Mr. GORE. Thank you very much.

I recognize the difficulty of these issues and I appreciate your sensitivity to them.

Dr. Stellman, we are particularly pleased to have you with us during a time of some trouble and recognizing that some of your thoughts are elsewhere, we are particularly grateful for your willingness to come and help us with these issues because we did not think we could do it without your presence here.

We thank you for being here and invite you to proceed.

Dr. STELLMAN. I have to apologize for no written testimony. It has been impossible to do it.

I would like to make an attempt at joining the women's issue with the broader issue of the theories of susceptible workers and even to broaden it out a bit from the question of genetics and to talk about what I see as the coming trend and that is consideration of the workers as the susceptible worker.

I believe the women's issue places the reasoning that is behind the susceptible worker theories in as clear a context as we can hope to have. As you yourself pointed out, we wear our X and Y chromosomes on our sleeve and it becomes a more easy matter to understand the reasoning behind these policies.

The assumption that it is legitimate to exclude women from certain workplaces is based on several generalizations that I think it pays to take a few minutes to review.

The first is, as Joan Bertin pointed out, is the assumption women are permanently pregnant until proven otherwise and the fact that one is fertile places one in the at-risk category.

In fact, pregnancies in the United States are planned. You have three fertile women sitting in front of you, none of whom is pregnant and none of whom plans to be. In fact, the current population study surveys in June 1977 place child-bearing expectations of women between the ages of 30 to 39, who are in blue-collar socioeconomic status, as approximately 1 percent.

In fact, the major unplanned pregnancies in our society are among teenage girls, not among women, and they are not the people whom we are discussing.

What does this show, this generalization about all fertile women being permanently pregnant as a class? It shows the application to a broad population of a narrow theory. I think that is the first principle of the susceptible worker that the case of women repre

sents.

Also, when we target in on women as a class, we are particularly forgetting about men and I don't assume it is news in the Halls of Congress that it takes a male and a female to reproduce.

Unfortunately, the policies of exclusion of women remove the responsibility for paternity from the males and, in fact, overlook the burden of science which shows that the males are indeed vulnerable, as Velma has pointed out.

I almost look at our scientific beliefs as a direct reflection on social beliefs in which sperm are cast into the aura of being invulnerable and, in fact, we anthromorphize the entire reproductive process when we picture poor helpless female ova waiting to be fertilized by the most strong and the most masculine of the sperm and that is the comment theory that applies in almost all reproduc

tive texts in which it says only the strongest of the sperm can make it to the position of fertilizing the ova.

This is ridiculous. First, I think it pays to realize some of those sperm are little girl sperm because, in fact, it is the male who determines the sex, so half of them are female and half of them are male.

This kind of anthromorphization of the whole process has pushed its way not only into employment practices, but into the biology we teach our medical students and scientists.

We know it is not true. We know that, in fact, ionizing radiation has a greater effect on the male than on the female and we know weakened sperm can indeed fertilize ova and result in stunted growths or birth defects or infertility.

We know cigarette smoke affects males. We know now that appropriate genetic testing is available that Down's syndrome, which had previously been attributed to tired, old ovaries, is onethird attributable to paternity.

So exclusion of women is attacking only a part of the problem if reproductive health is really the issue at question. If reproductive health is really the basis of the screening out of women workers who are fertile, then we are only attacking a very small part of the problem and I think an examination of some of the chemicals that have been the basis of this screening process is very useful for illustrating this.

I would like to focus on one in particular and that is methotrexate. We have both spoken about people in the health care industry, which is the largest employer in the United States today and major industry in the United States today and methotrexate is a very commonly used chemotherapeutic agent for the treatment of cancer patients and women have been banned, excluded from the production of methotrexate.

Now, the qualities of chemotherapeutic agents are they have a profound effect on the cellular biology, in particular the genes and the DNA and chromosomes.

There is no evidence at all to assume that the males are not affected by methotrexate. Yet, it is the females who are excluded. There clearly is an effect of methotrexate during pregnancy but for the nonpregnant worker, there is no evidence at all that one sex would be more affected than the other.

Yet, women have, by employment policy by a large company, been excluded from the manufacture of methotrexate. This illustrates to me very profoundly the whole application of the susceptibility theories to the selectivity of choosing who you are going to target and when, and not only are males and nonfertile females not allowed to remain in the manufacture of methotrexate, but females are the people who deliver the methotrexate to the patients on the floors, and there have been five studies on the effect of chemotherapeutics on the nurses who deliver these.

They have shown genetic changes of mutagens in the urine, so this, to me, is a quintessential example of how one chooses one's tests when it is economically and socially warranted.

One can easily exclude women from a manufacturing process, but one cannot exclude women from nursing. We would have to

shut down the health care system. The selectivity of the target group is, to me, a major danger of all susceptibility theories.

It is right in line with the history of the protectionism of the woman worker. From the outset, protective legislation has always protected women out of the good jobs and left them unprotected in the areas where they needed the protection most.

In California State, protective legislation always excluded women from overtime during the canning season. Weight-lifting laws have never applied to waitresses or nurses. Hours of work have never applied-night work laws have never applied to those areas where women were required to work at night for the good of the industry, so the selectivity of protection is another very key target that one must examine in dealing with all susceptibility theories.

I propose that most of them miss the preponderance of risk that workers take in simply seeking to eliminate the risks of having a worker around that one might have to protect for or having to put some extra money into a process to afford the best protection for all.

If we turn to the area of genetics and leave the issue of fertile versus nonfertile, the medical basis of selection of workers is more difficult to understand and it is not clear to me the extent to which any particular test is used at present in industry.

It is not clear to me which companies are doing what to whom. What is clear to me, rather than the debate over a G-6-PD or antitrypsin is that the trend is there.

The American Occupational Medicine Association, in its Denver meeting several years ago, devoted its entire meeting to the susceptible worker.

I see Velma is chairing a session at a major conference sponsored by the American Council of Government Industrial Hygienists in Arizona Occupational Center of Safety and Health on the susceptible worker.

This is to me a frightening portend of where we are going. Last month's Journal of Occupational Medicine ran an article and article response on employment and preemployment screening. It is very unusual for that journal to write an article and an article response, to publish it in that way. It is the major area of debate.

Several months ago, the American Industrial Hygiene Association published an article by a company in Wyandotte, Mich., which they explicitly laid out their methods for screening out susceptible workers.

I understand from talking with the company, more than 100 other companies have sent for reprints. It is not clear what the extent of the testing is and certainly the company responses will be different.

It is not a monolithic industrial world. Some companies are far more responsible than others. I think the trend is one that must be examined very closely.

I took the time to just pull out-I am not going to read through all these papers-but I took the time to pull out a few papers on alpha-1-antitrypsin which is an enzyme marker that is thought to be related to the predisposition for development of bronchitis and on the pulmonary diseases.

In the early 1970's, several studies were carried on on coke oven workers, which is an egregious thing to do and deserves comment because if there is one occupation in which everyone will agree workers are at extreme risk, it is working in a coke oven and there is no argument on any side of the issue that coke ovens represent cancer risks and chronic bronchitis risk and that is well known and agreed upon.

Yet, in the early 1970's, papers started appearing that were based on surveys conducted to assess the contribution of cigarette smoking, occupational and genetic factors in the development of industrial bronchitis. The Mittman group, in particular, in California, did several studies and are still doing studies on looking at particular susceptibilities.

They say that work, smoking, and family history accounted for 40 percent of the variability in the severity of symptoms among men with chronic bronchitis.

That leaves 60 percent unaccounted for and these findings suggest that the work group is composed of men with a range of susceptibility to development of bronchitis.

At least part of this variability is genetically determined. If susceptible subjects can be identified during preemployment screening and are effectively excluded from hazardous occupations, some case of chronic bronchitis may be prevented.

I would like to call your attention to the data itself in which the genetic screening tests were found not to be strictly significant and where, in fact, it was work and large amounts of cigarette smoking that accounted for almost all of the identifiable disease.

The emphasis on family history is another one that must be approached extremely carefully. Virtually every one of our OSHA standards, of the few that exist, calls for a medical screening that includes the family history.

It does not take a sociologist to know that the parents of coke oven workers were probably not surgeons and corporate executives, but were probably coke oven workers or similar people themselves. Family history, which do not take into account the exposures of the family, will lead us down another primrose path of dalliance toward selecting out workers on a prejudicial basis based on their socioeconomic status.

We have to find out who people's parents are and what they did if we are going to include them in the occupational history. I pulled out three very recent papers on alpha-1-antitrypsin, one on elastic recoil in the lungs, which is related to the development of chronic obstructive disease, and they clearly find that there is no relationship.

It is concluded that in a major working population, evidence of diminished pulmonary elastic recoil is not a function of AAT concentration. În Yugoslavia, 3,000 men in an industrial and mining center were screened specifically and out of that, 26 men were found to have the phenotype and the bulk of the work precludeswhile there is a very high incident of chronic obstructive pulmonary disease in this town, the low prevalence of the pi Z gene, it does not appear to account for much of the high rate of chronic obstructive pulmonary disease found in this population.

A similar community study of the relation of alpha-1-antitrypsin levels to obstructive lung disease in Arizona found that the data "militate strongly against the use of any quantitative determination of alpha-1-antitrypsin as a test to identify subjects with moderate deficiency for the purpose of predicting later development of chronic respiratory disorders."

I point these out because they are indirect contrast to what continues to be published in the peer review literature where, without any hesitation, quotes such as by a group at Johns Hopkins the association between very low concentrations of serum alpha-1-antitrypsin and the development of pulmonary emphysema has been well-documented through epidemiologic, clinical, and laboratory investigations.

The list of such references is continual and, in fact, the articles that have been published on preemployment placement rely heavily on this background work.

Reliance on these studies, which make their way into the literature, can lead us into the development of policies which are grossly contrary to the public health history of our country and to the, I think, the law of our country.

I think I would like to just turn the argument to the whole public health prospective since I am now an associate professor of public health and to ask several questions that are very much related to the questions that you have raised.

First, the hallmark of a screening test of any selection process depends on the test, A, being specific, and B, having high degree of efficacy in detecting the event that it is looking for.

There is no evidence at all that these tests are predictive, just as fertility is not predictive of child-bearing.

These tests do not protect all workers. Their level of detection is very poor; just as selecting and excluding fertile women leaves unprotected the men and the nonfertile women left on the job. If we turn aside from the discussion of how much variability you can explain, I think the most important thing to look at in the whole emphasis of the susceptible worker is to understand that it turns public health policy on its head.

If we look at infectious disease as the clearest example of how science and public health has approached a disease process, we can see clearly how public health is turned on its head.

Infectious disease is based on an agent infecting a host, resulting in a disease and at no time has there ever been a concentration on the host and I just pulled out of the literature the actual incidences of both measles and polio, to which we in the United States have devoted a great deal of effort in eradicating.

In 1950, there were only 33,000 cases of polio in the United States. That, in terms of the population in the United States, is not a huge number of cases. Yet, we unstintingly went ahead and poured millions of dollars and a great deal of thought and effort into polio.

Certainly as a child who grew up before the vaccine was available, I am clearly in favor of eliminating this great fear that parents had for their children. Yet 33,000 people in the context of our society is not a great deal of people and at no time was there an effort made to say, what made those 33,000 people different so that