Effectively Managing the Underexposed

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Effectively Managing the Underexposed

• Robert Emery, DrPH, CHP, CIH, CSP, RBP, CHMM,
  CPP, ARM
• Assistant Vice President for Safety, Health,
  Environment Risk Management
• The University of Texas Health Science Center at
  Houston
• Associate Professor of Occupational Health
• The University of Texas School of Public Health

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Consider This Paradox

• Of all the personnel monitoring you have
  performed in your career, for whatever potential
  hazard or insult ..
• Chemicals
• Radiation
• Mold
• Particulates
• How many results were at or above the established
  limit?

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Are We Overlooking the Majority?

• The recurrent answer from multitudes of
  practicing safety professionals is 1 to 5
• Much of our collective academic and professional
  preparation is focused towards the protection of
  this 1 to 5
• What about the other 95 to 99?

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The Underexposed

• Persons exhibiting monitoring results below any
  required or recommended limit
• Underexposed is actually a misnomer, as these
  persons are likely exposed, but just to a lower
  or even trivial level
• But these persons can still hold concerns or
  apprehensions about their exposures, and can
  consume vast amounts of program energy and
  resources if mismanaged

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Management of the Underexposed

• Ironically, once assessed or monitored, the
  underexposed population of workers is either
  ignored or, if problematic, managed through a
  series of unwritten techniques
• These management techniques are developed over
  years of experience, and many battle scars, but
  are rarely documented

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General Classes of the Underexposed

• 1. The unconcerned
• 2. The curious
• 3. The inquisitive
• 4. The concerned
• 5. The upset
• 6. The upset with symptoms
• 7. The outraged,
• and not shy about making it known

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Identifying Who is Who?

• Sometimes its hard to tell
• But using a methodical approach, self selection
  can occur
• The trick is the subsequent and appropriate
  management of these individuals as the different
  classes of individuals become apparent

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Beyond Risk Communications

• Certainly the well articulated precepts of risk
  communication are applicable, but its more that
  merely talking
• Processes and actions must match and mesh with
  the messages being sent
• Empathy and respect is crucial

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1. The Unconcerned

• The easiest to handle
• May not have known or cared if they were being
  exposed
• Mere education that the exposure may exist, but
  is being monitored and controlled is sufficient
• They then turn their attentions elsewhere
• Likely best left alone at this point

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2. The Curious

• May be aware of exposures and have heard about
  them from somewhere else
• Once educated, can be re-assured by providing
  monitoring results and follow up care

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3. The Inquisitive

• Likely aware of exposures and have talked about
  them
• Along with education, displays of monitoring
  results in context must be provided
• Means for communications of any subsequent
  concerns a must!
• The installation of an environment of trust
  follow up actions are crucial

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Barriers to Trust

• Disagreement amongst experts
• Lack of communication, coordination amongst risk
  management organizations
• Inadequate risk communication skills, actions

• Lack of exposed person participation
• Apparent mismanagement or neglect
• History of distortion, secrecy

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Functioning Without Trust

• Applying a lesson from business
• In contract negotiations, accountability, not
  trust, is the dominant value
• Accept the obligation to prove contentions to
  critics, using methods such as third party
  sampling, analysis, oversight or audits
• By relying more on accountability and less on
  trust, organizations become more trustworthy

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Data in Context Post-Flood Relative Humidity
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4. The Concerned

• All previous steps required, along with proactive
  and frequent follow up
• Even if calls have not come in, dropping by and
  checking on things (better if with a sampling
  device) can serve to re-assure
• Third party analysis of samples always helpful to
  maintain trust

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5. The Upset

• Allowing persons to vent is critical!
• Seek to organize a forum where venting can occur
  with managers, supervisors or other key folks who
  have likely been cced on multiple e-mails
  present.
• Typically have hunted up information on the web
  (usually the wrong information) but important to
  let them have their say
• Respond calmly and rationally
• When describing options, always emphasize that
  the final decision rests with the employee!

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The Options

• When exposures are demonstrated to be below the
  accepted standard, the ultimate decision rests
  with the employee
• Continue to work
• Work in PPE
• Arrange some sort of trade out of work
  tasks/locations?
• Request annual leave/vacation
• Seek doctors note and access sick leave
• Apply for a transfer?
• ?

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The Options

• When exposures are demonstrated to be below the
  accepted standard, the ultimate decision rests
  with the employee
• Continue to work
• Work in PPE
• Arrange some sort of trade out of work
  tasks/locations?
• Request annual leave/vacation
• Seek doctors note and access sick leave
• Apply for a transfer?
• Resign? (exercise caution here!)

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6. The Upset with Symptoms

• Never discount the symptoms being described!
• Articulate that the symptoms are real its just
  the root cause of the responses that may be in
  question
• Understand the emerging field of
  psychoneuroimmunology

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Pathways for Indoor Air Quality-related
Physiological Responses

• Illness
• Loss of Productivity
• Worker discontent
• Protracted WCI/Legal Issues

Physiological Response
Allergen or Irritant
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Cues

• Pavlovian Conditioning
• Immune conditioning demonstrated in animals
• Can produce many physiological responses
• May also increase anxiety, fear, anger, etc.
  (buttons)
• Conditioning stimulus can be any sense

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Pathways for Indoor Air Quality-related
Physiological Responses

• Illness
• Loss of Productivity
• Worker discontent
• Protracted WCI/Legal Issues

Physiological Response
Allergen or Irritant
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Pathways for Indoor Air Quality-related
Physiological Responses

• Illness
• Loss of Productivity
• Worker discontent
• Protracted WCI/Legal Issues

Physiological Response
Allergen or Irritant
Other cue- visual, odor, etc.
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Psychogenic Model

• Produced or caused by psychic or mental factors
  rather than organic
• Of psychological rather than physiological origin
• When the mind induces the body to create or
  exacerbate poor health
• Somatoform disorders
• Compilation of illnesses unexplained by
  physiological symptoms
• Somatization
• Source American Psychiatric Associations
  Diagnostic and Statistical Manual of Mental
  Disorders, 4th edition

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Complex Relationships
CNS
Autonomic Nervous System
Endocrine System
Immune System
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Synonyms

• Occupational neurosis
• Mass psychogenic illness
• Psychogenic idiopathic environmental intolerance
• 20th century disease
• Cerebral allergy
• Chemically induced immune dysregulation
• Idiopathic building intolerance
• Toxic agoraphobia

• Sick building syndrome
• Building related illness
• Multiple chemical sensitivity
• Chronic fatigue syndrome
• Environmental somatization syndrome
• Total allergy syndrome
• Cacosmia
• Functional somatic syndrome

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Stress Reported Associations

• Allergy/Asthma
• Autoimmune diseases
• Cardiovascular diseases
• Infectious diseases
• Malignant diseases
• Metabolic diseases

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Psychogenic Illnesses

• Physiologic responses are REAL
• Extremely difficult to treat
• Patient denial
• Employer disdain/impatience
• Limited response to traditional therapies
• Approach to problem is multilevel
• Patient/doctor/employer education
• Early/consistent involvement of environmental
  safety
• Deconditioning strategies

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Treatment

• Acknowledge the symptoms as real
• Actively investigate
• Explore options for removal from environment
• Make actions noticeable
• Provocative challenge?
• Cognitive-behavioral therapy
• Resistance to psychological treatment
• Explanation of stress playing a role in symptoms
• Regardless of monitoring results, office
  cleaning, control over ventilation, and increased
  outside air

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7. The Outraged

• Employ all approaches described so far
• Learn to know when to create Pearl Harbor File
  as litigation likely
• Documentation that reflects actions taken, dates,
  times, and third party results
• Review your case in this manner have we done
  everything we could reasonably do?
• How will our actions be perceived on the front
  page of the paper or the evening news?

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Important Point to Remember

• If we have not gotten our message across, then
  we ought to assume that the fault is not with our
  receivers
• Baruch Fischhoff, Dept of Engineering and Public
  Policy, Carnegie Mellon University 1995

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Case Study

• Despite best planning and controls, odors from a
  roofing project from a building adjacent to an
  existing, occupied building
• Odors are strong, but measured to be below
  recommended exposure limits
• Large population of workers (n gt 100) exposed to
  odors, producing a wide variety of responses
• What steps should be taken to address this issue?

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Lessons We Learned

• Advanced warning of project via multiple
  communication pathways (requires active
  Facilities involvement and awareness)
• Include explanations about options explored, and
  reasons for not being implemented
• Include information about substances to be
  encountered, and associated exposure limits,
  effects
• Include reminders for supervisors about available
  options for management of employees
• Active surveillance of worksite and exposures
• Mechanism for occupants to express concerns, and
  active follow up

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Summary

• The general professional consensus is that most
  of the persons we monitor are underexposed
• Although underexposed, these individuals can
  consume vast program resources and energy if
  mismanaged
• Academic and professional preparation in this
  area is generally lacking

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Summary (cont)

• The underexposed range in categorization, from
  the unconcerned to the outraged
• Utilization of the basic precepts of education,
  objective sampling, third party analysis, sound
  communication skills and empathy can aid in
  addressing their concerns