Evaluating work relatedness of byssinosis for worker compensation purposes.

T here is a provision in each state Workers’ Compensation law that should be designated as the “catch22” section. It is the provision which imposes on the claimant the burden of proving that his disability arose out of his employment. Offhand, this seems a reasonable requirement. Surely a worker whose disability was not caused by conditions on the job should not receive worker compensation benefits. Yet, when this apparently reasonable requirement is put into practice, it leads to a nightmare of frustration. This requirement is the major reason why some 19 out of every 20 severely disabled victims of occupational disease in the U.S. are not receiving worker compensation benefits. It is also the reason why 99 out of every 100 disabled byssinotic subjects have not received worker compensation benefits.2 Why is this provision so frustrating? Because it demands that medical science do something which it lacks the capability of doing, ie, to discriminate between lung diseases that are occupational and those that are nonoccupational in origin.3 The fact is that the symptoms of occupational diseases are generally the same as those of diseases caused by nonoccupational factors. A chronically disabled victim of byssinosis will have the same breathing difficulties as a person who has not been exposed to cotton dust, but who has asthma, chronic bronchitis or emphysema. The respiratory system of both will look the same on x-ray film and they will perform the same way on pulmonary function tests. Medical science has no reliable means of distinguishing these two persons. It is no wonder that contradictory medical testimony is so often offered by the claimant and the defendant in a contested worker compensation case. Doctors can generally be found to testify that the condition of the claimant could have arisen from working conditions or from other conditions. This is the heart of the “catch-22” situation confronting textile workers disabled by byssinosis. It is the principal reason they have to wait two years or more and go through multiple medical examinations before their claims can be determined, and it is the reason so many byssinosis victims have felt compelled to accept insurance company offers averaging less than one-quarter of the wage-loss they suffered.2 This inequitable system must be changed. The failure of state workers’ compensation agencies to provide prompt and adequate benefits to disabled workers causes severe hardship to the victims and shifts the cost of necessary income maintenance from the employers to the federal taxpayers (primarily through the Social Security disability program). The work-relatedness issue can be dealt with rationally by establishing presumptive criteria for determining whether a worker’s claim for total, permanent disability is likely to be work-related. In the cotton textile industry, where epidemiologic and laboratory evidence clearly links dust exposure with the development of disabling lung disease, it is appropriate for presumptive criteria to be applied. Bouhuys recommended the following criteria: 1. The worker has worked in a job in which exposure to cotton dust occurred. 2.The results of the worker’s lung function test indicate a pulmonary function less than 50 percent of normal (based on forced expiratory volume after 1 second). 3. The worker’s low pulmonary function cannot be improved materially by bronchodilator drugs. 4. There is no positive evidence of other more important causes of lung function loss. Application of these criteria to establish a rebuttable presumption that the claimant is entitled to Workers’ Compensation for total disability would put an end to the abuses prevalent under present law. It would no longer be necessary for the claimant to prove something that medical science does not have the capability to prove. The only role for medical evidence under this proposal would be to seek to establish whether a worker’s disability was caused by conditions other than the worker’s on-the-job exposures. Doctors employed by companies and the insurance industry frequently claim that smoking contributes more to textile workers’ disabilities than does exposure to cotton dust. This view is contradicted by the studies conducted by independent scientists such as Bouhuys et al , Merchants and Beck. Bouhuys et al found that “recent epidemiologic studies. . . . support the view that one should not assign any overriding role to the effects of smoking in judging the causative factors in the chronic lung diseases of cotton textile workers Both among non-smokers and among ex-smokers and current smokers, the prevalence of disabling function loss is close to three times higher than among community residents of the same age.” The data of Bouhuys et al on the dose-response relationship between smoking and lung function loss indicate that for a typical worker who fulfills the above criteria for disability compensation, only 25 percent of the lung function loss might be attributed to the effect of smoking. Merchant6 has concluded, on the basis of a review of extensive epidemiologic and laboratory studies conducted among cotton textile workers, that “the current data available indicate that the amount of respiratory disease is caused at least as much and in most cases more by the cotton dust exposure than by cigarette smoking.” In view of the clear evidence that “the effect of smoking is likely to be a minor component of the irreversible