Effectively Managing the “Underexposed”

1. Effectively Managing the “Underexposed” Robert Emery, DrPH, CHP, CIH, CBSP, CSP, CHMM, CPP, ARM 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

2. 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?

3. 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%?

4. 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

5. 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

6. 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

7. Identifying Who is Who? • Sometimes it’s 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

8. 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

9. 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

10. 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

11. 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

12. 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 Barriers to Trust

13. 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

14. Data in Context: Post-Flood Relative Humidity

15. 4. The Concerned • All previous steps required, along with proactive and frequent follow up • Sequencing of messages crucial – first acknowledge concerns voiced by communicating that you take any exposures seriously – then compare to “background” • 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

16. 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 cc’ed 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!

17. 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 doctor’s note and access sick leave • Apply for a transfer? • ?

18. 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 doctor’s note and access sick leave • Apply for a transfer? • Resign? (exercise extreme caution here!)

19. 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

20. toxin or infection Pathways for Indoor Air Quality-related Physiological Responses • Illness • Loss of Productivity • Worker discontent • Protracted WCI/Legal Issues Physiological Response Allergen or Irritant

21. 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

22. toxin or infection Pathways for Indoor Air Quality-related Physiological Responses • Illness • Loss of Productivity • Worker discontent • Protracted WCI/Legal Issues Physiological Response Allergen or Irritant

23. toxin or infection 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.

24. 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 Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th edition

25. Complex Relationships CNS Autonomic Nervous System Endocrine System Immune System

26. Sick building syndrome Building related illness Multiple chemical sensitivity Chronic fatigue syndrome Environmental somatization syndrome Total allergy syndrome Cacosmia Functional somatic syndrome Occupational neurosis Mass psychogenic illness Psychogenic idiopathic environmental intolerance 20th century disease Cerebral allergy Chemically induced immune dysregulation Idiopathic building intolerance Toxic agoraphobia Synonyms

27. Stress Reported Associations • Allergy/Asthma • Autoimmune diseases • Cardiovascular diseases • Infectious diseases • Malignant diseases • Metabolic diseases

28. 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

29. 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

30. 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?”

31. 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

32. 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 > 100) exposed to odors, producing a wide variety of responses • What steps should be taken to address this issue?

33. 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

34. 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

35. Summary (con’t) • 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