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U.S. DEPARTMENT OF LABOR

+ + + + +

ADVISORY BOARD ON TOXIC SUBSTANCES 

AND WORKER HEALTH

+ + + + +

MEETING

+ + + + +

THURSDAY

NOVEMBER 21, 2019

+ + + + +

The Board met in River Room A at the 

Holiday Inn Paducah Riverfront, 600 N 4th Street, 

Paducah, Kentucky, at 8:30 a.m., 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 REDLICH*
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CLAIMANT COMMUNITY 

KIRK D. DOMINA

RON MAHS

DURONDA M. POPE

CALIN TEBAY*

DESIGNATED FEDERAL OFFICIAL

DOUG FITZGERALD

*Present via telephone
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C-O-N-T-E-N-T-S

Introductions ................................. 4

Dr. Steven Markowitz, Board Chair

DOE Energy Program Ombudsman Presentation ..... 8

Malcolm Nelson

Parkinson-related disease Working Group

Update ....................................... 33

Dr. Marek Mikulski

Review of Public Comments .................... 41

Dr. Steven Markowitz, Board Members

Roll Call Vote on Proposed board

Recommendation-Approved................. 74

Review of Board Tasks ........................ 77

Dr. Steven Markowitz, Board Members

Plans for Next Meetings ..................... 111

Dr. Steven Markowitz

Additional Public Comments .................. 113

Dr. Steven Markowitz

Additional Review of Board Tasks ............ 116

Dr. Steven Markowitz, Board Members

Closing Remarks ............................. 119

Meeting Adjourned ........................... 128
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P-R-O-C-E-E-D-I-N-G-S

(8:34 a.m.)

CHAIR MARKOWITZ: We're going to get 

started.

This is Steven Markowitz, I want to 

welcome you back to Day 2 of the Advisory Board 

for Toxic Substances and Worker Health. And what 

we're going to do is just some quick 

introductions, there being some new people, new 

members of the public here. So we'll quick do 

introductions and by that time maybe two more 

members of the Board will show up.

So I'm Steven Markowitz. I am an 

Occupational Medicine Physician and 

Epidemiologist at City University of New York. 

And I've run the Former Worker Medical Screening 

Program at 14 sites in DOE, including this site.

Ms. Pope.

MEMBER POPE: Duronda Pope, United 

Steel Workers and a former worker of Rocky Flats.

MEMBER MIKULSKI: Marek Mikulski, 

University of Iowa. I'm an Occupational 
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Epidemiologist and I direct a medical screening 

program for former Department of Energy workers 

from two sites in the State of Iowa.

MEMBER MAHS: Ron Mahs I'm a former 

worker at Oak Ridge plants.

MEMBER BERENJI: Mani Berenji, 

Assistant Professor of Medicine, Boston 

University School of Medicine. I'm a practicing 

Occupation Medicine Physician.

MEMBER DEMENT: I'm John Dement, 

Industrial Hygienist and Epidemiologist, 

Professor Emeritus at Duke University Medical 

Center in Durham, North Carolina. And a former 

worker program participant with the Building 

Trades program for the last 20 plus years.

MEMBER SILVER: Ken Silver, Associate 

Professor of Environmental Health at East 

Tennessee State University in the College or 

Public Health. I've never worked for DOL or DOE, 

but the program has been with me for 20 years. I 

used to live in New Mexico and work closely with 

Los Alamos families to advocate for passage and 
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implementation of the program.

MEMBER DOMINA: I'm Kirk Domina from 

the Hanford Atomic Metal Trades Council in 

Richland, Washington and a USW member. I've 

been, I'm a current worker and I've been there 

since 1983.

MR. FITZGERALD: I'm Doug Fitzgerald. 

I'm the Designated Federal Officer. I'm 

basically the liaison between the Department of 

Labor and the Board. And I work closely with Dr. 

Markowitz in making sure we adhere to all the 

FACA, the Federal Advisory Committee rules and 

regulations.

CHAIR MARKOWITZ: On the side there.

MS. RHOADS: I'm the alternate DFO.

MR. BIRD: Kevin Bird with SIDEM.

MR. HARTMAN: Tim Hartman with SIDEM.

STEFAN: Stefan with SIDEM.

MR. VANCE: John Vance with the Energy 

Compensation Program.

MS. MEALS: Lee Meals with Meals & 

Tolar, Impairment Specialist.
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MS. DISMORE: Jill Dismore with 

Brightmore Home Care.

MS. STEELE: Donna Steele with USW 

right here in Paducah. I've worked at the 

Gaseous Diffusion Plant since 1975. I'm still 

there.

MS. WHITTEN: Dianne Whitten with the 

Hanford Atomic Metal Trades Council.

MR. NELSON: Malcolm Nelson, 

Ombudsman, Energy Program.

MR. BALLARD: Chris Ballard with 

Critical Nurse Staffing.

MR. McFADDEN: Steve McFadden former 

student at Hanford, Argonne and Livermore.

CHAIR MARKOWITZ: And do we actually, 

do we know whether there are people on the phone?

(Off-microphone comments.)

CHAIR MARKOWITZ: Okay, Mr. Tebay. 

Okay, okay. I'm sorry, yes, please, Rose. Yes.

MEMBER GOLDMAN: Rose Goldman, I'm an 

Occupational and Environmental Health Physician, 

Associate Professor at Harvard Medical School, 
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Harvard School of Public Health. And I have my 

clinical appointment to Cambridge Health Alliance 

in Cambridge.

MEMBER FRIEDMAN-JIMENEZ: I'm George 

Friedman-Jimenez. I'm the Medical Director of 

the Bellevue NYU Occupational Environmental 

Medicine Clinic. And I'm an Occupational 

Medicine Physician and an Epidemiologist.

CHAIR MARKOWITZ: Okay. So we have a 

full agenda for this morning. We're going to 

start with Mr. Malcolm Nelson, who is the 

Ombudsman in the Department of Labor for the 

Energy Employee's Occupational Compensation 

Program. Welcome, welcome back.

MR. NELSON: Thank you and good 

morning everybody.

MR. NELSON: Good morning, my name is 

Malcolm Nelson. And I'm the current Ombudsman 

for the Energy Program. And first of all, I want 

to thank you for inviting me to speak this 

morning. But more so, I want to thank you for 

all the work that you do.
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One of the problems with my office is 

that we often encounter claimants who we simply 

cannot help. The issues that they're 

encountering are just beyond our capabilities. 

And I just wanted to let you know what a pleasure 

it is, or it helps me when I can tell them that 

there is a Board that is wrestling with those 

issues.

And I can refer them to your minutes 

of your meetings and say, look someone is 

actually listening to these issues and trying to 

address them. So again, thank you very much.

I'm just going to quickly just talk 

about a couple of issues that kind of came up as 

I was listening to yesterday's conversation. One 

of the things that came up, we talked about there 

was some reference to the need for more 

education. And that's something that I really 

have come to believe.

One, just more education about the 

program in general, but there's a really specific 

issue that really plagues this program. And that 
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is that this program is really unique among 

worker's compensation programs.

In most programs you file your claim, 

when you reasonably expect or reasonably know 

that your illness is related to your work. In 

this program, you're almost expected to file a 

claim before you know that it really is linked to 

it. And in fact, in many instances, you file 

your claim without even having information that 

can say that you actually worked there.

And I really find this to be a problem 

because most claimants don't understand that. We 

routinely encounter claimants who tell us, I'm 

going to file a claim as soon as I get that 

employment information. Or as soon as I find a 

doctor who can link my illness. And yet that 

claimant doesn't even know about SEM. So it's 

like how you going to find that information?

It was a conversation I had the other 

day that really hit home with this. I talked to 

a claimant who worked at a facility, clearly 

having illness. Always thought that that illness 
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was related to his work. But told me he never 

filed a claim because he always thought if he 

filed a claim and it was denied, he'd be arrested 

for filing a fraudulent claim.

And I just think that's the kind of 

information we have to get out. That this 

program is unique. That you're actually expected 

to file your claim, and then there will be 

development of your claim. Not the other way 

around.

Another issue that came up yesterday 

as I was looking at your chart. You had that row 

that showed the number of claims that were denied 

due to insufficient causation evidence. And I 

have to admit, I was not surprised at that.

Because one of the things we find is 

that many claimants simply do not know how to 

develop evidence. And specifically do not know 

how to develop medical evidence.

We routinely talk to claimants who 

have received that letter saying, your medical 

evidence is insufficient. They've gone back to 
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their doctor. Yet when we ask them, well what 

did you give your doctor? The answer is nothing.

They did not take the OHQ with them. 

They did not take a copy of SEM with them. They 

did not, you know, really discuss their 

employment. They just said I need a letter, can 

you write it for me?

And that's one of the, also they don't 

take specialist reports. Very often there's 

already an IH report, a toxicologist report, a 

CMC report. They don't think to take those with 

them to that doctor.

And again, going back to that 

education, I really think one of the things that 

we've seen is a need to educate claimants on how 

to develop that medical evidence.

It's not simply enough to tell them 

they need that evidence, but to really work with 

them and explain to them if you have this 

evidence, this relative evidence, you need to 

take that evidence with you to your doctor.

And in that sense, we also, there was 
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a reference to making SEM easy for the doctors to 

use. And I totally agree with that. But I find 

it's even more essential to make SEM easy for the 

claimants to read.

Because in most instances, or many 

instances I talked to, claimants are going to 

doctors who don't even know that SEM exists. 

That doctor is relying on that claimant to 

provide them with SEM information. So SEM needs 

to be easy for claimants to navigate.

We talked yesterday about terminal 

illnesses. And yesterday the Department of 

Labor, clearly explained its reasons for asking 

for imminent information on death. The question 

I get from claimants is whether that is 

reasonable?

Is it reasonable to expect a doctor to 

provide that kind of report? And what I'm simply 

hearing is, and what often happens. The claimant 

is terminal. They're in hospice. They go to 

their doctor to ask for this report that says 

death is imminent. And the first thing the 
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doctor says is, you're in hospice. It's already 

been determined you have six months or less, why 

do I need to write anything more?

We also hear that many doctors simply 

balk at providing that kind of information 

because they don't want to play God. Trying to 

tell somebody you have a couple of days or a week 

to live, they say that's just not my role to say 

that.

We also, I've taken it upon myself to 

talk to a couple hospice administrators, and one 

noted to me that their job was to extend life as 

long as they could and to make that life as 

comfortable. And they felt it was inconsistent 

with that mission to then try to tell somebody, 

you're going to die in a couple days.

They also thought that there was a 

really kind of a moral issue in terms of what is 

that patient going to think about your care if 

you've already told them you think they're going 

to die?

So there's just a lot of issues which 
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comes down to, is it reasonable for a claimant to 

be able to obtain that information? And 

especially to be able to obtain that information 

if their death really is imminent.

I would talk about hearing loss but, 

you know, I think that issue is still pending, so 

I'm not going to say much about hearing loss. 

But claimants still have a lot of issues with the 

hearing loss standards that are currently used.

But two other issues and I'll kind of 

end and open it for questions. One is 

consequential illnesses. That's again one of 

those concepts claimants simply do not 

understand. They can be compensated and covered 

for consequential illnesses.

But we find, one, claimants don't 

understand that. They don't know what a 

consequential illness is. And they don't really 

understand when they have to file, as opposed to 

what is automatically covered when that claim is 

accepted.

And that really just becomes an issue 
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we find very often. That many claimants, we'll 

probably see is that claimants will just assume, 

well this new illness I have is a result of my 

accepted illness, so it's automatically covered.

And they all too often find that that 

is not the case. That in order to have that 

second illness of them, consequential illness 

covered they have to file a new claim. And 

that's just something they really do not 

understand.

The last issue I'm going to talk about 

today is an issue that came up just last week, 

when my office was in Alabama. We visited 

Cullman, Alabama where the biggest employer is a

beryllium vendor. And the way this law, the 

EEOICPA is interpreted, work employees of 

beryllium vendors are only covered under Part B 

of this program.

And under Part B, they are only 

covered for chronic beryllium disease and 

beryllium sensitivity.

I encountered a worker during my 
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visit, who noted that beryllium is now a known 

carcinogenic. And thus he asked, how come, you 

know, if you're covering me, you're covering us 

for the illnesses related to working with 

beryllium, why aren't we covered for cancers 

caused by beryllium exposure?

I'm not sure what this Board can do 

about that but, you know, I think if it is true 

that beryllium is a carcinogenic that is 

something that ought to be recognized. And the 

fact that there are these employees who are not 

being covered under the program.

In closing, I must say, and I should 

have said when I began. I want to acknowledge 

that I've been the Ombudsman now for, I think, 12 

years. Time flies, it's been flying by, but I 

think 12 years. And in that time I've seen a lot 

of improvement.

So I always want to commend the 

Department of Labor, and the resource centers, 

and all the other entities that have worked to 

make this program better. Nevertheless, there's 
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still a lot that needs to done. And I just again 

want to thank you for your efforts in working to 

make this a better program. Thank you very much.

CHAIR MARKOWITZ: Thank you. I have a 

couple questions, but other Board members have 

questions, maybe. First of all, beryllium is an 

established human lung carcinogen. And it should 

be, I don't know whether it is or not, but it 

should be recognized as such under Part E. Part 

B is straight from the Act. So it wouldn't be 

under Part B, just only recognized as chronic 

beryllium disease.

MR. NELSON: Yes.

CHAIR MARKOWITZ: But under Part E, 

now vendor employees may not be eligible under 

Part E. I don't know that. But all I'm saying 

is that apparently the way the system works is 

Part E should, and perhaps does recognize 

beryllium as a lung carcinogen.

MR. NELSON: Under Part E, it is 

recognized. I looked at SEM, and under Part E 

cancer is a known result of exposure to 
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beryllium. So under Part E there is that 

recognition.

CHAIR MARKOWITZ: Okay, okay. So you 

describe that some claimants or potential 

claimants are at a loss on where to start.

MR. NELSON: Yes.

CHAIR MARKOWITZ: And they need in 

your view, to develop their claims somewhat to 

maximize their chances of succeeding even before 

they go to their doctor with -- so don't the 

resources centers, the DOL resource centers, 

don't they do that with claimants?

MR. NELSON: Well there's a couple of 

issues. One, many claimants again because they 

don't understand this program, they think they 

need to develop their evidence before they file 

their claim. So we often find that claimants 

begin the process of trying to develop evidence 

even before they ever approach the resource 

center, or approach the Department of Labor, or 

anybody else.

And that causes a problem because they 
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get that initial report, which is going to be 

inadequate. And so then they submit that 

inadequate report, the report is found to be 

inadequate. Now they have to go back to the 

doctor and the doctor of course is going to be 

somewhat peeved because they're being asked to 

have to rewrite a report.

So some of it the fact again that 

claimants do not understand that with this 

program it's okay to file your claim and to then 

develop your evidence.

The other is that yes, the resource 

centers will provide guidance, but what I'm 

finding is that even with that guidance, when we 

talk to claimants many of them when we ask them 

what did you give your doctor when you asked for 

that report? The answer is nothing.

And, you know, whether it's that they 

did not fully understand the guidance, or whether 

they weren't given the guidance, I really don't 

know. I can't say.

But I can definitely say that we find 
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that we can almost assume that most claimants 

when they're developing evidence, they have not 

gone and gotten into, they have not obtained the 

OHQ, the SEM reports, those medical specialist 

reports.

And they've not submitted those to 

their doctor, which as I said again, results in 

the fact it's not surprising when that report 

written by the treating doctor is not found to 

be, is not sufficient.

CHAIR MARKOWITZ: Does that mean in 

your experience that some claimants have sought 

that kind of detailed help from the resource 

center and not received that kind of assistance?

MR. NELSON: I can't say. I mean 

it's, you know, it's a case-by-case basis and I 

mean, I don't want to start making accusations 

without having heard both sides --

CHAIR MARKOWITZ: Sure, okay.

MR. NELSON: -- of the story. 

Because, you know, I often hear the claimant's 

side. And of course from the claimant that they 
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received no help. When I talk to the resource 

centers or I talk to the district office, they're 

usually telling me they provided help, you know. 

And I'm hearing this and I don't want sit here 

and --

CHAIR MARKOWITZ: Fair enough. I 

don't mean to force the issues. I get it.

Are there other questions, or requests 

for Mr. Nelson? Dr. Friedman-Jimenez.

CHAIR MARKOWITZ: We'll welcome Mr. 

Tebay a member of the Board is on the phone and 

participating. Welcome. And Dr. Redlich from 

Chicago, welcome. Dr. Friedman-Jimenez.

MEMBER FRIEDMAN-JIMENEZ: Okay. What 

you said about the imminent death struck a very 

deep personal note. Four months ago, my mother 

who has end stage heart failure and angina was 

told by her doctor that she had two months to 

live. It devastated her. We've been dealing 

with the aftermath of that for months. And it 

really affected her very deeply to be told.

That's not the kind of thing that 
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doctors like to tell their patients.

MR. NELSON: Yes.

MEMBER FRIEDMAN-JIMENEZ: When the 

patient asks you can give them some sort of an 

estimate couched in statistical terms. But the 

bottom line is we do not have mathematical models 

that can accurately predict prognosis on that 

level of detail.

So, I think it's unrealistic to try 

and put that burden on the doctor. It needs to 

be dealt with because Kirk raised a case 

yesterday, Number 4219, where the claimant was 

misclassified by their job title.

And it was an error that was made. 

I'm not going to say who made the error. I don't 

know the details, but the job title was 

misclassified. The exposure was grossly 

misjudged. And the case was denied.

The daughter was not a dependent. She 

was older than that. And the claimant died, so 

was not compensated however much he would have 

been. And the daughter then would have inherited 
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either the benefit or less debt from her father. 

Or anyway there was an error that really should 

have been avoided.

The question is how can we prioritize 

the workflow of the program so that it better 

addresses these urgent needs and avoids these 

kinds of really devastating errors?

So I think this is a question I don't 

have a single answer to it. But this is a 

question that we should deal with as a Board. 

How do we prioritize the work flow to get the 

most important decisions made sooner and more 

accurately?

MR. NELSON: There's two other things 

I would note. I often hear, I've talked to some 

hospice administrators who questioned what doctor 

is available to make that report? You know, very 

often when you're in hospice, you're no longer 

seeing your specialist.

So, you know, who's going to be this 

doctor who can say that you only have a few days 

to live? And then, you know, as you say there's 
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always that personal note. I can remember my own

mother when she was passing away. My mother 

wanted to live. And had I asked the doctor how 

long does this woman have to live, she would have 

with her last dying breath reached up and slapped 

my face, you know.

So, I mean like you said there's a lot 

of emotion to that. And I think that's what 

we're hearing from claimants. That this is just 

-- sitting in a room we can talk about whether 

you can get that information or not. But in a 

real life situation, this is just something that 

was impossible to get.

CHAIR MARKOWITZ: I mean, Steve 

Markowitz, the problem is it's kind of 

understandable from the program's point of view 

that you want to prioritize, right. Because if 

there are a large number of people who fall 

within the hospice definition, then they can't, 

they may not be able to make it happen in that 

timeframe.

On the other hand, the bottom line is 
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it's too much to ask both the medical community 

and the families who bear the determination that 

death is imminent.

MR. NELSON: Yes.

CHAIR MARKOWITZ: Okay yes, Dr. 

Goldman.

MEMBER GOLDMAN: Dr. Rose Goldman. 

The other thing about it is, it's totally 

inaccurate. I mean I have told patients, I still 

remember somebody who had lung cancer. And they 

said, well how long do you think he's going to 

live? And I said, I don't think he's going to 

have more than two or three months.

So they got a whole bed set up in 

their living room and six months later they're 

calling me, well what's going on here?

(Laughter.)

MEMBER GOLDMAN: You know, we got this 

whole thing set up here. And, you know, so the 

point is -- and somebody who you think is going 

to live -- I've also been in that situation 

reassuring people, only to have some disaster 
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happen and they die in a month.

And so I think the other part of this 

besides the fact that it's difficult to frame it 

with the patients is that frankly, you really 

don't know. And to echo something that George 

said -- and statistics don't help.

Because what you have to tell patients 

is maybe 80 percent of people will die within a 

few months, but there's always the 20 percent and 

you could be that person. And you don't take 

away hope.

And having been on both sides of this 

I can say it's really very difficult.

CHAIR MARKOWITZ: Yes. We need to 

close. Is there any final comments or questions? 

Dr. Silver.

MEMBER SILVER: I've been concerned 

and a little bit of a dissenter about the role of 

the resource centers. I know they have a 

contractor who runs the resource centers. And 

I've noticed that some of them seem to emphasize 

volume over quality.
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Going out to senior centers and 

saying, oh, just file a claim and it'll be taken 

care of. And claim development, well, doesn't go 

very well. And pretty early on a lot of people 

who succeeded and just filed the claim, get a bad 

first impression of the program.

It's analogous to something going on 

in higher ed. Let me ask you, who do you think 

develops better as an environmental health 

scientist? Choice A, someone who is on the 

ground with a professor on a regular basis? Or 

someone who's out there on the web looking at our 

lectures, a hundred of them.

I mean it's obvious that if you deal 

remotely with people who've never met you, the 

claims examiners, it's going to be bumpy. And 

it's not going to develop very well. So I think 

if we have this high hope for the resource 

centers doing more to develop claims, we need to 

look at their contractual obligations.

CHAIR MARKOWITZ: Dr. Dement, and this 

is the last comment.
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MEMBER DEMENT: Last comment, we 

discussed yesterday the process of the OHQ and 

how it's used in assessing the exposures. In 

some ways, you know, to echo Malcolm's comment.

In most circumstances you would have 

an outcome and then you would develop the 

information about the exposures. And it would 

follow more of a logical path, rather than 

throwing everything out initially and then having 

less development later.

As you sort of follow, you know, down 

the path of those exposures and how it occurs. 

So in some ways it's a little flipped anyway. We 

would be better served if we had an initial sort 

of occupational history question.

I was very sure they basically got 

their occupational history, where they were, 

where they worked, the claim filed and then the 

exposures developed afterward. Because that 

could be much more directed. But that's not how 

the program works, but --

CHAIR MARKOWITZ: But I think EE-3, 
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the form EE-3, Mr. Vance, you can correct me, but 

I think EE-3 the employment history does capture 

that. And that is one of the initial forms if I 

got it right.

MEMBER DEMENT: It does come along 

with exposed to on the EE-3. It's a little more 

directed than the OHQ, that's true.

CHAIR MARKOWITZ: Mr. Nelson.

MR. NELSON: I didn't do this on 

purpose, but there is one additional issue I do 

have. And has to do with the OHQ. And what 

happens is --

CHAIR MARKOWITZ: And this is the 

occupational health questionnaire?

MR. NELSON: Yes, occupational health 

questionnaire. That's usually done very early in 

the claims process. And what often we find is 

that after the claimant is given that 

information, they think of new things.

And the issue we have is how do they 

revise that occupational health questionnaire? 

You know, especially as the claim begins to 
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develop and you begin to identify certain job 

categories or certain toxins to which they were 

exposed. That begins to jog their mind, and they 

begin to realize I have additional information.

And what we often find is that 

claimants will call the resource center. They 

will call the district office, the claims 

examiner to tell them information. But does that 

information get into the OHQ, so that when people 

are reviewing the claim, this additional 

information that the claimant has is included?

CHAIR MARKOWITZ: Well thank very --

Ms. Pope.

MEMBER POPE: I think we discussed 

this maybe a couple of Board meetings ago, about 

is there a process in which a claimant can update 

their information? And I think we threw around 

an idea of, it would be nice if there was a 

mechanism within the internet that they can go on 

line and update information, input information. 

That would be ideal, I would think. But what is 

the process, the current process to update 
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information?

CHAIR MARKOWITZ: Mr. Vance, I believe 

it's addressed -- the question is the claimant 

has submitted the original employment history 

form, they've submitted the occupational health 

questionnaire. If they then develop supplemental 

information, what's the procedure for them to 

submit that information?

MR. VANCE: At any point that a 

claimant wants to submit additional information 

in the form of written affidavits, any kind of 

occupational information that they feel 

warranted, they can do so.

And I'll just make a mention that if 

there would be a decision made in the case, they 

also have an opportunity for an oral hearing in 

which they can come and provide any kind of 

information formally to our appeals board.

CHAIR MARKOWITZ: Thank you. Mr. 

Nelson, thank you very much.

MR. NELSON: Thank you.

CHAIR MARKOWITZ: We're going to now 
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move on and talk about Parkinson's-related 

disorders. The Department -- when this term of 

the Board was started some, a little bit more 

than a year ago. The Department asked us 

actually to help them with sorting out 

Parkinson's disorders mostly on the question of 

which toxins are known to produce Parkinsonrelated disorders. And perhaps also on the 

medical side.

So we've had a Working Group 

addressing this issue. And Dr. Mikulski has an 

update.

MEMBER MIKULSKI: Thank you so very 

much, Dr. Markowitz. The document that I handed 

yesterday provides a summary of the presentation 

that we made earlier this year at the Board's 

meeting on the topic of Parkinsonism and the 

Parkinson's disease.

We included information in this 

document on the nosology, the most current 

classification, along with aliases and the 

references to ICD codes under both ninth and 
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tenth versions.

We also discussed briefly the 

pathology as well as some aspects of clinical 

diagnosis, which I can't stress enough. Should 

be done clinically, preferentially by --

preferentially but not exclusively by a 

neurologist.

We have also shown evidence from 

research studies that have shown associations 

with some exposures, or suggestions of 

associations between some of the exposures 

commonly present in the DOE sites and Parkinson's 

disease.

The research on Parkinson's disease is 

going sort of several ways. There are efforts to 

explain the hereditary etiology. And it is 

believed that a really small part of Parkinson's 

disease cases can be explained that way.

The second way are the research 

efforts to establish clinical testing to diagnose 

Parkinson's disease at the prodromal, early 

stages that can precede clinical onset of motor 
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function impairment by over two decades right 

now.

Third, are the attempts to investigate 

those potential risk factors that have been shown 

in the animal models in epidemiology studies in 

human populations. There has been a slew of epi 

reports that provide evidence in support of the 

association between Parkinson's disease and the 

exposures to pesticides, solvents, 

polychlorinated biphenyls and metals.

And these reports have primarily one 

thing in common. They provide evidence suggested 

of association. However, do not provide 

quantitative exposure assessments or for that 

matter, answer questions regarding latency or 

even temporality in order to, or making any 

causation presumptions premature at this moment.

So what we hope for this brief 

document is to provide a basis for 

recommendations to the Department of Labor, at 

least on the diagnostic questions. And we hope 

to work together with other members of the Board 
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on coining these into a set of recommendations.

And we are currently working on 

summarizing the information on the specific 

exposures and substances that have been 

implicated in these studies. Although this list 

is going to be fairly short, it does include 

substances as I said, that have been used widely 

at the DOE complex.

Hoping for any feedback.

CHAIR MARKOWITZ: So comments or 

questions? Dr. Goldman.

MEMBER GOLDMAN: I think one of best 

metals that have been associated with Parkinson's 

from very strong case series is manganese. The 

others as you said, are more epidemiological 

studies with pesticides.

But among Chilean miners there was a 

case series with, they were mining manganese and 

began, they had a syndrome that looked like sort 

of manic behavior that was followed by a strong 

Parkinsonian syndrome. So that's one of the most 

specific I think linkages.
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But the problem with manganese 

actually is there is a very poor correlation 

between the blood measured level and whether or

not you're going to get it. And so that was one 

of the problems with that case series. That the 

blood was not as predictive of who would have the 

most severe case.

So that's one of the ones that I think 

is more causally connected. And then the others 

that you mentioned are more based on sort of 

epidemiological studies where there the 

associations and the -- and it's harder to make 

that causality. But I don't know if you have a 

response to that?

MEMBER MIKULSKI: Well, it is really 

to establish causality would require a series of 

perspective studies. However, Parkinson's 

disease is still a fairly rare instance, which 

would require extensive resources to be directed 

into these studies. And the follow-up with a 

methodologically rigorous exposure assessment.

So far, basically the literature is 
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limited to retrospective research with selfreported occupational exposures and some case 

reports, some case studies along with a few case 

control type of a design. Studies which really 

limit the, don't give enough room here to provide 

these assumptions.

But yes, manganese is one of the most 

looked at in terms of metals, substances, given 

the obvious link with the manganeseism.

CHAIR MARKOWITZ: So the Site Exposure 

Matrices recognizes manganese and various 

manganese materials as related to Parkinson's.

I want to, yesterday we looked at some 

data. So let me just review it for Parkinson's 

disease in the last three years. There have 310 

claims. Roughly half of them have been accepted. 

Some are still pending but most have been 

resolved. And roughly half have been accepted.

And those that have not been accepted, 

almost all of them are not accepted on the basis 

of negative causation. That there's no, there is 

no demonstration that the toxins people were 
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exposed to caused Parkinson's. And about ten 

percent were rejected or declined, denied for 

insufficient medical information.

And that's of interest, because 

Parkinson's disease is not an easy diagnosis to 

make. And yet very few claims are being denied 

because the claims examiner doesn't have enough 

medical information to make that decision. 

That's encouraging actually.

So it really boils down to causation. 

And so we really in this effort we need to drill 

into what we know about the toxins, the animal 

evidence, the laboratory evidence, the human 

evidence, whether its case supports, epidemiology 

or what have you. And really come down with some 

decisions that would help the process. And 

that's the next step I think in this Parkinson's 

work.

MEMBER MIKULSKI: That's what we are 

currently working on and hope to be able to 

present more on that the next --

CHAIR MARKOWITZ: Just thinking ahead, 
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this Board's term ends next summer. We expect, I 

think we should have a telephone meeting of the 

Board in a couple months. Or certainly between 

now and next summer. And any issues that this 

term of the Board has raised we should bring to 

conclusion to the extent that we can, including 

the issue of Parkinson's.

So maybe we could aim for, if it's 

realistic, at the next meeting to get to that 

point where we've fully considered other toxins 

and whether they're causal. And then develop 

that into a recommendation to the Department. 

Does that sound realistic?

MEMBER MIKULSKI: Absolutely, I think 

we definitely should meet and before the next, or 

discuss this over the phone before the next in 

person meeting.

CHAIR MARKOWITZ: And I know Dr. 

Mikulski welcomes additional members of the Board 

to assist him in this process.

Was there a question or a comment over 

here? Yes, Dr. Dement.
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MEMBER DEMENT: I think you've touched 

upon some important issues. And as I sort of 

looked at studies. You know, temporality is a 

really big issue. And there are four or five 

prospective studies but they're done out of 

mostly cohorts that weren't designed to look at 

environmental exposures.

And so when we see things like 

cholesterol and smoking being protective, and 

asthma being a risk factor, but we don't see, you 

know, that other piece of you know, what are the 

real exposures? But that's what's really going 

to be needed to really nail down some of these 

other things, sort of beyond the manganese, I 

think.

CHAIR MARKOWITZ: Other comments or 

questions? Okay, thank you very much.

So we're going to spend a few minutes 

reviewing the public comments that we heard 

yesterday, or that came in in writing. I'll kick 

it off.

Ms. Barrie raised the issue of, I sent 
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this as a spreadsheet of, I think firefighters --

I don't know whether we have that? Whether you 

can find that on our website and bring that up so 

we can look at it? That'd be helpful.

Raised an issue of firefighters and 

what their exposures are at various sites. And I 

think she compiled information at the various 

sites on how many toxins they might be exposed 

to.

So we're looking at a number of 

substances in the SEM for firefighters. So at 

Ames it's a dozen or so. Hanford, it's 2,000. I 

think you can just scroll down. Brookhaven is 

34. So mostly, it's a relatively modest number, 

30 or 40 maximum. If you could keep going down. 

Or if you look at Paducah it's 15, Oak Ridge 

K-25 is 25. So a limited number of substances.

And I think the, if I recall her 

public oral comments, the issue was this kind of 

variation in sites. Whether there are, this job 

titles, and other job titles, and we've heard 

this comment before. Other job titles which 
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could be considered in the SEM as being site-wide 

workers. They get around to all aspects of the 

sites.

Obviously firefighters going to put 

out fires wherever the fire occurs in the site. 

Doing their inspections across the site. I think 

we've heard about the health physics technicians, 

or rad technicians who also, or industrial 

hygienists who go throughout the site.

Security personnel presumably go 

throughout the site. So, I have my own view of 

this, but I want to open the floor for other 

comments on this issue.

I'm sorry, Mr. Domina.

MEMBER DOMINA: Yes, it's kind of 

interesting looking at that where Hanford, 

because I'm from there, lists, you know, that 

many in this, because of, you know, we have a 

pretty robust system where they're pulling 

documents and stuff daily. We have a huge group 

of people who do that.

But for some of these other sites you 
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look at, the numbers are low. But part of that I 

look at, you know, our firefighters, you know, 

we're a large site, 570 some square miles. And 

they also do mutual aid where they could go 

across the country out fighting fires and 

whatever. And to respond to smaller communities 

when they need paramedics, instead of EMTs.

But it comes back, and like Dr. 

Markowitz said, you know, I've harped on the HPT 

thing. The other part which people may not 

understand that we send our people, like during 

the presidential inauguration, we have our techs 

in DC, slinging meters, looking for stuff.

And then there was an event which was 

not well publicized recently at a large hospital 

on the west side of the mountains, where they got 

into a cesium source. You won't see anything 

about that anywhere.

But our techs went over there because 

of the huge exposure that was involved. And 

state patrol guarding the building so nobody got 

near it. Because they called over and asked what 
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they should do? And our company said, you need 

to tear them down.

But it's the same thing as these 

different groups. Same thing with security, 

operations. When you have events, and like we 

have site-wide seniority, so we have backup 

seniority -- or excuse me, backup overtime groups 

where if there is an event, we have people that 

go everywhere. Not just in your assigned job 

area day to day. And it has to be looked at 

during these type of events.

And all these sites have, you know, 

you have your annual drills that's required. And 

the different things that we do. But I think it 

needs to look at, you know, widening I guess the 

path. It's just like when we approved that list 

a year or two ago about these job titles that DOL 

accepted. Because it's accepted in some other 

programs.

Once again, the HPTs are not listed on 

there. And it's, you know, it's just like when 

the SEM started with some of ours when we first 
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got together. You know, all the reactor areas 

for Hanford are in the 100 areas, near the river. 

And they didn't even list that job title. 

They're first in, last out. You know, and 

operations is right behind them, or any type of 

maintenance.

And so, I think things need to be 

looked at a little more globally. And then, you 

know, I can't speak for some of the other sites, 

but I'm sure some of the firefighters do mutual 

aid. You know, they help out their cities, and 

you know, good PR and everything. But I think we 

have to look at that. Because these people are 

exposed to all kinds of things and it's all the 

groups.

It's just like when we have car wrecks 

that are, "offsite". It's our members that are 

responding because they're there first. You 

know, whether it's shift traffic or whatever. I 

think we need to look at this more globally and 

you know, kind of think outside the box.

And it kind of goes back to the OHQs 
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and those different things that when some of 

these job titles may have been developed some 

years back on whatever, the program was in its 

infancy. And so you have to look now, how things 

have changed. And then think back about what we 

did back then and what's changed today, to make 

this morefriendly to the workers and the people 

that are trying to do the cleanup mission today.

CHAIR MARKOWITZ: Dr. FriedmanJimenez.

MEMBER FRIEDMAN-JIMENEZ: Looking back 

at the history of studies of firefighters, 

Monson, Musk and Peters in the 70s, first made 

the point that I'm aware of that firefighter 

exposures are extremely heterogeneous.

And this has been confirmed through 

many firefighter mortality morbidity studies. 

The World Trade Center program sees people, tens 

of thousands of people with exposures to 

pyrolysis products of various structures.

The pyrolysis products are very hard 

to characterize. And the ones that are in the 
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largest concentration may not be the most potent 

toxicants, et cetera.

We are currently seeing wild fire 

firefighters exposed to a whole different range 

of toxicants from towns that burned down in 

California. Paradise, California burned down and 

the toxicants released from the pyrolysis of 

houses are completely different than what's in a 

wild fire, out in the woods.

So looking at Fernald and Hanford, 

with 7 and 2091, they just happen to be sitting 

next to each other, substances for firefighters. 

It seems to me that the SEM is just not adequate 

to characterize the exposure of firefighters.

And it has to be formally recognized, 

I think. That firefighter exposures go way 

beyond what can even possibly be included in the 

SEM, unless you include firefighter exposure, 

even then it's so heterogeneous.

So it's very difficult to simplify 

firefighter exposures in the variety of diverse 

situations that these firefighters are in, as 
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Kirk was describing. So I think we need to 

formally recognize that. And include the SEM 

certainly, because there are a lot of substances 

that are out of the ordinary.

But also make the point that 

firefighter exposures include pyrolysis products 

of all the things that we know that are in the 

SEM, which we can't really predict very well.

CHAIR MARKOWITZ: Steve Markowitz, so 

we know that the program has some, uses class of 

job classes, of job categories that have certain 

attributes in common.

So for instance, there's a list of job 

categories for the hearing loss, right. And 

those job categories are presumed to have noise 

exposure. Then the issue is do they also have 

solvent exposure?

That group has a higher likelihood of 

having solvent exposure, that's why they're in 

the group, in addition to noise exposure. So we 

see that for that list.

But there's a separate list that Mr. 
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Domina referred to for people presumed to be 

exposed to asbestos, supposedly construction and 

maintenance job categories. Again, a carved out

identified list common across sites pretty much, 

which are presumed to have certain exposures.

So my question is could certain job 

categories that fairly universally across sites 

have site-wide jurisdiction, or do their work 

throughout the site, such as firefighters, such 

as the industrial hygienists, the rad 

technicians, security, I don't know all the job 

categories.

Could that class be developed and 

recognized in the SEM that those job categories 

would have frankly had potential exposure to any 

of the toxins at the site?

Yes, Mr. Domina.

MEMBER DOMINA: I think it could, 

because I think right now they use like surrogate 

data or a job title for another site, because 

I've seen it when they bled it down on some of 

the cases that we looked at. They'll use that 
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title from another site to try and find the toxic 

substance, you know, for a claim approval.

And I think that we could do that, 

because I think about the same thing with the 

firefighters with the burn pits. I'm sure most 

of these sites have burn pits. And they were 

escorted by security, you know. And you'd have 

rad techs, you'd have op, you'd have a whole 

bunch of people there, you know.

And so it's got to be more global and 

to get some of this stuff more claimant friendly.

CHAIR MARKOWITZ: Well, you know, 

Steve Markowitz, it's not just a question of 

claimant friendly. It's a question of getting it 

right. You know, getting the SEM accurate. You 

know accurate reflecting potential exposures.

And so let me ask Mr. Vance, not to 

put you on the spot, but has this been 

considered? Well, actually maybe it puts you on 

the spot, who knows. But --

(Laughter.)

CHAIR MARKOWITZ: I was just saying 
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not to put you on the spot. But has this been 

considered for these site-wide workers? And are 

there any administrative or other impediments to 

developing such a class of job categories?

MR. VANCE: With this, the answer is 

anything is possible.

CHAIR MARKOWITZ: We accept that 

answer.

MR. VANCE: Yes, okay. I mean we're 

always looking at different pieces of 

information. And of course anything the Advisory 

Board could certainly, you know, provide 

information on would be more than welcome. And 

we would consider that.

CHAIR MARKOWITZ: Okay. Other 

comments. Yes, Dr. Goldman.

MEMBER GOLDMAN: Well one thing that 

the State of Massachusetts did, because this is 

such a difficult problem with firefighters 

getting exposed to so many things is I think we 

have a law that any firefighter who develops a 

heart, lung, or may even be cancer, it's just 
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automatically said to be work-related. I'd have 

to check on that.

So what happens is just because you 

can't sort through and like, and try to figure 

out the individual chemicals, just like George 

said. So there's sort of this blanket thing that 

any firefighter who developed X, Y, and Z 

conditions just state that it's work-related.

So that's incredibly broad, you may 

not want to go there. But maybe something along 

that line where you just, because otherwise 

you're in a huge amount of work to try to tease 

it out for the firefighters at least.

MEMBER BERENJI: This is Dr. Berenji. 

I can actually confirm that there is a heart 

presumption, as well as a cancer presumption 

while in the State of Massachusetts.

CHAIR MARKOWITZ: Dr. Silver.

MEMBER SILVER: In the spirit of outof-the-box brainstorming, I seem to recall some 

firefighter epi studies where a crude dose metric 

was number of fires that the person had responded 
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to over the course of their career. And I think 

the associated outcome was decrements in lung 

function.

So it may correlate with years on the 

job or it could be helpful in using firefighters 

first in this group of free roaming employees.

MEMBER GOLDMAN: Well, a problem with 

that is the exposures to firefighters goes beyond 

fires. Because, you know, there's an exposure 

somewhere. Somebody is worried about it. Who's 

the first one to go out? It's, they call the 

fire department. We had a mercury spill, the 

fire department came out. So it wasn't a fire, 

it was just a spill.

So what you have now -- and they have 

the hazmat teams. And part of the issue is first 

they go out with all their equipment. And this 

is true for fires too, however once the fire is 

put out or they think they have it under control 

even though they shouldn't, it's hot. They take 

their respirator off, and then there's 

smoldering.
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So as you were saying the pyrolysis 

products. So the exposures for firefighters are 

really quite vast. And it goes beyond just the 

fires.

CHAIR MARKOWITZ: Dr. Silver.

MEMBER SILVER: Number of events 

responded to, which could be a crude exposure 

metric for the health physicist, IH techs as 

well. Just a thought, a quick response.

CHAIR MARKOWITZ: Yes, Dr. FriedmanJimenez.

MEMBER FRIEDMAN-JIMENEZ: There have 

been many attempts to make an index of 

firefighter exposure, and none of them really 

worked very well. Because in the knockdown 

phase, as Rose said, after the fire they take off 

their respirator. And one exposure like that can 

be worth 20 fires where they've had their 

supplied air respirator on the whole time.

And it's very difficult, it's 

impossible to capture that in an index that you 

can actually get data to create. So I think it's 
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not realistic.

CHAIR MARKOWITZ: Yes, Steve 

Markowitz, the SEM doesn't address intense heat 

duration, frequency of exposure, that's up to the 

rest of the process. The SEM just tries to nail 

down what the potential exposures are at those 

sites.

So we don't really even need to get 

into, you know, likelihood of exposure in the 

sense of measuring number of visits, or number of 

fires put out, or whatever. That's just going 

beyond what the SEM purports to do really, so.

CHAIR MARKOWITZ: Mr. Domina.

MEMBER DOMINA: A couple of comments 

that Dr. Goldman just brought up about the 

Hazmat. Well prior to 2000 or about then, we were 

Hazmat. It didn't exist. That's to back up what 

I said early. And also I had Kevin scroll up 

Savannah River, and so you see they have 26, and 

Hanford has 2091.

Well, Savannah River has the tank 

farms like we do. And they had some of the same 
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reactors that we do. So there's a huge disparity 

right there, you know. And I think that some 

sites are similar, some are different. But it 

has to be looked at, because why is there that 

huge of a disparity between two sites that have a 

lot of stuff in common?

CHAIR MARKOWITZ: So, actually I have 

been, drafted a recommendation we could make 

about this as a formal recommendation. Or we 

could I suppose give it to the department as just 

a less formal observation.

Maybe if I got the language up we can 

take a look at it and see whether it's something 

we want to pursue? So Kevin if you could, just -

-

The Board recommends that the 

department as part of Site Exposure, the SEM --

well we could spell it out, develop lists of job 

categories at DOE sites that likely have worked 

throughout the applicable sites. And would have 

had a potential exposure to all listed toxins at 

those facilities.
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Make it a little larger. Thanks. 

That good, in terms of the size? Can you see 

back there?

(Off-microphone comments.)

MEMBER FRIEDMAN-JIMENEZ: Potential 

exposure to some or all listed toxins.

PARTICIPANT: Toxicants.

MEMBER FRIEDMAN-JIMENEZ: Toxicants, 

yes.

CHAIR MARKOWITZ: Well toxins is the 

terms that, a toxic substance actually. Let's 

use toxic substance, that's from the Act.

So I don't know if Dr. Redlich or Mr. 

Tebay you could see this? So let just read it 

again out loud, what Kevin's written.

The Board recommends that the 

department as part of the SEM, develop lists of 

job categories at DOE sites that likely have 

worked throughout the applicable sites and would 

have had potential exposure to all listed toxic 

substances at those facilities.

Dr. Berenji.
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MEMBER BERENJI: Yes, I just have a 

small edit. So let me see if I can point to the 

right spot. So list of job categories at DOE

sites for workers. Yes, that's perfect.

CHAIR MARKOWITZ: I'm sorry, Steve 

Markowitz, I don't see how, we had, that seems to 

be covered by job categories, which again is the 

term that DOL in the SEM uses, is job categories. 

Develop lists of job categories that likely have 

-- or I guess lists of workers in job categories?

MEMBER BERENJI: Yes, I think you need 

to point out who this is referring to. Because 

otherwise it's a bit obtuse.

CHAIR MARKOWITZ: Okay, but the 

intention is that a particular job category 

captures all the workers in that job category.

MEMBER BERENJI: Correct, I think that 

needs to be explicitly stated.

CHAIR MARKOWITZ: Dr. Dement.

MEMBER DEMENT: I guess I have an 

issue with saying all substances at the site. 

Because I think it's too broad. I think we 
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should say something like, a substantial number 

and quantifiable, or unquantifiable number. I 

don't, you know, all is a bit broad.

CHAIR MARKOWITZ: Right. Well so --

MEMBER FRIEDMAN-JIMENEZ: Some or all?

CHAIR MARKOWITZ: Well, some or all 

includes everybody who worked at the facility. 

So the question is, and I agree with you that all 

seems a bit of an over statement. But once you 

say many or most, the SEM process is about 

identifying particular toxins and pinning them to 

particular diseases.

So the question is does developing 

those classes with that kind of, the language 

that doesn't say all, does that actually help in 

the decision making process?

MEMBER MIKULSKI: This is Marek, I 

believe that by putting in the list of workers in 

job categories, we're kind of implying that we 

are developing the list of actual workers, rather 

than job titles, job categories. So maybe, it 

would be, maybe we could take it out, lists of 
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job categories.

CHAIR MARKOWITZ: Or maybe we could 

just say the SEM identified job categories.

MEMBER MIKULSKI: Yes.

CHAIR MARKOWITZ: So that the workers 

aren't seen as subsets, but --

MR. BIRD: Where do you want me to add 

that?

CHAIR MARKOWITZ: Take out the develop 

lists of workers, and just say identified job 

categories.

And then later on instead of saying 

all, to all or many, to many or all listed toxic 

substances. And you know, that leaves it up to 

the industrial hygienist and later the CE to 

weigh additional information.

Dr. Dement.

MEMBER DEMENT: I would also recommend 

that we include the aliases for these job 

categories because, you know, they can be called 

many different things across different sites. 

And so, maybe job categories, you know, takes it 
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into account? But, you know, we know that 

they're called different things across sites.

CHAIR MARKOWITZ: Right, well that's 

why they'd have to develop at each site the job 

category in that list. But we're not going to 

develop that list for them, here today.

Yes, Dr. Friedman-Jimenez.

MEMBER FRIEDMAN-JIMENEZ: My concern 

with saying listed toxic substances is that most, 

many or most of the exposures that are pyrolysis 

products, are not listed. They go beyond the 

list. That's the point.

That we can't accurately characterize 

and list the toxic substances because if you take 

two chemicals and burn them, you might have 40 

different pyrolysis products that you haven't 

really characterized scientifically.

So I think that job category is what 

we're looking for, like IARC does it. They have 

a category of rubber workers. And they associate 

that with causation of cancers in that category. 

Because they're exposed to toxic substances that 
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haven't been as precisely characterized as --

because they can.

CHAIR MARKOWITZ: Yes, Steve 

Markowitz, well this is intended to be broader 

than just firefighters. So I agree with you that 

firefighters have a broader set of exposures 

outside that, or would be outside of the SEM. 

Hopefully the industrial hygienist has some 

appreciation of that.

But this applies to security 

personnel, to the safety personnel, you know, to 

a whole bunch of other classes of workers. And 

has the advantage of that kind of broadness I 

think. If we were developing something just for 

firefighters then I think it would look 

different.

Yes, Dr. Berenji.

MEMBER BERENJI: I'm just reading this 

and honestly I mean, I know we have to have some 

general statement so I understand the purpose. 

But I just have a feeling that this is going to 

be misinterpreted. That's just a general 
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comment.

CHAIR MARKOWITZ: Well, if there's 

some specific language that would decrease that 

likelihood.

MEMBER BERENJI: I mean just reading 

this as a non-clinician or a person who, you 

know, may not know all the specific 

terminologies. I mean what are we really trying 

to get at? We want to make sure that folks are 

able to get some sort of assessment based on what 

types of job tasks they have done. I feel that 

job categories, I mean that's just a general kind 

of, you know, categorization, which I do know we 

have to do.

But I mean based on what I've reviewed 

in these case files, you know, someone might be 

designated as a security guard, but they're doing 

a whole host of different other tasks. So, I'm 

not sure if we're going to be able to capture 

that by just designating job categories.

CHAIR MARKOWITZ: Well, Steve 

Markowitz, so the SEM is a starting point. The 
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desire is that it's a point that's used and 

hopefully a starting point for further developing 

using additional information that's particular to 

that person.

But this does set out sort of the 

universe of at least some of the concerns that 

these job categories would have.

Dr. Friedman- Jimenez.

MEMBER FRIEDMAN-JIMENEZ: Maybe we 

should say identify job categories. And we're 

not talking about a large number of job 

categories for which the SEM cannot accurately 

characterize, meaningfully characterize their 

exposure with respect to the outcomes of 

interest.

CHAIR MARKOWITZ: Steve Markowitz, I 

would just say that that probably applies to a 

lot of job titles. I mean that raises a kind of 

a different point, that's true. But doesn't get 

at the sort of the core purpose here, which is to 

say that, you know, there are some job titles 

really that work throughout the facilities. And 
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that needs to be recognized in the evaluation 

process, which is the goal here.

Yes, Dr. Silver.

MEMBER SILVER: I agree. It's a place 

to start but in the spirit of Kirk Domina's call 

for out of the box thinking, I recall how 

asthmatics were liberated from the use of SEM, 

right.

It's no longer a toxic substance that 

has to be identified and there are special 

presumptions now for asthmatics. This could go 

in that direction a couple of steps down the road 

once we bump into the limitations of using the 

SEM for these peripatetic professions.

CHAIR MARKOWITZ: By the way, there's 

not a proposal on the floor so let me propose 

that we accept this, make this recommendation but 

we can't move further unless that's seconded.

MEMBER FRIEDMAN-JIMENEZ: I'll second.

CHAIR MARKOWITZ: Fine. So the floor 

is open for comments. That's just a formal 

procedure, that's all. Floor is open for 
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comments. Mr. Domina?

MEMBER DOMINA: I just want to make 

sure because you guys are way smarter than I am 

by a long shot, is it, you know, each one of 

these sites had certain exotic chemicals that 

were just developed for that site itself. And I 

want to make sure -- and there is no known 

studies for any of it. And I just want to make 

sure that that's captured somehow -- and I don't 

know how, that's why you guys are here -- that we 

don't forget about that.

Because I know, I mean, NIOSH has 

documented it for us, you know, and I think about 

some of the people that Dianne and I have helped 

over the years and different things that they go 

through and what we have to go through to try and 

get claims approved when there's classification 

involved. And we can't lose sight of that. You 

know, these are the people, you know, we owe a 

lot to. So.

CHAIR MARKOWITZ: Dr. Friedman-Jimenez 

or Ms. Pope?
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MEMBER POPE: I echo what Kirk is 

talking about. From a worker's perspective, is 

trying to capture every job category or, because 

every site is unique within itself and just 

trying to capture every job category I think is 

just critical.

And developing a language that can 

widen the scope to make everyone inclusive within 

that language to make sure that everyone is 

covered because I think we owe that to them.

CHAIR MARKOWITZ: Dr. Goldman?

MEMBER GOLDMAN: I'm wondering if it 

wouldn't be a better idea to actually carve out 

the firefighters because after listening to Kirk, 

what's different about let's say a security guard 

at one plant with the special exposures and maybe 

a firefighter who, as you said, may be going to 

other plants or may be deployed someplace else.

So the firefighter's going to have a 

way larger exposures and it's going to be a lot 

harder to fit into the SEM of that site.

So it may be better to carve out the 
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firefighter personnel because they just could be 

having a lot more exposures and not have them 

tied to the SEM of that site.

CHAIR MARKOWITZ: Mr. Domina?

MEMBER DOMINA: You know, I agree with 

that too but then I was just thinking back to 

like, with the security personnel.

I remember back in the '80s there was 

a strike at one of the other New Mexico sites, so 

guess where Hanford security forces were, a bunch 

of them?

And so and then they go and they train 

too at different times with other ones and so I 

don't know, you know, I just don't know if, we 

have to, there's so much like I said when you got 

to look broad and over the time that -- on how 

things were done in the Cold War effort is a way 

different mindset than it is today.

I mean, I remember mixing up chemicals 

with my arm because that's how you had to do it 

to get something because of the situation it was 

in, was how critical on certain things for, to 
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maintain operation or whatever.

You know, I remember sticking my arm 

in a vat and stirring the chemicals in because 

that's what you had to do in a hurry, you know.

And so I know trying to cover 

everybody is a pretty tough task but, you know, 

for me it's like, I don't want to leave anybody 

behind.

MR. BIRD: Dr. Markowitz?

CHAIR MARKOWITZ: Sure.

MR. BIRD: We have Dr. Redlich on the 

line. She wants --

CHAIR MARKOWITZ: Dr. Redlich?

MR. BIRD: It's going to take a second 

to find her, sorry. She dropped off.

MEMBER REDLICH: This is Carrie 

Redlich. I'll just, I'm sorry about the noise, 

I'm in the Chicago airport.

I just wanted to second what Ms. Pope 

said in terms of -- and others -- that is when 

one's considering -- sorry, I don't know if you 

can hear me or not.
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CHAIR MARKOWITZ: I'm sorry.

MEMBER REDLICH: Well, if you can't 

hear me we'll forget about it.

CHAIR MARKOWITZ: I couldn't 

understand what she said.

MEMBER REDLICH: Okay. If you can 

hear me, I just wanted to second what Ms. Pope 

said as far as the range of different tasks and 

jobs that you're considering generally on this 

(telephonic interference) employment over many 

years and also more chronic, generally more 

chronic conditions.

CHAIR MARKOWITZ: Did anybody catch 

that?

I'm sorry, could you just try one more 

time, Dr. Redlich because we couldn't understand 

what you said.

PARTICIPANT: Try not using the 

speaker phone --

MEMBER REDLICH: Sorry. It's not that 

important, so I will, I was just seconding what 

Ms. Pope said.
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CHAIR MARKOWITZ: What's that? Oh, 

okay.

STEFAN: She was just seconding what 

Ms. Pope said.

CHAIR MARKOWITZ: Okay. Other 

comments?

So is there, if we could look at this 

language again, is there proposed modification of 

the language we're looking at, the 

recommendation?

MEMBER GOLDMAN: I'm just wondering if 

this --

CHAIR MARKOWITZ: I'm going to read 

the language again just for the people on the 

phone today. We're looking at this proposed 

recommendation.

The Board recommends that the 

Department as part of the SEM, identify job 

categories at DOE sites that likely have worked 

throughout the applicable sites and would have 

had a potential exposure to many or all listed 

toxic substances at those facilities.
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Dr. Goldman?

MEMBER GOLDMAN: Just to second what 

Mani said and some others. Maybe we should put a 

preamble into this a little bit to explain why we 

have this and then also put a post statement 

saying that maybe more efforts need to be made by 

the industrial hygienist on the second part of 

the interviewing to focus on tasks.

CHAIR MARKOWITZ: Right. So yes, I 

mean, it's, on our recommendations, we always 

provide relatively succinct rationale. So where 

we can explain why we came up with this and what 

we think it means.

So we will do that, yes. I would 

draft that and you would all look at that.

Other comments? Okay. So, yes, Mr. 

Mahs?

MEMBER MAHS: If you're talking about 

the broad, it could be a very broad set of 

categories or job titles. Because you're talking 

about firefighters going to every building in 

that plant, while construction workers are not 
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like maintenance who are in one or two buildings 

most of their career.

I've probably been in several hundred 

buildings between the Y-12, and X-10, and K-25 

over the years. Visible areas, radiation areas,

material access areas, new construction, 

demolition. You know, so been everywhere in all 

kinds of substances.

CHAIR MARKOWITZ: Yes.

If there are no other comments then we 

need to take a vote. We would vote in favor or 

opposed, although I can't remember actually how 

we take these votes.

MR. FITZGERALD: I can do the roll 

call.

CHAIR MARKOWITZ: Okay. Fine, do the 

roll call.

(Off-microphone comments.)

CHAIR MARKOWITZ: No, a motion's been 

made and seconded. The issue, I guess we could 

read the, if you could bring it back up, if we 

could read it once more.
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So Mr. Tebay and Dr. Redlich, we're 

voting on this.

(Off-microphone comments.)

MEMBER TEBAY: Can you hear me now?

CHAIR MARKOWITZ: Oh, yes.

MEMBER TEBAY: Okay.

CHAIR MARKOWITZ: Do you have a 

comment?

MEMBER TEBAY: No. I just heard 

you're taking a vote on it and then I dropped all 

communications there for a second.

CHAIR MARKOWITZ: Okay. Great.

So, Kevin, when you have a chance, 

could you just bring the language up for the 

recommendation?

MR. BIRD: Yes, sorry. Hold on one 

second.

CHAIR MARKOWITZ: The Board recommends 

that the Department as part of the site exposure 

matrices, identify job categories at DOE sites 

that likely have worked throughout the applicable 

sites and would have had a potential exposure to 
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many or all listed toxic substances at those 

facilities.

We're going to do a roll call vote 

now.

MR. FITZGERALD: Your choices are yes, 

no, or abstain. We'll start with the folks on 

the phone.

Mr. Tebay?

MEMBER TEBAY: Yes.

MR. FITZGERALD: Dr. Redlich?

MEMBER REDLICH: Yes.

MR. FITZGERALD: Thank you.

Dr. Berenji?

MEMBER BERENJI: Yes.

MR. FITZGERALD: Dr. Dement?

MEMBER DEMENT: Yes.

MR. FITZGERALD: Mr. Domina?

MEMBER DOMINA: Yes.

MR. FITZGERALD: Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: Yes.

MR. FITZGERALD: Dr. Goldman?

MEMBER GOLDMAN: Yes.
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MR. FITZGERALD: Mr. Mahs?

MEMBER MAHS: Yes.

MR. FITZGERALD: Dr. Markowitz?

CHAIR MARKOWITZ: Yes.

MR. FITZGERALD: Dr. Mikulski?

MEMBER MIKULSKI: Yes.

MR. FITZGERALD: Ms. Pope?

MEMBER POPE: Yes.

MR. FITZGERALD: Dr. Silver?

MEMBER SILVER: Yes.

CHAIR MARKOWITZ: Okay. So we're 

going to take a seven minute break and at 10 

o'clock, we only need one more hour so at 10 

o'clock we're going to resume and then finish, 

close it off.

(Whereupon, the above-entitled matter 

went off the record at 9:52 a.m. and resumed at 

10:03 a.m.)

CHAIR MARKOWITZ: Okay. We are going 

to start up now. Okay. So we're all here. Mr. 

Tebay and Dr. Redlich, we're going to start up if 

you're available.
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So we could come back to the public 

comments if we have time but we do need to come 

back to the issue of the claims review and our 

discussion about the quality, objectivity, and 

consistency of the industrial hygiene and medical 

evaluations.

So we need to resume that discussion 

and then if there's time, get to the same for the 

claims examiner.

One observation, I'll kick off the 

discussion. When I looked at the last five 

quarters of the medical director's evaluation of 

claims, there are about a hundred claims that 

were looked at for the issue of impairment and 28 

percent of them needed improvement.

So that says a couple things. It says 

that there are a fair number of claims where the 

impairment evaluation was considered not really 

adequate.

It raised the question whether there's 

a systematic problem in the work that the 

contractor's doing in terms of the impairment 
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evaluation because 28 percent is a lot.

It also raises the issue of, okay, the 

medical director's picking 50 claims per quarter 

to look at. If 28 percent of the impairment 

evaluations over a five quarter period needed 

improvement, what about all the claims that the 

medical director did not look at?

How many of them, is it likely that a 

fair number of them were also, would be found to 

need improvement, and yet those aren't looked at 

or re-looked at because they're not part of the 

medical director's review?

So that's a long way of formulating a 

question for Mr. Vance, which is, maybe I should 

have told you before I started that formulation

but I will next time.

So to me, 28 percent of a sizeable 

number of evaluations for impairment, a hundred 

or so over a year and a quarter means that 

there's a quality problem with the contractor and 

impairment evaluations.

When that kind of feedback comes to 
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QTC, the contractor, what's done in terms of the 

other claims for impairment? Do they decide to 

re-look at other claims and say, hey, maybe there 

is significant number of other claims that also 

need improvement? Do you have any idea of what 

the process is?

MR. VANCE: Yes. So let me give you a 

brief synopsis. And so yes, we go through this 

quarterly audit.

We have a, Dr. Armstrong, our medical 

director, will give us a report. That report is 

then forwarded to my staff who will then do a 

post audit analysis of those ratings and 

determine what effect that issue had on the 

outcome of the case.

And I think you're familiar with the 

outcome of these audits. Some of them are 

substantive issues with the quality of the 

report, the narrative, or the application of the 

AMA guides.

And I think that's the challenge, from 

my understanding, is that the guides provide very 
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broad interpretations of how ratings are to be 

done. And in a lot of those instances, there's 

not something that prohibits physicians from 

doing things so it's a challenge.

But what we then do is we take this 

information, we go back to QTC and we have a 

conversation with them and we go through each one 

of these cases.

And they get an opportunity to make 

sure that they understand what the nature of the 

issue is, that they get an understanding of who 

it is that's causing these issues and then it's 

on the contractor to try to perfect future claims 

coming through the process and they have their 

own internal quality control mechanism for doing 

that.

And then this is relative to how we 

evaluate the CMC process. So you know, we don't 

do these kind of systematic reviews for folks 

that do impairment ratings outside of our CMC 

process.

So this is basically the discretion of 
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the program in evaluating what we feel is the 

appropriate way of administering the AMA guides 

and that's this process, but we don't have a 

process where we then expand out and look at 

other cases that are not part of this auditing 

mechanism.

CHAIR MARKOWITZ: Yes. Do we know 

what QTC's quality assessment or quality 

evaluations consist of?

MR. VANCE: That's their, as a 

proprietary contractor they have internal 

mechanisms that they have to employ to make sure 

that they are trying to satisfy the contract 

provisions on the quality of the reports and this 

is a mechanism that's included in the contract, 

this quarterly review.

So it's a systemic review that's going 

on on a quarterly basis and then, you know, they 

are improving with time but, you know, you have 

different doctors that are getting engaged, new 

physicians that are involved and so it's a 

continuing process.
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CHAIR MARKOWITZ: So just a couple of 

follow ups. So it's not in the contract, at the 

elements of the contract from DOL stipulating 

that the certain kind of quality evaluation be 

done?

MR. VANCE: Just that it, I don't know 

what the exact terminology is but there is a 

quality assurance process that's engaged with, by 

the contractor and it is part of the contract.

CHAIR MARKOWITZ: Has QTC ever come 

back and said, you know, we see from the medical 

director's audit that there's an issue? We've 

looked at an additional number of claims and also 

found the, speaking specifically about 

impairment, and also found a similar kind of 

issue with these other claims that now require 

correction? Has that ever happened?

MR. VANCE: In our conversation with 

QTC, their main focus is making sure that they 

understand the nature of the issues that our 

medical director has identified and then applying 

lessons learned on future cases.
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CHAIR MARKOWITZ: Other Board members? 

Dr. Berenji. Thank you.

MEMBER BERENJI: Thanks, Mr. Vance. 

So I actually do a lot of independent medical 

examinations and I know at least with the 

companies I do work for them, they do audit my 

reports and there is some sort of accountability, 

at least for the clinician or the medical 

examiner who's doing these.

I'm not sure if there's been any 

discussion in the higher echelons of the DOL. I 

don't know if you're familiar with Dr. Hodgson. 

I believe he's still at DOL if I'm --

CHAIR MARKOWITZ: At OSHA, Michael 

Hodgson, yes.

MEMBER BERENJI: I mean, is there any 

sort of reporting of your medical director to a 

senior person? I'm sure he is reporting to Dr. 

Hodgson or someone in that capacity.

I mean, there's got to be some sort of

internal review of medical claims. I mean, there 

has to be. So I'm not familiar with that 
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process.

CHAIR MARKOWITZ: Other comments? 

Yes, Dr. Silver.

MEMBER SILVER: Do we have any insight 

into the distribution of errors in the impairment 

evaluations? Is it random like half of them 

low-balling the claim and half of them 

overestimating the impairment, or is there a 

consistent bias that is claimant-unfavorable?

CHAIR MARKOWITZ: So I mean, just I 

can't directly answer that question but if you 

read the medical director's report and the policy 

branch's review of those audits, that information 

is contained in those reports so it's available 

to us but I haven't looked at them.

And I don't think that kind of, as 

part of that process I don't see that that kind

of evaluation's been looked at.

Yes, Dr. Silver?

MEMBER SILVER: So we don't have the 

data therefore my next comment's a little bit 

speculative but my impression is that a lot of 
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independent medical examiners do work for this 

program and do a lot more work for other workers' 

comp programs.

And it could be that this is one of 

the more claimant-friendly programs so that their 

habit of not granting high levels of impairment 

carries over here and this program has to issue a 

corrective. But we won't really know until we 

see the distribution of quote, unquote, errors.

CHAIR MARKOWITZ: So getting back to 

the issue of causation, the medical director did 

look at 80 or so claims for issues of causation 

and found one that needed improvement.

That seems low and so far and we have 

more claims to review so we need to look further. 

I don't know that we can come to any conclusion 

today but we do need to look some more, I think, 

at claims.

And I've compiled some of what you've 

sent me in terms of the summary of the claims 

limitations but we need, I need to add more to 

that in order to really have data to present.
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But I have to say that one out of 80 

causation evaluations that need improvement seems 

very infrequent and it raises the issue to me 

whether -- how good that kind of causation review 

is.

And I think that we, you know, we're 

not developing recommendations today around the 

issue of the CMC and the IH the, you know, the 

quality, objectivity, and consistency but we will 

and it's one of the issues that we need to talk

about.

Dr. Dement?

MEMBER DEMENT: Sort of a workflow 

issue. You know, we've taken these claims that 

we have and we've all sort of picked the ones 

that we reviewed and we have some overlap and now 

we've reviewed a fair, a large number of them but 

there are still claims that we have not I think 

had at least one Board member look at.

Can we compile that and get it out to 

everybody and, you know, we can sort of pick a 

few additional ones to see what they are, if they 
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add more information to the base?

CHAIR MARKOWITZ: Yes. Sure. I'll do 

that. And in fact, you know, we, so in this, for 

today we looked mostly at the four categories. 

Asthma, ILD, sarcoidosis, and CBD.

But previously we had looked at, if 

you remember way back when, I think it was April 

or May of 2019, we looked at Parkinson's disease 

and COPD.

And I think we should add, those are 

different outcomes, I think we should add that to 

the same process so we have a bigger number.

It requires some work on our part but 

I think it would be worthwhile. I mean, it will 

I think allow us to make some recommendations 

about IH and medical assessments.

If -- thinking about the industrial 

hygiene evaluation, Mr. Vance, I need to ask you 

a question.

The medical director audits the 

medical consultant's reports. I know that the 

federal industrial hygienist reviews the 
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contractor industrial hygienist report when it 

comes in, because we see a memo to that effect on 

all these files.

But is there a separate, in parallel 

with the medical director's audit, is there a 

time in which a random number of the industrial 

hygiene evaluations are taken and a similar kind 

of audit be performed? And if not then what's 

the thinking about that?

MR. VANCE: The answer is no and I 

don't know what the thinking is on that.

(Laughter.)

CHAIR MARKOWITZ: Okay. Thank you for 

that succinct answer to the point.

So, you know, we're not going to, the 

question for us to talk about, we're not going to 

complete this today, is whether we think that 

there ought to be a process for review of those

IH reports and what that process should look 

like? What it should take into account and will 

it likely improve the claims evaluation?

And I'm not, I don't think we have a 
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predetermined answer to that. I think it's 

something we need to discuss.

Dr. Berenji?

MEMBER BERENJI: I actually took the 

liberty of already kind of writing this process 

out, that we kind of get an understanding based 

on the discussion we had yesterday so I'm happy 

to, you know, formalize that and at least, so at 

least we can have some input into this.

I think it's better for us to be able 

to be on the front end and be able to produce a 

document at least with our expectations for an 

industrial hygienist, how they should go about 

interviewing the claimant, what information they 

should be on the lookout for at least as a 

guideline.

Yes, I'm happy to be a point person on 

that but I think that's something that we can 

actually contribute an actual document which 

could be helpful.

CHAIR MARKOWITZ: Well, I wonder, you 

know, that's a good point. I wonder whether it 
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would be helpful if we had, since the Department 

is going to begin to do those interviews, whether 

we had the form, the set of questions they're 

starting out with, they're using, and then 

providing some input into that. Is that 

something that sounds feasible?

Mr. Vance?

MR. VANCE: Absolutely.

CHAIR MARKOWITZ: Okay. Okay. So 

then the Board, Ms. Rhoads, requests the set of 

questions or a form that they initially used for 

the occupational health interviews by the 

industrial hygienist. And we will take a look 

and provide our input.

Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: One of the 

recurrent impressions in our reviews was that 

industrial hygienists do not frequently contact 

the claimants directly and get one-on-one 

information.

So my question is, do we have any data 

on that? Do we know what percent of claims 
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actually involve an industrial hygienist talking 

with the claimant and is that something that we 

could look at to see if we can tease apart the 

issue there?

CHAIR MARKOWITZ: Well, let me venture 

an answer to that and then Mr. Vance can correct 

it. At present, the industrial hygienists do not 

talk directly to the claimant --

MEMBER FRIEDMAN-JIMENEZ: At all?

CHAIR MARKOWITZ: At all, that's not 

part of the process.

About, we learned from Ms. Leiton 

about 26 percent of claims in a recent period 

were sent to, for industrial hygiene evaluation. 

But that evaluation consists of review of 

whatever relevant documents are provided by the 

claims examiner and whatever research the 

industrial hygienist does. And then they write 

up their report. So there is no direct contact 

but that's changing this week.

Dr. Goldman?

MEMBER GOLDMAN: You mentioned that 
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there's the occupational health questionnaire and 

that at least from the reviews that were done, it 

didn't appear that the IH person had looked at 

that. Do you know what percentage actually 

looked at that to see something more about the 

tasks beyond just a job category?

And if not, could that be a 

recommendation that that be consulted and 

included in what the IH people receive?

CHAIR MARKOWITZ: I'm going to let Mr. 

Vance have the final word on that but in my 

review of the claims, what I see is that the 

claims examiner is including the occupational 

health questionnaire as part of what they're 

passing along to the industrial hygienist.

They make reference to it. I think 

there's a line in the SOAF where it indicates 

what the claims examiner is sending to the 

industrial hygienist.

But the industrial hygienist reports 

that we've looked at, they use a fairly standard 

set of references for their report including the 
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SEM and other things but I don't see any 

reference that they've necessarily looked at the 

OHQ or not, but if the protocol is otherwise, Mr. 

Vance --

MR. VANCE: No, Dr. Markowitz, you 

have it correct. So when the claims examiner is 

preparing the case for an industrial hygiene 

referral they will prepare an IH referral 

worksheet and that's basically like an analysis 

that's been done by the claims examiner with 

regard to the data that is in the case file.

It also should illustrate or 

communicate the filtering mechanisms that the 

claims examiner used to identify the toxins that 

they're asking the industrial hygienist to opine 

on.

They will incorporate a Statement of 

Accepted Facts. They will incorporate any other 

type of data from the case file that's relevant 

for the industrial hygienist to review.

That would include the occupational 

history questionnaire. That will include any 
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industrial hygiene records from the employment 

site and in some instances they'll also include a 

medical report if the medical report is sort of 

the basis for the specific toxins that are being 

evaluated.

So in other words, if they're not 

utilizing SEM or they're not utilizing, you know, 

information from the case file but a physician is 

saying, here are the toxins that I'm considering 

in my opinion, then that'll be sent to the 

industrial hygienist so that they understand the 

background of why the CE might be asking about 

something specific.

CHAIR MARKOWITZ: Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: In our 

occupational medicine clinic in New York City, 

almost all intakes are done initially by an 

industrial hygienist.

And then she goes back sometimes and 

talks to the patient again to get more 

information and we find that this is enormously 

helpful to the physicians. It saves a huge 
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amount of time in our clinical evaluations.

And I believe we had made a 

recommendation that the industrial hygienist be 

able to talk to the claimants. And I'm wondering 

what is the status of that and should we make a 

formal recommendation again? Because I think 

this would be very useful in improving the 

accuracy of the causation determinations.

CHAIR MARKOWITZ: So you know, in fact 

they are, the fact that they are starting that 

this week, I believe is the result of their 

acceptance of the recommendation that we made a 

couple years ago. It's taken a while to unwind 

but --

(Off-microphone comments.)

CHAIR MARKOWITZ: Yes, I think that's 

a faithful I think representation of what 

happened.

MR. VANCE: The specific language is 

available now online. Our procedure manual has 

been updated with language relating this.

And again, it's not a mandatory 
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process but it is an option they can exercise 

when seeking additional exposure information from 

a claimant and that process of doing it via 

phone, telephone interaction, is in our procedure 

manual now.

CHAIR MARKOWITZ: So we learned 

yesterday that the contractor or the contract for 

the industrial hygiene evaluations is up for 

renewal or it's open for a rebid or whatever the 

proper term is and Mr. Vance told me this morning 

that the RFP is coming out soon.

And I think it seems to me that it 

would make sense for a new contract or an 

extension of a contract or again, whatever the 

term is, is flexible enough or incorporates 

appropriate language that the industrial hygiene 

interviews, subject to funding of course. But 

industrial hygiene interviews would be part of 

the new scope of work for under this industrial 

hygiene contract.

That doesn't require a response. 

That's not a question, that's a statement.
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Yes, Dr. Goldman?

MEMBER GOLDMAN: Is that something 

that's feasible? Because you said that 25 

percent of all cases go to the IH and if you're, 

I think it would be great if they interviewed 

everybody. Is that something that's feasible, I 

mean, with the numbers or could that be in the 

scope or the budget to put that out?

(Off-microphone comments.)

MEMBER GOLDMAN: I guess, I mean, 

because we're making a recommendation and I'm 

wondering if in your mind you're saying, well, 

that's ridiculous, we don't have the budget to be 

able to fund that. So is this a realistic 

recommendation?

MR. VANCE: Well, the good news is I 

have nothing to do with procurement so you guys 

can make whatever recommendation you would like 

and the Department will consider any input with 

regard to what we would potentially be able to do 

on a contract vehicle like this.

So my recommendation is that you 
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consider your options and decide how you best 

want to communicate that to the Department of 

Labor.

CHAIR MARKOWITZ: Okay.

Dr. Friedman-Jimenez?

MEMBER FRIEDMAN-JIMENEZ: I think in 

our language, you know, our discussion a couple 

years ago, we did talk about some way of triaging 

this and not everyone was going to get a full 

industrial hygiene interview.

And I don't think it's necessary in 

most cases. We have presumptions for the most 

obvious cases and many of the cases are easily 

resolvable without an industrial hygiene 

one-on-one interview. But we should have some 

system developed by which those cases for which 

it's likely to be helpful would be identified and 

we could focus on that.

I don't think everyone needs an 

industrial hygiene. That's not what I was saying 

before and I don't think it's realistic.

CHAIR MARKOWITZ: Right. Okay.
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Dr. Dement?

MEMBER DEMENT: I would agree with 

George. I think, you know, what, 25 or 28 

percent go to an IH ultimately. Probably a 

fairly small percentage of that would benefit 

from a direct interview. So I think we'd be 

reluctant to say everyone needed to have an 

interview.

CHAIR MARKOWITZ: Dr. Berenji, your 

card is up. I don't that you intended to say 

something.

MEMBER BERENJI: Yes, thank you.

So I actually agree with Dr. 

Friedman-Jimenez. I think having some sort of 

list of terms, especially when it comes to 

diagnoses like sarcoid, CBD, any type of 

beryllium sensitivity.

At least if those terms pop up that 

would be an automatic trigger to get to an IH 

because I have a feeling that a lot of these 

cases might kind of get missed.

And if there's a way where we can at 
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least identify, you know, those cases that could 

potentially be more complicated that require a 

higher level of review, if we can try to expedite 

that as much as possible in coming up with search 

terms or any type of, you know, medical diagnosis 

that requires further assessment, I think that 

could be very helpful.

CHAIR MARKOWITZ: Dr. Silver?

MEMBER SILVER: I agree with that and 

we've seen a few interesting cases slip through 

the cracks because the OHQ didn't list an 

explicit exposure yet.

Some of their tasks in various work 

areas were highly suggestive. Yesterday Dr. 

Berenji presented the carpenter at Savannah River 

site who remembered bagging up a lot of 

contaminated dirt.

He had sarcoidosis. I also spent a 

little time on this case, had PFTs as low with 28 

percent. So something was going on but the IH 

with a little bit more effort I think could have 

figured out if beryllium was used in that 
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specific area where the contaminated dirt had 

been used.

And at our last face-to-face meeting 

there were similar issues in a Nevada test site 

laborers case where she'd been in a number of 

work areas that we know were tunnel construction 

but it was not well reflected on the OHQ.

And if the IHs could be prompted to 

dig a little bit deeper into work areas and the 

contaminants and the generic tasks present I 

think that would help a lot.

CHAIR MARKOWITZ: Dr. Goldman?

MEMBER GOLDMAN: I just want to third 

that. But to have a list -- but actually to have 

it very specific because I think if you leave it 

totally optional, I mean, people want to get 

their work done and get through quickly and 

calling a patient and arranging it is a time 

consuming task.

And so that kind of direction that Dr. 

Berenji mentioned I think would be really useful 

and for any of these kinds of conditions for 
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which an IH is called or recommended, that there 

be a high consideration for having the patient 

interview.

CHAIR MARKOWITZ: Dr. Silver?

MEMBER SILVER: One of the unique 

things about the DOE complex is that there are a 

lot of documents out there and some of those 

determinations can be made without interviewing 

the worker.

The SRS Savannah River carpenter said 

on his OHQ he's not sure if he was exposed to 

beryllium. But there are lists at each of the 

DOE sites of beryllium work areas and with a 

little bit of effort and organization of 

documents, I think a few more suggestive cases 

could be approved.

CHAIR MARKOWITZ: Oh, by the way, Mr. 

Vance told us this morning that the Procedure 

Manual 4.0 is now available online, so if any of 

you want to take a look.

We haven't yet discussed claims 

examiners, the issue, it's Task 2 of the Board 
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which is to look at how claims examiners weigh 

medical evidence and we focused so far on 

industrial hygienists and medical consultants.

But so let's move to the claims 

examiner. We made some comments around that 

yesterday. Kind of the challenge where the 

claims examiner who has presumably a limited 

background in health and occupational health in 

particular, arrives at a Statement of Accepted 

Facts which sometimes are contradicted in some 

claims we've seen, by the physician, the CMC.

Sometimes rightly, sometimes not 

rightly. But anyway, if other people have 

comments about the claims examiner's role and 

their work in, specifically in reference to what 

we've seen in the claims review. That's what 

we're discussing now.

Ms. Pope?

MEMBER POPE: So it seems like the 

claims examiner's job, in my opinion, is really 

they've got a lot of responsibility.

And I was, my question is who reviews 
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their claims, the claims that they're submitting 

to the CMCs, to the IH? Is there a senior CE 

that reviews a sample of claims that they submit? 

Or, I'm just curious about that process.

CHAIR MARKOWITZ: Right, right.

Mr. Vance, if you could describe how 

they're evaluated, specifically how the content 

of their work, the SOAFs that they come up with, 

how they're looked at for quality?

MR. VANCE: All right. So each one of 

our district offices has a managerial structure 

and then you have your staff that are actually

adjudicating the cases. So as part of that 

normal routine you're going to have supervisory 

oversight of staff.

So there is performance assessment for 

each claims examiner to determine whether or not 

they are performing the functions of their job 

adequately and that would involve looking at the 

quality of the work that they do in conjunction 

with exposure analysis, the preparation of 

documents for decision making, development, and 
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that sort of thing. So that's one quality 

assurance process, the normal management of 

staff.

We also have a supervisor review 

process where they're looking at some basic 

features of every decision that's being issued 

before it goes out the door.

We also have our annual accountability 

review process. And that's where we actually go 

out to each district office and commit to a team 

review of the work of each jurisdictional office.

And we devise categories of review 

for, you know, the accuracy of payments, the 

quality of recommended decisions, the quality of 

development, the quality and calculations of 

impairment and wage loss and those type of 

things.

And that occurs on an annual basis, 

not only of our district office but our final 

adjudication branch.

So we have these tools that are 

employed to make sure that staff are adhering to
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the processes, the rules, the legal constructs 

that exist under the law.

And then of course like what I 

mentioned yesterday is we are also moving to 

develop a formal quality assurance plan through 

the use of a unit that will be dedicated to doing 

this on a cyclical basis as well.

CHAIR MARKOWITZ: Thank you.

Comments, questions? Dr. Silver.

MEMBER SILVER: Do you see evidence of 

claims examiners avidly performing their jobs 

where maybe they're developing a career interest 

in occupational health and causation issues, 

putting Dr. Markowitz's textbook on their cubby 

bookshelf or really getting into it? Or is it 

still kind of a thankless slot in a bureaucracy?

MR. VANCE: My general comment to that 

is I think our claims staff try to do the best 

possible job that they can with the information 

they're presented with. And I'm sure some of 

them have wonderful libraries at their cubicles.

I have a vast source of information 
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sitting on mine but, no, I think that the overall 

impression that I think a lot of people recognize 

with our staff is that they are hardworking and 

they are trying to do the best they can with this 

very challenging set of circumstances that they 

have to face in each and every one of these 

cases.

So, you know, this is an organization 

of 240 claims examiners and 65 appeal board staff 

that are trying to do their job and you're going 

to have all kinds of different issues with regard 

to that.

But I think the overall focus and 

effort of the program is really making sure that 

we are producing the best possible outcomes that 

we can given the resources and the evidence that 

we have in these case files.

CHAIR MARKOWITZ: Mr. Domina?

MEMBER DOMINA: Seeing that we have 

the new claims or procedure manual out and it, we 

talked about it yesterday a little bit, I was 

wondering if we could pull up that language, the 
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one they're talking about terminal claimants 

because it came up again this morning, if we had 

time to look at it real quick or not, just to see 

what the claims examiners want.

You know, and I know we discussed it 

this morning and it was discussed yesterday but I 

just wanted to see and with the conversation I 

had with Mr. Vance, I kind of wanted to see maybe 

what's on there for us to look at if we had time.

CHAIR MARKOWITZ: Sure, we can try to 

look it up.

(Off-microphone comments.)

CHAIR MARKOWITZ: EEOICP PM 4.0. 

He'll find it.

So are there other comments on the 

claims examiners while we're on this topic? 

Okay.

We have 20 minutes. This was, my plan 

was to, we should talk about our work over the 

next period of time and set some time frames and 

some goals, and then if there's time we can come 

back to the public comments and discuss those.
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The Board, this term of the Board ends 

in July, I think, 2020. So that means that 

there's roughly eight months for us to continue 

this work.

My feeling is that the topics we've 

entertained, that we should pursue them to 

conclusion, handle new topics if we can, but the 

very important issues that fall within our 

charter we should address.

That means two meetings. One would be 

a telephone meeting, probably in roughly two 

months. Another would be an in person meeting 

probably in the April time frame, perhaps May.

But we want some time before the 

Board's term expires because we want to be able 

to submit those recommendations and then have 

some interaction with DOL after we submit those 

recommendations.

So we're not going to pick an exact 

time or place today, I just wanted to give you 

the time frames which is that we'll do a full 

telephone board meeting roughly in January, maybe 
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early February. We'll send out dates and try to 

figure that out. And then we'll meet in person 

April or May and take it from there.

Now at the next meeting, the telephone 

meeting, we're going to come back to the issue of 

Parkinson's disease, see if we're ready to make a 

recommendation to the Department.

I think we should revisit the issue of 

firefighters since there was a lot of interest in 

firefighters and I think we should re-discuss it 

and see if there's some particular recommendation 

we want to make about firefighters.

I think on the issue, to me the main 

issue in the telephone meeting will be to resume 

the look at claims review. And then begin to 

formulate and if we can, actually make some 

recommendations regarding the industrial hygiene, 

the medical consultant evaluation, with respect 

to objectivity, consistency, and quality.

And also, if we have some 

recommendation to make around the claims examiner 

or not regarding their weighing of medical 
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evidence.

So we would shoot, in that telephone

meeting to continue the discussion and to develop 

some recommendations if we're ready, around those 

topics.

Are there other, and then there's an 

action list that Ms. Rhoads has been keeping 

track of and we will get information about that.

Between now and then we'll continue to 

review claims and compile claims and then look 

into the various topics that we've developed an 

interest in, continuing the work on Parkinson's 

Disease.

Is there anything that I've forgotten 

or anything else that needs to be on our radar?

Well, if you think of it at 11:01 

today, you know, send me an email and I'll put it 

on the list.

Any questions about our workflow or 

what we kind of anticipate over the next six or 

eight months? Are there any big topics under our 

chartered mission that you think that we're 
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neglecting?

We do need to, as we've done in the 

past, periodically look at the public comments 

and -- because they are provocative in terms of 

our mission and introduce knowledge and ideas 

that maybe we haven't thought of, different 

emphases of affected community. So I urge you to 

read those comments.

We have developed in the past a 

summary of public comments, a spreadsheet in 

which we've compiled them, shortened them. Some 

of them are a little bit longer. Ms. Rhoads has 

done that work and will continue to do that work 

hopefully, Ms. Rhoads, yes, thanks.

Actually there is something from the 

public comment from yesterday that I'd like some 

clarification on.

In Ms. Hand's written comment, there 

is allusion to a list of authoritative sources 

that claims examiners, the CMCs and the like 

could, I think the implication was, should use to 

make their decisions.
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And this is a question for Mr. Vance. 

I'm sure you don't have a set list of sources 

that would limit anybody in the process, that 

they could only go to those sources and that 

there's no list of sources that are excluded.

But, you know, the sources that Ms. 

Hand lists are things like the National 

Toxicology Program, the toxicologic profiles from 

the Agency for Toxic Substances and Disease 

Registry, OSHA, Haz-Map, NIOSH, and the like.

So I assume those sources are all 

legitimate in a claims evaluation process for a 

claimant to submit or a physician, a personal 

physician who's doing a well-rationalized report, 

that those are perfectly legitimate and 

acceptable sources if they address, if they 

address the question at hand, the issue of 

causation in a particular case?

MR. VANCE: The answer is yes.

CHAIR MARKOWITZ: Okay. Great.

(Off-microphone comments.)

CHAIR MARKOWITZ: Thank you. Thank 
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you for that short answer.

Okay. I'm sorry, Dr. Goldman?

MEMBER GOLDMAN: What, for the CMC? 

What about other papers from the literature that 

could be something really good and how often, 

that's part one. Part two, how often, I saw that 

on the list, the approved list, of ATSDR 

profiles, are those consulted by the IH?

CHAIR MARKOWITZ: I, that's a question 

I guess for Mr. Vance.

MR. VANCE: I mean, you know, I know 

that we have various resources that our staff 

utilize in researching issues for claims, 

researching issues from the Advisory Board, 

researching issues from just different 

stakeholders.

So I mean, we really do have an 

expansive reach in being able to obtain 

information to help us evaluate epidemiology, to 

evaluate toxicology in issues relating to these 

claims. So I think that we're pretty open to 

using anything that we can look to to help us 
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through this process.

CHAIR MARKOWITZ: You know, I think 

looking at some claims, that it might be helpful 

if the industrial hygienists and the physicians 

were encouraged to list all the sources that they 

use so it's a little bit more, it can be more 

transparent in perhaps reassuring in the claims 

evaluation process.

This is true for the industrial 

hygienist as well. They typically don't list, 

for instance, that they've looked at the 

occupational health questionnaire.

They're given it but in their list of 

references they don't, I think it's a habit. I 

mean, I think it's just this is what we use for 

references and because they use the same 

references over and over again.

I think it would help if actually what 

they actually used to look at was, it was more 

inclusive. And that would communicate, increase 

transparency, would communicate to all the 

parties that, yes, we did take a look at that 
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study that you gave us to look at.

You know, that your physician cited or 

provided. It would increase I think transparency 

and communication.

I have a request from Department of 

Labor so we're going to add Ms. Rhoads to that, 

which is in, say from 20--, January 2018 to the 

present, so a reasonable time period and recent, 

is what changes in the exposure disease links 

have been made in the SEM.

I think it's probably limited so I 

mean, I don't think it's, it's not a huge task 

but because it gives us some sense of how much 

evolution there is in that particular aspect of 

the SEM.

Well, you know there's evolution in 

the number of agents listed, a lot of work in 

that. You reviewed the numbers yesterday.

But I don't get -- and you cited a 

couple of carcinogens I think that have been 

added with the help of IARC documents, but still 

don't get a sense of how active this scrutiny in 
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evolution of the SEM is in terms of specifically 

the connections between agents and diseases so if 

that's possible, that would be helpful.

Any comments, questions? Yes, Dr. 

Dement?

MEMBER DEMENT: Just one comment and 

I'm not sure where it's going to take us. We've 

tried, you know, even in the current manual we 

still have the only presumption for COPD being 20 

years of asbestos exposure which I think we all 

agree that's probably is a presumption that's 

scientifically valid but is very limited and 

there are many other exposures with lesser 

duration perhaps that would also, at least in my 

view, qualify as a presumption.

I don't know how we move this forward. 

I mean, we've made a couple of shots at it. 

We've, and it's still sort of in the limbo stage, 

I guess.

But I think, you know, it's a big 

issue and we look at it from our cohort of 

building trade workers, it's as big or bigger 
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than lung cancer with regard to mortality. The 

relationship of occupational exposures is clearly 

there.

CHAIR MARKOWITZ: Yes, well, I think 

it's something we need to talk through as a 

working group, how to bridge this chasm between a 

dozen or so specific toxic substances that are 

listed in the SEM as being related to COPD.

And the current state-of-the-art 

medicine which states that in the industrial 

environment, a much broader set of agents that 

lead to dust, gas, vapors and fumes.

So we can discuss that further. I 

mean, it's, we haven't come to agreement about 

that, the Department and the Board.

So but, Dr. Dement?

MEMBER DEMENT: Yes, I just was 

encouraged. You know, I state presumption but 

when we look at the proportion of COPD cases that 

are actually awarded, accepted, it's pretty good.

I mean, it's not, I'm not saying that 

we aren't, you know, the program's not doing a 
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good job of, you know, looking at it in a 

detailed way, but in some cases I think we, the 

whole process could be short circuited and dealt 

with more quickly and more efficiently.

CHAIR MARKOWITZ: Right. But there is 

an action, there's an issue I wanted to raise 

that we haven't really discussed much. We were 

provided with the types of claims that have been 

reopened as a result of the change in 

presumptions and categories. This was a meeting 

or two ago.

So the particular kinds of conditions 

that were reopened were bladder cancer, 

mesothelioma, lung cancer, and a couple of 

others, I don't remember.

But when I looked through, and we were 

given details on individual cases. So I looked 

at the lung cancer. There were some 500 lung 

cancers that the Department looked at because the 

presumption around asbestos had changed.

And so they went back and looked at 

those 500 and decided 50 of them needed to be 
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reopened and re-looked at. And I know the 

Department's going to give us a status update on 

that process.

But when I looked at the job titles of 

a lot of those cases of lung cancer, there were 

many job titles, many people who frankly would 

appear to qualify for occupational lung cancer 

based, not knowing necessarily what their SEM 

says because that's not part of what was provided 

to us, we could look at it.

But people like electricians and pipe 

fitters, and carpenters, who worked for a long 

time in the right era, '70s, '80s, earlier, that 

frankly looked like on the face of it that their 

lung cancer should have been considered to be 

occupational but that's only looking at very 

little information.

So what I would like to do if others 

on the Board are interested is to request from 

the Department a certain number of lung cancer 

claims, denied claims, from that list. So the 

relatively recent and in fact, I would propose we 
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select out the job titles of interest to high 

suspicion job titles. And take a look at those 

claims and just see how they're being handled. 

See what the considerations are, what the 

sticking points are.

I'm wondering if other Board members 

have some interest in this besides Dr. Dement who 

just raised his hand, Dr. Redlich.

Is anybody on the Board opposed to 

this idea? No, okay.

MEMBER SILVER: Reviewing cases has 

become habit forming.

CHAIR MARKOWITZ: Yes, right.

Okay. So, Ms. Rhoads if you could add 

it to the list and I'll formulate, Dr. Dement and 

I will formulate the requests with some detail 

and we'll circulate it before we submit it.

Any other closing comments or because 

we're about to close the meeting, questions, yes?

(Off-microphone comments.)

CHAIR MARKOWITZ: Is that for Mr. 

Tebay?
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PARTICIPANT: From Dr. Redlich.

CHAIR MARKOWITZ: Dr. Redlich, okay.

MEMBER REDLICH: This is Carrie 

Redlich. Can you hear me?

CHAIR MARKOWITZ: Yes, we can hear 

you. 

MEMBER REDLICH: So I apologize. I've 

been sitting on the runway at O'Hare quite a 

while so I heard all of you.

I did send, I thought I had sent a PDF 

last night but it did not leave my house fax 

until a few minutes ago so it's obviously for the 

future, but I just thought it was -- just some 

issues probably were already discussed this 

morning but others I would think we could address 

in the future. I think it's sort of 

self-explanatory.

CHAIR MARKOWITZ: Did anybody make out 

that comment? I'm sorry --

MR. BIRD: She had sent a PDF and she 

was talking about discussing it and wanted to 

know if now is a good time.
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MEMBER REDLICH: So I apologize. I 

don't know why it's not, I don't know why it's 

not there.

CHAIR MARKOWITZ: Okay. You sent us a 

PDF?

MR. BIRD: It just came through so we 

have it there.

MEMBER REDLICH: Yes, I can send a PDF 

for the future and I just thought if people could 

give it, it was some of the issues that were 

already raised yesterday and this morning but I 

just, after our meeting yesterday just summarized 

what some of the take home lessons I have learned 

from the cases we've reviewed.

So I think some of these we have 

discussed, I've put them down just so I wouldn't 

forget them before we meet again.

CHAIR MARKOWITZ: Okay. That's great. 

So as a question for Kevin. Is this 14 pages?

MEMBER REDLICH: Yes.

CHAIR MARKOWITZ: Okay. Okay, so --

MEMBER REDLICH: But there, but it 
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also just included one or two examples of some of 

the issues we've raised.

CHAIR MARKOWITZ: Okay.

MEMBER REDLICH: Okay.

CHAIR MARKOWITZ: So we need to sit 

and read this.

MEMBER REDLICH: Yes, no, I realize. 

This is more of a memory aid for the future since 

it's something we tend to lose track of where 

we've left off.

CHAIR MARKOWITZ: Okay. Okay. So, 

Carrie, we'll use this as background for our 

Board telephone meeting in January. Is that all 

right?

MEMBER REDLICH: Perfect. Thank you.

CHAIR MARKOWITZ: Okay. No, thank you.

Okay. So will you distribute that to 

us?

PARTICIPANT: Yes.

MEMBER REDLICH: And I obviously 

turned off my computer too quickly last night so 

I apologize.
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CHAIR MARKOWITZ: Okay. And then 

another thing that actually we need to do is take 

a look at the changes in the PM 4.0.

Is there a transmittal memo with the 

changes in the 4.0 or?

MR. VANCE: Yes, there is.

CHAIR MARKOWITZ: Okay.

MR. VANCE: So there will be a, just 

for everybody's information, there will be a 

transmittal document which actually communicates 

what's changed in Version 4.0 and then the PDF of 

4.0 in its entirety with those changes will also 

be up on the website.

CHAIR MARKOWITZ: Okay. It is on the 

website.

MR. VANCE: Yes, I just checked.

CHAIR MARKOWITZ: I'm looking at it, 

great.

Okay. So if there are no other --

PARTICIPANT: Can you scroll down on 

this terminal illness thing so I can see the rest 

of it, please?
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CHAIR MARKOWITZ: Oh, yes, sure. I 

don't see use of the word imminent. Did you see 

it?

(Off-microphone comments.)

CHAIR MARKOWITZ: I'm sorry, could you 

scroll back up Kevin and then make it a little 

larger?

Do you see it?

(Off-microphone comments.)

MEMBER BERENJI: There it is. It's in 

that second, in that paragraph. Yes.

CHAIR MARKOWITZ: Well, that, you 

know, the way that reads is that if it's 

determined that at either end stage or death is 

imminent, end stage is synonymous with terminal 

or hospice care. So, leeway there.

But I think my sense is that the 

Board's made its kind of collective opinion known 

on this issue, that application of an imminent 

standard for priority setting is quite a burden 

on the family, on the patient, and on the 

physicians taking care of that individual, if 
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I've captured that correctly.

Mr. Domina, was there anything else 

about this that you wanted to discuss?

Mr. Fitzgerald, are there any closing 

comments that you would like to make?

MR. FITZGERALD: I just want to thank 

you, Mr. Chairman, and the Board for all their 

work this past day and a half and I want to thank 

the public for their participation and 

attendance, both here physically here in Paducah 

as well as those on the Webex.

And I want to thank the SIDEM 

contractors here for doing a great job and my 

alternate DFO, Carrie Rhoads. Thank you very 

much.

CHAIR MARKOWITZ: I echo all those 

thank yous and add others, Mr. Nelson, Mr. Vance, 

the public, Board members, and the like. So thank 

you very much. The meeting is now adjourned I 

think.

(Whereupon, the above-entitled matter 

went off the record at 10:58 a.m.)