with that in 

8 September, two months ago, actually, 

9 identifying the changes in the procedure 

10 manual.

11 I haven't -- I have a lot less 

12 familiarity with that procedure manual than 

13 people in this room. I think they're the ones 

14 who are not sitting around the table.

15 And, I have a hard time discerning 

16 when text has changed. And, I don't -- even 

17 after walking through the transmittal letter 

18 about what changes occurred, I still don't 

19 quite know how to look at the new version of 

20 the procedure manual and understand exactly 

21 what's different.

22 So, I don't know whether other Board 
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1 members have had the opportunity to try to do 

2 that, but I'm not sure how to approach this 

3 issue.

4 Dr. Sokas?

5 MEMBER SOKAS: Yes, I don't know 

6 that this is going to be feasible for the phone 

7 meeting that we're having coming up. I mean, 

8 again, this may be new business for the next 

9 Board.

10 But, that's the kind of thing that 

11 it would be really helpful for me to have a DOL 

12 presentation where somebody kind of walks 

13 through it.

14 I think at our very first meeting in 

15 D.C., there was a similar presentation about 

16 some document that changes were being, you 

17 know, considered for and that really is 

18 enormously helpful.

19 CHAIR MARKOWITZ: So, you're 

20 referring to the rule making process?

21 MEMBER SOKAS: Well, that was the 

22 example. But, really, in terms of something 
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1 like this, just to set aside some time on the 

2 next in person Board meeting to kind of go 

3 through it and have the person, you know, who 

4 knows this inside and out say, yes, we used to 

5 do this but now we do this and pay attention to 

6 this.

7 CHAIR MARKOWITZ: So, the issue is 

8 not just a thing on the Board on changes in the 

9 procedure manual, but actually changes in 

10 policy, guidance, you know, the circulars, et 

11 cetera, right?

12 So, which I think -- which we had 

13 requested before and DOL does provide us with 

14 lists of the changes, but actually a 

15 presentation at a Board -- a brief presentation 

16 at a Board meeting would be helpful.

17 Ms. Vlieger?

18 MEMBER VLIEGER: In searching for 

19 the new PDF version of the procedure manual, 

20 one of the things that comes up based in my 

21 semi-learned Google search is the old procedure 

22 manual still seems to be populated on the site 
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1 without any notice that it's been changed.

2 So, that's -- because it's the old 

3 procedure manual that pops up many times.

4 So, if we could look into correcting 

5 that with whoever runs the website.

6 And then, as far as the new 

7 procedure manual, it's a PDF version, but I 

8 still find it -- it's searchable, but it's hard 

9 to navigate and stuff. And so, the changes 

10 that have been made are pretty broad 

11 incorporation of a lot of things that were 

12 circulars, bulletins.

13 And so, yes, a briefing would be 

14 swell.

15 CHAIR MARKOWITZ: Dr. Redlich?

16 Other comments on this issue?

17 (No response.)

18 CHAIR MARKOWITZ: If you could put 

19 your name placards down because, otherwise, I'm 

20 going to keep going to you.

21 So, I want to just spend a few 

22 minutes talking about the public comments 
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1 because, you know, we have these sessions. 

2 They're usually at the end of the day when 

3 maybe we aren't as fully attentive as we are at 

4 other times of the day.

5 But, even if we were, the issue is 

6 we don't have a structured way of looking at 

7 those systematically and ensuring that the 

8 relative -- the relevant comments really inform 

9 our conversation.

10 And, I think Ms. Rhoads has come --

11 at least on the oral comments has nicely put 

12 them in a spreadsheet and our request was very 

13 useful. So we have one place we can go to.

14 It's not the written comments, it's 

15 the oral comments. And, we can look at them. 

16 But, we don't -- in a Board Meeting, we don't 

17 walk through them. The committees don't 

18 separately look at them. They're not 

19 particular comments that are relevant -- highly 

20 relevant.

21 Our discussions are not sorted by 

22 committee and then discussed.
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1 So, I just wanted to spend a moment 

2 doing two things.

3 One is, discussing whether there are 

4 any comments yesterday that we might just want 

5 to briefly mention.

6 And then, secondly, thinking of a 

7 way that the newly constituted Board can 

8 actually do this a little bit differently so 

9 that there's more feedback.

10 Mr. Domina?

11 MEMBER DOMINA: I think a couple of 

12 the comments yesterday were more pertinent to 

13 the Part B Board that I heard.

14 And then, I also noted Ms. Smith 

15 from the Seattle Office took care of couple of 

16 them. I believe I saw her walk out with a 

17 couple individuals, too.

18 So, they got -- maybe on the Part B 

19 ones, maybe they need to be funneled to that 

20 committee. Because, not knowing the 

21 particulars of those cases, but it seems like 

22 they were talking about radiation more than 
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1 anything else.

2 Or else, you know, maybe somebody 

3 talk to them afterwards to clarify and see if 

4 that's where their case was. It's a Part B 

5 claim and not a Part E claim. And, that might 

6 clarify it.

7 I think at least two of them that I 

8 recall yesterday.

9 CHAIR MARKOWITZ: Dr. Sokas?

10 MEMBER SOKAS: So, I think that DOL 

11 having the Office of the Ombudsman represented 

12 is also incredibly helpful and that that's a 

13 huge advantage and to have the program 

14 represented here.

15 So, I think each of those things has 

16 been a big improvement over the, you know, the 

17 course of trying to address these particular 

18 comments.

19 I think some of the comments are 

20 clearly intended by the commenter to have us 

21 just appreciate the experiences that people go 

22 through.
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1 So, some of that is not, here's a 

2 problem, fix it. It's this is how this has 

3 impacted our lives and that's valuable.

4 I think there was, perhaps, and this 

5 may be what Mr. Domina is referring to, there 

6 also seems to be a problem, perhaps, with the 

7 handoff between the radiation exposures and the 

8 toxic exposures.

9 And, perhaps some understanding of 

10 the relationships and how people get into and 

11 out of the different systems, you know, whether 

12 it's one portal and then they get --

13 You know, because that, I don't 

14 understand at all. And, that was an issue that 

15 came up.

16 And then, the other thing from 

17 yesterday that, again, there may be some new 

18 causality relationships that we hadn't 

19 considered or thought about that, you know, are 

20 kind of percolating in the back of our minds.

21 They're in the spreadsheet, so I 

22 don't know that we need to definitively respond 
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1 to them except to know that maybe at some point 

2 we would do them.

3 And then, the reminder that we 

4 hadn't heard back about the solvent hearing 

5 loss issue and that there were those 

6 recommendations sitting there.

7 You know, again, it's challenging 

8 because you can't -- you know, there's really -

9 - this is not an appropriate forum to respond 

10 to individual questions.

11 But, again, I think that we 

12 certainly have, over the course of these 

13 different sessions, learned a lot and 

14 implemented and followed up on some of them.

15 I think your concern is, are we 

16 doing enough with that? And, you know, I'm 

17 sure we could always do more.

18 CHAIR MARKOWITZ: So, yes, I mean, 

19 my concern is not the individual claims of 

20 people who need help. And, it's great that 

21 there are resources in the room to help them.

22 But, I'll give you an example. Ms. 
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1 Hand raised yesterday, and she has before in 

2 written comments, about what's the difference 

3 between significant factor and the any factor, 

4 that any exposure should be or is considered to 

5 be a significant exposure?

6 Well, that reminds us that actually 

7 we haven't kind of looked at how DOL treats 

8 this issue of significant. I don't know that 

9 there's that much to look into, but it's 

10 something on -- it should be on our agenda.

11 It should go to a committee and it 

12 should be looked at.

13 Dr. Sood, yesterday, said that many 

14 of his patients have chronic bronchitis which 

15 is symptoms only, they cough and produce a lot 

16 of sputum.

17 So, the physical exam won't show 

18 much, x-ray may not show much, breathing tests 

19 won't show much. No objective findings. And, 

20 yet, they have documented chronic bronchitis.

21 So, that's a bit of a challenge for 

22 our discussion led by Dr. Redlich yesterday 
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1 about the issue of -- or the COPD, perhaps, 

2 discussion.

3 But, in any case, it's those kind of 

4 comments that need -- we need to somehow 

5 integrate and not necessarily address to that 

6 particular person, but because they raise 

7 issues that we should be discussing.

8 Ms. Vlieger?

9 MEMBER VLIEGER: Could we set up a 

10 matrix and categorize which ones should go to 

11 the local resource center, which ones should be 

12 referred back to the committee for review or 

13 comment? And, that way, we can at least 

14 disposition some of the comments and have done 

15 something on them.

16 CHAIR MARKOWITZ: Sure, we could. 

17 We could. I mean, if the DOL assembles them in 

18 a spreadsheet, we could classify them and 

19 identify which ones would be up to DOL to 

20 decide what to do with the ones might go to a 

21 resource center, a district office or the like.

22 And the ones -- and then, we could 
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1 also -- someone could assign them to a 

2 particular committee for follow up.

3 I think that's what we should do.

4 MR. FITZGERALD: Doug Fitzgerald, 

5 DFO.

6 We probably also get recommendations 

7 looking into things that are beyond the scope 

8 of the Board, so we probably just need to take 

9 a look at those and see which ones we will act 

10 on or refer somewhere else in the Department.

11 CHAIR MARKOWITZ: That would be one 

12 of our categories, beyond the scope of the 

13 Board.

14 Mr. Griffon?

15 MEMBER GRIFFON: Yes, a practice 

16 that we instituted at the other -- at the 

17 Radiation Advisory Board was to collect those 

18 comments in a matrix and then the next meeting, 

19 we'd come back and the Chairman would -- it'd 

20 be on the agenda.

21 We'd come -- we'd go through those 

22 comments from the prior meeting and say how 
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1 they had been dispositioned, whether it was 

2 individual claim, NIOSH dealt with it, whether 

3 it was something that was going to be moved to 

4 the Radiation Subcommittee to deal with, you 

5 know, et cetera, et cetera.

6 So, we track those that way. And, 

7 it's worked pretty well.

8 CHAIR MARKOWITZ: You know, I'm 

9 reminded of another topic that's been raised in 

10 public comments, use of consequential 

11 conditions. We've hardly discussed that at all 

12 as a Board.

13 And, it is something that falls 

14 within the purview of our mission and just 

15 hasn't been on our radar, despite the fact that 

16 it has been raised in public comment.

17 And, we've been busy and a Board 

18 should get to it, but it should be there.

19 Yes, Dr. Cassano?

20 MEMBER CASSANO: Sort of reiterating 

21 what other people have said. I think there are 

22 three different buckets that these belong to.
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1 One is an individual claimant who 

2 has been having difficulty for years and years 

3 and years.

4 The other is the identification of 

5 what may be a systemic problem or a Board 

6 issues that should go to a subcommittee.

7 And then, the third is beyond the 

8 scope.

9 But, I think as far as, you know, 

10 and I think we can handle the last two 

11 categories very well by either sending it to 

12 the appropriate Board or referring back to the 

13 Department of Labor.

14 My problem with the first column is 

15 that I really feel deeply that we, in some way, 

16 need to make sure that there is some kind of a 

17 real handoff to somebody that can help these 

18 individuals, if it's not just that this is my 

19 sad story, I want you to know about it.

20 But, the lady today that we saw. 

21 Some of these people are desperate and if they 

22 come here and they spill their guts to this 
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1 committee and then nothing happens, we're just 

2 another bureaucracy that doesn't help.

3 And so, I really feel that we need 

4 to -- it shouldn't take much time to be able to 

5 do some kind of real handoff of these people to 

6 an ombudsman or a local advocate that they can 

7 work with.

8 CHAIR MARKOWITZ: Ms. Leiton?

9 MS. LEITON: And, I mean, I think in 

10 a lot of these cases, and I think Jolene being 

11 here yesterday, Jolene Smith who's our District 

12 Director, she can look into the cases. She can 

13 help them with their issues and look and 

14 determine where it is.

15 I think that if these cases can be 

16 referred to us since we have the case and we 

17 can work on making changes or fixing problems, 

18 I think that would be a big help just because 

19 we do have the case and we can do something 

20 about it directly.

21 MEMBER CASSANO: I think both, we 

22 may need to do --
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1 MS. LEITON: Sure.

2 MEMBER CASSANO: -- in some 

3 instances, we may need to do both because there 

4 may be such frustrated -- and this maybe -- it 

5 may be perceived, but there may be such 

6 frustration with you guys that if that's all we 

7 do, oh, they're just referring us back to 

8 somebody that hasn't helped us for 10 years.

9 And, that's no disrespect to you, 

10 but that may be the perception. So, and 

11 dealing with veterans like this all the time, 

12 it really sort of breaks my heart when I see 

13 people that I can't help and I need to get them 

14 to somebody that can.

15 CHAIR MARKOWITZ: Dr. Markowitz.

16 So, you mean the -- you say both, 

17 you mean both DOL and -- I'm sorry -- OWCP and 

18 the Ombudsman office?

19 MEMBER CASSANO: Any of those and 

20 the Ombudsman officer or a local advocate so 

21 that, you know, if they have a perception of an 

22 adversary relationship with DOL already, they 
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1 have somebody that can work with them to try to 

2 mend that relationship.

3 CHAIR MARKOWITZ: That would be my 

4 preference, too. Because, we're not in the 

5 position to sort through this, if there are no 

6 objections to that.

7 Dr. Friedman-Jimenez? Okay.

8 Ms. Vlieger?

9 MEMBER VLIEGER: Getting back to the 

10 question on consequential conditions, I heard 

11 that there were some changes that were being 

12 contemplated in how those are processed. Could 

13 Ms. Leiton apprise us of that?

14 MS. LEITON: I did hear this comment 

15 prior to the meeting. I looked at our 

16 procedure manual, John Vance, our Policy Chief, 

17 looked at our procedure manual. I'm not aware 

18 of changes that have been made to 

19 consequentials or being contemplated.

20 So, if you have specifics you want 

21 to provide, I'm happy to look into it.

22 MEMBER VLIEGER: Could you tell us 
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1 how, just in brief, how they are processed now?

2 MS. LEITON: We've got an entire 

3 chapter in the procedure manual that's 

4 dedicated to how we process consequential 

5 illnesses.

6 I could take some time to go through 

7 that, but I don't know that -- I mean, I think 

8 that if everyone reads the procedure manual 

9 chapter, that might be easier first and then if 

10 there are questions afterwards, I am happy to 

11 answer them.

12 But, it's pretty straightforward 

13 about how we process them, I think.

14 CHAIR MARKOWITZ: Dr. Sokas?

15 MEMBER SOKAS: And, I think that's 

16 an area where clinician judgment comes into 

17 play and so that the CMC reviews are going to 

18 be important for that.

19 CHAIR MARKOWITZ: Dr. Silver?

20 MEMBER SILVER: At the Oak Ridge 

21 meeting, I had very strong feelings similar to 

22 Dr. Cassano. I'm not used to sitting like a 
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1 potted plant when members of the public come 

2 before us with these stories.

3 And, it may be wishful thinking, but 

4 I seem to recall that we decided to take pure 

5 Part B radiation testimony in our public 

6 comment period and integrate it with the 

7 Radiation Board's tracking system.

8 When Mark Griffon mentioned it at 

9 Oak Ridge or one of our earlier meetings, I 

10 believe we made a decision to integrate our 

11 pure Part B radiation public comments with your 

12 tracking system.

13 You're not on the Board anymore, 

14 it's not your system. It seemed like a great 

15 idea at the time.

16 MEMBER GRIFFON: No, I thought --

17 I'm not exactly sure what was, you know, what 

18 we discussed, but I thought it was the idea of 

19 a model that could be used similarly on this 

20 Board that was used on the other Board.

21 And, I think -- I mean, my 

22 experience on the Radiation Board side of 
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1 things is that, because we always, I think, 

2 have representation from the multiple agencies 

3 at our meetings or at the Radiation Board 

4 meetings, that like questions that came up 

5 yesterday, I know one of them was a site 

6 coverage issue and that's why it got referred 

7 to DOL and the person's frustrated.

8 But, all the folks were there, 

9 including DOE, who ultimately has to do the 

10 research to provide DOL on when this site 

11 coverage periods.

12 So, there is that exchange like if 

13 there's comments that should go to NIOSH, they 

14 know right away, they're there. DOL is also in 

15 the room, so they know, okay, this one should 

16 go to DOL. So, there's good crosstalk on that.

17 But, I don't know that we have -- I 

18 don't know if it would make sense to have one 

19 tracking system, you know, between Boards. 

20 But, it would be a first step towards dealing 

21 with the first bucket of cases that are clearly 

22 radiation. These people are coming to us 
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1 because we happen to be in town and they 

2 shouldn't have to have, you know, fly to your 

3 next Board location to give their testimony.

4 CHAIR MARKOWITZ: So, apparently, 

5 Ms. Rhoads has gotten -- received recently some 

6 -- the system that the Radiation Advisory Board 

7 uses in an email. So, we'll take a look.

8 MS. RHOADS: Just the spreadsheet.

9 CHAIR MARKOWITZ: Oh, okay.

10 (OFF MICROPHONE COMMENTS)

11 CHAIR MARKOWITZ: Oh, okay, okay.

12 Okay, any other comments on this 

13 issue?

14 Yes, Mr. Griffon?

15 MEMBER GRIFFON: Just a last follow 

16 up on that. I'm assuming that as we go and 

17 identify where -- how these are dispositioned, 

18 some of the people -- the staff are going to 

19 say, this is a Department of -- or this is a 

20 NIOSH issue and we'll forward this over to 

21 NIOSH so they can follow through. Yes, so 

22 there's follow through.
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1 So, we don't have to have an 

2 integrated tracking system, I don't think, but 

3 we definitely should forward the disposition to 

4 the appropriate agencies to deal with.

5 CHAIR MARKOWITZ: Dr. Cassano?

6 MEMBER CASSANO: I'm just wondering 

7 if in some instances some of the comments and 

8 the speakers could be dispositioned very 

9 quickly at the meeting if the Ombudsman raises 

10 his hand and goes, you know, I'll speak to her 

11 afterwards or something like that.

12 Or, you know, if it's something 

13 that's of interest to any one subcommittee, the 

14 Chair of that subcommittee say, you know, we'll 

15 take a look at that.

16 And, that way, they get some instant 

17 feedback and instant feeling of, okay, 

18 somebody's actually listening to me.

19 Because, usually, by 6:00 in the 

20 afternoon, we're all sitting here like this and 

21 we may not look like we're as attentive as we 

22 really are.
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1 CHAIR MARKOWITZ: Well, you know, 

2 I'm not entirely sure we can do that because it 

3 involves interaction and some decision making.

4 I understand being attentive and to 

5 make sure people don't feel like they're high 

6 and dry. But, we have to limit the amount of 

7 interaction.

8 Thankfully, the part to maximize the 

9 amount of time they have to make public 

10 comments and also because it's not clear 

11 exactly where a committee might go to.

12 Oh, yes, I'm sorry, did --

13 MS. LEITON: No, I mean, I think I 

14 said it before. We were able to take care of a 

15 couple of them. We're happy to do that when 

16 we're here if there's a case specific thing, we 

17 might be able to help them with.

18 And, I'm sure that Malcolm and his 

19 team are willing to do the same. Sorry.

20 MR. NELSON: Malcolm Nelson, the 

21 Ombudsman.

22 Just to let you know, my office will 
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1 always have a representative at one of these 

2 meetings. We are always going to have a table. 

3 So, always feel free, we generally don't want 

4 to disrupt the meeting, but let people know, as 

5 soon as the meeting is over, we will generally 

6 have somebody manned at that table to assist 

7 anybody who has a question.

8 And, we feel it is our job to assist 

9 people who have complaints. So, you should 

10 never feel like you're imposing on us. If 

11 somebody needs assistance, you can refer them 

12 to us. We will, if appropriate, we will refer 

13 them to the Department of Labor, NIOSH or where 

14 ever.

15 CHAIR MARKOWITZ: Great, thank you.

16 Okay, so let's move on.

17 In our last half hour, I wanted to 

18 spend just talking about issues that we think 

19 the next Board might set as a priority.

20 We can continue this discussion at 

21 the telephone meeting of the Board.

22 But, also, our ideas about our last 
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1 18, 19 months to the extent to which we need to 

2 revise our structure, the way we work, things 

3 that have not worked particularly well or areas 

4 that we can make improvements in.

5 We should discuss that because we've 

6 been -- you know, we can -- the next Board can 

7 benefit from that.

8 So, the floor is open.

9 One issue, I'll kick it off, and I 

10 think the next Board should take a look at, we 

11 started to do this, which is how -- what it 

12 means to say that a condition is aggravated or 

13 contributed to by an exposure.

14 And, we started to do that when we 

15 talked about causation, but we haven't 

16 systematically looked at how the Board --

17 should we have a program that treats that in 

18 its consideration of claims?

19 Aside from just having this blanket 

20 phrase from the statute about contributing, 

21 aggravating or causing. Because that is a very 

22 liberal standard and they mean different things 
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1 for different illnesses.

2 In thinking about COPD, for asthma, 

3 for instance, readily aggravated by any of 

4 these exposures.

5 So, it's a topic I think that the 

6 next Board should look at the program's 

7 function and see how it's treated and whether 

8 there are opportunities to improve their 

9 treatment.

10 Other issues or other aspects of the 

11 Board you think might be improved?

12 Dr. Welch?

13 MEMBER WELCH: Well, I think Garry 

14 already pointed out that we need to revisit the 

15 site exposure matrix at a broad level. 

16 Because, I would say what our subcommittee did 

17 was dive into the question of exposure assess -

18 - sort of broad.

19 The committee was -- the site 

20 exposure matrix committee, what we felt really 

21 we need to look at exposure assessment in 

22 general for the claims process and focus on 
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1 things that are really outside of them SEM 

2 rather than the SEM itself, except for this 

3 idea of adding new causation links.

4 And, partly, that's because the --

5 it's a little -- it's kind of an overwhelming 

6 project, the SEM.

7 But it -- but I think probably that, 

8 depending on what the composition of the next 

9 Board is, either this Board -- because there's 

10 a lot of turnover then, but would probably help 

11 to have this Board or our subcommittee make a 

12 list of some of the important points that we 

13 know have been raised by comments or in 

14 discussion that keep coming up.

15 Otherwise, if it's a big -- not that 

16 much turnover in the Board, then the actual 

17 memory of the people on the Board about the 

18 discussions would probably suffice for that.

19 CHAIR MARKOWITZ: Dr. Redlich?

20 MEMBER REDLICH: You know, I would 

21 just hope that continued look at the data. 

22 And, I know there's data in different forms and 
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1 I had spent a lot of time looking at the 

2 available data from the various sites on the 

3 internet.

4 The analysis that Dr. Dement did of 

5 the data we were given was, by far, the most 

6 useful in terms of understanding, you know, 

7 where to focus efforts.

8 And, given the magnitude of this 

9 system and, you know, exposures and everything 

10 we've been talking about, I do think our giving 

11 where the majority of the claims are, the 

12 majority of potential problems can just help 

13 focus efforts or prioritize efforts.

14 And, what I recognize, you know, 

15 that all data has issues and problems, despite 

16 that, and it's a complicated data set 

17 obviously.

18 But, I really think that can really 

19 help.

20 CHAIR MARKOWITZ: That's an 

21 excellent point.

22 Dr. Cassano?
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1 MEMBER CASSANO: I think the 

2 combination of our two subcommittees will 

3 greatly help the work of both of them.

4 I think the direction that we need 

5 to go is actually in looking again at the whole 

6 process and where the weak links are in the 

7 entire process from CE to CMC and then the 

8 feedback back to them to see where that needs 

9 to be, what pieces need to be improved.

10 Obviously, some of that is dependent 

11 upon what presumptions get accepted and what 

12 other issues in our recommendations get 

13 accepted and some of the issues that we saw.

14 And, I think both of our 

15 subcommittees would go away. But, we still 

16 know we're going to have problems. And so, I 

17 think that's the direction we need to go.

18 CHAIR MARKOWITZ: Dr. Silver?

19 MEMBER SILVER: In dealing with 

20 exposure assessment, I think we'd all agree 

21 that it can't be done well unless a claimant's 

22 employment history is well documented.
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1 And, we have seen how DOE has made 

2 great progress over the last 15, 20 years. 

3 Greg Lewis was at our meeting in October and 

4 was pretty impressive.

5 But, at each of our meetings, Ms. 

6 Blaze has submitted public comments about an 

7 ongoing situation at Santa Susanna where we 

8 can't even take for granted that first step of 

9 the exposure assessment process documentation 

10 of employment.

11 So, at some point, when we look at 

12 exposure assessment, we should revisit that 

13 issue.

14 CHAIR MARKOWITZ: Ms. Vlieger?

15 MEMBER VLIEGER: One of the areas 

16 under the program that we have never discussed 

17 is the durable medical equipment authorization 

18 and also the related services for DME, personal 

19 use DME and modifications to the home.

20 Sometimes this process is akin to 

21 getting a government contract and it can be 

22 quite burdensome to a client who's never done 
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1 any of that type of work.

2 The requirement to have the 

3 documents to back up the request, I understand. 

4 But, it is a burdensome program, even just to 

5 get oxygen once it's prescribed is burdensome 

6 on the employee.

7 So, I think if we could discuss 

8 that. I think we have an example here at the 

9 table of a claimant who cannot get a portable 

10 oxygen concentrator and not through some 

11 effort.

12 CHAIR MARKOWITZ: And, you know, the 

13 board bronchitis.

14 That would be a weighing medical 

15 evidence issue, is that where it would get?

16 MEMBER CASSANO: I believe at the 

17 very first meeting, there was quite a 

18 discussion about DME and the authorization for 

19 DME and that the Board -- that the DOL was 

20 having issues.

21 I think John Vance spoke about that 

22 and that how they did sort of want our input 
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1 into how that authorization -- I think 

2 primarily from the aspect that it's costing 

3 them a whole heck of a lot of money. Some of 

4 it may be legitimate and a lot of it may not 

5 be.

6 And so, it is -- oh God -- I guess 

7 it does come under our subcommittee unless we 

8 somehow want to, as you say, reorganize so that 

9 there are a specific group of people that look 

10 at the whole DME question.

11 Because, we've got a lot to do, I 

12 think. And, well, I'm -- it does fall in our 

13 purview in some way, I think it may benefit 

14 from having a smaller group actually looking at 

15 it.

16 CHAIR MARKOWITZ: This is Steve 

17 Markowitz.

18 The issue wasn't which committee 

19 should go to the issue I was raising, was it 

20 within the scope of the Board's mission. And, 

21 that next Board can determine.

22 We can list it, put it on the radar 
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1 and then say, you know, the next Board will 

2 consider this and make a decision whether it 

3 falls within the scope and then what to do 

4 about it.

5 I think that's --

6 (OFF MICROPHONE COMMENT)

7 CHAIR MARKOWITZ: Yes, no, no, and I 

8 realize it wasn't specific enough.

9 The way medical evidence, to me, 

10 was, you know, task one or two of the mission, 

11 not of a committee. But, I understand.

12 Dr. Sokas?

13 MEMBER SOKAS: And, just to 

14 accompany that, the issue of home care services 

15 in general belongs on that list because that's, 

16 obviously, comes up a lot and is a cost.

17 CHAIR MARKOWITZ: Small issue.

18 Mr. Domina?

19 MEMBER DOMINA: Now that Dr. Sokas 

20 just brought that up about the home health, I 

21 was wondering if Ms. Leiton could enlighten us, 

22 because I know that it seems that when people 
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1 are going through the renewal process right 

2 now, it's taking a fair amount of time.

3 And, I know -- I think we had an 

4 update at the last meeting about what they were 

5 doing to try and speed up the process. 

6 Because, it is important for the people that 

7 have it and then, they end up, they're out in 

8 no man's land when they still need the home 

9 health care.

10 MS. LEITON: So, home health care is 

11 a very big issue in our program, especially as 

12 we accept more claims and we have more elderly 

13 people who need this care.

14 The DMEs are also a big important 

15 issue.

16 So, we have determined in the last 

17 year to centralize our home health care process 

18 so that, when a person is referred to for home 

19 health care, it goes to a specific unit that is 

20 based out of national office.

21 The examiners themselves can be 

22 anywhere in the country, but they report to one 
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1 person in the national office.

2 And, the reason we did that is 

3 because it's become a very growing issue. And, 

4 a lot of home health care companies, a lot of 

5 issues surrounding it.

6 So, we centralized the process. We 

7 are looking at ways to make it more efficient. 

8 We're consistent in the way we adjudicate these 

9 claims.

10 In the process of doing that, we 

11 have had delays. And, we've identified those 

12 delays. We've worked with a couple of home 

13 health care companies who have given us lists 

14 of cases that have had problems.

15 And, we are working to -- we've 

16 actually got a project going right now to make 

17 sure that anything that might have fallen 

18 through the cracks in the midst of this 

19 transition, has been either authorized or --

20 well most -- anything that fell through the 

21 cracks that didn't -- that have a missing

22 authorization has been corrected at this point.
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1 And, we're notifying everybody about 

2 what the procedures are, what documentation we 

3 need and identifying the areas that will help 

4 us avoid any further delays moving forward.

5 I believe that any backlogged or

6 lapsed authorizations have been fixed at this 

7 point and we have identified ways to ensure it 

8 doesn't happen in the future.

9 MEMBER DOMINA: Just a quick follow 

10 up. So, you got -- so there's nobody, I guess, 

11 out there in no man's land, for lack of a 

12 better term? So, you're pretty much caught up 

13 or --

14 MS. LEITON: I believe that we are. 

15 I was expecting to have all of the cases 

16 identified and any lapses completed by this 

17 Board meeting. I haven't got the staff's 

18 update today, but I'm fairly certain and fairly 

19 confident in saying that any gaps that occurred 

20 have been corrected.

21 MEMBER DOMINA: So, is it possible 

22 for you to forward those to Dr. Markowitz 
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1 whether they could be distributed if that --

2 MS. LEITON: I would need to check 

3 with the DFO to see if this is really within 

4 the scope of the Board at this point.

5 MR. FITZGERALD: Yes, I kind of 

6 question whether or not this whole issue is in 

7 scope here. Looking at the four areas of 

8 investigation the Board is authorized in and 

9 chartered to look into, I'm not sure exactly 

10 where that falls in the category.

11 I know it's an area of interest for 

12 advocates and for anybody in the community, but 

13 I'm not sure this is proper forum for that.

14 CHAIR MARKOWITZ: I think Ms. 

15 Vlieger is next?

16 MEMBER VLIEGER: I'm going to 

17 respectfully disagree with the DFO and Ms. 

18 Leiton because these are determinations that 

19 are made based on medical opinion to the claims 

20 and whether or not the medical opinion and 

21 supporting documents are sufficient. I believe 

22 it still falls under the purview of the Board.
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1 MR. FITZGERALD: I wouldn't be 

2 taking issue with the fact about the medical 

3 determination or the weighing of medical 

4 evidence in these cases.

5 I think the issue is whether or not 

6 the program is processing the renewals.

7 CHAIR MARKOWITZ: Thank you.

8 Dr. Redlich, did you have a comment?

9 One thing I think that the new Board 

10 should do is we look at the most commonly 

11 denied claims, the list of the conditions which 

12 are most commonly denied to the extent that 

13 those data are available.

14 And, secondly, I think that one of 

15 the areas that the Board should look at is the 

16 neurologic illness. We see it in the procedure 

17 manual and Parkinson's disease.

18 We've had public commenters discuss 

19 it. Ms. Vlieger's mentioned toxic 

20 encephalopathy.

21 It's a very difficult area. It's 

22 much more difficult than respiratory disease or 
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1 cancer and the like, but it's common. The 

2 exposures were common in the workplace as DOE. 

3 And, I think the Board should take a 

4 substantive look at it and see if --

5 And, this is brought home in part by 

6 one of the comment -- public commenters 

7 yesterday, the neuropsychologist who spoke 

8 about this.

9 So, I -- to me, I would list it as 

10 one of the priority areas for consideration.

11 Dr. Redlich?

12 MEMBER REDLICH: I would just second 

13 that. And, from the lung data we looked at, 

14 there were clear changes in trends, you know, 

15 more asthma, COPD cases, less beryllium.

16 So, I think seeing where to -- what 

17 are the most common and uncommonly denied would 

18 be very helpful.

19 CHAIR MARKOWITZ: How about the 

20 functioning of the Board? I just want to open 

21 this up, we only have a few minutes left, but I 

22 would, in part, just to stimulate your thinking 
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1 over the next couple months.

2 Are there ways in which we should be 

3 structuring this different or functioning 

4 differently in terms of communication, decision 

5 making or the like?

6 Dr. Cassano?

7 MEMBER CASSANO: I think there was a 

8 suggestion a while ago that, in addition to all 

9 the subcommittee meetings that there be a phone 

10 -- some type of phone meeting between the 

11 Chairs of the different subcommittees in 

12 between so that we all knew what the other 

13 subcommittees were doing so there was no 

14 duplication of effort.

15 And, I think in all of the other 

16 work that we had to do, that sort of got 

17 dropped.

18 Some of our issues are going to go 

19 away because we're now combined. But, it's 

20 still nice to know like the issue with the CMC 

21 that you had a problem with. If we had known 

22 about it or Rosie had known about it, they may 
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1 have looked at more cases or something like 

2 that.

3 So, I think that's helpful in that 

4 we're not duplicating effort and not -- and if 

5 there's information that can be shared between 

6 the two subcommittees in between a large Board 

7 meeting to further our work, I think it becomes 

8 important.

9 CHAIR MARKOWITZ: Other comments?

10 (NO RESPONSE)

11 CHAIR MARKOWITZ: So, just to review 

12 then what we're going to do in the next two13 plus months, I guess we have until mid14 February.

15 I think we're going to need to have 

16 our telephone Board meeting, if we can, close 

17 to the end of January because we're going to 

18 need a little bit of follow up time after that.

19 And, the end of January would be the 

20 latest. We need six weeks prior for the 

21 publication in the Federal Register. So, if 

22 you work six weeks back from the end January, 
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1 then you're coming very close to where we are 

2 now.

3 So, we're going to have to set that 

4 meeting soon.

5 We're going to have an SEM 

6 Subcommittee meeting before that, so that then 

7 will be set presumably a week or so before the 

8 full Board meeting.

9 And then, there's work to do in 

10 terms of writing up our comments on the 

11 responses.

12 We will receive hopefully responses 

13 to our April 2017 recommendations which are, I 

14 think, there were only two. And so, we will 

15 discuss that at the telephone -- at our 

16 telephone Board meeting.

17 Is there any other piece of work 

18 that I've -- and then, we need to write up kind 

19 of our ideas of what recommendations for the 

20 next constituted Board might want to take a 

21 look at and change.

22 Anything other work we need to do 
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1 besides celebrate the holidays?

2 Dr. Silver?

3 MEMBER SILVER: I know it's an iffy 

4 proposition, but if we do get reappointed and 

5 we meet again in person, it would be nice to 

6 have a couple of outsiders turbo-charged topics 

7 for us with presentations.

8 We did a little of that in D.C., but 

9 have we ever had a presentation from the 

10 Ombudsman's Office?

11 (OFF MICROPHONE COMMENTS)

12 MEMBER SILVER: Yes, well, you know, 

13 a refresher might be in order and I think the 

14 new Board would appreciate that.

15 And, New Mexico has a State Office 

16 of Nuclear Worker Advocacy. They are swamped 

17 with cases, but if there are others like that 

18 around the country who, you know, have the 

19 track record and were looking to this Board for 

20 solutions, we should consider working with them 

21 in advance to give a brief presentation and, 

22 you know, shake the cobwebs out.
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1 CHAIR MARKOWITZ: Dr. Redlich?

2 MEMBER REDLICH: We haven't 

3 interacted with any physicians from the 

4 Department of Labor. I'm not great with names, 

5 so I don't know who the government person is, 

6 but I think that would be helpful.

7 MS. LEITON: That would be Dr. 

8 Armstrong. I know that he's interacted with 

9 the subcommittee. I'm sure that we could 

10 arrange something, if that's what the Board 

11 wants.

12 MEMBER REDLICH: Because I think 

13 that at least the current manual suggests that 

14 -- I know you've used expert -- physician 

15 experts to help develop that, but it raises 

16 questions about the expertise of whoever you 

17 have been using in the past.

18 MS. LEITON: So, I think there's a 

19 couple of things. Dr. Armstrong is fairly new 

20 to our program -- to OWCP.

21 So, when I referenced other outside 

22 medical consults, there have been a number from 
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1 various universities helping us with beryllium 

2 disease and things like that.

3 So, I'm not sure how that would be 

4 addressed. We can talk about it.

5 MEMBER REDLICH: And, I suspect part 

6 of it is when a document gets revised many 

7 times, it can morph into something different 

8 than --

9 MS. LEITON: Yes.

10 MEMBER REDLICH: -- the original.

11 CHAIR MARKOWITZ: Any other comments 

12 or questions?

13 Mr. Whitley?

14 MEMBER WHITLEY: I'd almost -- I 

15 know we don't set the date because of it being 

16 a new Board, but I would hope that at least 

17 some of the Board will be on the -- because of 

18 continuity.

19 I'd almost think that our next --

20 the next meeting, the recommendation for this 

21 Board's next meeting might need to be back in 

22 Washington.
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1 I know it's very helpful and very 

2 good to go to sites and, not that we shouldn't 

3 go to sites after that, but it's a -- let's 

4 just assume it's part of the new Board. We've 

5 got new people in Washington and these things 

6 we're asking for like the doctors and all that, 

7 that's where they are.

8 So, it would be real easy to get 

9 presentations, meet them and do that, if you 

10 had -- and it would be the new Board.

11 And so, I'm just -- this is a 

12 suggestion and it's really just a 

13 recommendation from this Board because it's a 

14 new Board.

15 CHAIR MARKOWITZ: Dr. Cassano?

16 MEMBER CASSANO: I think it might 

17 also be useful to have a presentation from 

18 somebody from the Radiation Board just to see 

19 how not only how they do business, but also 

20 maybe some -- I know we're sort of -- we're a 

21 unified set of null, but that may not be true.

22 I think there may be some issues 
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1 that cross over in general. So, that might be 

2 useful.

3 CHAIR MARKOWITZ: Any other 

4 comments?

5 So, later, I'll ask you what you 

6 what you mean by unified set of null.

7 (OFF MICROPHONE COMMENTS)

8 CHAIR MARKOWITZ: Okay, thank you.

9 So, we're going to close now. I 

10 just want to thank the Board members. You 

11 know, this meeting, I think, again, illustrates 

12 how complimentary the experience of people 

13 around the table, the people who worked at the 

14 DOE sites for decades, people who have 

15 represented DOE workers in the process, 

16 scientists and physicians who have worked on 

17 these issues for a long time and even those who 

18 are more recent, just how complimentary we've 

19 been able to work together in addressing 

20 important issues within the program.

21 So, I want to thank you for that.

22 MR. FITZGERALD: I also wanted to 
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1 thank the Board for all their hard work on 

2 behalf of the Department. It's very helpful.

3 I want to thank all the public 

4 participation we had. It really helped make 

5 the meeting much more full and rich, I believe.

6 And, if there's nothing else did you 

7 want to add anything else before I --

8 CHAIR MARKOWITZ: I wanted to thank 

9 Ms. Leiton, actually, for sitting on the hot 

10 seat with us for a day and a half, Mr. Nelson 

11 for coming and being available and for his 

12 expertise.

13 And, of course, Doug and Carrie for 

14 their work with us. And, Kevin Byrd and his 

15 group for the support working with us.

16 And, if I forgot to thank anybody 

17 else, forgive me.

18 MR. FITZGERALD: And, with that, we 

19 adjourn this meeting. Thank you.

20 (Whereupon, the above-entitled 

21 matter went off the record at 10:54 a.m.)