Effectively Managing the “Underexposed”

Robert Emery, DrPH, CHP, CIH, CSP, RBP, CHMM, CPP, ARMVice 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

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?

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%?

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

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

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

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

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

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

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

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

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

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

Data in Context: Post-Flood Relative Humidity

Percent Relative Humidity in the Non-Flooded Areas (Floors 1-7) of the Medical School Building & John Freeman Building Pre and Post Flood 06/09/01

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

-2.0 8.0 18.0 28.0 38.0 48.0 58.0 68.0

Days past flood event

Perc

ent R

elat

ive

Hum

idity

Measured Humidity Levels ASHRAE Guideline Reoccupation Occurs

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

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!

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? ?

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 caution here!)

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

• Illness

• Loss of Productivity

• Worker discontent

• Protracted WCI/Legal Issues

Physiological

Response

toxin or infection

Allergen or Irritant

Pathways for Indoor Air Quality-related Physiological Responses

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

• Illness

• Loss of Productivity

• Worker discontent

• Protracted WCI/Legal Issues

Physiological

Response

toxin or infection

Allergen or Irritant

Pathways for Indoor Air Quality-related Physiological Responses

• Illness

• Loss of Productivity

• Worker discontent

• Protracted WCI/Legal Issues

Physiological

Response

Other cue- v

isual,

odor, etc.

toxin or infection

Allergen or Irritant

Pathways for Indoor Air Quality-related Physiological Responses

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

Complex Relationships

CNS

Autonomic Nervous System

Immune System

Endocrine System

Synonyms 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

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

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

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

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?”

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

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?

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

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

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