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U.S. DEPARTMENT OF LABOR

+ + + + +

ADVISORY BOARD ON TOXIC SUBSTANCES 

AND WORKER HEALTH

+ + + + +

MEETING

+ + + + +

TUESDAY

JUNE 16, 2020

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The Board met via telephone at 12:00 

p.m. Eastern Standard Time, Steven Markowitz, 

Chair, presiding.

MEMBERS

SCIENTIFIC COMMUNITY

JOHN M. DEMENT

GEORGE FRIEDMAN-JIMENEZ

MAREK MIKULSKI

KENNETH Z. SILVER

MEDICAL COMMUNITY

MANIJEH BERENJI

ROSE GOLDMAN

STEVEN MARKOWITZ

CARRIE A. REDLICH
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CLAIMANT COMMUNITY

KIRK D. DOMINA

RON MAHS

DURONDA M. POPE

CALIN TEBAY

DESIGNATED FEDERAL OFFICIAL

MICHAEL CHANCE
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C-O-N-T-E-N-T-S

Welcome/Introductions ......................... 4

Review of Agenda ............................. 15

DEEOIC Updates ............................... 17

Parkinson's and Related Diseases --

Report and Review of Proposed

Recommendation.......................... 29

Asbestos Job Titles -- Report and Review of

Proposed Recommendation................. 48

SEM -- IARC Group 2A Carcinogen -- Report .... 81

Board Resources Request ..................... 109

CMC and IH Assessment ....................... 118

Claims Review (lung cancer, post-1995 claims)130

DOL Request for Assistance B Provider 

 Outreach .............................. 161

Work Plan ................................... 184

Additional Issues ........................... 186
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P-R-O-C-E-E-D-I-N-G-S

12:12 p.m.

MR. CHANCE: All right. Thank you 

very much. Good morning, everyone. Actually 

good afternoon for many on the East Coast. My 

name is Michael Chance. Today is June 16th, 

2020. I'd like to welcome you to today's 

teleconference meeting, the Department of Labor's 

Advisory Board on Toxic Substances and Worker 

Health. I'm the Board's Designated Federal 

Officer or the DFO.

We appreciate the work of our Board 

members in preparing for today's meeting and 

their forthcoming deliberations. We are 

scheduled to meet today from noon, we had a 

little bit of a late start, until 5:00 Eastern 

Time. There will not be a public comment period 

for this particular meeting.

Today, as you are aware, like our 

April meeting, this meeting will be completely 

virtual as a precaution against the COVID-19 

pandemic. We of course hope everyone is staying 
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safe out there and taking proper precautions as 

this format is designed to ensure. I'm joined 

virtually by Carrie Rhoads from DOL and Kevin 

Bird from SIDEM who is our contractor. I 

appreciate Kevin's work in helping to pull all of 

this together.

For the timing, we shall take a break. 

The agenda is up on the WebEx at the moment. For 

those of you who are signed into the WebEx, we 

will have a break. Please consult the agenda as 

break times are listed. Copies of all meeting 

materials and any written public comments are or 

will be available on the Board's website under

the heading, Meetings, and the listing there for 

the subcommittee meetings.

The documents will also be up on the 

WebEx screen so that everyone can follow along 

with the discussion. Please visit the Board web 

page for additional information where after 

today's meeting, you'll see a page dedicated 

entirely to the meeting. Web page contains 

publically available materials submitted to us in 
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advance of the meeting. We publish any materials 

that are provided to the subcommittee.

There you will also find today's 

agenda. If you are having a problem, please 

email us at energyadvisoryboard, that's all one 

word, @dol.gov. If you're joining by WebEx, 

please note that the session is for viewing only. 

It will not be interactive. The phones will 

also be muted for non-Advisory Board members.

Please note that this is a new way of 

conducting meetings. We ask that you be patient 

as we work out all of the technological issues. 

But I think we had a pretty good meeting in 

April, and this format worked out well.

About meetings, minutes, and 

transcripts, there is a court reporter. There 

will be a transcript, and minutes will be 

prepared from today's meeting. During the Board 

discussions today, as we are on a teleconference 

line, please speak clearly enough for the 

transcriber to understand.

When you begin speaking, especially at 
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the start of the meeting, please state your name 

so we can get an accurate record of the 

discussions. Also, I'd like to ask our 

transcriber to please let us know if you're 

having issues hearing anyone or with the 

recording. I think we've already had a few 

problems with phones this morning, so let's make 

sure that everybody is properly heard and 

recorded.

As the DFO, I see that the minutes are 

prepared and ensure they're certified by the 

Chair, Dr. Markowitz. And today's meeting will 

be available on the Board's website no later than 

90 calendar days from today per FACA regulations. 

If it's available sooner, they will be published 

before that 90-day period.

Also, although formal minutes will be 

prepared, we'll also be publishing verbatim 

transcripts as I mentioned which are obviously 

more detailed in nature. Those transcripts 

should be available on the Board's website within 

30 days.
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I'd like to remind Advisory Board 

members that there are some materials that have 

been provided to you in your special -- in your 

capacity as special government employees and 

members of the Board which are not for public 

disclosure and cannot be shared or discussed 

publically included in this meeting. Please be 

aware of this as you continue on with the 

meeting. These materials can be discussed in a 

general way which does not include using any 

personally identifiable information such as 

names, addresses, and facilities that the case is 

being discussed or doctors.

And another extra word of caution 

today for everybody is regarding the 

nondisclosure agreements. Recently Board members 

have been granted access to redacted contract 

information that the energy program has with

contractors to provide expert opinions from 

industrial hygienists. Board members will soon 

have access to a contract with the contract 

medical consultants as well.
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Please be mindful that the Board 

members signed the nondisclosure agreements or 

NDAs to get access to these contracts so the 

terms of these contracts cannot be disclosed or 

discussed in a public meeting. These are better 

discussed in working groups, so please keep that 

in mind as we proceed with the meeting today. So 

thank you for bearing with me and getting through 

my opening script. With that, I now convene the 

meeting of the Advisory Board on Toxic Substances 

and Worker Health, and I will now turn over the 

meeting to Dr. Markowitz.

CHAIR MARKOWITZ: Thank you, Mr. 

Chance. And I want to -- the Advisory Board. 

Welcome to the members of the Board. Welcome --

and also welcome to the members of the public. 

Whether we have members of the public online --

MEMBER GOLDMAN: There's a tapping 

sound.

CHAIR MARKOWITZ: I'm sorry?

MEMBER GOLDMAN: There was a tapping 

sound when you were talking, Steve.
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MR. BIRD: Yes, Dr. Markowitz, it 

sounds like you might have a bad audio connection 

kind of cutting out.

CHAIR MARKOWITZ: That's not good. Is 

it still cutting out?

MR. BIRD: Yeah, there's like kind of 

a strange like tapping or repeating sound that's 

kind of in the background. It makes it hard to 

hear you.

CHAIR MARKOWITZ: Yeah. Well I'm 

going to -- you want me to just call back in and 

see if I get a better connection?

MR. BIRD: Yeah, I think -- I don't 

know. I'll let Carrie make that call and 

Michael. Excuse me. But I think, excuse me, it's 

going to be very hard to hear you.

MS. RHOADS: Yeah, you're cutting in 

and out in the middle of your sentences. So 

maybe try another line.

CHAIR MARKOWITZ: If I speak like 

this, or is this the same?

MS. RHOADS: I can hear you that time. 
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I still hear the tapping sound. 

CHAIR MARKOWITZ: You still -- okay. 

Well -- okay. So just give me a moment.

MS. RHOADS: Okay.

(Pause.)

MR. BIRD: And Carrie, if this doesn't 

fix his issue, I can try to call him and then 

conference him in or something like that.

MS. RHOADS: Okay. Hopefully we'll 

get a better line this time.

CHAIR MARKOWITZ: Am I in now?

MS. RHOADS: Yes, and I don't hear a 

tapping sound yet.

CHAIR MARKOWITZ: Okay. Well that's 

good.

MS. RHOADS: Good.

CHAIR MARKOWITZ: Okay. So let me 

know if there's a problem. So I was just asking 

Calin whether -- do we know whether we have 

members of the Board on the call -- oh, excuse 

me, the public?

MR. BIRD: We can ask the operator. 
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We do have members of the public tuned into the 

WebEx though. So --

CHAIR MARKOWITZ: Okay, okay. Well 

that's good. That's all I wanted to know. So 

just to point out particularly for members of the 

public. For some of the materials -- for the 

agenda but also for some of the materials that 

we're going to review today, all of which will be 

shown on the WebEx.

But if you want to access them 

otherwise, they're on our meeting website. You 

just have to go to the Advisory Board's website 

to today's meeting. And at the bottom, you'll 

see briefing book materials and the various 

materials will be listed. The minutes from the 

last meeting are not yet available but will be 

available shortly.

So let's do introductions from Board 

members and then we'll review the agenda. So I'm 

Steven Markowitz. I'm an occupational medicine 

physician, an epidemiologist at the City 

University of New York.
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MS. RHOADS: Do you want me to go down 

the list?

CHAIR MARKOWITZ: Yeah, if you could, 

Carrie. That'd be great.

MS. RHOADS: Sure. Okay. Dr. Dement?

MEMBER DEMENT: I'm John Dement, 

professor emeritus in the Duke University School 

of Medicine, industrial hygiene and epidemiology.

MS. RHOADS: Thank you. Mr. Domina?

MEMBER DOMINA: Kirk Domina, I'm the 

employee health advocate for the Hanford Atomic 

Metal Trades Council in Richland, Washington.

MS. RHOADS: Thank you. Dr. Goldman?

MEMBER GOLDMAN: I'm an occupational 

environmental medicine physician at Cambridge 

Health Alliance and also associate professor at 

Harvard Medical School and Harvard School of 

Public Health.

MS. RHOADS: Thank you. Mr. Mahs?

MEMBER MAHS: I'm Ron Mahs. I'm a 

former employee at all three plants at Oak Ridge 

representing the building trades at AFL-CIO.
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MS. RHOADS: Thank you. Dr. Mikulski?

MEMBER MIKULSKI: Marek Mikulski, 

University of Iowa College of Public Health, 

occupational epidemiology.

MS. RHOADS: Okay. Ms. Pope?

MEMBER POPE: Duronda Pope, a former 

worker of Rocky Flats and currently with the 

United Steelworkers Union.

MS. RHOADS: And Dr. Redlich?

MEMBER REDLICH: I'm an occupational 

environmental medicine and pulmonary physician on 

the faculty at Yale School of Medicine and the 

School of Public Health. And I'm director of the 

Yale Occupational Environmental Medicine Program.

MS. RHOADS: Thank you. Dr. Silver?

MEMBER SILVER: Ken Silver, associate 

professor of environmental health in the College 

of Public Health at East Tennessee State 

University, about 100 miles east of Oak Ridge. 

Before coming to ETSU, I worked very closely with 

families, congressional offices, and 

organizations to campaign for EEOICPA and the 
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Part E amendments.

MS. RHOADS: Thank you. Mr. Tebay?

MEMBER TEBAY: Calin Tebay, Hanford 

Workforce Engagement Center representative and 

site-wide beryllium health advocate at Hanford.

MS. RHOADS: Okay. And Dr. Berenji, 

are you on the call yet?

(No response.)

MS. RHOADS: Okay. How about Dr. 

Friedman-Jimenez?

(No response.)

MS. RHOADS: Okay. That's everybody.

CHAIR MARKOWITZ: Okay. Thank you. 

So let's just review the agenda. Let me say this 

is the final full Board meeting of the Board's 

term which ends end of July. Our hope this 

meeting is to vote on certain recommendations 

that we can vote on but also to discuss if 

there's other issues, make additional progress. 

And I expect over the next four weeks, we'll be 

able to do some additional work so that we can 

hand off various issues to the next Board in a 
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suitable fashion.

First we'll hear some updates from the 

program, and then we will discuss the report and 

recommendation on Parkinson's-related disorders 

led by Dr. Mikulski. If Dr. Berenji joins us, 

we'll hear a report on the IARC Group 2A 

carcinogens in relation to the Site Exposure 

Matrices. If not, we'll discuss that regardless 

but probably in less detail. And then I'll lead 

a discussion on job titles related to asbestos 

and a recommendation.

We'll take a break. Let me add that 

all our time frames here are entirely 

approximate. It's really just guessing how much 

time each topic would take. We certainly will 

finish by 5:00 p.m. So I don't expect a problem. 

We'll take a break, and then we'll discuss the 

very preliminary language on resource request 

that the Board has discussed in the past. And 

then we'll discuss again just some draft language 

relating to the assessment of the contract 

medical consultants and the industrial 
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hygienists.

We'll discuss and review claims that 

we received, some 20 or so lung cancer claims. 

And I don't recall the number of post-1995 

claims, but about 10 of those actually. We will 

discuss the Department of Labor's request for us 

to look at the development letters that they send 

to providers to see if we can help them improve 

the response from providers, and then any 

additional issues that would arise. And we'll 

finish with the work plan for the last month of 

the Board's term. Are there any additional items 

anybody would like to add?

(No response.)

CHAIR MARKOWITZ: Okay. So let us 

begin with the report from the program. I think, 

Ms. Pond, are you on the phone or Mr. --

(Simultaneous speaking.)

MS. POND: I am.

CHAIR MARKOWITZ: Great.

MS. POND: This is Rachel Pond. Thank 

you for the opportunity to provide some brief 
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updates about the program and address a couple of 

Board issues this morning. I'm just going to go 

ahead. I'm going to probably just start with 

just some general updates about what we've been 

up to and then address some Board activities.

First, I just wanted to mention -- and 

I may have mentioned this last time but I'm not 

sure. But we did undergo -- at the end of March, 

we underwent a new case assignment process for 

the way that we assign cases to our district 

offices. We actually instituted this similar 

process in our FAB offices a couple of years ago, 

and it has worked fairly well.

Historically we used to assign cases 

according to where the latest state of employment 

was. So if they were in Paducah, it went to 

Jacksonville. It they were in Denver or Rocky 

Flats, for example, their cases went to our 

Denver offices. And that was pretty appropriate 

and necessary early in the program only because 

we had -- we wanted to make sure that people 

could develop specialties in those particular 
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facilities, and we were doing a lot of traveling, 

a lot of outreach. And we could send targeted 

people to places close to those district offices.

However, as the years have progressed 

and the program has expanded a little bit, we 

determined that those jurisdictional lines aren't 

necessary. And this will allow for a wider 

variety of examiners reviewing cases. It also 

allows for hiring flexibility so that we -- we 

were starting to decrease in certain areas like 

in our Cleveland office. We weren't getting as 

many claims.

And in our Denver office, this way we 

can even that out. We were not overworked in one 

office and underworked in another, or basically 

we can evenly distribute those claims all the way 

across the country. It seems to be working 

fairly well so far.

We did have a series of trainings for 

all of our district office staff who are working 

on these claims, meaning that we have specialists 

who knew a lot about certain plants and certain 
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facilities. And they would go and give 

presentations to the district offices about those 

particular sites so that when they're developing 

claims, they have a better understanding of the 

unique particulars of those sites and those 

areas.

So that's been going well. And we 

also continue to have specialists who are POCs, 

for example, points of contact for those sites if 

claim managers around the country have questions. 

I just wanted to mention that because it's 

something I think that authorized reps around the 

country are noticing. And it's just because you 

may not -- people always expect that they'll go 

to Jacksonville if they've worked at a particular 

site in that area. So that has changed.

I also just wanted to acknowledge some 

of the things that we have done related to the 

current COVID-19 emergency. We have gone to 

complete telework for all of our district office 

staff. Luckily, we have digitized all of our 

case files, at least most of them in terms of 
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active cases files have been digitized for years 

and so they're paperless. And people can review 

case files online.

We do have some historical cases and a 

lot of them actually. We've had a project going 

for the last year or two to turn all of our old 

case files into paper. So a lot of that's been 

done. And those that have not been done, we've 

been able -- we have contractors that are still 

working on turning those into -- the paper into 

digitized case files. And so whenever a case 

file is needed, we've been able to do that. So 

honestly, it's going to safe to remain at home 

and still do their job.

We also have an interactive voice 

response system for our phone calls which means 

that any phone calls that come in can be 

transferred to -- it'll go into the claims 

examiners' phone lines and then transferred into 

whatever number they want to forward it to 

without revealing phone numbers -- personal phone 

numbers.
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So that's been working very well. 

I've been happy to be able to report that our 

quality remains constant. Our timeliness has 

been fairly constant as well. We still do rely 

on other records from Department of Energy. And 

there's been some record centers that aren't able 

to provide records. So we are allowing for that. 

Some physicians that aren't able to provide 

support because they can't see a patient were 

also allowing some leeway in terms of deadlines 

for those activities.

That being said, we also did publish a 

couple of bulletins that will allow for temporary 

use of telemedicine during this time, which means 

that for face-to-face examinations in order to 

authorize payment, we normally -- I'm sorry, for 

home healthcare, we normally require face-to-face 

examinations in the last 60 days. And we, during 

this time, are waiving that and under certain 

circumstances, if a physician wants to do 

telemedicine, as long as that physician has the 

state licensing requirement for telemedicine and 
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other specifics are met, they can provide it with 

those reports based on a telemedical examination. 

We also are allowing for that to occur with 

routine physician appointments in certain 

circumstances where the physician feels like it 

would be unsafe to see the patient in the office.

We have also had some changes to our 

resource center hours in terms of what's open. 

We had to close all of our resource centers, but 

our resource center staff are still working. 

They have also been able to telework. They've 

been answering phones from a remote location. 

Just as I explained, that we were able to do that 

with our district office staff. They are able to 

do that through our interactive voice response 

system, and that has been working well.

As well they've been able to talk 

through claims information, intake claims. 

They've been going into the office around the 

country one day a week to gather any document 

that claimants want to submit. They've been 

dropping them outside the door. And we've been 
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able to pick them up and process those. 

Effective next week, our resource centers will 

still be closed. But we will have staff going in 

every day, at least one person in the office per 

day, to be able to talk to claimants, answer 

phones, and those sorts of things.

So that's -- we've also changed from -

- well we're not having any in-person hearings 

for our hearing reps and people who want to have 

hearings. So those have been revised to only 

WebEx or telephone hearings during this time 

period. So I'm happy to report we've been able 

to continue to work and things have been going 

fairly well during this time.

I also just wanted to mention that we 

have not been doing so much outreach. So we are 

going to try to do a webinar, a stakeholder 

update June 25th. That information has gone out 

to our provider -- our email blast group for 

claimants and whoever signed up for those. We 

will be getting more information about that out 

on our website hopefully this week as well.
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So that's basically kind of a very 

brief update of some of the things going on with 

us. In terms of Board activities, we did receive 

some recommendations based on the last meeting 

that were related to the OHQ. We have reviewed 

those recommendations. They are currently in 

clearance within the Department. I hope to have 

that out very shortly. But we are making some 

changes to our OHQ that we hope to start piloting 

soon.

With regard to the March 5th letter 

from the Board, recommendation to change the 

language in Exhibit 15-4 related to asthma, we 

did make some changes and provided a May 1st 

response. I've got a reference to mechanism of 

disease but kept some of the other language. 

I've also gotten a lot of data requests from the 

Board.

We've provided -- as Dr. Markowitz 

alluded to, we've provided some cases regarding 

lung cancer and cases with post-1995 IH reports. 

We've also sent in a lot of development letters 
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to try to give the Board an idea of what we're 

sending out with regard to asking physicians for 

documentation.

And we've sent out -- we've received a 

request for the contract which we just very 

recently have been able to get out to you. 

Andthen there was some information that had been 

requested on the Site Exposure Matrices, which we 

have -- we've provided a response and we're 

working on gathering more information related to 

that data request. Those are the updates I have. 

I'm happy to take any questions from the Board 

regarding any of those things and anything else.

CHAIR MARKOWITZ: Thank you. And 

thanks also for the timely response to our 

various requests. I just have a quick question. 

If I understand it correctly, the district 

offices around the country will be handling cases 

from other geographic areas around the country. 

And I assume that each district office develops 

some degree of experience and expertise at the 

particular sites which fall within their 
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geographic area, that the claims examiners get to 

know those particular DOE sites and et cetera.

So my question is, I understand the 

advantage of flexibility of being able to handle 

claims at other district offices. But is there 

any chance that there's some loss of expertise or 

experience at the particular DOE sites? And if 

so, how do you address that?

MS. POND: So as I mentioned, we 

didn't actually consider that when we made this 

change. And that's why we did some expensive 

training before the change occurred. We had 

specialists, people who are particular 

knowledgeable in each of the district offices 

related to specific sites. And they gave 

presentations to the other district offices with 

regard to what to look for related to those 

sites.

We've maintained those points of 

contact so that if claims examiners around the 

country had questions, they can go to this person 

and obtain more information. We also maintained 
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some books full of information in each district 

office that has specific information related to 

what to look for at these sites so that those 

have all been shared nationwide. And people can 

reference those to look up, well in this 

particular location, you need to look out for 

certain types of records. I mean they get pretty 

detailed in terms of what claims examiners should 

be looking for.

So yes, while I see that some 

expertise having known certain sites for a long 

time, it may be lost in this transition. I think 

that we've put mechanisms in place to be able to 

address that and work with each other to make 

sure that the knowledge is being shared.

CHAIR MARKOWITZ: Okay. Thanks. Any 

other questions from the Board members? Okay. 

Thank you very much.

MS. POND: All right. Thank you.

CHAIR MARKOWITZ: Let's move on. 

Kevin, if you could put up the PowerPoint that I 

sent you yesterday. Dr. Mikulski -- also Kevin, 
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if you could have handy the Word file that is the 

complete recommendation and rationale of Dr. 

Mikulski's group, although I think if we just 

show initially the PowerPoint, that would be the 

best way to start. So Dr. Mikulski?

MEMBER MIKULSKI: Thank you. This is 

Marek Mikulski. Kevin, can you go to the next 

slide please? I will briefly go over the revised 

test of the recommendations. And afterwards, we 

can open the floor to comments and edits and 

hopefully vote on the final text of the 

recommendations to submit to the Board.

So the first set of questions that the 

Board was asked to advise on was related to the 

diagnosis and the terminology of Parkinsoniantype disorders. And we were asked specifically 

about differentiation between manganism and 

Parkinson's disease. Can you move to the next 

slide please?

We recommend that for the purposes of 

claim adjudication or the clinical diagnosis of 

Parkinsonism as established by a clinician be 
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treated the same as a diagnosis of Parkinson's 

disease. This combining of diagnosis and the 

following recommendation is based on the lack of 

biomarkers or valid clinical diagnostic tests 

that would allow a clear differentiation between 

these disorders. As part of our recommendation, 

we had also provided the commonly used aliases 

for both disorders, and we recommend that these 

are used when updating the SEM information. We 

have also provided ICD 9 and ICD codes to help 

with the adjudication process. Next slide 

please.

So the next set of questions was 

related to exposures associated with the 

diagnosis of Parkinsonism. And we were 

specifically asked about causation presumptions 

including duration of exposure. Next slide. 

After reviewing the literature, we recommend that 

exposures to solvents, carbon disulfide and 

trichloroethylene, be presumed, in addition to 

carbon monoxide and manganese products that 

cause, contribute, or aggravate Parkinsonism.
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There is ample evidence, both from 

DOE's own studies and former worker program 

reports, that these exposures were common 

historically throughout the DOE weapons complex. 

And in human studies including case reports and 

epidemiologic studies have found their 

association with increased risk of Parkinsonism. 

In addition, based on the epidemiologic studies, 

we recommend eight years as a minimum exposure 

duration in adjudicating the claims with these 

newly identified exposures. Next slide please.

At this moment, we do not feel that 

the evidence is strong enough to issue a 

recommendation for other solvents, including 

methanol, n-hexane, toluene as well as 

polychlorinated biphenyls and pesticides. 

However, as this is an emerging research coming 

up in claims, we do recommend that DOL performs a 

periodic review of human studies to update the 

list of toxicants that may be associated with 

these diagnoses. Next slide please.

Finally we also included in our 
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recommendation this statement, and we hope that 

this will help clarify the Board's recommended 

use of causation presumptions throughout the 

claim adjudication process. These presumptions 

are based on the current state of knowledge and 

are intended to streamline the adjudication 

process, and those individuals with 

straightforward presentation of the disease by 

removing the need for detailed review by IH and 

CMCs. The claim does not need the presumption. 

It does not imply lack of sufficient evidence.

It just means that their claim would 

need to be more thoroughly taking into 

consideration the work history by both IH and ME 

to make adjustment on whether the exposure 

contributed and related to the claimed disease. 

And let me stop at this point. Are there any 

questions to these recommendations?

CHAIR MARKOWITZ: This is Steven. So 

if we could -- what we need is a move to accept 

the recommendation. And if you could, Kevin, 

just go up to a couple of these slides. If you 
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go up to the top, so what we're voting on is --

go to the third slide. So this is the first part 

of the recommendation that Dr. Mikulski outlined. 

And if you go to the next slide. I'm sorry, the 

next slide.

MR. BIRD: Sorry. Do you want Slide 4 

or 5?

MEMBER MIKULSKI: Page 5.

CHAIR MARKOWITZ: Yeah, the following 

one.

MR. BIRD: Okay, great.

CHAIR MARKOWITZ: So this is the 

second part of a recommendation. And then this 

really centers on carbon disulfide and 

trichloroethylene, eight years of exposure. Then 

the next slide is the final part of the 

recommendation. Now is there a move to accept 

this recommendation?

MEMBER GOLDMAN: This is Rose Goldman. 

I move to accept them.

CHAIR MARKOWITZ: Thank you. Is there 

a second?
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MEMBER DEMENT: It's John Dement. I 

second.

CHAIR MARKOWITZ: Okay. So now we're 

open for discussion. Well, I read the longer 

write-up that Dr. Mikulski and the group did, 

which has been provided for a couple weeks now to 

the entire Board. And if need be, Kevin can 

bring that up if anybody wants to look at any 

part of it.

But I thought it was an excellent 

review, very balanced, very insightful about the 

current state of evidence. It weighed things 

appropriately. And I was convinced that this is 

the appropriate recommendation based on current 

knowledge. Are there other comments, other 

discussion?

(No response.)

CHAIR MARKOWITZ: While you're 

thinking for a moment, let me just ask about Dr. 

Berenji and Dr. Friedman-Jimenez. Do you know 

whether they're on the line?

MS. RHOADS: I just had an email from 
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Dr. Berenji. She's trying to join now.

CHAIR MARKOWITZ: Okay.

MS. RHOADS: She should be on in a 

minute.

CHAIR MARKOWITZ: Okay. We haven't 

heard from Dr. Friedman-Jimenez, right?

MS. RHOADS: I have not.

CHAIR MARKOWITZ: Okay. Yeah, I 

texted him, but haven't heard --

MS. RHOADS: Okay.

CHAIR MARKOWITZ: -- back. Okay. So 

--

MS. RHOADS: I emailed him as well.

CHAIR MARKOWITZ: Yeah. So any 

further discussion on this recommendation?

MEMBER REDLICH: This is Carrie 

Redlich. Just in terms of how it would be 

implemented to those who are more familiar with 

the literature in terms of trying to assess the 

amount of exposure, and we have this seven-year 

period of time. Then do we have a sense of 

amount or generally potentially the types of 
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jobs? I'm just thinking of trying to help 

someone decide whether there was sufficient 

exposure.

MEMBER MIKULSKI: So there is, of 

course, no quantification of exposure included in 

the studies. But most of these exposures were 

low chronic exposures, which in my mind would've 

been typical of most of the DOE operations as 

symptoms for the most frequent of the uses in 

degreasing and also in the production processes.

MEMBER GOLDMAN: This is Rose Goldman. 

To add to it, this literature is a bit difficult. 

That eight years came mostly from one study that 

was one of the better studies done with a lot of 

IH that looked at workers with long-term 

exposure. And the only ones -- they had a minimum 

of eight years. So that's where that came from.

That would not necessarily apply to 

something like manganese where we don't have that 

kind of data. And what we know about manganese 

is more from overdoses and the same is true for 

carbon monoxide. Those two have the development 
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of Parkinson's after recovering usually from a 

high exposure. So this was more based on chronic 

exposures months before the solvent.

MEMBER REDLICH: This is I think 

largely my relative ignorance on this area. But 

in terms of skin exposure, is that something that 

you think is another contributing factor?

MEMBER MIKULSKI: Absolutely. I think 

that the two main routes of the exposure would 

have been inhalational and dermal in this case. 

But again, to quantify that, it would've been far 

more difficult. We can add that in the 

recommendation. However, I think that the text 

itself implies that these are occupational 

exposures and as such would have included those 

routes.

MEMBER REDLICH: Yeah, because I think 

the importance of the skin is I think you 

mentioned was there. So low levels, airborne 

levels do not rule out the opportunity for lots 

of skin exposure.

MEMBER MIKULSKI: Well the eight years 
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is coming from the epidemiologic observations of 

the workers working in the degreasing parts for a 

small industrial plant making gauges. And 

definitely there was a potential for dermal 

exposure in that study.

MEMBER GOLDMAN: Can we go to the 

recommendation? Did it say specifically -- I 

have to see that slide again -- that it had to be 

inhalation or was it just general exposure which 

would have included both respiratory as well as 

skin?

MEMBER MIKULSKI: Kevin, can you go up 

two slides?

MEMBER GOLDMAN: Okay. So here's --

(Simultaneous speaking.)

MEMBER GOLDMAN: -- TCE. These 

exposures associated with -- so at that point --

all right. So we were just -- this was mostly 

addressing trichloroethylene. And I don't think 

we specified that it had to be chronic inhalation 

exposure. It was just more on the order of 

minimum exposure. So that could be skin or air. 
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We didn't really specify.

MEMBER REDLICH: Yeah, so I was just 

wondering the assumption tends to be that it's 

inhalational. Maybe we should just somewhere in 

this -- I don't know exactly where the best place 

would be -- would be to just mention that it 

includes skin exposure.

MEMBER GOLDMAN: I'm wondering on the 

background, do we mention that TCE can be -- and 

carbon disulfide are both inhalation and skin in 

the background?

MEMBER MIKULSKI: Yes, we did. Yes, 

we did mention it in the description, in the 

background text for all the solvent exposures 

pretty much.

CHAIR MARKOWITZ: This is Steven. If 

you go to the next part of the recommendation. 

The next slide, yeah. So if we wanted to include 

this, if you look at the third line from the 

bottom, it says, a minimum exposure duration of 

eight years. We could add either through 

inhalation or through skin absorption, that 
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phrase there to include this concern if we want 

to or just leave it as a rationale.

MEMBER GOLDMAN: Yeah, I guess one of 

the questions would be we'd have to go back. I 

mean, this is based, believe or not, to try to 

come up with a minimum of eight years, this one 

study. And I'm not sure if those workers had skin 

and air exposure.

So I think Carrie's point is well 

taken. One good thing about just leaving it as 

exposure, you can make an assumption of what it 

is. If we really wanted to tie it back to that 

study, I think we'd -- with the eight years, we'd 

have to check and see if they had both skin and 

air exposure. I don't remember offhand. Do you?

MEMBER MIKULSKI: I believe that those 

were both exposures. I don't remember 

specifically. But the process itself would have 

implicated both dermal and inhalation. They were 

working right next to the solvents containers and 

soaking those parts in the solvents. So one way 

or the other, I'm sure there was some potential 
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for even the minimal skin exposure.

(Simultaneous speaking.)

MEMBER REDLICH: There are others that 

know more about this than I do, but it's much 

harder to prevent skin exposure. So my 

experience, it's rare that there's a setting with 

something like solvents. It's much easier to 

prevent inhalation exposure. So if there's 

inhalation, there's almost --

(Simultaneous speaking.)

MEMBER GOLDMAN: -- skin exposure. 

Yeah, you had more efficient absorption through 

air, though. But I don't think there would be a 

problem with putting that in probably. Just put 

it in parenthesis, skin or air.

MEMBER MIKULSKI: I agree, yes.

CHAIR MARKOWITZ: So Kevin, if you 

could bring up the Word version of this so we can 

make a change. It would be in the Parkinson's 

disease file.

MR. BIRD: Do you all see the Word 

document now?
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MEMBER MIKULSKI: Yes.

MR. BIRD: Okay. Am I in the right 

spot here, or should I --

CHAIR MARKOWITZ: Yes, you are. Up to 

eight years, should we just say either through 

inhalation or through skin absorption?

MEMBER MIKULSKI: And/or skin 

absorption maybe.

CHAIR MARKOWITZ: Okay.

MR. BIRD: Like that?

CHAIR MARKOWITZ: Yes.

MEMBER MIKULSKI: And if we go after, 

the first sentence ends with Parkinsonism claims. 

As I re-read it right now, I think we can cross 

out claims.

CHAIR MARKOWITZ: Okay. Is there any 

further discussion?

(No response.)

CHAIR MARKOWITZ: Okay. So in that 

case, we can take a vote. Does anyone want us to 

read out loud again the recommendation, or can we 

leave it as is and just vote on it? Anybody in 
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favor having it read aloud?

MEMBER BERENJI: Yes, this is Mani 

Berenji. I apologize. I came in a little late. 

So if you could restate the recommendation, that 

would be very helpful.

CHAIR MARKOWITZ: Sure. Okay, great. 

Well, welcome. Glad you could join us. Dr. 

Mikulski, do you want to read it?

MEMBER MIKULSKI: Sure.

CHAIR MARKOWITZ: But just let me 

interrupt for a second. We're not -- I don't 

think -- we're not looking at the first part of 

the recommendation. There's another part to it, 

right?

MEMBER MIKULSKI: Yes, I'm only going 

to read the one about causation presumptions. 

The Board recommends that in addition to carbon 

monoxide and steel manganese products already 

included in the EEOICPA Procedure Manual and DOL 

Site Exposure Matrix, exposures to carbon 

disulfide and trichloroethylene be presumed to 

cause, contribute, or aggravate Parkinsonism. 
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These exposures were present in the DOE weapons 

complex and have been shown to be associated with 

increased risk of Parkinsonism in human studies. 

The Board also recommends, based on the 

epidemiologic studies, a minimum exposure 

duration of eight years, either through 

inhalation and/or skin absorption, for Part E

causation in adjudicating Parkinsonism claims 

with exposures to carbon disulfide and 

trichloroethylene.

At present, the Board issues no 

recommendations for methanol, toluene, n-hexane, 

and polychlorinated biphenyls, or other workrelated exposures common throughout the DOE 

weapons complex. The Board also issues no 

recommendation for pesticides or specific 

pesticide products that may have been used on DOE 

installations. Current evidence is not 

sufficient to support a presumption of these 

additional agents with regard to Parkinsonism. 

As new research is emerging, the Board recommends 

the periodic review of human studies literature 
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on the risk factors for Parkinsonism for DOL to 

provide updates in this field.

Presumption of causation implies the 

judgment that the literature at the current time 

is sufficient to support the statement that the 

exposure can contribute to causation of the 

disease or aggravate the course of the disease in 

exposed populations, and the judgment that the

degree exposure in the individual is sufficient 

to have produced this contribution to causation 

in that individual. The use of presumptions is 

intended to identify the subset of people with 

the straightforward presentations to streamline 

the compensation process by eliminating the need 

for detailed causal evaluation by the physician 

and industrial hygienist.

It must be emphasized that, if an 

individual does not meet the criteria for the 

presumption of causation, this does not imply 

there is not sufficient evidence of causation. 

It simply means that individuals who do not meet 

these presumptive criteria and would need to be 
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evaluated through a fact-based process entailing 

industrial hygiene and medical review to make the 

judgment whether the exposure contributed to 

causation of the disease. So a couple more --

yes, thank you.

CHAIR MARKOWITZ: Okay. So I think we 

need a roll call to do a vote actually.

MS. RHOADS: I can do that. Okay. 

Dr. Dement?

MEMBER DEMENT: Yes.

MS. RHOADS: Mr. Domina?

MEMBER DOMINA: Yes.

MS. RHOADS: Dr. Goldman?

MEMBER GOLDMAN: Yes.

MS. RHOADS: Mr. Mahs?

MEMBER MAHS: Yes.

MS. RHOADS: Dr. Markowitz?

CHAIR MARKOWITZ: Yes.

MS. RHOADS: Dr. Mikulski?

MEMBER MIKULSKI: Yes.

MS. RHOADS: Ms. Pope?

MEMBER POPE: Yes.
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MS. RHOADS: Dr. Redlich?

MEMBER REDLICH: Yes.

MS. RHOADS: Dr. Silver?

MEMBER SILVER: Yes.

MS. RHOADS: Mr. Tebay?

MEMBER TEBAY: Yes.

MS. RHOADS: Dr. Berenji?

MEMBER BERENJI: Yes.

MS. RHOADS: Dr. Friedman-Jimenez, 

have you joined us?

MEMBER FRIEDMAN-JIMENEZ: Yes, I have 

joined you. And yes, I vote yes.

MS. RHOADS: Okay. Thank you. That's 

everybody. It's unanimous.

CHAIR MARKOWITZ: Okay. Welcome, Dr. 

Friedman-Jimenez. And I want to thank Dr. 

Mikulski and the work group for a thorough review 

and recommendation. I would point out this was 

developed in response to a question from the 

Department of Labor for assistance, and I think 

that this is an example of a very useful 

interaction. So let's move on.
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MEMBER REDLICH: Yeah, I was just 

going to say thank you for doing such a thorough 

job on this.

MS. BRISTOL: Yeah.

MEMBER MIKULSKI: Thank you to all for 

your support.

CHAIR MARKOWITZ: Dr. Berenji, do you 

want to go next, or do you want to wait for a bit 

while I talk about asbestos? Or do you want to 

give your report on the Group 2A carcinogens?

MEMBER BERENJI: Oh, apologies. You 

can go ahead and present. I'm just trying to get 

everything together. So I'll be a few minutes.

CHAIR MARKOWITZ: Okay. That's fine. 

No problem. So we're going to skip ahead and 

talk about the recommendation around asbestos job 

titles. So Kevin, if you could go back to the 

PowerPoint to the next slide. Okay. So --

MR. BIRD: Sorry, Dr. Markowitz. 

Would you rather me pull it up as a PowerPoint, 

or would you rather me pull it up as a Word file?

CHAIR MARKOWITZ: PowerPoint 
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initially. Okay. Let me read the recommendation 

and then discuss what the group has worked on. 

We recommend that the Department of Labor 

evaluate the job categories and associated 

aliases for all Department of Energy sites in the 

Site Exposure Matrices and revise its list of 

occupations with presumed pre-1995 asbestos 

exposure, Exhibit 15-4, to reflect current 

knowledge as summarized in the rationale provided 

below and associated data and references. 

Supervisors of the listed job categories should 

also be considered for inclusion. A committee of 

the Board should work with the Department to 

conduct this exercise and achieve a consensus on 

a revised list of occupations with presumed pre1995 asbestos exposure. So if you'd go to the 

next slide.

This is the current list of job titles 

in the Procedure Manual that are presumed to have 

significant exposure to asbestos. And we've 

looked at this list many times, mostly 

construction trades with a few other people 
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involved, added auto mechanic, maintenance 

mechanic, and a couple of others, heavy equipment 

operator. So, some time ago, the Board suggested 

that this list was not quite full enough.

And we actually had looked at what we 

thought to be a subgroup, relevant job titles at 

a number of different sites. And we made some 

specific recommendations around those job titles 

to be added. We kind of realized that the 

complex -- the DOE complex has many job titles 

that have evolved over time, both within and 

across the DOE site.

And we're not going to be able to come 

up with a complete list of all the specific job 

titles that we thought should be added. So we 

kind of took a different approach, if you could 

go to the next slide. So we started to look at 

the literature on job titles in relation to 

malignant mesothelioma.

We used that disease outcome because 

it's highly specific for a history of exposure to 

asbestos, much more so than lung cancer and not 
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as -- maybe not quite as specific as asbestosis. 

But asbestosis presents different challenges. So 

we used job titles in relation to mesothelioma as 

a window into what job titles should be 

considered as having significant exposure on a 

presumption basis prior to 1995.

So here, I'll show a publication from 

15 years ago. It's in the U.S. It relies on 

U.S. data compiled by NIOSH in one year, 1999. 

They looked at death certificates, and they 

looked at what the death certificates by industry 

and occupation. And you can see they provide the 

proportionate mortality ratio. Let me take a 

moment and explain what that is.

That's a measure of risk. And if it's 

above, in this slide, 1.0 -- if you look at that 

column, it's above 1.0 and it's elevated. More 

commonly, PMR is expressed as above 100. But in 

this slide, you see it as 1.0. And what it is, 

is the proportion of people in a given trade.

Let's see. You can see plumber there. 

The proportion of deaths among plumbers that's 
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caused by mesothelioma and then you compare that. 

You divide that by the total proportion of all 

deaths caused by mesothelioma among all 

occupations. So if on average one percent of 

deaths across all occupations is caused by 

mesothelioma and they find among plumbers' deaths 

that it's five percent, then we would take that 

five percent divided by one percent and come up 

with a PMR, in this case 4.76. So it's a measure 

of the increased risk.

It's not the best measure, and it's 

vulnerable to certain issues which we probably 

don't need to go into here. But it is a 

recognized measure that's used. And in fact, so 

we see from this study 20 years ago, very few 

occupations were identified as having excess risk 

of mesothelioma.

Now let me say that there are other 

occupations that were at increased risk. But in 

part because they were looking at very limited 

data, one year from 19 states, and again, only 

death certificates that included information 
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about industry and occupation. They really were 

constrained in how many occupations they could 

actually look at. If you go to the next slide.

So NIOSH continued this work and in 

2016 published a longer list and using a very 

similar approach with PMR. And here they're 

looking at deaths from 23 states for malignant 

mesothelioma from 1999, 2003, 2004, 2007. So 

they had multiple years. And these are just the 

occupations with elevated rates or risks of 

mesothelioma, and it's gone from 4 to about 16 or 

17.

And we see, if you just look at a 

bunch of them are actually drawn directly from or 

identical to the list on Exhibit 15-4 as part of 

the Procedure Manual. So this was published in 

2016. And I would point out the title of the 

table is based on 1,830 malignant mesothelioma 

deaths.

So John Dement had the brilliant idea 

of looking at the same data -- same type of data 

only what is currently available. And if you go 
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to the next slide. And John, if I get any of 

this wrong, just feel free to correct me. But 

there is something called the National 

Occupational Mortality System which is a 

compilation really of deaths that NIOSH has put 

together, the National Institute, for a number of 

different outcomes. We're just focusing on 

malignant mesothelioma.

And what they've done is for a large 

number of death certificates coded what a death 

certificate says about the person's occupation 

and what industry they were in and then related 

those listings to the cause of death. And they 

published a few years ago. Cynthia Robinson is 

the leader of NOMS who published the analysis in 

2016 in a great journal, the American Journal of 

Industrial Medicine, actually on leukemia and 

heart disease, not only mesothelioma. But this 

system NIOSH has been operating for almost three 

decades and from 26 states. So it's a large data 

set. Next slide.

So what John did was go in and look at 
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malignant mesothelioma. Kevin, if you could move 

it ahead. Yeah. See, here I just defined what 

the proportionate mortality ratio is, which I've 

already gone over. So we don't need to go over 

it again.

And we found when we looked at the 

current NOMS data that instead of the 17 job 

titles that were found and published in 2016, 

there were now 64 individual job titles with 

increased mesothelioma risk. And these are 

deaths from 1999 to 2014. Not every year, but a 

good number of years actually. Ten years out of 

that time period.

So in the next three slides, we 

provide the individual job categories by the 

standard Census coding system. And if you look 

at the fourth column from the right, you see the 

PMR. And now it's in the hundreds, not in the 

ones. So for instance, architects has a PMR of 

337. That means almost three and a half times 

the risk of the general risk for mesothelioma 

based on 19 deaths.
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And if you look on the two columns on 

the right, these are confidence intervals. 

That's what the CI stands for. And as long as we 

see the lower confidence level above 100, we're 

confident that this was not a statistical fluke. 

And so this slide and the next two slides, they 

only provide the job titles. No, you can go 

back. That's okay.

But we only provide the job titles. 

The previous slide, Kevin? Yeah, thanks. The 

job titles which have elevated PMRs which are 

statistically significant. So you can see here 

architects. You see various types of engineers, 

marine engineers for obvious reasons. A lot of 

asbestos on ships. But we also see chemical 

engineers and mechanical engineers, electrical 

engineers.

What's interesting is I think it's a 

reasonable interpretation that there was 

sufficient exposure to asbestos in enough of each 

of these occupations such that a broad look at 

mesothelioma rates in these occupations is 
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showing a significant elevation. If you go down, 

we see chemical technicians. We see fire 

fighters. Law enforcement workers, I have no 

explanation for that.

It's not surprising that we see a job 

category that's hard to explain. What's 

remarkable about this list and as we go through 

the next two slides is how many of these job 

categories are readily explained by the likely 

history of exposure to asbestos. And here's the 

construction and extraction trades, and you see 

for insulation workers a PMR which is sky high, 

3,539 worked heavily in asbestos and various 

other familiar job categories.

And if you go to the next slide. So 

we've moved from construction now to the Census 

codes of installation, maintenance, and repair 

occupations. And this is of interest because I 

think there are a lot of job titles in DOE that 

haven't quite been captured by the list in 

Exhibit 15-4 that would be encompassed by the job 

categories.
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And the other thing of interest here 

is that whereas in construction we expected to 

see a lot of categories, it wasn't clear within 

this overall group, installation, maintenance, 

repair, that we would see quite this number. 

Although when you look at them, actually most of 

them are readily explained. Now I think there's 

one more slide with additional elevated risks.

Yeah, so this is on the production 

side. And production can be tricky with respect 

to asbestos exposure because some production 

workers have exposure, some don't. We're 

interested in presumptions, and you see here that 

people who work with metals, because they 

frequently work with heat, have exposure to 

asbestos on a routine basis. They did in the 

relevant time period, and there's some other 

production occupations as well listed down below. 

I think that's the last slide of the 

occupations. If you could go to the next one, 

yeah.

So how does this fit into the overall 
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knowledge about mesothelioma? So we looked at a 

number of the large studies. It's mostly the 

study design called case control because of 

occupations and risks by occupations. And these 

are a number of the major studies over the last 

20 years.

In the U.S., I already showed you the 

Mazurek study of 2016. The Tomasallo study is 

shifted to Wisconsin. It's really just one state 

and then the others are various countries. You 

wouldn't really expect their experience with 

mesothelioma in terms of risk to be that 

different from ours. So it did provide a useful 

diagram.

There are also some registry-type 

studies which I haven't included here. Australia 

has an excellent registry. They published 

occupations in relation to that, and Italy has an 

excellent registry too. Next slide. It may be 

the end of the slides.

Yeah, so this is just a repeat of the 

-- so in a full report on this which was 
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distributed to the Board members a couple weeks 

ago, there's several pages of text describing 

what I really just reviewed and also including 

that attachment with a listing of other relevant 

studies. Actually, we took the important tables 

from all of those relevant studies and included 

those tables in the report, in the rationale with 

a list of the references. Actually, if you could 

put up the Word version of this, Kevin, just for 

a moment. Okay. So if you could just scroll 

down here.

So here's the rationale which we 

describe what we did. And then keep going down. 

This is available on the website, by the way. 

Keep going, yeah. We briefly attached some of 

the other U.S. studies and then referred to the 

international studies and then some comments that 

we included about this.

We're not going to vote on the 

rationale. We're just going to vote on the 

recommendation. If anybody has any suggestions 

on the rationale today -- I mean, on this call, 
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that's fine. Otherwise, in the next day or two, 

if you have additional suggestions. If you could 

just go down a little bit more.

Just want to show the full report, get 

a sense. This is from the Procedure Manual. 

This is what I just showed. Now hold on here. 

Back up for a moment. I just want to show this. 

This is the usual way we look at these things. 

And I'm sorry, but it's in small print here. But 

these are the same job titles with PMRs. But now 

they're in descending order of PMR.

So you can see -- that's good. So you 

can see the insulators topped the list with a sky 

high PMR, and then you go down. All of the job 

titles on this list had elevated PMRs that were 

statistically significant. And you see most of 

them in the 200 to 300 range. But in any case, 

it's the usual way we look at these in the terms 

of studies. But what I showed before was by 

overall occupational to the major group in order 

to show that it's not just construction workers 

but other workers who have exposure to asbestos. 
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Just keep going down a little bit to see if 

there's anything to show. Okay. Keep going.

So this is the Mazurek study. Keep 

going. But we also provide -- keep going. I 

already discussed this. This was the 2006 study. 

But here's the Tomasallo study from Wisconsin 

where they list the occupations and industry. 

And then we start getting into important -- this 

is a Peto study in 1995. It made a big splash. 

Go up just a little bit more.

This is a PMR approach in England. 

You can see a list of elevated PMRs. This was 

done five years ago actually. So if you could go 

back to the top of this page. Stay on the word, 

version, but go back to the top of it all.

So if you want, I can read the -- let 

me read the recommendation very quickly. So we 

recommend the Department of Labor evaluate the 

job categories and associated aliases for all DOE 

sites in the Site Exposure Matrices and revise 

its list of occupations presumed pre-1995 

asbestos exposure to reflect current knowledge as 
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summarized in the rationale below and associated 

data and references. Supervisors of the listed 

job categories should also be considered for 

inclusion. A Committee of the Board should work 

with the Department to conduct this exercise and 

achieve a consensus on a revised list of 

occupations with presumed pre-1995 asbestos 

exposure. Okay. So is there a move to accept 

this recommendation?

MEMBER SILVER: This is Ken Silver. I 

move that we accept it.

CHAIR MARKOWITZ: Okay. Is there a 

second?

MEMBER MAHS: This is Ron. I second.

CHAIR MARKOWITZ: Okay. So open for 

discussion.

MEMBER DEMENT: This is John. I think 

just one point. The current list of jobs 

considered asbestos exposure actually aim from an 

older ATSDR document. And if you look at that 

document, those lists basically came from the 

same information, the same data set. So the 
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prior list is, in large part, really based on an 

older set of the same data that we're looking at 

now.

It's subdated February 4 to include 

greater numbers. We're also looking more in 

detail at mesothelioma, and that's possible 

because of ICD 10 and a specific code for 

mesothelioma. So it gives us, I think, a lot 

more focused attention to specific jobs and a lot 

more data to base the determinations on.

CHAIR MARKOWITZ: Well, the NOMS data 

we showed was based on about 6,000 mesothelioma 

deaths whereas the publication in 2016 was based 

on 1,800. So you just get more dense. You get 

more statistical power and just look at a lot 

more occupations. By the way, those occupations 

that don't appear to have excess risk on this 

doesn't necessarily mean that people in those who 

have done those jobs don't have excess risk. It 

could be a number of things. It may mean that 

the exposure wasn't sufficient widespread in that 

occupation to cause a risk -- elevated risk or 
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some other reasons. Other discussion?

MEMBER SILVER: Ken Silver here. 

Outside the four corners of this list, if I 

remember correctly, the Department of Labor 

accepted one of our other recommendations so that 

30 days of employment at a DOE site was 

sufficient for meso. Is that correct?

CHAIR MARKOWITZ: Yes.

MEMBER SILVER: So it would be 30 days 

in one of these job titles?

CHAIR MARKOWITZ: Yes. I mean, well -

-

MEMBER SILVER: Okay. Thank you.

CHAIR MARKOWITZ: -- approximately, 

yeah. I mean, they have to, they had to 

translate this list into DOE job title list. 

Other comments, questions, suggestions?

MEMBER GOLDMAN: This is Rose Goldman 

again. I just had a question. I'm trying to 

look at this list. But I know that for a number 

of custodians, for example, there was some early 

literature about custodians with pleural plaques 
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and asbestos. Not asbestosis but having pretty 

significant asbestos exposure because they're 

always down in the basements and they're not a 

boilermaker repairing things or plumbers. But 

they're just sort of always down there and 

sweeping.

And I would think -- I mean, anybody 

who gets mesothelioma, 99 percent of the time, if 

not 99.9, it's due to asbestos. And I'm just 

wondering if you could have a phrase in there 

that even if they're not on that list. Like, 

custodians aren't there, unless that comes under 

maintenance. But that's sort of an ignored group 

sometimes for low level chronic asbestos exposure 

where people could have mesothelioma.

And I could see where somebody who is 

like a custodian who got it, they wouldn't 

necessarily been seen. I don't know. Would they 

come under maintenance because that's a group, 

for example -- I don't know. Somehow, I think 

for mesothelioma, there just has to be a really 

careful look because there are almost always some 
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asbestos exposure. And it isn't from their house 

or environmental which is highly unusual. It 

would be from work.

CHAIR MARKOWITZ: Well, this is 

Steven. I agree with you that as a rule, 

custodians in the heyday of asbestos would've 

routinely had exposure. I'm actually going to --

as we speak, I'm going to look up -- try to look 

up on the Census coding system where custodians 

appear under what job title. Yeah, there's a job 

title called janitors and building cleaners.

MEMBER GOLDMAN: So do they have an 

increased risk than other janitors and building 

cleaners? Did I miss that in all of your charts 

then?

CHAIR MARKOWITZ: They do not appear 

in the charts. And with a little bit more time, 

I could look up their PMR. But I think it wasn't 

elevated because otherwise they would have 

appeared.

MEMBER GOLDMAN: So then I'm just 

going to add something. Then perhaps even though 
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these are the jobs that you make the presumption, 

could there be a phrase that says even if they're 

not that job but they did a job where they 

potentially could've had asbestos exposure. If 

they have mesothelioma, there needs to be, like, 

additional questioning from the IH or somebody, I 

mean, because that's so often -- I mean, almost 

always associated. And it's sneaky sometimes how 

people got it.

So I don't know that -- I mean, this 

is a fantastic effort to put down jobs so you 

would have the presumption. But maybe to put a 

line in there. Even if you're not listed on that 

job that you could still have had it. And so you 

still need additional inquiry and questioning.

CHAIR MARKOWITZ: So yeah, so that's 

like the phrase of a sentence that was in the 

Parkinson's disease recommendation that even if 

you don't need these presumptive criteria, then a 

close look at the person's prior exposures should 

be undertaken in order to ascertain whether 

there's causation. We could certainly add that 
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to this.

My hesitation about adding janitors, 

per se, is because we'd have to provide the 

underlying studies. And then we get into the 

asbestosis literature and then we never finished 

the job is my concern. I mean, I agree with you 

about custodians, and they don't appear here.

MEMBER GOLDMAN: Well, there may be a 

way to phrase it. I don't want to drag this out 

further. But with that phrase, I mean, it's 

really different. Like, trichloroethylene and 

Parkinson's, it's not necessarily a slam dunk. 

It's an increased risk.

With mesothelioma, I mean, you really 

need to -- I mean, to emphasize that this is 

almost always related to asbestos exposure. And 

so even if the person isn't in that group, 

particularly for that diagnosis, there should be 

a great effort to do additional interviewing to 

see whatever their job was in the DOE, there was 

a potential for asbestos exposure.

CHAIR MARKOWITZ: Okay. So Kevin, 
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let's see. We're looking at the Word version, 

right?

MR. BIRD: Yes.

CHAIR MARKOWITZ: Okay. So the fifth 

line down after the word, inclusion. Okay. 

Let's try to get some language which can capture 

this. Let me take a stab and then we can modify 

it. So for other job titles with mesothelioma --

well, I guess that claims in relation to asbestos 

exposure. Claims in relation to -- I'm sorry, 

yeah. No, in relation to asbestos exposure, 

comma, a careful investigation of possible 

occupational sources of asbestos exposure should 

be undertaken.

MEMBER GOLDMAN: Well, I guess -- I 

don't know if this form is just for asbestos 

exposure in general for many things like lung 

cancer, or this recommendation is directed for 

mesothelioma. But if it's for more general 

asbestos exposure, then what you might consider 

is for that phrase saying maybe -- pointing out 

that for mesothelioma maybe to say, in the case 
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of mesothelioma, comma, with a greater than 90-

plus whatever, 99 percent relationship to 

asbestos, greater effort should be made to 

inquire about a job-related asbestos exposure, 

even if the -- it doesn't fit into one of the 

categories, the presumptive categories.

MR. BIRD: Apologies, Dr. Goldman. I 

lost you a little bit there in the middle of 

that.

MEMBER GOLDMAN: Oh, okay. Sorry. So 

I'm just saying rather -- I mean, because this is 

a document I believe in general for asbestos 

exposure for other things, asbestosis, lung 

cancer, I think that it would behoove us, even 

though that the mesothelioma data was used to 

identify which jobs really have asbestos

exposure. By the same token, anybody who has 

mesothelioma to me, you could presumptively say 

it's related to asbestos exposure.

So I mean, I would pull that out from, 

like, lung cancer and other things and maybe to 

make a statement that in the case of 
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mesothelioma, there's such a strong presumption 

greater than 95 percent that it's related to some 

asbestos exposure, that greater effort should be 

made to interview the person about potential 

work-related asbestos exposure, even if their job

category is not in one of the presumptive 

categories.

MEMBER REDLICH: I mean, this is 

Carrie Redlich. I agree with Rose. It just 

seems that mesothelioma, remember is really a 

very rare cancer. And if someone was at a site -

- and in terms of general other practice, if 

someone was at a site that had asbestos and it's 

a rare person that gets mesothelioma, we assume 

it's related to that site. But dose response is 

just not the same as for other cancers. And --

(Simultaneous speaking.)

MEMBER GOLDMAN: Right. I'm not even 

sure you -- I agree. And I'm not even sure you 

need X number of years. I mean, there have been 

--

MEMBER REDLICH: That's what I'm 
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saying because I don't think --

MEMBER GOLDMAN: Yeah.

MEMBER REDLICH: -- you need X number 

of years or a specific -- I mean, if you got 

mesothelioma and the latency is such that it 

would fall, and it's a wide latency, during the 

period that you worked at a DOE site that 

anywhere at that site had asbestos during that 

time, I think that would be very appropriate. 

There's no other cancer --

CHAIR MARKOWITZ: First of all --

MEMBER REDLICH: -- that it's so 

tightly linked to an exposure.

CHAIR MARKOWITZ: Yeah. So the 

Procedure Manual has for mesothelioma 30 days of 

exposure and a latency of 15 years. So let me --

MEMBER REDLICH: Okay. Well, that's 

okay.

CHAIR MARKOWITZ: Yeah. So what if we 

took the sentence -- if we go back, Kevin, to the 

sentence that I added, should be undertaken. And 

we added after should be undertaken something 
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like with a very high degree of suspicion for 

malignant mesothelioma. Would that address the 

point?

MEMBER GOLDMAN: Well, I think the 

starting point actually isn't a high degree of 

suspicion from malignant mesothelioma. I mean, I 

would consider starting with the cases of 

mesothelioma. I would consider in the case of 

malignant, starting that sentence a little bit 

differently.

Like, instead of for other job titles, 

blah, blah, blah, I would just start after that 

considered for inclusion. And then after that 

sentence inclusion, period, I would say, in the 

case of mesothelioma, comma, with greater than 90 

percent linkage to asbestos exposure, comma, all 

cases should have additional inquiry into 

potential asbestos exposure even if not among the 

presumptive job titles for asbestos exposure. 

Something along that line just because like 

Carrie said, I mean, you could -- it's such a 

strange thing.
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It is very rare, but it's almost 

always -- and it's the kind of cancer people say, 

well, I never had it. But if you dig deep 

enough, you find it. Like, I can still remember 

a case, for example, when I did a rotation with 

Dr. Selikoff, I saw a woman who had mesothelioma 

and she worked at the Metropolitan Opera.

She was a dancer. And I said, well, 

how in the world did you get it? And said, well, 

we were dancing and the curtains were lined with 

asbestos. And we would be dancing, and there's a 

lot of harder than you think plunking down on the 

stage, and there was dust always there. So she 

had years of asbestos exposure, and who would've 

thought of that in a ballerina, right?

And so I think that just having that 

diagnosis of mesothelioma means one has to be 

prompted to go further in the inquiry because 

even what we might consider small exposures and 

maybe that's why it didn't come out with the 

custodians because it's just there are many, many 

more custodians and mesothelioma is really rare. 
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But I just think that should be the prompt, that 

it really is different than an increased risk of 

some percentages for lung cancer, whatever. This 

is, like, really -- we really have to presume 

that there's an asbestos exposure. You just have 

to ask more questions about it.

CHAIR MARKOWITZ: Okay, so. Kevin, 

where it says, should be undertaken, if you could 

take out remove with a very high degree of 

suspicion of -- just a little bit, yeah. That's 

it. And then put a period there. And then take 

Dr. Goldman's new sentence and insert it after 

undertaken. Okay, okay. So does that capture 

the thought now?

MEMBER GOLDMAN: Yes, I think that --

let me just -- yes, I like that. I don't know if 

others agree, but I think that captures it for 

that specific -- and it's a very rare exposure. 

It's not going to come up that often. But I 

think we just have to really make that 

presumption that if you have mesothelioma, it's 

related to asbestos.
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CHAIR MARKOWITZ: Right. By the way, 

at the end of that sentence which says, among the 

presumptive job titles for asbestos exposure, if 

you could change that to among the job titles 

with presumed asbestos exposure. Do you see 

that?

MR. BIRD: Sorry, Dr. Markowitz. Say 

that again. Where exactly?

CHAIR MARKOWITZ: Go down two 

lines,which is presumptive job titles. Yeah, 

okay, okay. Take out the presumptive. Okay, 

okay. And then right before asbestos in that, 

put in presumed. Okay. Other additional 

comments? Discussion about the recommendation?

MEMBER SILVER: Yeah, Ken Silver here. 

I love the PMR approach. I wonder if there'd be 

any wisdom in codifying the overall approach. 

The epi literature doesn't stand still. There 

may be future PMR studies that reveal additional 

occupations. And perhaps we could slip in a 

sentence, advising DOL to keep an eye on the 

occupational epi literature for occupations that 
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meet the same criteria.

CHAIR MARKOWITZ: Yeah, the --

MEMBER DEMENT: This is John.

CHAIR MARKOWITZ: When we put -- yeah, 

go ahead, John.

MEMBER DEMENT: Why couldn't we just 

add that in the rationale as opposed directly in 

a recommendation?

MEMBER SILVER: Works for me.

CHAIR MARKOWITZ: Okay.

MEMBER DEMENT: I think it's just 

better in the rationale.

CHAIR MARKOWITZ: Okay, yeah. I can 

add that. That's fine. Any other comments, 

discussion?

MEMBER REDLICH: This is Carrie. I 

had one minor suggestion. I think it's the fifth 

line down for other job titles with claims in 

relation. Do you want to say for other job 

titles for other employees?

CHAIR MARKOWITZ: It's really for 

people who have other job titles, right?
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MEMBER REDLICH: Yeah, so maybe.

CHAIR MARKOWITZ: Yeah, yeah. So why 

don't we just add for people who have other job 

titles. I agree. It's very awkward. Yeah.

MEMBER REDLICH: Thanks.

CHAIR MARKOWITZ: Thank you. Okay. 

Any other comments, discussion? Otherwise, we'll 

close it and vote.

Okay. Anybody want me to re-read this 

recommendation? Or can we just take a vote?

(No response.)

CHAIR MARKOWITZ: Okay. Let's move to 

a vote if we could do a roll call.

MS. RHOADS: Okay. I can do that. 

Dr. Berenji?

MEMBER BERENJI: Yes.

MS. RHOADS: Thank you. Dr. Dement?

MEMBER DEMENT: Yes.

MS. RHOADS: Thank you. Mr. Domina?

MEMBER DOMINA: Yes.

MS. RHOADS: Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: Yes.
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MS. RHOADS: Dr. Goldman?

MEMBER GOLDMAN: Yes.

MS. RHOADS: Mr. Mahs?

MEMBER MAHS: Yes.

MS. RHOADS: Dr. Markowitz?

CHAIR MARKOWITZ: Yes.

MS. RHOADS: Dr. Mikulski?

MEMBER MIKULSKI: Yes.

MS. RHOADS: Ms. Pope?

MEMBER POPE: Yes.

MS. RHOADS: Dr. Redlich?

MEMBER REDLICH: Yes.

MS. RHOADS: Dr. Silver?

MEMBER SILVER: Yes.

MS. RHOADS: Mr. Tebay?

MEMBER TEBAY: Yes.

MS. RHOADS: Okay. That's everyone, 

and unanimous again.

CHAIR MARKOWITZ: Okay. Thank you. 

So let's move -- we're right on schedule 

actually. Let's move to Dr. Berenji. Kevin, I 

think you can -- you can go back to the agenda on 
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the screen. But Dr. Berenji?

MEMBER BERENJI: Yes. Can everyone 

hear me?

CHAIR MARKOWITZ: Yes.

MEMBER BERENJI: Great. So this is 

our work group presentation on whether IARC Group 

2A Carcinogen should be added to the SEM and 

specifically linking them to particular cancers. 

Our working group had a chance to convene over 

the last few months, virtually, of course. And I 

know we've all been busy with our other work 

activities.

So I just wanted to thank Rose, 

George, and Duronda for all your patience and 

your continued contributions to this effort. We 

actually did produce a working draft of our 

report, and I did submit the draft to my 

colleagues in the work group as well as Dr. 

Markowitz whom I believe had a chance to review 

it briefly. Is that correct?

CHAIR MARKOWITZ: Sure.

MEMBER BERENJI: Okay. I can go ahead 
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and just summarize the report because I know I 

sent it in late last week. And I'm not sure if 

Kevin has had a chance to get a copy. But I'm 

happy to review it verbally. Or if you want me 

to share it with Kevin, Dr. Markowitz, I'm happy 

to do that as well.

CHAIR MARKOWITZ: You know what? Let 

me -- I think I have it. Let me send it to 

Kevin, and why don't you just keep talking. How 

about that?

MEMBER BERENJI: Okay. So really our 

working orders are to really look at the Group 2A 

carcinogen. And for purposes of this review, we 

specifically focused on the most recent agents 

that were recently reviewed by IARC in the last -

- I would say last five to ten years. So I was 

able to actually go to the IARC website, and I 

was able to download an Excel spreadsheet with 

all the recent 2A carcinogens that were reviewed 

by IARC.

So I believe I presented this 

information at our last virtual Board meeting in 
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the form of a PowerPoint. But just to summarize 

briefly, we identified 22 agents in total. These 

are 22 Group 2A agents that were assessed by 

IARC, and these are between the years of 2016 

through 2019.

And over the last few months, Rose, 

George, Duronda and I have had a chance to kind 

of go through this list. Rose was actually very 

helpful in reviewing the particular pesticides. 

Rose, did you have any comment or any other 

feedback on your analyses of the Group 2A 

carcinogens, specifically the pesticides?

MEMBER GOLDMAN: I don't see the draft 

in front. I mean, in terms of what we wrote?

MEMBER BERENJI: Yes, I believe you 

had actually -- if I'm not mistaken, I believe 

you actually put together --

MEMBER GOLDMAN: Oh, yeah. Let me --

I tell you what. Let me just pull up what I 

found. I tried to -- circle back to me. Oh, and 

here it is.

MEMBER BERENJI: Sure.
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MEMBER GOLDMAN: And should you 

include what I, the things that I found?

MEMBER BERENJI: Yes.

MEMBER GOLDMAN: I'll just pull that 

up.

MEMBER BERENJI: Yes, I actually 

incorporated your analyses of those three 

particular pesticides into the draft. And I 

apologize. Did you all receive the draft because 

I had emailed that last Tuesday night?

MEMBER GOLDMAN: I don't think I got 

it, but I'm going to circle back to see the 

pesticide thing that I wrote to you. So come 

back to me.

MEMBER BERENJI: Sure. And I know 

George had some really good feedback as well, 

especially as it pertains to the quality of the 

IARC analyses. George, did you want to provide 

some additional feedback on that?

MEMBER FRIEDMAN-JIMENEZ: A few 

things. First, the presumption of causation --

causality, I would call it causation. I think we 
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should make a statement similar to the one that 

was in the asbestos document qualifying what we 

mean by presumption of causation, specifically 

that it's when you classify a person as having a 

work-related disease without medical review 

because they have particularly strong evidence of 

exposure to a toxic substance that in which 

there's really no controversy.

And the point here is that presumption 

of causation really only identifies the minority 

of cases for which there is causation. It's the 

minority for which you don't even have to do a 

medical evaluation. It's just so obvious.

But what I don't want to see is that 

presumption of causation turns into the level of 

evidence that is expected in order to judge it as 

causal. So in other words, if we set the bar at 

a certain height, if a person doesn't make that 

level of evidence, that definitely does not mean 

that there is not causation or there's not enough 

evidence for causation. What it means is that 

they then go to the next step which is a medical 
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evaluation which involves a doctor taking a lot 

of information and making a judgment based on the 

literature and the patient's presentation and 

exposure history whether there is causation or 

not.

And I'm just concerned that if we 

don't make a strong statement about that, that 

it's going to evolve into the minimum amount 

that's required to judge causation and not the 

amount that sort of skims the slam dunk cases off 

the top to make it more cost effective, quick and 

easy to identify these most obvious cases and not 

have to do the full evaluation. Presumption of 

causation is really just a tool to streamline the 

process for a small minority of people. But 

there's going to be a lot more for which it's 

questionable.

And when you actually look at the 

data, then you can decide whether there's 

sufficient evidence in that person or not because 

it's very hard up front to make that decision and 

draw that cut point without knowing the details 
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of that case. In other words, people who don't 

make evidence of presumption need to be judged on 

a case-by-case basis whether there's causation or 

not. That doesn't mean that it's presumed that 

there is no causation.

So I can work on a statement like 

that, shorter than what I just said. But I think 

we need to have something in there to define what 

we mean by presumption of causation, that it's 

really just a part, a minority of the cases that 

we're identifying that make it without even 

having a medical evaluation. These cases can be 

decided by the claims examiner, someone that 

doesn't have technical knowledge. So that's one 

point I wanted to make.

The other one is I think the EPA does 

make judgments on causation for chemicals. But 

as far as I can tell, their process is not as 

detailed, as well documented, and certainly not 

as transparent as either IARC or the National 

Toxicology Program. I was unable to find for 

glyphosate, I just took as an example, the 
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committee that made the decision, the names of 

the members, and more importantly, what 

disciplines they represented.

How many toxicologists? How many 

epidemiologists? Where they were from? How many 

mechanistic people? How many statisticians? I 

wasn't even able to find the document where the 

glyphosate evaluation was clearly defined on the 

EPA website. And whereas IARC publishes a 

monograph, really detailed monograph on each of 

these evaluations, and the National Toxicology 

Program also publishes their usually biannual 

report on carcinogens.

So I think that the best committees, 

the best expert committees are really the IARC 

and the National Toxicology Program. And we need 

to find out more about the EPA because it's 

nowhere near as transparent as the other two. So 

that's a concern that I had about making these 

decisions based on largely EPA evaluations.

MEMBER GOLDMAN: Well, this is a good 

moment for me to follow up because now I have the 
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piece of paper so I can be specific. So I just 

want to speak to two organophosphates, malathion 

and diazinon, and then glyphosate, both of which 

were categorized by IARC as 2A probable 

carcinogens and their monograph 2014. And they 

give for malathion limited evidence of 

carcinogenicity in humans for non-Hodgkin's 

lymphoma and prostate cancer, diazinon for nonHodgkin's lymphoma and lung cancer, and 

glyphosate, non-Hodgkin's lymphoma, and they go 

through this.

But here's where it's apropos of what 

George was saying. So then I hadn't really heard 

this other than glyphosate which is in the news a 

lot. So I went to think, well, why hadn't I 

heard this? So I went to see what other -- what 

EPA and others said.

So then I went to, for example, here. 

No conclusive proof malathion causes cancer in 

humans, although some studies found increased 

incidence in some people who are regularly 

exposed, animal studies. So that was ATSDR. But 
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actually it was written in 2003 and last updated 

in 2014, so prior to IARC coming out.

And then the other thing is -- are you 

still there -- malathion was classified by EPA. 

Now here's something interesting. If you google 

it, it says, suggestive evidence of 

carcinogenicity on the Google Line. But then if 

you go to EPA and to IRIS in 2004 Federal 

Registry, pesticides would not be reassessed by 

IRIS. So you can't look for that.

So then I went to the National 

Pesticide Information Center which hasn't updated 

any of its fact sheets since 2011. Then I went 

to the National Toxicology Program and there 

really was almost nothing there, malathion and 

cancer, some old reports of bioassays from 1978. 

And then I went to the report on carcinogens in 

which malathion and diazinon and glyphosate were 

not even listed.

And so now there's also an EPA draft 

risk assessment for glyphosate which is from 12-

18-2017. And I actually have the link to it, and 
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it says it's releasing for public comment the 

draft on health and ecological risk assessment 

for glyphosate. And it says that it's not likely 

to be carcinogenic in humans, and it's found no 

meaningful risk to human health when it's used 

according to the pesticide label.

And so here's the problem that we're 

facing I think in terms of us coming out with 

something. IARC basically gives malathion and 

diazinon and glyphosate are probable human 

carcinogens. And they're used widely or at least 

in the past they were used widely, and yet we 

have EPA, ATSDR not putting out that they're 

potential carcinogens -- human carcinogens. And 

we have missing in action National Toxicology 

Program.

So I think in terms of getting to that 

presumption, I mean, if we really want to give 

the weight to IARC, then there would be a 

presumption that if you had exposure to malathion 

and you've got non-Hodgkin's lymphoma, would we 

say that's a presumption if it's strong enough? 
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What about prostate cancer because that's 

incredibly common, anybody who may have had some 

exposure and then for how long? And I think it's 

sort of hard to come up with a clear cut 

presumption and for which cancers and for these 

agents.

So I'm undecided where we should come 

down on this other than to say these are 

potential human carcinogens. And maybe there 

should be added -- definitely added historytaking for people perhaps who did the grounds 

work or who were around using these things, to 

make that causal connection. But I'm not quite 

sure about the presumption part.

MEMBER FRIEDMAN-JIMENEZ: This is 

George. I'd like to comment on Rose's question 

here. I think this gets at the very heart of 

what we mean by presumption. And if we're going 

to make a presumption of causation, that involves 

both a presumption of general causation in 

populations that the toxic substance can cause 

the cancer. We need strong evidence of that. 
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And the presumption of exposure in the 

individual. In other words, their job isstrongly 

believed to have given sufficient exposure to 

cause the cancer.

But I have a big concern about 

including IARC 2A carcinogens under presumption. 

2A by definition means limited evidence in 

humans. In other words, epidemiologic evidence 

is not completely conclusive. There's room for 

some bias that's unexplained, very few studies, 

whatever the reason is that the committee didn't 

believe that the evidence was conclusive in 

humans.

And sufficient evidence in animals. 

In other words, we know it causes cancer. But 

it's just not clear whether it causes cancer in 

humans and in which organs. And there are some 

interspecies differences that the biologists 

understand and others that they don't understand.

But my point is that I think the 

presumption should be seen as really a slam dunk 

case. And I don't think that 2A carcinogens are 
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adequately certain to be a slam dunk case. So I 

think we should leave the presumptions for really 

Class 1 carcinogens for which evidence in humans 

is sufficient and make a very, very strong point 

that people that have 2A carcinogen exposures and 

there's a question need to be evaluated case by 

case by a competent physician with the training 

to do these kinds of evaluations which is labor 

and time intensive and requires a lot of 

resources. And that's is what we're trying 

streamline.

But I think you cannot streamline it 

and be adequately accurate when you have 2A 

carcinogens because it's just not certain enough. 

That's my opinion. I'd like to know what other 

people think about that.

MEMBER BERENJI: Thank you, George, 

and thank you, Rose. Duronda, did you want to 

comment on your experiences, especially with 

pesticides at Rocky Flats or other sites that 

you're familiar with?

MEMBER POPE: Yes, sure. It has been 
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my experience at Rocky Flats in particular that 

the workers out there were not protected. So 

they were exposed to many, many pesticides that 

they were spreading out on the ground out there. 

But I think it's very critical when George was 

speaking about these presumptions and the way we 

craft this language. It's going to be critical 

in terms of how they're building this case, and 

this information is all going to weigh heavily on 

how that is interpreted.

MEMBER DEMENT: This is John. Can I 

make a comment? I think there's two areas here 

that I think George touched on. One is just 

general causation. And I think what the DOL is 

really asking us is, is there sufficient evidence 

for some of these 2A carcinogens to make the link 

in the SEM that if you put that exposure, it's 

going to say, it can cause this cancer.

It's not necessarily a presumption. 

We're not going to a presumption. We're just 

saying there's a link in the SEM. That's my 

understand of what we're supposed to be doing.
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MEMBER FRIEDMAN-JIMENEZ: I agree 

completely, John. And I think having a substance 

listed in the SEM is not equivalent to having a 

presumption. The presumptions need to be spelled 

out clearly and carefully in the Procedure 

Manual. But there should be the 2A carcinogens 

and maybe even some 2B where there's no question 

should be in the SEM and it should be understood 

that the SEM is there for doctors to see what the 

possible links are and then look at the 

literature themselves and make the judgment.

That's what we do in occupational 

medicine. We do individual level causation 

judgments. And that's probably going to be a 

large part of the cases that don't have slam dunk 

level evidence but for which when you look at the 

case carefully, the evidence is pretty clear. 

And most doctors would come down on the side of 

saying there's a causal relationship in that 

individual. So I agree completely with what John 

is saying. I think there's a very big difference 

between being listed in the SEM and being a 
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presumption of causation.

MS. POND: This is Rachel. I just 

want to -- I would agree with that assessment as 

well. It is kind of what we're looking for here.

CHAIR MARKOWITZ: So this is Steven. 

So if we remove presumption from the discussion, 

it's a lot easier. But I want to get back to the 

point that I think it was said that a 2A 

carcinogen, it's not clear actually whether it's 

a carcinogen.

So I think IARC is rating it as a 

probable human carcinogen. I think we should 

take that at face value because I have to make 

the link, particular cancer sites. And that can 

be challenging, and it may not be possible for 

all the 2A carcinogens.

But when IARC pronounces it and if 

it's a relatively recent evaluation, I frankly 

don't see the point in going back to older 

evaluations from ATSDR or any other source to 

question the IARC decision. The IARC really is a 

transparent, high quality decision making 
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process. So I think we should be able to rely on 

IARC.

Glyphosate's a special case because 

it's hugely politicized and there's some 

disagreement. But putting aside glyphosate or 

the other issues, I think we should be able to 

rely on IARC for determination of general 

causation as a probable human carcinogen.

MEMBER GOLDMAN: So can we -- just to 

be sure then, we could list it under the SEM that 

if somebody has those conditions that they should 

inquire if they had a job with these exposures. 

And then it would be up to them -- up to the 

treating physician to determine if there was a 

linkage. And we could list that, but it would 

not have to be as a presumption. Is that 

correct?

CHAIR MARKOWITZ: That's correct. So 

I think that the group has done an outstanding 

job actually on their seven-page review of the 

various relevant 2A carcinogens. And I think the 

only -- from my point of view, the only piece 
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that needs to go a little further is actually 

trying to make a decision on which cancer sites 

can be reasonably related to the 2A carcinogens 

which isn't -- I'm not really entirely clear from 

this document. It's an outstanding document, but 

needs a step forward.

MEMBER BERENJI: Thank you, Steven. 

So unfortunately, I'm going to be stepping down 

from the Advisory Board. So perhaps if this work 

is to be continued, Steven, perhaps we should 

identify a new person who's going to spearhead 

this effort.

CHAIR MARKOWITZ: Unless the Board 

votes you in as an honorary member. Yeah, we'll 

get to that. We'll get to that.

MEMBER GOLDMAN: So in terms of --

just to answer that. Is it too difficult just to 

-- I mean, we listed some of the things, both in 

-- Mani, she had a spreadsheet, and I just listed 

the latest on IARC on these three pesticides just 

to say -- just to extract it out of here nonHodgkin's lymphoma, prostate cancer, malathion 
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probable 2A, possible 2A carcinogen in humans. 

Or just to take -- for those cancers, just 

extract it, like, what we have and just list 

those -- or I mean, for those diseases? Is that 

what you were thinking of?

CHAIR MARKOWITZ: This is Steven. So 

the way it's written now is by 2A carcinogen, 

brief reviews of each. And I would just -- in 

each section just come to some conclusion if 

possible that that particular agent is reasonable 

to consider related to cancer X, for each of the 

agents.

That's the single, in my view, the 

single step that's still needed and could be done 

by mid-July before the Board term ends. We 

didn't vote on it, but to complete that step 

would be terrific. It would be a nice to hand 

off to the next Board.

MEMBER FRIEDMAN-JIMENEZ: This is 

George Friedman-Jimenez. I think that we could 

do this as a simple table. The IARC monographs 

are incredibly detailed and well referenced with 
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hundreds of references and lots of details on 

exposure and on all of the science, the different 

scientific disciplines, evidence.

I think all we need to do is extract 

from each IARC monograph or each substance that 

we're talking about which organ system has 

sufficient evidence in humans, which organ 

systems have limited evidence in humans, and 

which have sufficient evidence in animals, and 

just put that table into the SEM. And it would 

be a pretty complete list of what the overall 

world literature is showing.

There are a few, I think, that NTP has 

classified that IARC has not. But almost 

everything that NTP classifies has already been 

classified by IARC. So I think just going 

through the IARC monographs and making a table, a 

simple table of one, two, or three organ systems 

for which the cancers have been judged to be 

sufficient evidence or limited evidence for 2A 

and the name of the chemical. And then that can 

go into the SEM, and that will be the basis for 
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the -- and with references to the monographs 

because if someone wants to look up the cancer, 

the best reference is almost always going to be 

the IARC.

Second references, we haven't talked 

about yet, are textbooks of cancer epidemiology. 

For example, Schottenfeld and Fraumeni fourth 

edition has excellent discussions of some of 

these occupational carcinogens. So if a doctor 

is making one of these evaluations, they should 

be able to get the references quickly from the 

SEM for a particular cancer site and a particular 

toxic substance. So that's what I would 

recommend, just a simple table of all the IARC 1 

and 2A carcinogens.

CHAIR MARKOWITZ: Well, this is 

Steven. We've been asked to provide a rationale. 

And frankly, it's already written. The group has 

already written it. So I agree, add a table to 

the rationale. But I would keep the rationale 

because a lot of work has gone into it.

MEMBER FRIEDMAN-JIMENEZ: It's a huge 
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amount of work to do that for all of those 1 and 

2A carcinogens.

CHAIR MARKOWITZ: Well, I think we 

were just addressing the relevant 2A carcinogens. 

And I wasn't suggesting any work beyond what's 

already been done actually, so with reference to 

all the IARC monographs.

MEMBER BERENJI: Steven, I think I 

completely understand what you're saying here. 

And honestly, like you already alluded to, the 

work has been done. I think we just have to 

specifically state for each particular 2A 

carcinogen that we evaluate it whether there's a 

direct link to a particular cancer in humans. 

And honestly, the information is already 

summarized. It's just we have to actually state 

it clearly. So that's relatively easy to do.

(Simultaneous speaking.)

CHAIR MARKOWITZ: Go ahead.

MEMBER REDLICH: Oh, no. Go ahead.

CHAIR MARKOWITZ: I was just going to 

say the Group 1 carcinogens are already in the 
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SEM. So I think we really can just focus on the 

2As.

MEMBER FRIEDMAN-JIMENEZ: Are all the 

Group 1 carcinogens in the SEM with all of the 

cancer sites?

CHAIR MARKOWITZ: We've been told they 

are by DOL. But when we come up with a 

recommendation in relation to this work on 2A, we 

can add a line that DOL should assure that all 

Group 1 carcinogens are included in the SEM.

MEMBER FRIEDMAN-JIMENEZ: Okay. 

That's good. Although there are more 2A than 

there are 1, so --

MEMBER REDLICH: Yeah, I sent everyone 

just now. There's a template that IARC has that 

organizes by organ site which I think is helpful 

because clinicians probably see someone with a 

specific cancer.

MEMBER BERENJI: Oh, this is great, 

Carrie. Thank you.

MEMBER REDLICH: I think something 

like this. This one doesn't differentiate 1 and
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2A.

MEMBER GOLDMAN: I didn't see it. Did 

you send it by email, or is it up there?

MEMBER REDLICH: I sent it by email.

MEMBER FRIEDMAN-JIMENEZ: She just 

emailed it.

MEMBER GOLDMAN: Okay, yes. I just 

got it.

MEMBER FRIEDMAN-JIMENEZ: I think this 

table is great. Many of these are not 

occupational. They're booze or drugs. So it's a 

subset of this. But this is great, yeah.

MEMBER REDLICH: We can just edit it 

or something similar, just as an idea.

MEMBER FRIEDMAN-JIMENEZ: I think 

there's a list of all of the occupational 

carcinogens of the subset so we can find that 

already listed.

CHAIR MARKOWITZ: There's a 

publication by Loomis that addresses that.

MEMBER REDLICH: Yeah, I have that one 

also.
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CHAIR MARKOWITZ: Okay, yeah. So 

okay. So we need to come to some closure here. 

Dr. Berenji, any other comments or --

MEMBER BERENJI: At least from my 

standpoint, I think I'm going to incorporate the 

PDF that Carrie just sent us and try to create 

something similar for at least the purposes of 

this report. And then I will go back to the 

draft of the report and try to summarize 

succinctly what we are discussing here which is 

to kind of point out whether there's enough 

evidence in humans to be able to incorporate into 

the SEM. I mean, that's kind of my 

understanding. Rose, George, Duronda, any other 

comments?

MEMBER GOLDMAN: Well, I'm looking 

over the list that Carrie just sent. Thank you 

very much. Very informative. And frankly, what 

we could do is look at this list and just delete 

stuff that doesn't apply. But actually from --

or just post this because actually they had 

leukemia and lymphoma. They listed diazinon. 
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They listed glyphosate. So they listed these 

pesticides that we were talking about for 2A. 

And maybe the thing to do, I mean, why not just 

post this?

MEMBER REDLICH: Well, I sent another 

article that also is occupational. So anyway, I 

think it is helpful sometimes to differentiate 1A 

and 2. This is meant as not, as one example.

MEMBER GOLDMAN: Where did this come 

from? This is really good.

MEMBER REDLICH: It's from IARC. If 

you google it, you can find it. But it's 

literally a PDF. But it doesn't --

MEMBER GOLDMAN: Okay.

MEMBER REDLICH: -- it doesn't cite 

it. But it's from IARC. I could send the web 

page if I can find it.

CHAIR MARKOWITZ: At the bottom of the 

table is the citation actually. So again, the 

most important piece, I think, the final step in 

the document that this group has already worked 

up is to name the cancer sites in -- if possible, 
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in relation to the particular 2A agent. And if 

that step could be done in the next month, that 

would be terrific.

MEMBER BERENJI: Sure. I think that's 

relatively easy to do.

MEMBER GOLDMAN: Yeah.

CHAIR MARKOWITZ: Okay, great.

MEMBER GOLDMAN: And I think it's 

really important because people tend to not 

understand that a given chemical doesn't cause 

cancer in every organ.

MEMBER REDLICH: Well, and also that 

it's more of an increased risk.

MEMBER GOLDMAN: Yeah.

MEMBER REDLICH: Yeah. I mean, but 

that would be good to do something like this.

CHAIR MARKOWITZ: Okay. So is there 

any further discussion on this?

(No response.)

CHAIR MARKOWITZ: Okay. So we're 

going to take a break for 15 minutes. It's 2:25, 

so we'll take a break until 2:40. We're just 
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about on time. So we will see -- don't hang up. 

Just stay on the phone and we'll see you in 15 

minutes.

(Whereupon, the above-entitled matter 

went off the record at 2:25 p.m. and resumed at 

2:41 p.m.)

CHAIR MARKOWITZ: So let's get 

started. Actually, so Kevin, thank you for 

bringing this up, it looks very small. I don't 

know if you could make it any larger.

MR. BIRD: Yeah, I could. Is that 

better?

CHAIR MARKOWITZ: Okay, yes, that 

works. So Ken, you want me to just lead off and 

initiate the discussion, or?

MEMBER SILVER: If you don't mind, 

yes.

CHAIR MARKOWITZ: Yes, okay. So this 

has to do with the Board's idea of requesting 

resources from the Department. And Ken and I 

talked about, we tried to come up with a 

reasonable and succinct description of what it is 
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that we think we need resources for. And so 

that's, we have all of a page, a page and a half. 

We understand the request is going to have be 

more involved, more detailed, a better rationale, 

et cetera.

But it is important that the Board 

agree on what it is that we want. And so there 

are two items. One is it's organizing, 

reviewing, extracting data from claims, analyzing 

those data. This may be fresh in your mind, for 

those of you who looked at some of these lung 

cancer or post-1995 claims.

But the path to acquire or to organize 

and develop a database for the extracted claims 

data, organize an in-depth claims for review, 

review and abstract selected data from claims, 

enter and organize the data, and then analyze and 

describe whatever it is that we've learned from 

those claims.

And that these tasks would require 

certain expertise, administrative assistance to 

organize and enter data, expertise in 
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occupational medicine and epidemiology, as well 

as industrial hygiene. And then some limited 

data analysis and description. So that's the 

first bit of tasks.

The second one has to do with 

scientific and technical reviews. But we -- Ken, 

if you have any amendments on what I just present 

it -- otherwise, we can just open the floor and 

see if this captures what it is that we think 

we're after.

MEMBER SILVER: No amendments.

CHAIR MARKOWITZ: Is there anything we 

forgot?

MEMBER SILVER: That question is 

directed to the Board members.

CHAIR MARKOWITZ: Correct, correct. 

And have we captured the set of skills needed to 

do this work.

Okay, so while people are thinking 

about that, let's move on to the second area, 

which is we've been asked and sometimes on our 

own addressed issues involving scientific and 
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technical subjects in relation to various topics. 

We just discussed 2A carcinogens, we 

discussed Parkinson's Disease, and in the past 

week discussed any number of other issues, and 

which would require a fair amount of work of over 

I think the last two terms of Board. And it 

would be, it would accelerate the work if we were 

able to get certain resources to help us.

And a particular task or the search 

and identify relevant literature in this 

particular request for them to review and 

objectively summarize, in a very focused way, the 

relevant literature, with some provisional 

conclusions to the queries that the Board is 

trying to address. And then the expertise needed 

is research assistance, and then kind of the same 

spectrum of occupational medicine, epidemiology 

and industrial hygiene of expertise. 

I suppose we could add toxicology to 

that, but I think it's -- that expertise may not 

overlap with the others, and there are only so

many experts you can really get. So I'm not sure 
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I'd add that interaction.

So any thoughts about this?

MEMBER DEMENT: This is John. I think 

you've captured some of the tasks that's taken so 

much of the Board's time, and that is trying to 

review these claims that are thousands of pages 

without having the benefit of at least some 

pointers to the places in the documents where the 

key documents are. 

It's, I would say at least 50 or more 

percent of my time at least is spent trying those 

pieces of information. That would be of great 

assistance.

I think the skills, you're going to 

have somebody with some data management skills. 

I'm not sure that, up under skills/expertise, 

it's going to be somebody who has some data 

management skills.

CHAIR MARKOWITZ: Okay, okay, that's 

good.

MEMBER FRIEDMAN-JIMENEZ: This is 

George. I think the data management skills can 
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be a research assistant who will search and 

retrieve relevant literature and also can put 

together the database. I also think that the 

occupational medicine/epidemiology person needs 

to be able to do more than just read and 

summarize. 

They need to really critically 

evaluate some of the literature. Because it's 

not always going to be the case that there's a 

single opinion from IARC. Sometimes the opinions 

will disagree, and the person's going to have to 

make some judgements as to which is the better 

review, whether it's IR for NTP or EPA or ACGIH 

or whatever. 

So I think it goes beyond just reading 

and summarizing and needs to be critical 

evaluation of the literature and the reviews.

CHAIR MARKOWITZ: Okay, both those 

suggestions are great and they've been accepted. 

We're not voting on a recommendation now, but I 

have captured both data management and critical 

evaluation in a revision that's not showing on 
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the screen, but I had it in a Word file, so 

that's great. Anything else?

MEMBER FRIEDMAN-JIMENEZ: Question for 

John. Do you have any recommendations for the 

qualifications of the person doing the industrial 

hygiene review? Do you have any suggestions 

beyond what's being done already, or do you think 

the people that are doing it now would be the 

right people to do it?

MEMBER DEMENT: You mean the people 

who are doing now within the contracts?

MEMBER FRIEDMAN-JIMENEZ: Yeah.

MEMBER DEMENT: Well, you know, we've 

discussed this a lot. I, now certainly somebody 

who's certified in the comprehensive practice of 

industrial hygiene is important as a 

qualification. But I think it goes further than 

that. I think it has to be an industrial 

hygienist who deals with more than just taking 

samples. 

It has to be somebody who is also 

somewhat familiar with the epidemiology and 
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causation. I don't know how you write that into 

the skillset that's needed, but I think we have 

occupational medicine combined expertise with 

Epi. In some ways, the industrial hygienist has 

to speak the same language. And the same 

language in many cases is the EpiData.

CHAIR MARKOWITZ: But what if we call 

that exposure, in addition to industrial hygiene 

exposure assessment?

MEMBER DEMENT: Yes.

CHAIR MARKOWITZ: Okay. Because 

that's, you know, sort of a science.

MEMBER SILVER: To narrow it even 

further, should we throw in the phrase medicallegal decision making? Because that is what 

we're doing here.

CHAIR MARKOWITZ: Well, you know, I 

don't know that we need that from outside 

consultants or contractors in terms of, you know, 

kind of the brute work that you need to get done. 

The way I view this help is that, it's to either 

get at information in claims or get at literature 
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that we then can use. 

And in considering the medical-legal 

or you know, framework as it applies to EEOICPA 

claims. But I'm not sure that we need the outside 

input into that, if that makes sense.

MEMBER SILVER: I was triggered by 

John excluding industrial hygienists who just 

take samples, wondering what kind of added savvy 

would qualify card-carrying industrial hygienist 

who is strong in exposure assessment. And that 

was one thing that came to mind. And another is 

familiarity with the DOE complex. 

I think one of the shortcomings of the 

contract CIHs is a little bit naive about the 

complexity and rarity of some of the processes at 

DOE facilities. And it would be good if at least 

one of the disciplines represented in this, the 

doctors, the IH, the administrative people had 

some track record in the DOE complex.

CHAIR MARKOWITZ: So why don't we, 

under skills/expertise, add item C, something 

like familiarity with DOE complex.
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MEMBER SILVER: All right, thank you.

CHAIR MARKOWITZ: Yes. Anything else? 

Okay, well, this helps. The Board or the next 

Board will see another version of this. I mean 

some board at some point is going to have to make 

an official request. So this will be, this 

write-up will be amplified. But this helps in 

identifying core functions.

So I think then if there -- are any 

other comments? Otherwise we can move on to the 

next issue.

Okay, the next is listed as the 

contract medical consultant and industrial 

hygiene assessment or evaluation. And so there's 

a separate file, Kevin, on this. This is the 

workgroup that consists of Duronda Pope, Ron 

Mahs, John Dement, and myself. And again, this 

is preliminary. We're not going to vote on this. 

We want to see if we get some of the initial 

approach down, we want some feedback.

But in addition when, as we worked 

this up, we realized that we really had to 
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understand specifically what the current 

assessment or evaluation of the industrial 

hygiene and medical expertise within the program 

is. The particular task assigned to the Board is 

to evaluate the quality, objectivity, and 

consistency of the industrial hygiene in contract 

medical evaluations. 

So that's what led to a request to the 

Department for the specific language of the 

contracts with the industrial hygienist, hygiene 

contractor called Banda, and the medical 

contractor, which is QTC, I think. 

And so those are the materials that 

have just been provided to us. We haven't really 

had a chance to look at them. At least, I think 

many of us haven't. And we're not going to 

discuss those in specific details anyway. 

But now that we have them actually, we 

can better describe here what it is that, if 

anything, what needs to be done, what gaps need 

to be filled. So then, let me read some of this 

so we can discuss, or at least briefly run 
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through it.

So as a preliminary thought, the Board 

recommended the Department develop an ongoing, 

independent, third-party-based system of periodic 

evaluation of the objectivity, consistency, and 

equality of individual claims assessments 

provided by program industrial hygienists and 

physicians. 

By the way, when we say program, 

that's not limited to the DOL employees, but that 

means all of the contractors as well.

And so the rationale, we note that the 

program currently assesses aspects of the 

contract, the medical reports, the quarterly 

review of approximately 50 claims by the Medical 

Director of the program. And there's a table we 

provide results of the Medical Director's audit 

from, these were the most recent ones available, 

as of a couple months ago.

And this would need to be updated if 

additional ones are available. But looked at 250 

audits, claims. I don't see any CMC reports. 
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And this is how it breaks down in terms of the 

type of report and then the percentage that need 

improvement. 

This notion of needing improvement 

doesn't, in this table, separate out to minor 

versus major. But you can see there's a pretty 

clear pattern, which we've discussed before, 

which is that causation is generally not seen to 

be, represent much of a problem in terms of the 

current reports.

But in the other areas, quite a few, 

quite a high percentage, actually, of reports 

need improvement. Again, some of that 

improvement might be minor. This evaluation here 

is not making a big distinction here. And so 

those two findings are noted in the next 

paragraph on medical review.

One interesting thing which we 

haven't, we need some understanding of is when 

the Medical Director finds -- has a finding of 

needs improvement, it's reviewed by the Policy 

Chief or the Policy staff, who agrees or doesn't 
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agree. And then I think that feedback is passed 

along to the contractor. 

But the question is, aside from 

perhaps some improvement in that particular 

claim, to what extent did the generic problems, 

which are identified through this review, are 

addressed more broadly. And that's something 

that we need some clarification from the 

Department about.

Because frankly, if you have 23, 28 

percent problems that means there's a, you know, 

just a systematic problem that needs to be 

addressed. So we need some clarification about 

what the Department does about that.

And on the industrial hygiene side, 

Kevin, let's go to the next page. And so our 

understanding of industrial hygiene assessment is 

that there's not this kind of quarterly sit-down 

look, the way the Medical Director does, but that 

each report, as it's submitted to the program, is 

evaluated by the federal Industrial Hygienist, 

who looks at it for consistency and quality. And 
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then puts their stamp of approval on it or 

requires some correction.

And we see that in the claims, that 

the federal IH doing a low-process evaluation. 

And so but there's no look-back, really, on 

sample of claims to see if there are the broad 

directions that require some intervention to look 

at whether there are some errors or overlooked 

items that occur on a reasonable basis, 

reasonable frequency and require correction.

And so we note that they share these 

different approaches to be on the medical side 

versus the industrial hygiene side.

One last note here is that we still 

have to look at the Banda and CTC quality reviews 

to see how what they do impacts on our 

understanding of the process.

In any case, so let me open the floor 

here and see if people have other thoughts. And 

if you could scroll back up, Kevin. I think what 

we also want is some feedback on whether this 

ongoing, independent, third-party-based approach 
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is reasonable and necessary. 

You have, for instance, right now the 

Medical Director doing these quarterly reports. 

I mean, I'm sorry, you have individual reports 

review. Do we need to recommend that somehow 

this process be made more independent, or what? 

So, the floor is open.

MEMBER DEMENT: I'll start. This is 

John. I guess I feel like there needs to be an 

independent assessment. We, based on, you know, 

reviewing a lot of claims over the last few years 

and there seem -- for some industrial hygienists 

and some CMCs, there seems to be a pattern at the 

review of them. 

And sometimes a pattern is just one of 

a relatively brief and shallow report. In some 

cases, industrial hygienist, for example, it's 

not clear based on my review in more detail of 

the cases, that some of the claimants' statements 

are being considered. 

So I just think that it's almost at an 

individual level. There needs to be some level 
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of oversight of each CMC and industrial hygienist 

to make sure there's not a systematic set of 

errors that they're making. So I think a 

independent review is necessary.

MEMBER SILVER: This is Ken Silver. I 

agree with John. And one of the claims that I 

reviewed for today makes me raise this question. 

Is there any evidence that after a DOL denial is 

reversed on appeal or at the Final Adjudication 

Branch, that the CMC or the IH get feedback on 

what they missed when they contributed to a 

recommended denial? What new evidence or what 

new interpretation was presented at the last 

stage of the process to overturn their work? 

I don't want to incentivize the IHs 

and CMCs to try to, quote unquote, beat the 

claimant, but it seems like there would be a lot 

of value in making sure that feedback loop is 

closed. It was eye-opening for me that a family 

doctor in a rural community in Tennessee is 

better at accessing and interpreting occupational 

epi studies than the contract medical consultant.
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MS. POND: So this is Rachel. You 

know, most of our CMCs are op med doctors or 

certain specialists, depending on what we're 

referring them for. And we do get family 

physicians that will send information in. And 

sometimes that information is -- really, it 

depends. 

I mean, we get web -- we get a lot of 

different analyses that doesn't always have the 

backup, or it's got backup that isn't based on 

the kinds of occupational things that we're 

looking at. So, you know, we do have doctors 

that are specialized in it. 

But when we get something from a 

family doctor who knows the claimant and has 

evaluated claimant and has more familiarity with 

their history than the CMC and provides more 

information, then we will weigh that and 

oftentimes remand the case or reopen a case for 

further evaluation.

MEMBER SILVER: Well, it probably 

doesn't happen every day, but I really did see a 
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case where the FAB weighed the family doctor's 

opinion submitted on appeal versus the CMC's 

opinion and decided that the family doctor's 

opinion had more probative value. But I'm asking 

more of a procedural question. In case like that 

however rare, once the dust has settled, would 

the CMC get to look at what happened?

MS. POND: No, we don't usually send --

we don't usually send the reports from. So in 

this case, what I just described, where we do 

have -- and we are actually relying more heavily 

on treating doctors when we can, just because as 

I said, they have more of the history of the 

claimant. And if they can provide us with 

rationale that's sufficient to reopen the case or 

accept the case, then we will rely on that.

We'll oftentimes send the CMC report 

to a treating doctor to say this is what the CMC 

said, what is your opinion on this based on your 

knowledge of the claimant. So that is one trend 

that has moved, been, we've kind of been drilling 

into our CEs to make sure that they're paying 
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attention to what the treating is saying so that 

we don't weigh a onetime visit from a CMC too 

heavily.

But as to your question, we don't 

normally send treating physicians' rebuttals or 

contradictions back to a CMC because we pay them 

on a per, you know, a per claimant basis. They 

will look at the claim, they'll review it. And 

we do try to take lessons learned. 

We have calls with CMCs to talk about 

things that we've found in general on a regular 

basis, but that's about as far as we go at this 

time.

MEMBER POPE: This is Duronda. Is it 

the Board's job to be the independent third-party 

audit?

CHAIR MARKOWITZ: Yes. This is 

Steven. I think the keyword there is job, right? 

I don't -- I'm not sure that's a reasonable or 

unreasonable interpretation of our charter.

MEMBER POPE: Sort of like what we're 

doing.
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CHAIR MARKOWITZ: You know, to the 

extent that it needs to be on an ongoing basis 

and really relied upon by the program, not as 

advice but as, you know, a real evaluation, I 

think it should be something that has a different 

relationship with the program than we do. I 

mean, I think we can provide advice on what that 

should look like. 

But if -- but this is a really a 

specific ongoing function that I don't really see 

as part of the Board's domain. But I'm open to 

other, you know, opinions.

MEMBER SILVER: Most auditors get 

prescription eyeglass benefit plans, don't they? 

And if the next board were to get a contractor, 

the contractor would provide employees with what 

they need to get through these massive case files 

and derive statistically relevant sample of files 

to review.

So we're not really set up to have 

auditing as our job. We can raise the questions 

and gather preliminary evidence how to address 
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them more systematically, but I don't think we 

can really be the auditor.

MEMBER POPE: Point taken.

CHAIR MARKOWITZ: However tempting 

that might be. Okay, any other comments or? 

Okay, so the plan here then is for this working 

group is to take a look at the provisions of the 

contract with the medical and the industrial 

hygienist contractors somehow appropriately, 

properly fold that into the rationale here. And 

then formulate a draft recommendation, which 

would go the next Board form them to do whatever 

they want with it. But we'll, we can push it as 

far as we can within the allowed timeframe.

Any final comments on this before we 

move to claims review? Okay, so we were given, 

sent a number of claims. We have requested, I 

think we got 20 lung cancer claims and about ten 

post-1995 claims. Just a reminder of the 

background. By the way, there's no, I'm not 

aware of anything we have, Kevin, to show at this 

time. Although we are definitely not on break. 
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But the just, by way of reminding you 

about on the lung cancer claims. So one of the 

reports from the Department, the report 682, has 

listed a large number of lung cancer claims, with 

certain information about those claims, including 

a job title, when people were hired, when they 

were -- when their job was finished, when their 

cancer was diagnosed.

And on the surface, it looked like a 

lot of these lung cancer claims, they're from a 

group that was denied. And it looked like, given 

the presumptions in the procedure manual, that 

they didn't understand why they were denied 

because they looked like they should be. See, 

that's the presumption that it should be 

accepted. So do you want to take a look at that, 

we'll try to understand it better.

And then on the post-'95 claims, these 

were people whose employment began at the 

Department of Energy after 1995, and we wanted to 

see how their exposure was viewed in the claims 

evaluation process. So let's start with the lung 
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cancer claims. And we had a number of 

volunteers. And so including Dr. Silver, Dr. 

Redlich, Dr. Domina, Dr. Dement and myself.

Anybody want to start?

MEMBER SILVER: Well, I have an easy 

one. Ken Silver here, a very easy one. It was 

only 18 pages with no real meat. And that hasn't 

happened before in any other --

CHAIR MARKOWITZ: What's the last four 

digits? What's the last four digits?

MEMBER SILVER: Three digits.

CHAIR MARKOWITZ: Okay.

MEMBER SILVER: 6-4-6.

CHAIR MARKOWITZ: Okay, thanks.

MEMBER SILVER: So that hasn't 

happened before with any of our other case file 

retrievals, but let me sink my teeth into 

anything there.

MEMBER GOLDMAN: So are we -- this is 

Rose, are we supposed to be putting the CD in and 

looking as you're talking, or are we going to see 

a summary? I'm just wondering what we should be 
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doing.

CHAIR MARKOWITZ: Don't put the CD in 

and look because you'll get a little lost.

MEMBER GOLDMAN: Okay.

CHAIR MARKOWITZ: We really are after 

just some summary assessments of the claims that 

people looked at.

MEMBER DEMENT: This is John, you want 

me to go second?

CHAIR MARKOWITZ: Sure.

MEMBER DEMENT: Well, I had four 

claims, only three of which were all on my CD. 

It must have been a misnumber on one. But when I 

looked at the claims with regard to the asbestos 

presumption, I can't say that, you know, they 

made an error in applying the presumption with 

regard to work duration prior to 1995 and the 

outcome in question.

But I did look at the claims in more 

detail, because these were lung cancer claims 

that were denied. And there's one claim that I 

found to be particularly troublesome, and it's 
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number 0541. This is an individual who worked at 

the Idaho National Lab about 11 years, between 

'80 and 2012. It is heavy equipment operator, 

operating engineer, a working operator foreman. 

And basically an operating engineer.

Only had about a month of employment 

before 1995, most of it was after 1995. And so 

the claim was reviewed by the Industrial 

Hygienist, who actually had a initial report and 

then some supplemental reports. The SEM 

identified asbestos as an exposure. It also 

identified silica, diesel, and several metals, 

including cadmium and nickel and beryllium.

So the Industrial Hygienist basically 

finds that exposures post-1995 would not be in 

excess of applicable standards and regulations. 

A usual, it's pretty much a usual statement.

The CMC in this case reviewed the 

industrial hygiene report and looked at the data 

for causation. The CMC report is totally 

confused. It basically confuses diesel fuel with 

diesel exhaust exposure, and it then states that 
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diesel exhaust are categorized as IARC Group 3, 

but it was in fact categorized as a Group 1 in 

2012.

And the CMC does the same thing with 

cadmium. Cadmium was a Group 1 carcinogen in 

2012. So you know, given, this is one of the 

reports that there are significant factual 

errors, in my opinion, with regard to the CMC 

report, both on individual compounds, as well as 

just considering all these materials in totality 

with regards to causation.

This individual was, I think was a 

nonsmoking individual, or well, a former smoker, 

but he quit smoking many years ago, before his 

diagnosis of lung cancer. This is one of the 

reports that really, when I looked at with the 

CMC report, really was cut and paste some 

materials from the internet that had to do with 

diesel fuel.

It talks about aquatic toxicity, 

irrelevant material stuck in the report. It was 

one that was a red flag to me that in my opinion 
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this CMC report should be looked at in detail. 

Others as well.

CHAIR MARKOWITZ: So this is Steven. 

I looked at some of these files and claims so I 

can review a couple. They're claims that end in 

1985, that's the number. This one was easy. The 

person was a cafeteria worker with lung cancer. 

And I've no idea why this was 

subsequently reported as being a labor because 

the person didn't appear to be that, there was no 

documentation of that. So this was just not a 

claim that we intended to review.

Another claim, 9032, was interesting, 

a very interesting claim, actually. This was a 

roofer and janitor at DOE for I think from 2003 

to 2014 and didn't meet the criteria for latency. 

So I can understand why they weren't accepted as 

the presumption. 

The statement of accepted facts, I 

couldn't find an industrial hygiene report, but 

the statement of accepted facts says that the 

exposures were within regulatory limits. And 
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this was quoted by the CMC as -- accepted by the 

CMC and stated as the reason why there would be 

no occupational contribution from a roofer and 

janitor during those 12 years or so.

There is a personal physician who 

wrote a strong report in opposition to the CMC's 

conclusions. And the Director of the, I think 

District Office, overruled the denial, citing the 

personal physician's strong letter, strong 

support of, in opposition to the CMC.

So I don't have quite the chronology 

correct because you know how it is that the 

Director overruled the denial, I'm not sure. But 

in any event, it was in my view an inadequate job 

by the CMC and a reliance of the Claims Examiner, 

perhaps Industrial Hygienist, I'm not sure, but 

at a minimum the Claims Examiner on this post1995 but within regulatory limits.

I'll tell you another claim, 5648. 

This is a lung cancer 2013, which was denied 

appropriately because they only worked for a very 

short period of time as a glazier, a glassworker. 
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Interestingly, when I looked up glazier on the 

SEM, in the construction -- under the 

construction rubric, the glazier is not listed as 

having a link to lung cancer. At least I 

couldn't find that.

But in Exhibit 15.4, which we reviewed 

earlier, the glazier is one who's recognized as 

having significant exposure to asbestos prior to 

1995. So it may be that this, there, the 

Department needs to look at the SEM, in the SEM 

at the rates for glazier, because it should be 

linked to lung cancer if Exhibit 15.4 is going to 

be maintained, so.

Any other claims anybody wants to talk 

about?

MEMBER SILVER: This is Ken again. I 

have an issue that arose in two claims. Question 

for the doctors on the Board, the CMC's asserted 

in both claims, lung cancer claims, that because 

there was no radiographic evidence of asbestosis 

or pleural plaques, the lung cancer could not 

have arisen on asbestos exposure. 
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In other words, lung scarring is an 

obligate step on the way to lung cancer. I 

understand that it's a marker of exposure and if 

it's there it says whoa, this person had a lot of 

asbestos, but is that a contested issue, or is it 

pretty well settled you can develop asbestosrelated lung cancer without fibrosis or plaques?

CHAIR MARKOWITZ: It's a settled issue 

that the risk exists in the absence of 

nonmalignant disease. But there's a certain 

subset of physicians out there who are involved 

in litigation who don't believe it. And it's 

possible that you encountered a couple of them. 

But it really is really thinking that you don't 

need to have any scarring due to asbestos, too.

MEMBER GOLDMAN: This is Rose. I 

think it also depends if the person was a 

cigarette smoker or not. If it's a nonsmoker 

it's easier legally to make the case for, you 

know, perhaps, you know, the role. 

What happens in a lot of people if the

person's a cigarette smoker, then they just 
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dismiss the asbestos exposure, although you 

shouldn't really because it's potentially a 

multiplicative effect. But I think there's been 

a lot of arguments over that one.

MEMBER SILVER: So that argument 

probably shows up all the time in tort cases, 

right, when there are very large amounts of money 

on the line. But in a claimant-friendly 

administrative compensation program is it 

appropriate for this setting? I believe both of 

these workers were in fact smokers.

CHAIR MARKOWITZ: Well, this is 

Steven. In a science-based evaluation, presence 

of nonmalignant disease should not be required to 

draw a causal relation between exposure --

asbestos exposure and lung cancer.

MEMBER SILVER: Thank you.

MEMBER GOLDMAN: Could you repeat 

that? It didn't come through, it was very soft. 

Could you just repeat that?

CHAIR MARKOWITZ: If you want to make 

-- the decision is based on science and the 
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weight of the evidence, then you would not 

require the presence of nonmalignant disease in 

nonmalignant scarring in particular among 

asbestos-exposed to conclude that a person had 

asbestos exposure and that it's causal with their 

lung cancer.

MR. BIRD: Sorry to chime in here, 

this is Kevin. Just a quick reminder to everyone 

to, if you're not speaking, if you could keep 

yourself on mute that would be great. Thank you.

CHAIR MARKOWITZ: All right, let me 

add another claim, claim 7497. Interesting. 

Nine months as a carpenter, so the person did not 

meet the presumption of 250 days of exposure to 

asbestos. So the decision was correct from the 

point of view of presumption, did not meet the 

presumption. 

The CMC decided that nine months as a 

carpenter wasn't sufficient to contribute to a 

lung cancer, which, you know, I'm sure there's 

variation in thinking about that.

But the CMC report hosted, cited a 
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number of reasons why there couldn't be any 

causality. One was that no air monitoring 

results were available. That's an unreasonable 

criterion on which to base the decision. And the 

CMC with many of these claims cites the cigarette 

smoking as critical to the development of lung 

cancer.

Although we've been told by the 

program that the consideration should be apart 

from the initial cigarette smoking, that message 

hasn't gotten through to a number of the CMCs.

And then one final, before we move to 

post-'95 claims I just want to cite one other 

claim, 6018. This is an ironworker for a long 

time. I mean, a career ironworker, but only had 

a year and a half work as an ironworker within 

the Department of Energy. So he met the 250-day 

presumption criteria for asbestos but did not 

meet the 15-year latency requirement because the 

latency was 14 years, eight months from the time 

of his work at the DOE.

And so strictly speaking it didn't 
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come under a presumption. The CMC noted that 

this wasn't sufficient contribution, quoting low 

level exposure for a short period of time. And I 

think of we gave that case to five different 

CMCs, we'd probably get half of them deciding one 

way and half of them deciding another way, which 

gets to the issue of consistency.

So what my take-home from these 

reviews is that we've got considerable variation 

in the quality of the CMC. And to some extent, 

some of that's understandable because it's 

discussing opinion, but some of it is due to the 

inadequacy of some of the CMCs.

Can we move to post-'95 claims? Did 

anybody look at some post-'95 claims?

MEMBER DEMENT: This is John, I looked 

at a number of them. You know, the issue of 

post-'95, looking at the post-'95 claims was sort 

of in response to our comments that it looked 

like the circular or the memo with regards to 

post-'95 exposure assumptions of being within 

regulatory standards, that memo was rescinded. 
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But we see the same statement over and over again 

in the industrial hygiene report.

So we responded that we thought that 

that was not appropriate. The DOL responded back 

to us saying that, I think mistakenly saying that 

we were wanting them to assume exposures, 

significant exposures post-1995, which we're not. 

Really just saying you just don't presume that 

they weren't there.

There's one statement in the DOL 

response I think is particularly important. 

They, you know, the discussion of considering all 

the information, and in the DOL response they 

say, in other circumstances employees' 

descriptions of specific exposure activities 

and/or work processes will be such, will be of 

such convincing quality to warrant affirmation of 

significant exposures in the absence of 

monitoring data.

But basically the way that DOL reports 

go, industrial hygiene reports, they say in 

absence of in an area, again post-'95, the 
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exposure's assumed to be within regulatory 

standards. So what happened with that of course 

is that statement is then used by the CMC in some 

cases to assume not significant exposures and 

make a negative determination.

There's one that, there's a couple 

reports that I looked at that I think are worthy 

of some discussion. One was number 5756. This 

was a claim for COPD and a never-smoker who was a 

pipefitter at Portsmouth, with most of his work 

being post-1995. The claimant on the OHQ talked 

about multiple exposures, including welding fumes 

at the DOE, doing DOE site work.

In fact, providing some handwritten 

statements that were available in the claims file 

describing he and coworkers doing welding in an 

unrelated shop and also welding within confined, 

sometimes confined spaces, that is, within a 

large pipe trench. The IH assessment relied on 

the SEM and it used post-1995 statements with 

regard to exposures, not exceeding regulatory 

standards.
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In this particular case, the CMC used 

the industrial hygiene report and that statement 

to find lack of causation. But most disturbingly 

is a CMC statement in addition to the industrial 

hygiene basically not looking at this or 

considering this specific description of the 

work.

The CMC says that current occupational 

safety and health standards are designed so that 

no harm -- to cause no harm and no more than one 

in a million people exposed. This, I've seen 

other CMC reports and I assume for the person. 

This individual clearly doesn't know the basis 

for occupational safety and health standards and 

risk assessment. And in my view, this 

assessment's clearly off base.

For two reasons. One is the CMC's 

assumptions and also the industrial hygienist's 

lack of considering specific exposure 

circumstances, including welding, within 

compliance basis for a period of about eight 

years.
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There's a similar case, and this is a 

more difficult case. Number 4550. This is a 

person who worked as a quality control position. 

Basically I think more data quality control. 

But they worked away from the Yucca 

Mountain site but had to come on site and be at a 

site trailer for several times during the month, 

and in some cases go into the actual work areas, 

including an area that was described as the 

exploratory studies facility.

This individual had a document in the 

file that I reviewed that described just driving 

to the sort of remote site. It was dusty, the 

site itself was dusty. The trailer was dusty, 

the work area was dusty. 

This individual was a never-smoker who 

was diagnosed with silicosis based on a chest Xray and a B read, with a very supporting 

physician's report that basically ruled out other 

causes and thought that this exposure to silica 

during the Yucca Mountain site, doing some work, 

was at least contributory to this person's 
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silicosis.

This is another case where it's not 

clear to me that the industrial hygienist 

actually considered anything beyond the job title 

and the SEM report in making, make a 

determination for no exposure. In this case, the 

comment was, would have been passing and 

incidental.

So again, I, you know, we are not 

trying to say that post-1995 exposures are 

assumed to be significant. And sometimes they 

are, and I think the industrial hygienists really 

need to look closely at more than just the SEM, 

more than just a job description in trying to 

make some of these determinations.

It may be that end of the day, the 

determinations still would be denied, but in this 

case I really don't think the record was given 

full view.

CHAIR MARKOWITZ: John, I have a 

question, Steven. In both those cases, was there 

sufficient information in the file for the 
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industrial hygienist to depart from the idea that 

post-'95 exposure levels were safe?

MEMBER DEMENT: I think in this case, 

as a industrial hygienist, to me there was enough 

information in the file to, if I were reviewing 

this file, to make me go back and say let me 

explore this further. 

I think with regard to welding within 

a shop, a fairly small shop, with no ventilation, 

and they actually, he had coworker statements 

confirming the fact that that was the case, 

should have been convincing enough, at least on 

the industrial hygiene side, to take a harder 

look. 

And you know, we have made 

recommendations and DOL has adopted procedures 

for talking with the claimant directly, and I 

think that needed to happen in this case. 

Probably in both of these cases.

MEMBER SILVER: John, this is Ken. 

Was there any recognition in the claim file that 

out at Yucca Mountain we have the isomorphs of 
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silica that are presumed to be more potent 

cristobalite and tridymite?

MEMBER DEMENT: Actually, the 

physician, the person's physician made those not 

specific statements, but acknowledged that that, 

those sites you know, had silica, based on cases 

that this individual had reviewed before in 

surface soils.

CHAIR MARKOWITZ: This is Steven. 

Well, that's interesting because you know 

previously we had been thinking that the 

essential problem was that Yucca's case-specific 

exposure information didn't really enter the 

record from the point of view of the claimant, 

such that either the claims examiner or the IH 

could really make a complete determination about 

exposure. 

And that's in the past why we have, we 

recommended that interviews be conducted with 

claimants for some, and also that the OHQ be 

included, so that the quality of the information 

in the evaluation process is improved. 
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But here actually you are looking at a 

couple of claims in which the information was 

probably there, but underutilized by the 

industrial hygienist.

MEMBER DEMENT: Yeah, I am saying the 

information was there, Steven, at least in my 

view raised the red flag. You know, the Yucca 

Mountain situation, if I am just given that this 

person was an individual who was occasionally on 

site and developed silicosis, yeah, you know, it 

probably wouldn't be difficult to conclude that 

it's unlikely that it related to the exposure. 

Except the physician eliminated other 

exposures and there was documents in the file 

that showed more than just, that showed casts 

(phonetic) that would have caused exposures to 

silica that could have contributed to this 

outcome.

CHAIR MARKOWITZ: Okay. Anybody else 

look at the post-'95 claims?

MEMBER REDLICH: This is Carrie. You 

know, several of these claims just have some of 
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the same themes that we have had before, such as 

number. So the COPD, let's see, 2876. But I 

believe there is just a comment that, you know, 

they are acknowledging exposure to, you know, 

what was it here, asbestos dust. Some of them 

work at the uranium mines in Colorado.

And but basically the SEM acknowledged 

exposure, but then there was a comment that after 

exposed to diesel exhaust, asbestos, cement, 

crystalline silica, welding fumes, that then that 

the CCIH opined that exposures to any of those 

after March 11, 1996 would not have exceeded 

regulatory standards. And the CMC then opined 

that there was not significant, the exposures 

were not a significant factor in contributing or 

causing COPD.

And then, you know, the claimants sort 

of appealed and gave a description of the work 

that they did in terms of you know, just a lot of 

dusty exposures, being very close to an excavator 

and the like. And that to me seemed like 

sufficient exposure. 
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So I think it's a example where it 

seems that the CMC is, you know, potentially 

overly influenced by the IH report. This happens 

to be one of the particular physicians we have 

raised questions about before in our prior review 

of claims. So it's a little disheartening that 

this same person (telephonic interference) claims 

after we have raised questions about this 

particular physician.

I've got a bit of a sore throat, so 

I'll stop there.

CHAIR MARKOWITZ: Okay. 

MEMBER SILVER: This is Ken. Linking 

this back to the quality issue we had on the 

agenda a moment ago, my analogy is that the best 

football teams after a couple of days sit down 

and look at the reruns and analyze their fumbles, 

their interceptions. And Dr. Redlich makes an 

excellent point, we've raised these same issues 

over and over again. 

And I saw an example where the FAB 

overruled the CMC once a better analysis came 
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from the family doctor. It seems that good 

management if you want to be a winning program 

would, you know, take a look at the fumbles and 

the interceptions with the player in the room.

MEMBER DEMENT: This is John. One of 

the themes that I find very difficult with regard 

to some of the outcomes, particularly COPD, you 

know, there's a number of claims where there 

would be maybe four or five different exposures 

actually identified in the SEM as related to that 

job category and linked to COPD, actually.

And then the determination by the 

industrial hygienist that, you know, then they're 

either low exposure or passing exposures or 

within regulatory standards. But nobody, 

including the CMCs, ever says but wait, there 

were five of them, not one, and looks at the 

totality of the exposure appropriately.

MEMBER REDLICH: You know, that's 

exactly the situation on the last one that I --

CHAIR MARKOWITZ: Yeah, I mean, this 

is Steven. Part of the problem is, you know, the 
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CMC is sitting there and it is hard to judge 

exposure. 

And so but the fault is hey, let's 

look in the industrial hygiene report or the 

statement of accepted fact version of the IH 

report that says low frequency, nothing above 

regulatory level. And that makes the 

decisionmaking very easy for the CMC. No 

significant exposure.

MEMBER DEMENT: Especially if you have 

the opinion that if they're within regulatory 

standards, only one in a million exposed people 

would be affected.

CHAIR MARKOWITZ: But that's, you 

know, that's a misinformed CMC.

MEMBER DEMENT: Yeah. But to -- the

point I think Carrie's making too, this is a 

misinformed CMC who makes these recommendations 

over and over. We see them in many reports, you 

know. Somewhere somebody, some other doctor 

needs to look at that and say wait, this is offbase and we need to make a change.
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CHAIR MARKOWITZ: Well, you know, we 

saw it in the --

(Simultaneous speaking.)

MEMBER REDLICH: -- Position there is 

no other physician, and I've reviewed a lot of 

these records, that comes close to reviewing the 

same number of claims as this physician, at least 

among the subset that we have been given. So 

it's a sizable number of claims by a single 

physician.

MEMBER MAHS: Doesn't that mean he 

makes a little more money?

MEMBER SILVER: I think they are paid 

piece rate, yeah.

MEMBER MAHS: That's what I was 

getting at, they're paid by the client.

MEMBER SILVER: Regarding COPD, I know 

the Department of Labor wasn't open to pay for 

gas and fumes of being incorporated into the 

regulations or the procedure manual, because it 

has to be a specific toxic substance. But I 

wonder if a middle ground approach would be 
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guidance to the IH and the CMC in cases of COPD 

to consider as many credibly documented exposures 

as possible. 

I had Case 4457 of a lab technician at 

Portsmouth. And because of the SEM, he was only 

allowed ammonia, asbestos, and chlorine 

exposures. But elsewhere in the case file, 

there's pretty solid evidence that he was exposed 

to hydrogen fluoride. The company's medical 

surveillance program indicated that he had that 

exposure years before he developed COPD. 

It's documented on the occupational 

health questionnaire that he worked with 

isocyanates for the last ten years on and off and 

had exposure to magnesium chloride pellets 

described as a very dusty operation. Perchloric 

acid, nitric acid. I mentioned hydrofluoric, 

right?

But to evaluate the claim, they only 

considered ammonia, asbestos, and chlorine. So 

maybe some guidance could be developed for COPD 

claims to consider as many credible exposures as 
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possible, you know, lead them right up to the 

cusp of VGDF even if they don't spell it out.

CHAIR MARKOWITZ: Okay, so we probably 

need to move on. But I think these comments 

actually can feed into our report on consistency, 

quality and objectivity of the industrial hygiene 

and CMC reports. So some of these observations 

will be built into that rationale and 

recommendation.

MEMBER DEMENT: This is John. I 

actually like Ken's suggestion for COPD. You 

know, maybe there's a middle ground that we, you 

know, we've already written the rationale for 

VGDF, just a guidance document, a statement.

MEMBER SILVER: For a while, QTC was 

trying to cap the number of exposures considered 

at seven. In this case, didn't even, they 

limited it to three. But maybe we're 

recommending that they list the cap and consider 

as many credible exposures as are contained in 

the claims documentation. 

If one of the CMCs stays up on the 
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literature, they'll say wow, you got 15 vapors, 

gasses, dust, and fumes here. My professional 

judgement, it might have caused or contributed to 

this.

CHAIR MARKOWITZ: So what's the 

follow-up on this, for this?

MEMBER SILVER: I don't know, do we 

need a recommendation down the road or? It's 

kind of hard with the Board wrapping up its 

business to have an idea like this now.

CHAIR MARKOWITZ: But you know, 

regardless, for continuity, we can certainly send 

along some, an observation that, you know, they 

can take up. Otherwise it'll disappear, so 

that's a shame.

MEMBER SILVER: In cases of COPD, do 

not limit the IH evaluation to exposures in the 

SEM. Consider all exposure, inhalation exposures 

that are credibly documented in the case file.

CHAIR MARKOWITZ: So let's follow up 

on that. We're not going to formulate a specific 

recommendation I think, and be able to vote on it 
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now. But let's, we'll offline sharpen that up 

and make sure it's in our exit report, how about 

that?

MEMBER SILVER: Okay.

MEMBER REDLICH: Some of these are 

appropriate denials. I mean, this is, some of 

these are so -- and they go through so much 

effort. Then we just sort of, maybe we could 

make some, I don't know, common sense, you know, 

the greater the years of employment need to have 

a closer look. 

If it's only one or two months of 

employment, it's going to be less likely that 

COPD is going to be related to that employment. 

So someone has, you know, 15 years in a 

industrial, dusty environment. It's just some of 

the, I just sort of feel like maybe they've just 

been sort of common sense checks on the system.

MEMBER DEMENT: This is John. I 

agree, Carrie, you know, some of files are 

extremely long for a few months of exposure. It 

was a lot of work to come to a conclusion that 
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probably should have been short-circuited, but 

nonetheless it took a lot of time.

CHAIR MARKOWITZ: Okay, so let's move 

on. DOL's requested some helpfulness on trying 

to get providers to be more responsive. I 

thought maybe some Board members hadn't had a 

chance to review the development letters, we 

could take a look at a couple to kick off the 

discussion.

Ken, I sent you some files. If you 

could go to redaction letter number 5.

MR. BIRD: Yeah.

CHAIR MARKOWITZ: I'll just, if 

there's a way -- this is a short letter. 

Actually, we don't need to see this topic, it's 

so much, if you could just scroll it up some. 

It's a one-page letter. And on Parkinson's 

Disease. And apparently they've gotten medical 

statements. Can you scroll up so we can see the 

rest of the letter.

Okay, so that's the whole letter and 

it states what the problem is, what the past 
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action by that provider was. They enclosed the 

IH report and asked specific questions, this is 

in the fourth paragraph, provide us with opinion 

about, you know, whether these exposures met the 

standard.

I thought this was an excellent 

letter. I'm going to show you other letters 

which I think they're a bit problematic, but this 

one is to the point and provides necessary 

information. It's bureaucratic, but that's the 

nature of the beast, I think. So I thought this 

was a pretty good letter. 

Maybe it didn't get a response, I 

don't know. But as opposed to, say, let's look 

at another letter, redaction letter, the 

development letter, whatever it's called, number 

6 or 8. Why don't you try 8.

Here is my view of this. It's if 

you're going to write to a provider, okay, so 

here is a letter, it's about neuropathy and these 

are dates of when the neuropathy was diagnosed 

and the employment dates. And then we go into 
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what a well-rationalized support consists of. 

It may ask for, okay, submit a letter 

where they go into the occupational history, what 

the medical opinion previously showed. Keep 

going to the next.

And then talked about referrals to the 

IH. And then formulate some questions separating 

out contributed or aggravated from causal. So 

here's my problem with this letter. If you could 

scroll up, please. It's pretty simple, doctors 

don't like to read, and they especially don't 

like to read bureaucratic language. 

I would right up front in the letter 

state what you want from that provider, what 

you're asking of that provider right off. I 

mean, it can be the second sentence or not, 

second paragraph, not necessarily the first. But 

this is what we're asking of you.

And then I would summarize, try to get 

it on one page, I would summarize whatever you 

want to show. If you need a definition of wellrationalized, include a second page, not part of 
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the letter, but you know, a helpful glossary, 

guide, whatever, that gives definitions or if you 

want to include that IH report, include that as a 

separate thing. 

But strip it down as much as possible 

so the doctor can see exactly what it is you want 

from them and what it is they need to use and 

produce without a lot of the overly descriptive 

terms. That won't you guarantee you a response 

but at least it'll guarantee you there's more 

that's read.

Also one other letter, letter number 

6.

MEMBER GOLDMAN: Before you leave 

that, Steve, I hear what you're saying, but 

sometimes it's really helpful to have the detail 

there so the person really knows what's wanted. 

And I'm wondering if there's not a middle ground 

where you write that first paragraph like you 

said, with the key things, this is what we want 

you to know. 

And here is some important supporting 
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information to take into consideration your 

opinion. Because there's a lot of records, as 

you all have pointed out, and sometime that's a 

nice little guide that's there. Perhaps 

something like that.

CHAIR MARKOWITZ: Yeah, I mean they 

have to tease out the elements by which the 

provider's making his decision and then organize 

the information they're trying to provide by 

those elements, kind of spoonfeeding into what a 

well-rationalized letter would look like, right. 

And that could be done within the body of the 

letter, it could be done kind of on a separate 

sheet, just kind of a summary thing.

MEMBER GOLDMAN: Right, I think that 

might be a good idea, have the bullet, the big 

picture, like you're saying, but then this other 

attachment as a guide to what information is 

really wanted and desired, so that when the 

person constructs the letter, you get what you're 

asking for.

CHAIR MARKOWITZ: The other thing that 
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strikes me is these letters are very labor 

intensive. I mean, the Claims Examiner puts, I 

think, puts a lot of effort into summarizing and 

getting the details right. And it's probably 

necessary, but it should be done in a way that 

the provider can use those same details, abstract 

them quickly, and insert into, you know, her or 

his letter.

MEMBER FRIEDMAN-JIMENEZ: This is 

George, I have a question. This letter doesn't 

seem too bad, in fact, it provides a lot of 

information to the physician. But one thing that 

strikes me is the two questions at the end, 

trying to tease apart whether the exposures 

contributed to, aggravated, or caused the 

neuropathy.

I think it's unnecessarily complex. I 

mean, I think it's not possible to tease that 

apart in most cases because we don't have enough 

information to say whether it was contributing to 

or the primary cause. We don't know exactly how 

these different chemicals interact with each 
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other or with other things like diabetes or other 

potential causes of neuropathy.

And without having that level of 

scientific understanding of how the different 

causes interact or compete with each other, it's 

not possible to distinguish between being a 

primary cause, a single cause, or being a 

contributing cause. And it's not clear to me why 

they're asking the doctor to distinguish here. 

Does anyone know why they would try 

and separate these apart? Because the OSHA 

standard --

MEMBER GOLDMAN: That's a good point.

MEMBER FRIEDMAN-JIMENEZ: The OSHA's 

definition of work-related does not distinguish. 

It lists cause, contribute to, or aggravated in 

one sentence. And it's not realistic.

MEMBER GOLDMAN: Isn't that the one 

sentence you're supposed to say anyway, that's in 

this thing? I mean, you don't have to 

distinguish it, I thought it was just if it was 

any of those in that one sentence and it either 
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caused or contributed or exacerbated an 

underlying condition.

MEMBER FRIEDMAN-JIMENEZ: Right. It's 

not clear what they're going to do with this 

information. Are they going to deny the claim 

that the doctor says no, it didn't cause but yes, 

it contributed to or aggravated? Or what, why 

are they asking these two questions separately?

MS. POND: So this is Rachel. You 

know, everybody usually ask this question in 

various ways. My take on this is that they 

probably did that because sometimes it is easier 

for a doctor to rationalize or come to a 

conclusion and say yes when we don't include that 

causation piece. They're a little bit more 

hesitant to say yes to a question like this if we 

say cause.

So by separating it out, the doctor 

can say okay, I feel more comfortable saying 

this, this was a contributing factor, a 

significant factor in contributing to or 

aggravating, but I'm not as comfortable saying it 
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caused this. 

A lot of our questions, you know, we 

used to just lump them all together, and then we 

found that that to be the case with the doctors, 

that they don't want to say caused but they're 

more comfortable with saying aggravated or 

contributed to.

MEMBER FRIEDMAN-JIMENEZ: But then 

they would just answer yes to the combined 

question, cause, contributed to, or aggravated. 

And it makes you a little uncomfortable here 

because you don't know how that information's 

going to be used.

MS. POND: Well, as I --

MEMBER FRIEDMAN-JIMENEZ: I 

understand what you're saying --

MS. POND: I'm sorry, I didn't mean to 

cut you off. If they say yes to either one, that 

gives us the, that gives us what we need to 

satisfy the statutory requirements. So that 

would be why they separated out. Again, if they 

said no because they didn't think that it caused 
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but maybe they thought it could aggravate or 

contributed to it, they might have said yes in a 

situation where they said no. You see what I'm 

saying?

MEMBER FRIEDMAN-JIMENEZ: Yeah.

MEMBER GOLDMAN: I don't -- I think 

it's feasible to do what the Department of 

Labor's doing. It's just dividing up the wording 

of the part B into two questions. And my 

understanding is if you answered yes to either of 

the two, then that would be sufficient.

MS. POND: Right.

CHAIR MARKOWITZ: This is Steven. I 

think there are a lot of doctors, particularly 

those who aren't trained in occupational 

medicine, who just don't feel comfortable with 

the whole causal framework. But they're willing 

to in their own mind agree to something softer. 

And that's why separating them out 

gives them that option. Maybe I'm just repeating 

what Rachel said, but it does make sense to me. 

It's illogical, but it makes sense to me.
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MEMBER GOLDMAN: I agree.

CHAIR MARKOWITZ: Kevin, can you put 

up letter 6? This is the last letter I just want 

to show you. And again, it's just the amount of 

effort that goes into these letters. I 

understand now why you couldn't, the Department 

didn't just send us generic letters. Because 

these don't really look so pinpoint-driven that 

really look very custom. 

Looks like people are putting a lot of 

-- I want to scroll down and look at this. This 

is a three-page letter and it's, well, let's go 

back to the first page, actually. Could you 

scroll down so we could see the bottom of the 

first page, if there is.

MR. BIRD: Right now we're looking at 

the bottom of the first page.

CHAIR MARKOWITZ: Okay, fine, let's go 

to the next page then. Yeah, so you know, they

cite what the SEM shows. And then when they have 

an IH report, they enclose the IH report, scroll 

down. And then they want you to answer this 
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question, below rationalized narrative. And then 

if you scroll down you'll see the repeat on the 

same exposures.

I don't know if you can scroll down 

there, Kevin, so we can take a -- all right, so 

you can shrink this letter a little bit and we 

can see more of the whole page at the same time. 

Or not. Can you scroll down, Kevin? Okay, it 

really is. Is this letter number 6?

MR. BIRD: Yes, yup.

CHAIR MARKOWITZ: Okay, well, I have 

it on a PDF, and the first page is much longer 

than what you've showed.

MR. BIRD: Here, I can share the PDF 

separately, hold on one second.

CHAIR MARKOWITZ: Okay. Anyway, my 

point is this is a three-page letter, two-and-ahalf-page letter, which is just the kind of 

letter that on the one hand usefully provides a 

lot of information, the other hand it's just so 

easy for the provider to get lost in it. And so 

I just think that there needs to be some approach 
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that organizes it better for that provider than 

it currently is.

It says here, it gives a standard in 

paragraph three, the long paragraph about sort of 

what we, what kind of evidence we need. And 

let's go to page 2, it goes into the SEM. I'm 

not sure the provider cares about what a SEM is 

or what a SEM does. I think we can just 

affirmatively tell a person that, you know, we 

think they're exposed to asbestos, silicon 

dioxide, wood dust.

And then get to, sort of get to the 

question. At the end of the second page they 

cite chapter, maybe even verse too, about what a 

well-rationalized report is. 

So anyway, I just think that you can 

write up a much shorter, less time-intensive 

letter for the Claims Examiner that would get to 

the point and give the, spoonfeed the information 

that the provider needs to write the letter or 

not so that they can turn it around in a way that 

doesn't require a whole lot of effort.
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Anyway, that's my two cents.

MEMBER DEMENT: This is John. Yeah, I 

looked at a couple of these too, Steven, and my 

comment is more to the maybe substance of it 

rather than the format. Could you put number 2 

up, Kevin.

CHAIR MARKOWITZ: Okay, so he --

MR. BIRD: Sorry, do you mean page 2, 

or you mean --

MEMBER DEMENT: No, it's report, the 

example number 2.

CHAIR MARKOWITZ: Okay, so Kevin, I'll 

have to find it. Kevin doesn't have those, I'm 

going to have to send it to him, which I'll do.

MEMBER DEMENT: I could just describe 

it, Steven, that's fine. This is a individual 

who had a claim for COPD as a welder at 

Portsmouth. The SEM lists asbestos, phosgene, 

SO2 and welding fumes for his exposures that were 

linked to COPD. But the, or the request for the 

development letter, this asked the treating 

physician to develop a well-rationalized opinion 
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with regard to asbestos.

And I know why, you know, asbestos has 

a presumption if you meet it, it's a lot of 

exposure and a long period of time. It seems to 

me this one was off the mark, it should have 

asked for a well-rationalized opinion with regard 

to the exposures of interest.

The other thing that sort of struck me 

as I went through is sometimes, and almost all of 

the letters I saw, it limits the assessments of 

exposures of interest to those that were either 

identified by the industrial hygienist or the 

SEM. And in some cases, if this is a treating 

physician and they actually have had the 

opportunity to have discussed exposures with this 

individual, they may have an idea about different 

exposures. 

And I think that should be a little --

the development letter should be left a bit openended in that regard, if they know of exposures 

that they've assessed themselves with the 

individual.
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There was one other one, that was 

number 3. And this was, it's not so much -- it's 

not so much a letter as far as the process. This 

is a person who was claiming for cirrhosis of the 

liver and had worked at Portsmouth for a long 

period of time between '74 and 2005.

The worker was a maintenance worker, a 

maintenance mechanic, laborer. Anyway, it was a 

maintenance worker who, if you look at the SEM, 

it has lots of exposures to solvents, including 

carbon -- TCE. But the letter going back to the 

physician said there were no exposures found 

linked to this outcome. 

The MD had already provided a first 

letter in which he said there were, he found no 

personal lifestyle or risk factors to account for 

this cirrhosis of the liver.

It's a question for the SEM, I guess. 

Is liver cirrhosis in the -- the physicians on 

our panel can talk about cirrhosis of the liver 

solvent exposures, whether or not it's different 

in presentation from alcohol-related or not.
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MEMBER GOLDMAN: This is Rose. I 

mean, there are very few solvents that really

lead to cirrhosis of the liver. You know, 

dimethylformamide and there's a few, it's a 

handful. Lots of solvents, it's my 

understanding, can lead to some inflammation and 

you get some abnormal liver function tests. 

But to really go on to scarring, 

there's less, you know, tetra, what is it, 

hydrofluoric -- no, not hydrofluoric. Carbon 

tetrachloride, DMF, dimethylformamide. I mean, I 

can pull a couple out of my mind. But it's not 

that many that really lead to actual cirrhosis, 

unless somebody else has other information that I 

don't have. And whether this person really had 

cirrhosis or just chronic elevated liver function 

tests.

MEMBER DEMENT: Yeah, I'm just 

pointing out that the letters that went back, 

even though if you go into the SEM and you pull 

up maintenance mechanic for Portsmouth, it lists 

carbon tet and TCE. It lists a lot of 
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chlorinated solvents. But those weren't --

MEMBER GOLDMAN: Carbon tetrachloride 

is one of the ones that will cause that. TCE to 

my knowledge doesn't really lead to cirrhosis, 

but carbon tetrachloride is one of the oldie 

goldies that could lead to that.

MEMBER DEMENT: Anyway, that's just a 

comment for, you know, what's in the SEM or not. 

Apparently there must not be a linkage for 

cirrhosis of the liver with solvent.

MEMBER REDLICH: I would just second 

the comments. I mean, I think this is an issue 

that we did raise before, which was that the 

question that the -- and given some similar 

specific examples where what they should be asked 

is did the person's work at whatever site or, you 

know, period DOE-covered work, contribute to 

their cause or disease and not presupposed 

specific exposures. 

You know, or if one wanted to 

highlight, you know, one could say or other 

exposures. I mean, this came up when, you know, 
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when -- now already several years ago with, you 

know, mining exposure COPD where the question was 

aluminum, the cause is the person's COPD. And 

this person has simply been asked if their work 

in the mine contributed. So this seems to be an 

easily fixable issue.

CHAIR MARKOWITZ: I've got a question 

-- Steven. That language doesn't address what 

the Department wants, based on the law, which is 

tied to the magic words of caused by toxic, 

caused, aggravated, continued by toxic

substances. You know, not just work, but by 

toxic substances, that has to be there somewhere.

MEMBER REDLICH: But it could be or 

another toxic substance, you know, just leaving 

it open for -- so because it's, otherwise it's 

the question has already been narrowed. And 

that's putting the part of the IH, the part of 

really the decisionmaking that would appropriate 

for a physician with the appropriate expertise in 

terms of what types, what exposures can cause 

what diseases. 
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And the IH is already taking liberties 

based on the links in the SEM and the right to 

select the exposures they think are the relevant 

ones.

CHAIR MARKOWITZ: So you're saying 

that, you know, the letter would say based on the 

information that we have and are providing to 

you, but also based on your own interview of the 

patient and what you've learned in that manner, 

please answer the question about, you know, the 

contribution of toxic substances. Is that what 

you're saying?

MEMBER REDLICH: Yeah, I mean, you 

know, frequently the ones that are identified are 

very appropriate, it could just be a little bit 

more open-ended or other, you know, toxic 

substances that based upon your assessment, you 

know, could be contributing.

CHAIR MARKOWITZ: Okay. Any other 

comments? By the way, Kevin, which one do you, 

do you have -- is this one of the ones that Dr. 

Dement wanted to look at, or?
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MR. BIRD: So I have 2, 5, 6, and 8.

CHAIR MARKOWITZ: Okay, okay. Is it 

2?

MR. BIRD: Right now we are looking at 

2, yes.

CHAIR MARKOWITZ: Yeah.

MEMBER DEMENT: Yeah, that's the one, 

that's the case where COPD with multiple 

exposures. The physician was asked to comment on 

asbestos.

CHAIR MARKOWITZ: Okay, any other 

comments on this topic? Otherwise we'll move on. 

Okay. The, so, I will summarize some of these, 

any other comments that we've made and I'll pass, 

they can be passed along. One issue that we have 

never dealt with but I don't think we need to 

deal with at this meeting but I want to keep on 

the radar is our review of prepublication policy 

revisions.

I actually don't know whether there 

were are any sent to us in the last two months, 

not since the last meeting. Anybody from DOL 
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know whether we were sent any?

MS. POND: I'm sorry, can you repeat 

the question?

CHAIR MARKOWITZ: You know how we're 

supposed to have access to looking at 

prepublication policy revisions in the manual, 

you know, ten days prior to publication. I don't 

know whether we've received any in the last two 

months or not. But yeah.

MS. POND: I believe you would have 

received the last one, but that was I'm not sure. 

Carrie, do you know when that was that we sent 

that to them?

MS. RHOADS: It was a while ago. Was 

it one of the emergency ones for COVID?

MS. POND: I think that was the 

bulletin, so we did, that was a really short 

turnaround, I'm not even sure we gave you enough 

time for that. But we needed to get that out so 

we could do the --

(Simultaneous speaking.)

MS. RHOADS: Yeah. There was one 
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other one after that, I thought.

MS. POND: I thought the last update 

was like 3 point -- I'm pretty sure we still 

provided it to them, but there wasn't significant 

changes. They were mostly related to changing 

some titles and things like that, but.

MS. RHOADS: Okay.

MS. POND: I know if you said -- hold 

on. Yeah, we've been providing them every time 

we have an update, so you should have it, Carrie. 

MS. RHOADS: I'll look for it. What's 

it -- I'll look for the last one I sent.

MS. POND: All right, thank you.

CHAIR MARKOWITZ: Okay, thanks. My 

point actually was that the next board should 

develop a mechanism for making sure that these 

are discussed by the Board, either a person on 

the Board who agrees to triage them and point 

out, you know, the extent to which they're 

relevant for other Board members, or some 

mechanism to make sure that it's done. 

Because the timing is odd, we meet 
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every few months. These prepublication things 

come out roughly ten days before publication, so 

that's just going to be some advice we'll pass 

along to the next board.

The final topic on the agenda is a 

work plan to be, work we need to get done in the 

next month. So I just want to go down the list 

here, make sure that we agree. We finished the 

Parkinson's disease and the asbestos job titles, 

and I will submit them to the Department.

The working group on IARC Group 2A, I 

think, is going to make some progress on trying 

to pinpoint which chemicals, or excuse me, which 

cancer sites are caused by the 2A chemicals and 

maybe attach an abridged table to their report. 

Did I get that right, Dr. Berenji?

MEMBER BERENJI: Yes, that's correct.

CHAIR MARKOWITZ: Okay, thank you. On 

the issue of the Board resource request and the 

CMC and IH assessment, the respective working 

groups will make some progress on this, based on 

the discussion here. And then pass along 
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whatever draft recommendations or observations 

they have.

The claims review, you know, I think 

those observations are mostly feedback into the 

issue of the CMC and the IH assessment as far as 

I can tell. And then the provider outreach, you 

know, I'll assemble some of the, a few of the 

observations we made and we can circulate them.

But that's about it. Did I, now, did 

I leave anything off the radar for the next 

month? Okay. I understand just in terms of 

continuity or flow, is there some estimate from 

the Department as to how soon a new board might 

be identified?

MS. RHOADS: Well, we're, we can't 

really say. We're hoping to not have any gaps 

between this board's term and the next term.

CHAIR MARKOWITZ: Okay.

MS. RHOADS: But that will depend on 

how fast it goes through the process.

CHAIR MARKOWITZ: Okay, so we're going 

to close the meeting soon. Are there any other 
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issues that people would like to raise, any 

comments, any ideas about transition that people 

want to mention?

So fair enough. From the Department's 

point of view, any items that we haven't 

addressed that were put to us or that we sort of 

promised to deliver that you want to remind us 

about?

MS. POND: This is Rachel. No, I 

don't think so at this point. Mike?

MR. CHANCE: No, I don't think so. I 

think the -- and to Carrie's point, I think we've 

done everything we can do to move the, all the 

information along about selecting the new board. 

So I believe we're doing everything that we can 

on our end.

MS. POND: And I just will say, this 

is Rachel again, that I do appreciate this. I 

know that some of you opted out for the next 

term, so I appreciate all the work that you have 

contributed to the Board while you have been with 

us, and I just wanted to mention that. So thank 
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you.

CHAIR MARKOWITZ: Actually, there is 

something that we haven't, that we need to keep 

on the radar, which is our request for the 

documentation in the SEM for the health 

physicists and the security guards from the 

gaseous diffusion plants. But that's not, it's 

not a topic we're going to address today. But I 

--

MS. POND: Well, Dr. Markowitz, we did 

send you a letter back, because I think you 

should have that, in which we talked a little bit 

about what we can provide and what we're willing, 

what we're going to be providing. Carrie, 

they've got that letter, right?

MS. RHOADS: They should, yes.

CHAIR MARKOWITZ: Yeah. No, I wasn't 

saying that, commenting on the status as much as 

just I wanted to make sure it stayed on the 

radar, on our radar.

MS. POND: Okay.

CHAIR MARKOWITZ: As something to deal 
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with, that's all. So let me say that I want to 

thank Board members for all the work and really 

working together over the last couple of years on 

some interesting, I think, and sometimes 

difficult issues. 

You know, it's, we have the 

opportunity to provide advice to the Department, 

but also to impact the program that's extremely 

meaningful to a lot of people across the country. 

And to come up with, you know, concrete advice 

that can really make an impact on the program. 

We've tried to do that, and I've 

enjoyed working with everyone in doing that. We 

don't know who's going to be on the next board. 

In the event that, for those who don't get to 

work together, I'll regret not being able to 

continue to work together. But so it goes. I 

just wanted to thank you all for your work and 

making contributions.

I also want to thank the Department 

for the, really, the cooperation, for 

interaction, for really the back and forth on 
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some of these things. For helping us, 

particularly the newer members of the Board, to 

understand the process, a complicated process 

you've worked on for the past 16 years or so. 

And I think I want to especially thank 

Carrie Rhoads and Michael Chance as the liaisons 

to the Department. And of course Kevin Bird, who 

makes all this production happen. So thank you 

very much.

MR. CHANCE: Great, thank you, Dr. 

Markowitz. And I guess with that, we will close 

the record. Thank you very much, everyone, have 

a great day.

(Whereupon, the above-entitled matter 

went off the record at 4:31 p.m.)