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Dr. John Howard

Director, National Institute for Occupational Safety and Health

Dr John Howard

Physician, attorney, and regulatory expert, Dr. Howard led Cal/OSHA for a decade and now uses his considerable expertise at the national level to help guide research on occupational safety and health. Of note, he has coordinated efforts to assist response and recovery workers affected by conditions at the New York City site of the 9/11 attack.

Resume: Dr. Howard is a physician, public health administrator, and in 2009 was reappointed to a new six-year term as director of NIOSH. He was appointed by former President George W. Bush as special coordinator to handle medical issues affecting 9/11 rescue workers at the World Trade Center. He has also served as chief of California’s Division of Occupational Safety and Health (DOSH) from 1991 to 2008, implementing the state’s ergonomic standard. Prior to his appointment to NIOSH, he was an assistant professor of environmental and occupational medicine at UC Irvine. His clinical work as an internist involved asbestos-exposed shipyard workers, and he published research findings on occupational lung disease.

Schools:  Howard received his doctor of medicine degree from Loyola University, cum laude, in 1974; a master of occupational health degree from the Harvard School of Public Health in 1982; and a master of laws degree in administrative law and economic regulation from George Washington University in 1987. He received a law degree from UCLA in 1986. Juris Doctor, University of California Los Angeles after his medical degree

Certifications/Designations:  In 2008 Dr. Howard received the ISEA Distinguished Service Award.

 

Q&A  

 

What are the top issues in California occupational safety and health today?

I think of my experience at Cal/OSHA during the recession of the 1990s, I think we had to make difficult budgetary adjustments. When I left in 2002 there had been five or six years of that. There had been effects on the inspectorate, the workforce, on the number of inspections that were able to be accomplished, effects on the number of standards that could be produced. Although California clearly excels in that area more than any other state. But there had been those budgetary issues. And now in 2011 those budgetary issues are quite severe. What I think is a major issue for the government occupational health and safety programs is how you get more efficiency out of the investment that you have.

When the investments are going down every year, how do you do the same kind of work? How do you improve the workload? How do you improve the quality, how do you get the same efficiency out of the dollar that you’ve invested? I think that is a very serious issue. I know that it’s one that Ellen Widess is facing. Len Welsh faced it. I faced it. And I think any chief of Cal/OSHA, any regional manager, any district manager, consultation area manager, all management structures of a government program face those issues.

And similarly, I think the same thing happens when either you’re an in-house consultant, or private consultant in private occupational safety and health, or you’re a consultant being hired by an employer. It’s the same issue.

We have probably the worst year on record, even take these major industries, construction, manufacturing, agriculture, facing the economic strain that they have. The same thing ripples down to the private sector in occupational safety and health. So to me that goes to my second issue. The first issue is budget.

The second issue is what do we provide as occupational safety professionals? Whether you work in government, whether you work for yourself. Whether you work for an employer. What exactly are we providing? Are we providing enough?

This is a theme now I’ve used for a couple of years, both for the American Society of Safety Engineers, and the American Industrial Hygiene Association as well as the Occupational Environmental Medicine Association. We as environmental safety and health professionals, no matter what our orientation is, industrial hygiene, medical, psychology, nursing, we have to expand our scope of practice so we’re offering the employer [and] the worker more than we did 15 or 20 years ago. We can’t be technicians who have to understand how we do programs. We have to understand that there is more to the worker than just the occupational side. For instance, this is the third issue, which relates to total worker health.

First is budget, second is expanding the scope of practice and the third is total worker health. So if a worker is not at work, does the employer, does the economy, does the nation care why that worker is not there? In other words, was it a work-related injury or was it falling off the ladder at home? Or a car accident? Or some other health- and safety-related issue, or a health issue that’s personally related? You know, poor diet, poor nutrition, poor exercise. Does that matter to the worker, to the worker’s family, to the enterprise, to the employer? I don’t think we as safety and health professionals should make a differentiation. Oh no, that’s work related. Or no, that’s not work related. We don’t have anything to do with that. I think that third limitation in practice is very severe. So the third issue is total worker health. We as worker safety and health professionals, we can save you, your family, the employer, the enterprise and the nation’s economy, by taking into consideration in our practice all of those issues.

Budget, budget, budget. Expanding scope of practice and as professionals looking at total worker health. To me those are the three big issues that affect us in California and in the United States. And that’s why safety and health employees are the first ones to be let go because our scope of practice is so narrow. Employers say we have a tough budget, we don’t need those people, we’re pretty safe.

 

Injury and illness rates continue to decrease, with some exceptions. What's the next great leap forward in occupational safety and health?

Well, there is a premise in question we need to unbundle. Are rates totally accurate? They are as accurate as we can get them right now. But is there underreporting? If there is underreporting, how much is there? What kinds of injuries are underreported? What kinds of illness are underreported? We have known for many years, there has been lots of research, that illnesses related to occupation are grossly underreported. There is lots of literature on that.

From the fatality side there is no evidence that it is underreported there. The mild-to-moderate injury side, there is some indication that those injuries are lost to our reporting system. They may show up in emergency rooms. They may get some kind of workers’ comp, but they somehow don’t make it into our occupational health and safety counting system. So saying that injury rates are going down, well, fatality rates I really believe in. Bureau of Labor Statistics does a terrific job. Census Survey of Occupational Injuries, there has been some surveys showing that they’re not underreported, other studies show they are underreported on injuries. And illnesses are for sure underreported, so I’m not so sure you can say, look at the future, use injury rates as a planning tool, take them as the tablets from Mt. Sinai, no, no, no.

If I was running an enterprise and I really wanted to know what my injury and illness rate was, I would look at my log, sure. And figure out how we got that. I would look at any kind of health insurance claims that the insurer provides. They pay for plans, but they don’t really delve into that data. They don’t call up Kaiser or Aetna to find out. Sometimes in [workers’] comp they don’t delve into that data. Or just survey the workforce. Anything happen you didn’t report? So that question is a difficult one to answer as it was stated. If you get to the most accurate data, then you could use that as a tool as a springboard for planning.

Let’s assume that your question doesn’t have that stuff in it, and they were going down. How does that affect what we do in safety and health? Then we get into the issue, what’s beyond the initial injury? An injury is an instantaneous effect, and illness is diagnosed on a specific day. But what is the disability issue? A lot of times in occupational safety and health we don’t focus on disability. What is the burden that comes from work-related illness? We have no handle on that. I’m not sure we have a handle on how much disability comes from injury. Somebody gets a workers’ comp claim, they may get partial, permanent, total. It’s part of another system. We don’t really factor that into how well we did in safety and health to prevent that thing in the beginning. So that’s one little caveat I would mention with regard to that injury rate. Sure, they look good, but I’m not so sure they are accurately representative of what’s going on. And two, they are not disability numbers.

 

One group -- Hispanics/Latinos -- suffers a disproportionate number of injuries and illnesses. Why? How should California address this problem?

I certainly think a lot of both academics and private consultants in health and safety have written papers on this issue. And certainly OSHA has done some work on this issue and Cal/OSHA. I think the general view, which I support, has to do with the cultural issues, the language issues, the training issues, all of those issues go into having essentially a person who may be doing fairly hazardous work who isn’t prepared to do that work.

There may be some issues related to culture where that worker may be less likely to complain, to speak up due to economic issues, cultural issues…to ask to complain, to say that’s too dangerous. To say, how do I do that better? So there may be a lot of issues there.

Certainly those issues have grown more serious as the economy has gotten worse. So I think…we put a lot of attention on that issue starting in the 1990s and all the way through the 2000s. And I think it’s borne some positive impact, but certainly a lot of work needs to be done in that area, especially as the economy doesn’t improve. Because people are very reluctant to speak up on safety and health issues when there is a 9.2% unemployment rate, and in California a 12.2% unemployment rate. It is just very difficult to speak up these days.

 

If you could change anything about Cal/OSHA, what would it be?

            a. Should enforcement be increased?

            b. Communications

            c. Training for inspectors

One of the three things I thought would be important to happen, during Len Welsh’s tenure did happen. Cal/OSHA got pretty much off the general fund and onto a special fund because that gives it a little more funding stability.

The general fund is probably the most precarious kind of funding California has. So that was accomplished. It was great.

The second was the rate of serious, which was always a thorny issue when California compared itself to the federal OSHA system. And of course, the issue with the Appeals Board and how they interpreted the serious versus the Cal/OSHA enforcement.

That second issue during Len Welsh’s time was helped by the Assembly bill and the third issue, of course, is extremely important. It has grown in influence, and that is the collaboration between [the] Consultation Service and the comp loss control consultants and the employer.

Again bridging back to that statement I made about the workers’ comp system being a different kettle of fish, I think bringing in the Consultation Service in close proximity to the other consultants, chiefly the employers’ workers’ comp’ work insurer loss control specialist, I think is a real positive development. We started that and I would certainly like to see that increase.

I guess the fourth issue is in an idealized system you would want Cal/OSHA system in general to be able to hire more folks.

There is a critical mass that’s extremely important to make an impact whether you’re on the inspectorate side or on the consultation side. To make an impact in a regional area of California whether it’s construction, manufacturing, agriculture, whatever it is, to make an impact, to change employer attitudes.

Employers that are in that category where they don’t pay too much attention to Cal/OSHA stuff. You really have to be seen. Employers have to hear, “Oh, Cal/OSHA was at our place the other day.”

You have to have that intensity of impact. And that can only come from people. That’s I think is the fourth idealized thing.

I divided California employers into five categories. There are the industry leaders. They go way beyond what any government standard offers. Then there are the spontaneous compliers. They are always interested in what Cal/OSHA is doing. They follow “Cal-OSHA Reporter,” the workers’ comp advisor, they are involved and just spontaneously complying with the reg. Then there is the hesitant complier, you know, you have to talk them into it. That is the big, big group. And I think that is where people can have the impact and the most impact.

Then you have the inhabitants of the parallel universe that think Cal/OSHA is a town in Wisconsin or something. They don’t know what is going on. That kind of employer needs that personal impact of hearing about an inspector coming.

Then the fifth group is the hostile people. They know about Cal/OSHA and they are actively hostile. These are the employers that civil penalties and inspections don’t influence. Then you really have to have criminal sanctions.

I think those two fundamental groups, the hesitant compliers and the residents of a parallel universe, those two groups I think really benefit from having that personal impact.

 

 

Some observers say injury and illness rates are higher than they appear because employers find ways to hide injuries, or not record them. Do you agree this is a serious problem and if so, how should it be addressed?

Our system is the honor system. It relies on employers and workers to participate according to the rules. It is hard to know exactly…if everyone is doing that. It would cost a lot of money, a lot of personnel, a lot of resources to have another kind of system. So even to verify a percentage of that. Cal/OSHA even does that on an inspection to log. But to go back to source documents is a labor intensive and fiscal intensive activity.

 

 

California  has a long history of crafting groundbreaking regulations that the rest of the country eventually picks up. What's the next one?

I don’t have a crystal ball to predict what issues Cal/OSHA is going to tackle from a standards side. A couple observations. This is the 20th anniversary of the 3203 regulations, the Injury and Illness Prevention Program. In July of 1991 is when 3203 came. And now federal OSHA is considering a similar kind of thing. That is a great testament. California excels above all other programs, above all state programs, the federal program, at doing standards. There is no question about that. The Injury and Illness Prevention Program, the Aerosol Transmissible Disease Standards. All of those are great accomplishments. In terms of the future, the one that I would, we started, and I followed it, is the issue of sensitization of certain people biologically responsive to very, very low levels of a chemical. They are sensitized to either a chemical agent [or a] biological agent. That is a very difficult area and it gets us into that whole area of occupational genetics. And how we protect those people. So to me that is kind of a frontier. I don’t think Cal/OSHA is even there yet. I think they’ve had some meetings. But that’s a real frontier area.

 

Will AB 2774 resolve the problems cited by DOSH on serious violations and provide a more equitable appeals system? If not, how should it be reformed?

It certainly may be possible. I don’t know. But the issue of the Cal/OSHA appeals system is something that is long overdue. The system benefits from lots of people looking at its efficiency, looking at what can make it better. When the Legislature increased the amount for penalty violations from $7,000 to $25,000, there was a multifold increase in appeals within a year or two. And it really has been a serious issue since then. It really is a system that didn’t adapt to that. The system was designed originally to be very user friendly. The employer didn’t need a lawyer to represent them. All of those issues need to be revisited. The judges writing 3-, 4-, 5-, 15- or 20-page opinions over a couple citations. All of those issues, and there are many more than the few I cited, need to be looked at from an adjudicative efficiency system. Is this the best way to adjudicate? Now the Appeals Board has a lot of progress in this area. They have instituted a lot of efficiency measures and they need to be congratulated about that. But I do think a lot more needs to be done on that system.

 

Should DOSH approach enforcement with more of an eye toward achieving compliance, rather than looking for violations to cite? And if so, would such an approach work?

I’m not so sure, because to me the two are the same. Writing a citation for not complying with a regulation or a standard that the law says you have to comply with are the same thing. The citation system has been around for a long time. Joe Deer, who was the assistant secretary for OSHA in the early 90s, actually suggested that it be changed so the inspector point out the violation so the second time, you know, you would get a citation. That wasn’t popular with either lawyers or worker advocates. So I am not so sure about that. So I think a lot more discussion needs to happen on that issue.

 

What should Cal/OSHA do to help small employers create safe workplaces and comply with Title 8 regulations?

This is the same issue of people, of the impact of people, of consultants. The small employer is difficult to find sometimes, difficult to work if you’re working with that employer because they have no internal resources. It really is a very resource intense activity. It is one we have been struggling with for years on a state and federal level. But for me that personal impact issue comes again there. You really have to have enough people to be able to impact the small employer community. While 88% of California employers have less than 10 employees. So it is a huge number of employers.

 

 

What about safety do employers struggle with the most?
I’m not sure I’m the best one to ask that question. In conversations with employers and folks who do safety and health for employers, certainly the issue of, not identifying the hazard, but how do you fix it at the lowest possible cost? And how do you make the argument to an employer when you as a consultant realize there is a problem and it may not be obvious to the employer? How do you make that argument? And how do you win the cost-effective argument? The employer has a lot of other places to put money, and you have to be able to demonstrate, well, if you give it to me to fix this health or safety problem, here’s what I’m going to be able to do for you. I will be able to prevent this or that injury. Making that business case to the employer, again, is something we have to expand in our scope of practice. A lot of consultants do that now. And they do it very, very well, but it is always a struggle.

 

Are there reliable and knowledgeable training people available?

There are a lot of terrific trainers in the private sector, people who do great work with Hispanics, Latinos, non-native-speaking workers. There are some great trainers out there. I think it is not necessarily the role of government to do that. So I think that is a private-sector issue.

On the government side there is the OSHA Training Institute, which helps professionals, safety and health people keep up to date. But the worker training issue, I think there are a lot of great people out there. The question I think for us in the next five or 10 years is how do you do that most effectively. You know we’re used to there being a teacher in the front of the classroom and they talked and maybe they showed some pictures. There were some slides. So sitting in a classroom may not be the best way to engage people. Having them do it on a computer may be the best way. For literacy-challenged folks, maybe doing pictographs instead of text. You know, there are a lot of issues related to worker training that I think are very interesting and ones that I know at NIOSH we’re trying to figure out how do you really reach people? How do you engage them? There are a lot of studies showing after 15 or 20 minutes people’s concentration disappears. So how do you package the training in short spurts so it’s effective? There are a lot of great trainers in California right now investigating that.

 

What kind of training is the most crucial for employers to provide?

I think, to me, what’s crucial for the employer to provide is what’s unique about my workplace. What’s unique about my work? You can get general training about a lot of things. You can read a book or take a class. But especially when you have huge number of contract employees who go from workplace to workplace, or you have an industry like construction where things are a little different in every workplace. What are the specific hazards? I think the employer training on that issue is the most crucial.

 

What else do you read to get your occupational safety and health information?

I read all the trade journals. I read more academic journals on safety and health. The trade journals you can get the most bang for the buck because you can sit down at an airport and have 10 or 15 minutes and thumb through a trade journal and find out what’s knew, or read an article that won’t take you that long on safety training.

I think the trade press in occupational health and safety does a great job. Some of the more academic journals, scientific publications, take longer to read and investment in time.

 

How did you get started in safety? Was there any particular experience in your career that triggered your interest in safety? What’s interesting about it? What’s interesting about it now?

I started in clinical medicine and I was a specialist in lung diseases at UCLA. I worked in the pulmonary department. We saw a lot of folks with end-stage lung disease that [was the] result of asbestos exposure or other occupational exposures. I became interested in understanding those diseases because they were often extremely difficult to treat, let alone cure. The only way to eliminate them would have been to prevent [them] in the first place. That’s how I got interested in preventive medicine, which occupational medicine is a branch of.

 

What’s interesting about it now?

I think it is a real exciting field because every time you turn around there is someone telling you let’s do it a little differently. I just found this new hazard that didn’t exist before. For instance, the popcorn lung with diacetyl. We’ve been looking at indium tin oxide, which is used in the flat-screen TVs, causing a lung disease called alveolar proteinosis. You just don’t know; it is always a changing field and it is a challenge to keep up.

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