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INsTIT u T E O F DIE DICIN E Deaden of HeeJtb Pro m Orion and Disease Prevention Tech" Pricings, Needs for Ceding In~rmadoa on OccupaMons and F"vironments Report ~ a Study by the Commode on Enhancing the Practice of Occupations and E~imnma~ai Redline SubcommiMae on ~rm~ion Systems logo National Academy Press

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee appointed by the members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy makers pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This study was supported under a cooperative agreement through the Public Health Service, Centers for Disease Controt/Agency for Toxic Substances and Disease Registry; National Institute of Environmental Health Sciences; and the Environmental Protection Agency (contract no. ATU30021~. 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Publication No. lOM 90-03 Printed in the United States of America

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This report is dedicated to the memory of Dr. James V. Warren, Study Director of the Committee on the Role of the Physician in Occupational and Environmental Medicine and Study Director Emeritus of the Committee on Enhancing the Practice of Occupational and Environmental Medicine. Dr. Warren's enthusiasm and intellectual curiosity energized both tOM committees. Initially skeptical, Dr. Warren became a fervent advocate for increasing the role of primary care physicians in occupational and environmental medicine. He was an inspiration to the many individuals who worked with him over the past four years. ... ///

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COMMITTEE ON ENHANCING THE PRACTICE OF OCCUPATIONAL AND ENVIRONMENTAL MEDICINE Bernard D. Goldstein (Chair), Professor and Chairman, Department of Environmental and Community Medicine, UMDNd/Robert Wood Johnson Medical School, Piscataway, New Jersey John A. Benson, Jr., President, American Board of Internal Medicine, Portland, Oregon Joseph M. CannelIa, Corporate Medical Director, Mobil Oil Company, Princeton, New Jersey Linda Hawes Clever, Chairman, Department of Occupational Health, Pacific Presbyterian -Medical Center, San Francisco, California Adrian L. Eclwards, private practice, New York, New York Edward Huth, Editor, Annals of Internal Medicine, American College of Physicians, Philadelphia, Pennsylvania Philip J. Landrigan, Ethel H. Wise Professor and Chairman of Community Medicine, Director, Environmental and Occupational Medicine, Mount Sinai Medical Center, New York, New York Richard C. Reynolds, Executive Vice President, Robert Wood Johnson Foundation, Princeton, New Jersey Linda Rosenstock, Director, Occupational Medicine, University of Washington, SeadIe, Washington Bailus Walker Jr., Dean, College of Public Health, Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma Consu/tant Kathleen M. Rest, Assistant Professor, Occupational Health Program, Department of Family and Community Medicine, University of Massachusetts Medical Center Worcester, Massachusetts lV

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SUBCOMMITTEE ON INFORMATION SYSTEMS Linda Hawes Clever, (Chair), Chairman, Department of Occupational Health, Pacific Presbyterian Medical Center. San Francisco, California Molly J. Cove, Associate Professor and Head, Division of Public Health, Department of Health Policy and Management, The Johns Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland Adrian L. Edwards, private practice, New York, New York Daniel R. Masys, Director, Lister Hill National Center for Biomedical Communications, Bethesda, Maryland James A. Merchant, Director, Institute of Agricultural Medicine and Occupational Health, University of Iowa, Iowa City, Iowa Linda Rosenstock, (ex-officioJ, Director, Occupational Medicine, University of Washington, SeanIe, Washington Bailus Walker ~Jr., Dean, College of Public Health, Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma institute of Medicine Staff James A. Frazier, Study Director James V. Warren, Study Director Emeritus Gary B. Ellis, Director, Division of Health Promotion and Disease Prevention Rosena A. Ricks, Study Assistant Contributors Robert Aclams, private practice, MenIo Park, California Charles E. Becker, Associate Director, North California Occupational Health Center, San Francisco General Hospital, San Francisco, California

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Contributors (continued) Joe! Bencler, Vice President, Health, Safely, and Environmental Affairs, Corning Fiberglas Corporation, Toledo, Ohio Paul Blanc, Assistant Professor of Medicine, University of California, San Francisco, California Kenneth Chase, Consultant, Washington, D.C. James E. Cone, Director, Occupational Health Clinic, San Francisco General Hospital, San Francisco, California Robert Dyer, Consultant, Washington, D.C. Philip Edelman, Medical Director of the Poison Control Center and Chief, Toxicology Center, Orange, California Richard Bruce Friedman, Professor of Medicine and Vice Chairman, Department of Medicine, University of Wisconsin Medical School, Madison, Wisconsin Bruce Haynes, Director of Emergency Medical Services Authority for California, Sacramento,~ California Waiter Hulon, Corporate Medical Director, Ethyl Corporation, Baton Rouge, Louisiana Richard J. Jackson, Chief, Office of Environmental Health Hazard Association, California Department of Health, Berkeley, California Toby Litovitz, National Capital Poison Center, Georgetown University Hospital, Washington, D.C. Diane Liu, Occupational Medicine Fellow, Occupational Health Clinic, San Francisco General Hospital, San Francisco, California David Logan, Clinical Toxicologist, Mobil Corporation, New York, New York Thomas Made, Medical Epidemiologist, Surveillance Coordinating Activity, National Institute of Occupational Safety and Health, Atlanta, Georgia Dorothy McManus, Environmental Protection Agency, Washington, D.C. vl

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Contributors (continued James Melius, Director, Division of Occupational Health, Department of Health, Albany, New York Frank Mycroft, Staff Toxicologist, Hazard Evaluation System and Information Service, Berkeley, California Kent Olson, San Francisco Poison Control Center, San Francisco General Hospital, San Francisco, California Marianne Parshiey, private practice, Portland, Oregon Kenneth Renwick, Emergency Room Physician, Modesto, California William O. Robertson, Medical Director, SeanIe Poison Center and Washington Poison Network, Children's Hospital, SeanIe, Washington don Rosenberg, Chief, Hazard Evaluation System and Information Service, Berkeley, California Philip Scearcy, Minnesota Regional Poison Control Center, St. Paul Ramsey Medical Center and Ramsey Clinic, St. Paul, Minnesota Leo J. Sioris, Director, Minnesota Regional Poison Control Center, St. Paul Ramsey Medical Center, and Ramsey Clinic, St. Paul, Minnesota Virginia Sublet, Agency for Toxic Substances and Disease Registry, Atlanta, Georgia Alvin TarIov, President, Kaiser Family Foundation, MenIo Park, California Laura Welch, Director, Occupational Medicine, Professor of Medicine, George Washington University, Washington, D.C. Sponsors' Representatives James R. Fouts, Scientific Advisor to the Director, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina 1 V11

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Sponsors' Representatives (continued Max Lum, Director, Division of Health Education, Agency for Toxic Substances and Disease Registry, Atlanta, Georgia David P. Rail, Director, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina d. Rouh Reigart, Associate Professor Pediatrics, NIEHS Representative, Medical University of South Carolina, Charleston, South Carolina Elston Seal, Medical Research Officer, Environmental Protection Agency, Research Triangle Park, North Carolina .. . v///