3
Occupational Safety and Health Regulation in Context

The creation of safer workplaces and the reduction in the number of occupational injuries, diseases, and deaths have been counted among the 10 leading public health achievements of the last century (CDC, 1999a,d). Safer workplaces are the cumulative result of many changes involving social attitudes and expectations, economic development, class and power relationships, science and technology, information resources and analytic capacities, government policies, and more.

This chapter focuses on government regulatory policy and the legal context within which the Occupational Safety and Health Administration (OSHA) has operated in developing the 1997 proposed rule on occupational tuberculosis. (See also Appendix E.) Understanding this context helps in understanding some of the differences between the proposed rule and the 1994 guidelines of the Centers for Disease Control and Prevention (CDC). First, however, it is useful to consider briefly the strategies available to workers seeking safer workplaces.

STRATEGIES FOR REDUCING WORKPLACE HAZARDS

Governmental regulation of workplace hazards is one of several possible strategies for workers seeking protection from unsafe working conditions. One way of categorizing these strategies is shown in Table 3–1, which distinguishes public versus private strategies and individual versus collective options. Each strategy has its strengths and limitations. These may vary depending on the kinds of workers and workplace hazards involved and on the economic environment, including the level of unemployment (Mendeloff, 1978, 1988; Robinson, 1991).



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Tuberculosis in the Workplace 3 Occupational Safety and Health Regulation in Context The creation of safer workplaces and the reduction in the number of occupational injuries, diseases, and deaths have been counted among the 10 leading public health achievements of the last century (CDC, 1999a,d). Safer workplaces are the cumulative result of many changes involving social attitudes and expectations, economic development, class and power relationships, science and technology, information resources and analytic capacities, government policies, and more. This chapter focuses on government regulatory policy and the legal context within which the Occupational Safety and Health Administration (OSHA) has operated in developing the 1997 proposed rule on occupational tuberculosis. (See also Appendix E.) Understanding this context helps in understanding some of the differences between the proposed rule and the 1994 guidelines of the Centers for Disease Control and Prevention (CDC). First, however, it is useful to consider briefly the strategies available to workers seeking safer workplaces. STRATEGIES FOR REDUCING WORKPLACE HAZARDS Governmental regulation of workplace hazards is one of several possible strategies for workers seeking protection from unsafe working conditions. One way of categorizing these strategies is shown in Table 3–1, which distinguishes public versus private strategies and individual versus collective options. Each strategy has its strengths and limitations. These may vary depending on the kinds of workers and workplace hazards involved and on the economic environment, including the level of unemployment (Mendeloff, 1978, 1988; Robinson, 1991).

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Tuberculosis in the Workplace TABLE 3-1. Worker Strategies to Control Workplace Hazards Strategy Type Individual Collective Private I. Quitting hazardous jobs; searching for jobs in safe workplaces III. Joining labor unions; bargaining with employers for safe working conditions Public II. Suing in court for individual rights to information about hazards, to refuse hazardous assignments, and to report hazards without reprisal IV. Organizing to secure government action to prevent or reduce health and safety hazards in the workplace SOURCE: Adapted from Robinson (1991). People quit jobs (Option I) for many reasons under many different circumstances. In theory, if employers perceive that employee departures are motivated by safety concerns and if they find hiring new workers troublesome, they may be motivated to improve working conditions. As a workplace-change strategy, the quitting option has serious limitations. In particular, workers with low levels of education and skills, who are often found in the most hazardous jobs, may lack better alternatives and, possibly, a real understanding of the risks that they face. Such individual workers are also not well prepared to challenge employers’ unsafe working conditions in court (Option II).1 Unions and collective bargaining (Option III) have given workers a more powerful voice to influence employers and improve working conditions. The priorities in collective bargaining, however, generally involve wages, benefits, and job security. These objectives are relatively easy to understand, measure, and assess if achieved. They also generally affect union members across a wide range of job circumstances. In contrast, unsafe working conditions may be less visible and may affect a smaller proportion of a union’s members. Unions do negotiate with employers over issues such as hazard pay, provision of protective equipment, safety training, and reduction or elimination of workplace hazards. They have, however, cited lack of technical capacity to analyze health and safety problems and evaluate possible remedies for these problems as a barrier to the use of collective bargaining to negotiate workplace safety issues (Mendeloff, 1978). Lack of technical capacity and other resources may also constrain union use of litigation as a strategy to improve workplace conditions.

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Tuberculosis in the Workplace Furthermore, the winning of worker protections on a company-by-company or industry-by-industry basis is a formidable challenge. Therefore, workers have often sought government—especially federal government—protections (Option IV), including protection for the very right to organize workers and bargain collectively. Regulatory strategies usually put the main burden of identifying and analyzing hazards and remedies on government officials rather than on workers. Regulatory strategies to improve workplace safety and health have their own limitations. Some regulations face little resistance from those who are regulated; others are highly unpopular and provoke years of litigation. Policymakers are frequently challenged for not adequately weighing the expected benefits of regulation against the expected costs. Some regulations are relatively inexpensive and technically easy to implement, monitor, and enforce, but others are not. In any case, implementation of regulations as intended cannot be assumed. The above discussion emphasizes strategies available to workers. Even when they are not actively sought by workers, employers, government officials, and others may take steps on their own initiative to identify and correct workplace hazards. For example, employers may easily become aware of real or potential hazards before workers recognize them and may take steps to reduce the hazard (and the liability that might result). Public health and other researchers may likewise identify hazards that affect both workers and members of the general community. They may then seek to publicize the hazards and find ways to eliminate or reduce them through voluntary action, scientific discovery, or technological innovation. THE OCCUPATIONAL SAFETY AND HEALTH ACT OF 1970 AND ITS ADMINISTRATION The first federal agency that focused on workplace safety was the U.S. Bureau of Mines, established in 1910 (CDC, 1999d). Its creation followed increasing attention to deaths in the workplace. For example, in 1906– 1907, the first systematic survey of workplace accidents was undertaken in Allegheny County, Pennsylvania. It counted 526 deaths from such accidents in the county, including 195 among steelworkers. Until 1970, states had the primary responsibility for regulating workplace conditions. The first state laws on worker safety date to 1837, and a few states had created inspection programs and started collecting injury and illness data before 1900 (OSHSPA, 1999). As they developed, state programs tended to rely more on education and consultation with employers rather than on formal enforcement of regulations backed by fines for employer violations (Mendeloff, 1978). Not surprisingly, state laws and activities that regulate workplace health and safety were—and are—highly variable. Today, for example,

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Tuberculosis in the Workplace states can choose to develop and adopt their own plans under the Occupational Safety and Health Act, and about half have chosen to do so (see below). If states choose not to develop such plans, federal occupational safety and health rules—including rules intended to protect workers from tuberculosis—will not apply to state and local government employees. Whether or not they choose to develop state plans, states may innovate in areas not covered by federal regulations. For example, some states adopted so-called worker right-to-know laws before federal regulators first adopted a hazard communication standard in 1983 that applied to those working with hazardous chemicals (OSHSPA, 1999). Creation of OSHA The 1960s saw a broad expansion of the powers of the federal government in many areas such as civil rights, education, health, social welfare, and knowledge development. Toward the end of the decade, serious efforts began to secure federal regulation of workplace health and safety. In 1969, the U.S. Congress passed the Federal Coal Mine Health and Safety Act, which set health and safety standards for all mines and expanded the powers of federal mine inspectors (CDC, 1999d). The next year, Congress passed the Occupational Safety and Health Act (P.L. 91–596). As summarized at the beginning of the statute, the purpose of the legislation was to assure safe and healthful working conditions for working men and women by authorizing enforcement of the standards developed under the Act; by assisting and encouraging the States in their efforts to assure safe and healthful working conditions; by providing for research, information, education, and training in the field of occupational safety and health; and for other purposes. The 1970 legislation created OSHA and assigned it responsibility for standard setting and enforcement. The statute also created the National Institute for Occupational Safety and Health (NIOSH), which undertakes training activities, makes recommendations to OSHA relating to health and safety standards, and supports epidemiologic, toxicologic, and other research on workplace hazards. NIOSH certifies personal respiratory protection devices for a wide range of workplace uses. OSHA is part of the U.S. Department of Labor (DOL), whereas NIOSH is part of CDC in the U.S. Department of Health and Human Services (DHHS). The statute created two additional bodies. One is the National Advisory Committee on Occupational Safety and Health, which advises both DOL and DHHS on the feasibility of and alternatives to new standards.

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Tuberculosis in the Workplace The second is the quasijudicial Occupational Safety and Health Review Commission, which adjudicates citations and penalties. Decisions by this commission may be appealed to the federal courts. Rules may also be challenged in federal court on a “preenforcement basis” within 59 days of their publication in final form. A third body, the Federal Advisory Council on Occupational Safety and Health, which advises the Secretary of Labor on occupational safety and health issues involving federal agencies, was created by the Executive Order 11612 in 1974. OSHA standards are predictably challenged in court both before and after enforcement. As discussed below and in Appendix E, several U.S. Supreme Court decisions have shaped how the agency does its work and justifies its proposals and policies. For most of its 30 years, OSHA has survived amidst continued discussion about its basic premises (see, e.g., Page and O’Brien [1973], Mendeloff [1978, 1988], McCaffrey [1982], Mintz [1984], Robinson [1991], and Reich [1994]). Proposals are periodically introduced in Congress to curb or abolish the agency. In the 1980s, the Reagan administration trimmed federal regulation in many areas by means of executive orders and cuts in agency budgets including those of OSHA and NIOSH (Mendeloff, 1988; Robinson, 1991). In the 1990s, the Clinton administration issued Executive Order 12866, which requires more agency analyses of the costs relative to the benefits of regulations. Appendix E describes in more detail the key provisions of the OSHA statute and relevant executive orders and judicial decisions. The rest of this section provides a brief overview of OSHA’s goals, the criteria that it uses in devising health and safety regulations, and the scope of its rules. Goals and Criteria for OSHA Standards The fundamental goal of the Occupational Safety and Health Act is “to assure so far as possible every working man and woman in the Nation safe and healthful working conditions” (29 USC 651 2[a]). The statute’s general-duty clause provides that employers are to (1) furnish their employees work and a workplace that is free from recognized hazards that are likely to cause serious physical harm or death and (2) comply with safety and health standards set forth under the act. The statute also provides that employees are to comply with applicable safety and health standards. In practice, this provision has little meaning. OSHA may not fine employees or otherwise punish them for failure to adhere to standards.2 2   The agency may require employers to ensure certain actions by employees (e.g., use of personal respirators under certain circumstances). It cannot, however, hold an employer strictly liable for employee noncompliance if the employer has taken reasonable measures to train, monitor, and otherwise supervise employees. (984 F.2d 823).

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Tuberculosis in the Workplace OSHA’s current regulations and enforcement actions to prevent the spread of tuberculosis are based on the statute’s general-duty clause and on general standards involving respiratory protection (29 CFR 1910.134) and warnings of biological hazards (29 CFR 1910.145).3 The 1997 proposed rule is based on separate provisions of the 1970 statute that authorize OSHA to issue mandatory occupational safety and health standards applicable to specific industries or hazards. When OSHA creates a health standard, it must set the standard to “most adequately” ensure “to the extent feasible, on the basis of the best available evidence, that no employee will suffer material impairment of health or functional capacity even if such employee has regular exposure to the hazard dealt with by such standard for the period of his working life” (29 U.S.C. 655). The same paragraph of the statute also calls for “the attainment of the highest degree of health and safety protection for the employee.” It provides, however, for “other considerations” to be taken into account, including the “latest available scientific data in the field, the feasibility of the standards, and experience under this and other health and safety laws.” Whenever practicable, standards are to be stated in terms of objective criteria. Reflecting its interpretation of its statute, case law, and executive orders, OSHA has described a workplace standard as “reasonably necessary or appropriate if it substantially reduces or eliminates significant risk and if it is economically feasible, technologically feasible, cost effective, consistent with prior Agency action…supported by substantial evidence.” (62 FR 201 at 54169, October 17, 1997). Box 3-1 lists OSHA’s interpretation of several of these phrases. Significant Health Risk In discussing what constitutes a significant health risk, OSHA has described such a risk as one that exposes a worker to a risk of death of 1/1,000 over a 45-year working lifetime. This criterion derives from the plurality statement of the U.S. Supreme Court that indicated that OSHA could regulate only a “significant risk” and that it is reasonable and acceptable for OSHA to regulate on the basis of odds of 1 in 1,000 that a practice or situation will prove fatal (448 U.S. 607 at 655). The ruling, which involved a standard on benzene, required that OSHA justify its rules with quantitative risk assessments. The decision, however, stated 3   The most recent OSHA standard on personal respiratory protection, which was issued in 1998, does not apply to tuberculosis (29 CFR 1910.134). The agency, which had published the proposed rule on occupational tuberculosis in 1997, instead provided a separate interim regulation (29 CFR 1910.139). The interim regulation describes the provisions of the 1987 respiratory protection standard that apply until a tuberculosis standard is published.

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Tuberculosis in the Workplace Box 3-1 Key Terms Relevant to Justification of OSHA Standards as Used by the Agency Significant risk: “generally…at a minimum, a fatality risk of 1/1,000 over a 45-year working lifetime…[is] a significant health risk.” Substantially reduce risk: No explicit definition found. Material impairment: No explicit definition found. Economically feasible: “A standard is economically feasible if industry can absorb or pass on the costs of compliance without threatening its long-term profitability or competitive structure.” Technologically feasible: “A standard is technologically feasible if the protective measures it requires already exists, can be brought into existence with available technology, or can be created with technology that can reasonably be expected to be developed.” Cost-effective: Within the context of the OSHA statute and applicable judicial decisions, the cost-effectiveness of required protective measures is narrowly defined in terms of “the least costly of the available alternatives that achieve the same level of protection.” Substantial evidence: No explicit definition found. “Scientific certainty” is not required; rather, actions need only be supported by a “body of reputable scientific thought.” SOURCE: 62 FR 201 at 54169 (1997) that the risk determination was not to be a “mathematical straightjacket” nor did it require “anything approaching scientific certainty” (448 U.S. 607 at 655). The ruling also noted that “safe” was not the equivalent of “risk-free.” In the 1997 proposed rule on tuberculosis, OSHA defines infection with M. tuberculosis as a material impairment of health and applies the 1/1,000 risk criterion to the risk of infection rather than the risk of death. Substantially Reduce Risk The committee found no quantitative guidance in case law or elsewhere about what constitutes a substantial reduction in a significant risk. In the benzene case, the court stated that evidence should indicate that it is “more likely than not” that a rule will eliminate or reduce the risk being regulated. The court further concluded “that Congress intended, at a bare

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Tuberculosis in the Workplace minimum, that [OSHA] find a significant risk of harm and therefore a probability of significant benefits before establishing a new standard” (448 U.S. 607 at 642, 645). Chapter 7 discusses OSHA’s estimate of the reductions in the numbers of cases of tuberculosis infection, disease, and death that would result from implementation of the 1997 proposed rule. Material Impairment In its 1997 proposed rule, OSHA concluded that tuberculosis infection was a material impairment of health because it poses some risk of progression to active disease and because treatment of infection involves some risk of adverse effects. (See Chapter 7 for commentary on this assessment.) The term “material impairment” is not defined explicitly in the proposed rule or the statute, nor has it apparently been defined in case law. Other OSHA standards have also defined infections and subclinical conditions as material impairments. For example, in the rule on bloodborne pathogens, the agency declared that hepatitis B virus infection as well as the disease itself constituted a material impairment of health (56 FR 64004, December 6, 1991). Before that, in its standard on lead (43 FR 52952, November 14, 1978), OSHA designated not only death and overt symptoms of lead poisoning but also certain subclinical pathophysiological changes as material impairments. Feasibility The OSHA statute refers to standards that ensure “to the extent feasible” that workers’ health and functional capacity will not be impaired. OSHA has interpreted technical feasibility to mean that a standard can be implemented with existing technology, adaptations of available technology, or reasonably foreseeable technological developments. Consistent with a 1981 U.S. Supreme Court decision on cotton dust regulations, OSHA has interpreted economic feasibility basically to mean that the cost of complying with a standard is not so high that it will cause a substantial number of businesses to fail (452 U.S. 490). Cost-Effectiveness For OSHA, a standard is cost-effective if the measures required are the least costly of the available alternatives that achieve the same high level of worker protection required by its statute. This is consistent with the Unfunded Mandates Reform Act of 1995, which requires the use of the most cost-effective means of accomplishing a regulatory objective. It is also consistent with the 1993 Executive Order 12866, which requires a

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Tuberculosis in the Workplace regulatory flexibility analysis to determine— “to the extent permitted by law” —whether the costs of a regulation are justified by its benefits.4 The 1981 U.S. Supreme Court decision on cotton dust regulations held that “a cost-benefit analysis by OSHA is not required by the statute” (452 U.S. 490 at 500). In a 1993 appellate court decision that generally upheld 1991 OSHA regulations on bloodborne pathogens (29 CFR 1910.1030), the Seventh Circuit Court of Appeals noted that OSHA did not (indeed is not authorized to) compare the benefits with the costs and impose the restrictions on finding that the former exceeded the latter. Instead it asked whether the restrictions would materially reduce a significant workplace risk to human health without imperiling the existence of, or threatening massive dislocation to, the health care industry…this is the applicable legal standard (984 F.2d 823 at 825). The same court also suggested some boundaries of reasonable costs for a life saved by a regulation. It noted that the bloodborne pathogen rule’s “implicit valuation of a life is high—about $4 million—but not so astronomical, certainly by regulatory standards,…as to call the rationality of the rule seriously into question” (984 F.2d 823 at 825).5 It also noted that the diseases targeted—infection with Hepatitis B or AIDS—were diseases that killed people “in their prime” (984 F.2d 823 at 826). The court goes on to note the benefits of avoiding serious consequences other than death. In sum, OSHA’s application of cost-effectiveness analysis is fairly circumscribed. It is similar to the kinds of analyses occasionally used by the Health Care Financing Administration program to limit Medicare payments to the level of the less expensive of two treatments that achieve equivalent outcomes for a health problem (HCFA, 1999 [Carriers Manual section 2100.2]). 4   Cost-effectiveness analyses examine the costs associated with achieving a desired outcome such as saving a life or preventing a case of disease. Cost-benefit analyses use monetary measures of benefits as well as costs. Notwithstanding this distinction, cost-effectiveness analyses frequently use the term “benefit” more generally to describe a desired effect or outcome (e.g., a life saved) without an explicit monetary valuing. A valuing may be implicit; for example, if a rule is estimated to save up to 200 lives yearly at a total estimated direct cost of $200,000,000 yearly, it implies that a life saved is worth at least $1,000,000. 5   In the rule on bloodborne pathogens, OSHA estimated that implementing the rule would cost employers $813 million per year and would avert 187–197 deaths per year among workers and their sexual contacts. Dividing yearly costs by yearly deaths approximates the $4 million figure cited by the appellate court. In the 1997 proposed rule on tuberculosis, OSHA estimated that implementing the rule cost employers $245 million per year in direct costs and would avert an estimated 138–190 deaths per year among workers and their families and other contacts. It estimated $89 million to $116 million in cost savings related to avoided costs for medical care and absenteeism.

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Tuberculosis in the Workplace Role of Evidence The statute provides that OSHA can regulate on the basis of the “best available evidence” [(29 USC 655(f), 6(b)(5)]. The U.S. Supreme Court has said that “scientific certainty” is not required; rather, actions need only be supported by a “body of reputable scientific thought” (448 U.S. 607 at 655). The court also said that OSHA could also use assumptions that risked error on the side of overprotection. The court explicitly acknowledged the relevance of epidemiologic evidence. OSHA Standards and Communicable Diseases The agency has traditionally focused on materials used in industrial processes to which exposure was relatively predictable and measurable. A cotton dust standard in the cotton-textile industry, for example, could assume that workers in a cotton-textile mill would be exposed to cotton dust. The 1997 proposed rule on occupational tuberculosis was only the second that OSHA has developed to deal with an infectious disease hazard. The other led to the 1992 standard on bloodborne pathogens. Regulation of the occupational risk of communicable disease introduces at least three additional complications for regulators that must be kept in mind in assessing the proposed rule on occupational tuberculosis. First, exposure to Mycobacterium tuberculosis is not readily predictable and cannot reliably be measured, so exposure must be inferred from epidemiologic and other data. Because exposure depends upon numerous factors that vary considerably from workplace to workplace, it cannot be assumed that health care and other workers will actually be exposed to M. tuberculosis. Second, the risk of exposure and negative health effects has the potential to change rapidly because of events outside the workplace, requiring unusual flexibility and coordination with other actors involved in preventing the transmission of tuberculosis. If community prevalence drops substantially or infection control measures change significantly, OSHA’s risk assessment or regulatory response may cease to be relevant. Third, the risk of communicable disease may not originate in the workplace. No one brings formaldehyde or other regulated toxins into the workplace, but workers, patients and others do bring communicable diseases into workplaces. Thus, OSHA must deal with the question of whether infections in a hospital or other covered workplace are to be attributed to a worker’s occupational risk or community risk. Application to Private and Public Employers and Employees For the most part, OSHA’s direct regulatory focus is on private employers. Separate provisions of the statute describe its application to federal workers and to state and local employees.

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Tuberculosis in the Workplace Under the statute, federal agencies are to develop safety standards consistent with those issued by OSHA, maintain occupational safety and health records, and report to the Secretary of Labor regarding their programs. As set forth in a 1980 executive order, federal agencies must (1) follow OSHA standards unless the Secretary of Labor approves an alternative safety plan, (2) comply with the act’s general-duty clause by eliminating recognized hazards that cause or are likely to cause death, (3) permit unannounced inspections under certain conditions, and (4) allow employees to report safety problems without fear of discrimination or retaliation. OSHA may inspect and cite federal agencies, but it cannot fine them. State and local employees are not covered by OSHA rules unless their states have adopted state occupational safety and health plans approved by OSHA. If states adopt plans that are “at least as effective as” the federal plan, the federal government pays up to 50 percent of the cost of enforcing the plans. Almost half the states and territories have approved plans, and two of these states (New York and Connecticut) cover only public employees.6 If OSHA adopts a final rule on tuberculosis, states with state plans would have to adopt a comparable standard within 6 months. States with approved plans must still require employers to submit reports to OSHA as though no plan were in place, and OSHA may also inspect workplaces in these states to monitor state performance. In states without approved plans, public hospitals, medical examiners’ offices, most prisons and jails, and other facilities would not be subject to an OSHA tuberculosis standard. They might, however, be affected by general or tuberculosis-specific infection control provisions in state licensure laws, Medicare or Medicaid requirements, or private accreditation standards. Further, if a public facility such as a prison contracted with a private agency to operate the health unit in the facility, then that agency would have to comply with OSHA requirements even if the rest of the facility was exempt. Multiple-Employer Workplaces For hospitals and other employers covered by OSHA rules, outsourcing arrangements have become an increasingly popular way to cut costs and increase flexibility. Thus, some nurses may work for the hospital directly, whereas others may be supplied by one or more outside agencies. Food-service employees may be supplied by one contract and janitors by another. As a result, professional and nonprofessional workers at 6   The other jurisdictions are Arizona, California, Hawaii, Iowa, Kentucky, Maryland, Michigan, Minnesota, Nevada, New Mexico, North Carolina, Oregon, Puerto Rico, South Carolina, Tennessee, Utah, Vermont, Virginia, Virgin Islands, Washington, and Wyoming.

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Tuberculosis in the Workplace hospitals and other workplaces may be employed by a number of different employers. These employers share responsibility for employee safety and health under OSHA. For example, a hospital may operate a tuberculin skin testing program only for its employees, meaning that each contractor that supplies the hospital with workers may have to set up its own testing program. Alternatively, a hospital may agree—for a fee—to also test a contractor’s employees. Some responsibilities for tuberculosis control are not readily shared. In particular, hospitals typically must provide isolation rooms and ventilation equipment that protect both their employees and the employees of independent contractors. They may, however, contract for maintenance of the equipment. Employees and Nonemployees Federal law obligates employers to provide employees with safe working conditions and to comply with specific OSHA standards. In most situations, employers’ obligations do not extend to volunteers. If volunteers receive some significant compensation in kind (e.g., room and board), OSHA claims that an employee-employer relationship exists. Medical or other residents and fellows who are compensated for their services qualify as employees for purposes of federal occupational safety and health regulations. Medical, nursing, and other students who are not compensated do not appear to be covered, although a health care facility may still choose to test them or require that they be tested by their schools. The situation with respect to physicians can be complicated. Within a hospital, patients may be seen by physicians who are employed by the hospital, physicians who are employed by an affiliated medical school, physicians who are employed by a managed care plan or other corporation, physicians who have incorporated their own practices, and physicians who practice without having incorporated or created an equivalent legal entity. Physicians in all but the last category appear to be subject to OSHA’s requirements for employee protection. Resources and Enforcement Actions The fiscal year (FY) 2000 budget authority for OSHA provided for $381 million in funding and for 2,262 full-time-equivalent employees (DOL, 2000). About $82 million of this total was designated for grants to state plan programs, and $141 million was designated for agency enforcement activities. Another $54 million was designated for federal compliance assistance, which involves various kinds of voluntary employer and

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Tuberculosis in the Workplace employee technical assistance and training programs. In 1998, when OSHA’s budget was $336.5 million, the agency reported that states and territories with state plans allocated another $111.3 million to their own programs (OSHSPA, 1999). In its FY 2001 budget request, OSHA stated that it expected to issue seven standards in FY 2000 and five more FY 2001 (DOL, 2000). For FY 2000, the agency estimated that federal OSHA employees would conduct more than 34,500 inspections and 27,500 consultation visits. State plan personnel would conduct another 55,000 inspections in FY 2000. OSHA’s enforcement activities include responding to complaints made by employees covered by OSHA and periodically inspecting covered workplaces on a scheduled basis. OSHA’s compliance officers inspect work sites and counsel employers regarding compliance concerns. The reports of these compliance officers provide the basis for regional office personnel to determine whether violations exist and citations should be issued. In 1999, OSHA began a targeted inspection program that focuses on the work sites with the highest injury and illness rates on the basis of the data reported to OSHA (Jeffress, 2000). Penalties for violations range from zero in the case of de minimus technical violations that do not affect safety or health to $70,000 for the most serious repeated or willful violations. If violations are not corrected within a specified time, a “failure to abate” violation can result in fines of up to $7,000 per day. Appendix E describes enforcement activities and penalties in more detail. CONCLUSION OSHA operates within the boundaries provided by its statute, applicable executive orders, and relevant judicial decisions. The provisions of the 1997 proposed rule on tuberculosis reflect the directions and constraints set by each of these sources. The next chapter compares that rule and the 1994 CDC guidelines on tuberculosis in health care facilities.