Thank you for joining us. I find this area very exciting because I think it tells us sometimes we don't realize what kind of contributions occupational medicine has made to the entire world. And also we'll be having speakers who are doing the most current things that we are changing the world with. So that's our plan today. There's part one and part two. And Dr. Gadadi is going to start out because he is the historian for occupational medicine. I'll go over his bio in a minute. So that will be our kickoff. And then I feel very privileged to have people who were my mentors because I went to change for emergency medicine. So Dr. Gadadi and Dr. Rose for the second session, Dr. Pacheco have all been my mentors. So I'm excited to have them present about their important work. So Dr. Gadadi is an international consultant and physician scientist based in Washington, D.C. with a practice in occupational and environmental medicine and health. Also health, safety, environment, risk, and sustainability. Dr. Gadadi has a strong interest in history. Dr. Gadadi has prepared himself for serious historical research focused on occupational medicine through workshops of the American Association for the History of Medicine and participation in the American Osler Society. He is an archivist, although we technically haven't given him a little medal for that, but he should get one, for ACOM and occupational medicine. And we do have a section on history and archives. And he's assembled a very impressive collection of books and artifacts that he's going to donate to ACOM. So we will have an archive site. He has curated several exhibits and papers of a major figure in OEM, Ernie Mastromedio, for the University of Toronto. He retired in 2008 from the George Washington University Medical Center and then spent most of his career before that at the University of Alberta in Edmonton, Canada, received his MD from the University of California at San Diego. He trained in internal medicine, pulmonary medicine, and occupational environmental medicine. And you will find that all of our speakers are boarded in so many areas, it's fascinating. Some of us only have one now. And he obtained his MPH at the John Hopkins Hospital in Baltimore, did two years of clinical research at NIH in Bethesda, and he was a Fulbright Visiting Research Center Chair at the University of Ottawa in 2015, and, of course, he was former president of ACOM. So join me in welcoming Dr. Gadadi, and he will kick us off with the greatest hits of OEM. Thank you, Catherine. I think one of the most profound things I've ever heard a president or leader of ACOM say is attributed to Catherine. And that is that we, as occupational physicians, are all about protecting the health of the people who are creating our future, even as we speak. So our role in the world is really to protect the people who make things, the people who run things, the people who plan things. So the role of the worker, the role of us protecting the worker, I think, is fundamental to our greatest contributions. What we're going to be talking about now is, for the next few minutes, is the greatest hits in the sense of where occupational medicine has given, occupational environmental medicine has given back. In other words, we are used, or we use the fruits of scientific research across all of biomedical sciences and all of clinical sciences. Do we just consume it? No, we give it back. We actually are a very productive medical field, both as a specialty and as a field of practice. We have given back to medicine a very great deal. Now, please don't spend too much time taking notes if you're a history buff, because all of this is going to be in a forthcoming book that ACOM is helping to develop called Occupational Environmental Medicine, Protecting Health at Work in the Community. That will be available later this year. The book is not available at this meeting. Now, some foundational observations as we were, before we go into this, to kind of explain and set the context for the contributions of occupational environmental medicine. OEM is an integrated field. The problem is that environmental medicine does not have a payments system. It is not a structured system in the way that occupational medicine is with workers' compensation and the entire regulatory apparatus. So as we go through, we're going to be considering environmental medicine as an integral part of OEM, but we're going to be putting more emphasis on occupational medicine because that's what predominates in practice and where we have the structure, if you will, of the integrated specialty. It will also, I think, be readily apparent to you that the taproot for modern occupational medicine was really the railroad surgeons of the 1800s. Railroad medicine and surgery was actually considered a distinct specialty in those areas. It was well supported. There were any number of medical and surgical journals at the time for the railroads. That really is the taproot, particularly for clinical practice as it later evolved. In 1918, Harry Mock, who founded the organization that later became known as ACOM, wrote an absolutely brilliant book called Industrial Medicine and Surgery, in which he pulled together the clinical side. He pulled together the toxicology side, a little bit of at least the rudimentary form of epidemiology. He dealt with the problems of vulnerable populations. He dealt with health promotion in the workplace. It was truly a brilliant book. It came about the same time as he and a small group of other forward-looking individuals formed ACOM in the first place. You really owe Mock a great deal of the forward progress in the specialty. Also, I think we should be aware that occupational and industrial hygiene, which at that time was known as industrial hygiene mainly, and in the rest of the world is now usually called occupational hygiene, actually began with occupational medicine. It split off around 1940, 1950, and became a primarily nonmedical specialization in practice. Before that, the people who were doing the evaluations in the workplace, on location, were usually physicians. They were using fairly rudimentary methods in order to do this, but the involvement of engineers and chemists who formed the modern specialty of occupational hygiene split off from occupational environmental medicine. So there, within our own field, is a major contribution. Now, first of all, how has occupational environmental medicine contributed to clinical practice over the years? Well, it actually has contributed fairly profoundly, obviously in the recognition of occupational diseases, because without the contribution of astute clinicians who spotted problems and then investigated them, occupational disorders could never have been targeted for prevention or compensated fairly. Injuries are obvious, diseases are not, but it really is largely the observation of astute clinicians that advance the field in occupational diseases. So that whole area would not have been really apparent had it not been for people like us. Emergency trauma century. I mentioned earlier that in the 19th century, it was the railroads that were really driving the development of occupational treatment and diagnosis. And during this period, railroad surgeons developed mobile hospitals, surgery packs, which were now used today routinely for surgical care, prepositioned supplies for emergency use in various locations, usually close to a depot or a transfer point for the rail system, and developed entire hospital and clinic networks. Guthrie, Scotten Temple, Pacific Medical Center in San Francisco, all of these began as railroad hospitals and railroad health care systems. And the railroad health care systems were unusual in their day, because they had workers on the boards of directors. There was considerable input on the part of the people who were being served in health care, and the quality of the health care was pretty good, especially for the day. Clinical effectiveness research. We wouldn't normally think of this as arising out of occupational medicine, but it did. Because Archie Cochran, of the Cochran Collaboration fame, began his work in the first place to establish the utility and to estimate the optimum frequency of surveillance of co-workers in an effort to minimize co-workers' pneumoconiosis. So this is ironic, because Cochran was one of the major leaders, along with Bradford Hill, in the development of randomized clinical trials. Today, randomized clinical trials play almost no role whatsoever in occupational and environmental medicine, because you can't randomize these populations. But the thinking, the prepared mind, the cognitive models carried over. And that's what was so great about the contribution, how it arose from a rather unlikely source. Then in contributions to clinical practice, one of the biggest contributions, especially to child health, of occupational medicine came in the 50s, when Philip Drinker, who was a physiologist who was interested in respirators and in respiratory protection, just by the way, very much like J.B.S. Haldane before him, an eminent physiologist in his own right, Drinker developed the iron lung during the polio epidemic. He actually was a little bit discouraged at some one point, because he said, I've done all this work on respirators and occupational lung disease, but everybody remembers me for the iron lung. Well, it was a huge contribution, and he richly deserved the credit that he got for that. A great deal of hematology arose from benzene research. We forget that before the rise of epidemiology, toxicology was our main source of information about chemicals and their effects. The early history of benzene research was all about experimental work in hematopoiesis, from which we learned a great deal about stem cells and about the origin of formed units in the blood. Even something as routine as color vision testing and testing for phoria was an early innovation that had an occupational basis for fitness to be able to discriminate colors on the job. So the contributions to clinical science are really quite large. We don't just take the methods of clinical medicine and apply them to workplace problems. We have actually innovated and improved our understanding of fundamental biomedical subjects. How about contributions to medical sciences more broadly, non-clinical medical science? Well, the whole field of environmental and occupational toxicology is a good example. This arose from the beginning, from the very beginning going back to Paracelsus, of course, and the greatest toxicologist of her era, the greatest applied toxicologist, was also our patron saint, if you will, Alice Hamilton, who worked in occupational toxicology and who really pioneered the era of regulatory toxicology and how we use this information and apply them. Lead, by the way, was the big seminal model. The understanding of lead toxicity was kind of the key, the Rosetta Stone, if you will, to looking at all sorts of different toxic effects, whether related or not, and it was the model that toxicologists carried around in their mind for understanding cumulative effects during the era and even still today. I tell my students that if they understand lead toxicity, they understand about 70 percent of metals toxicity. All they have to do is think in terms of analogy. Industrial fatigue, which is less toxicology and more what we now understand as ergonomics, was a wartime innovation. We're all familiar with the idea of the Frederick Winslow Taylor idea of human factors, the one best way, which we now know leads to fatigue, and the beginning of ergonomics in that era. Well, industrial fatigue and the capacity to work was a major issue in wartime, in World War I. In order to determine how much workers can work without their performance falling off and what we could expect from the defense industry infrastructure of the day, the British put together an industrial fatigue board and initiated original research and looked into the problem and determined that, yes, it is true, that the more you work with workers, the more productive they are up to a point, and then it drops off, and the performance curve drops off quite steeply. If you go beyond that optimum, you're actually increasing the risk of injuries and you're also reducing the overall performance over a period of time. That contribution from World War I was a major innovation in work physiology, in stress, and ultimately in sleep. Epidemiology of cancer and the etiology of cancer is another area where occupational medicine was a groundbreaker. We're all familiar with the story of Percival Pott and the recognition of scrotal cancer and of Pott's hunch that it had to do with some carcinogenic factor in the soot that was accumulating in the underpants of the young boys who were developing scrotal cancer. What we tend to forget is that that clinical observation then stimulated an unbroken line of research to the present day, which actually was centered in the early years in Japan, which, in the early part of the 20th century, was actually the world leader in carcinogenesis research, and isolated compounds and isolated chemicals that reliably produced cancer in animal models. Well, what they used were coal tars, what they used were extracts of that very same soot that caused the scrotal cancers. This was the standard way of inducing cancer for carcinogenesis research, and it developed in parallel with the viral theory of cancer pathogenesis, which was also, by the way, a Japanese innovation. We rely on these individuals to take a clinical observation, and then in the early 20th century we spent over a century of research to carry it forward into carcinogenesis bioassays that we use today. The assays that we use, for example, to determine carcinogenicity and that IARC relies on and so forth didn't arise out of thin air. They arose from this line of research, and by one particular champion of this area who thought that it had general applicability for carcinogenesis to screen new chemicals for their carcinogenic potential, and this is Wilhelm Hüfer. Hüfer, as the name implies, is German. He emigrated to the United States. He became one of the country's two leading cancer, occupational cancer experts. Unfortunately, the other leading cancer expert was Robert Keogh, who was steadfastly opposed to a lot of what Hüfer did, and we now, Hüfer's reputation suffered greatly from that, but is now largely being rehabilitated, and we now recognize that Hüfer was way ahead of his time and was a, his picture, by the way, is the third from the left, that he was right about occupational carcinogenesis being very important. Who was saying otherwise? Well, unfortunately, it was groups like the American Cancer Society and groups that were heavily invested in smoking cessation as the primary means of cancer control. In this country. Occupational cancer was considered a marginal issue, not very important. All the effort was being put into anti-smoking campaigns, and by the way, there's also a German connection there, because the same thing was going on in Germany in the 30s, 40s, and 50s, big campaigns that focused on smoke cessation and kind of forgot about occupational causes of cancer, which Hüfer was trying to remind us is indeed important. Again, the carcinogenesis bioassay was also largely refined by Umberto Safioti, who standardized the process and created the modern bioassay that is used in pharma as well as in occupational research. And then, of course, the enormous impact of Irving Selikoff, probably the single most important individual in occupational medicine in the second half of the 20th century. He not only appreciated the importance of asbestos and undertook monumental, serious studies that defined and speciated the carcinogenicity of asbestos, but also made fundamental contributions. For example, the most reliable model for positive interaction or synergy in cancer causation, which we invoke all the time. Many contributions, but asbestos, of course, is the one that he's remembered for. Occupational and environmental medicine, particularly occupational, made many contributions to respiratory medicine, in particular. I mentioned J.B.S. Haldane, who was the leading British respiratory physiologist of his era. He was particularly concerned with protecting minors, underground minors. But he also used that same knowledge to look at personal protection against poison gas. So he was also very much involved in defense. He developed studies in respiratory physiology and ventilatory support. For example, respirators, and looked at issues like effort and resistance, and really led the way to a deeper understanding of that, which has culminated in our modern respirators, which have very low resistance to flow. Back in the early part of the 20th century, asthma was dimly understood as being a problem of bronchoconstriction, and the treatment for it was, of course, stromonium and atropine and other common bronchodilators, right? Well, that was the standard treatment of the time, before theophylline. We then determined that that wasn't always working and that refractory asthma was a problem. We also began to understand that some people got asthma as a result of occupational exposures. Well, Jack Pepys, who was a pulmonary physician from South Africa who emigrated to the United Kingdom, thought that this area was far from settled and somebody needed to look into it. So he set up a laboratory at Brompton Hospital, characterized occupational asthma, and identified the long-term, slow constrictive form that led to the knowledge that obstructive lung disease was more than just periodic bronchoconstriction, and that led to the recognition of chronic inflammation as being the root cause of asthma, which, of course, revolutionized our treatment methods and our understanding of what was going on, and led to the anti-inflammatory approach for asthma treatment. The initial observation came from occupational asthma. At the other extreme, in restrictive disease, we have had less success in changing outcomes with fibrotic lung disease, but our understanding of restrictive lung disease, and especially related conditions like interstitial pulmonary fibrosis, have benefited a great deal by the experience with fibrotic occupational lung disease. So lots of clinical contributions, very practical contributions. How about to the more basic sciences? Well, environmental epidemiology was actually a relatively late innovation in the characterization of disease. Environmental methods were still pretty crude, notwithstanding John Snow and so forth, in the early 20th century. At that time, professors like Wade Hampton Frost began to look at methodology and began to develop what we then called chronic disease epidemiology as being a separate problem from attack rates and acute infectious disease epidemiology. The basic studies that were done on smoking, the study of physicians in the United Kingdom, was a seminal event, and it was done by the same people like Bradford Hill and Archie Cochran and Sir Richard Dahl, who were also at the same time working on occupational lung disease, and the earliest studies, for example, in asbestos. So this was all part of an intellectual mix that led to new methods, and new methods that were more appropriate to chronic disease. By the way, Wade Hampton Frost, whose portrait is down on the left here, by all accounts was a terrible lecturer. Apparently it took a generation of students to figure out what he was actually saying and codify it so that it could then be taught as a coherent body of knowledge. In terms of applications of this knowledge, it was not limited to occupation either. It also created the new field of air pollution epidemiology. We're all aware of the Denora episode in 1948. We tend to forget that in that era there was virtually no ground rules for environmental epidemiology. The methods that were used to study Denora were the hygiene and wet chemical exposure methods that were used for occupational studies, and by the hygienists, because that was all they had. After that event, and two or three others, the U.S. Public Health Service began to look at adapting methods that had been developed for occupational epidemiology. Then when photochemical air pollution became the norm in California and the issue became much more subtle and difficult to characterize compared to the London and the Denora episodes, a physician whose original interest was in occupational epidemiology and social medicine, John Goldsmith, stepped up and developed a series of methods that were most applicable to air pollution. Air pollution, of course, epidemiology, of course, has become a very sophisticated science. One of the reasons it has become very sophisticated is that if you look at relative risk for air pollution, it's quite small. If you look at attributable risk, it's enormous. So different methods had to be used in order to take that into account, and the methodology was developed, at least in part, beginning with pioneers like John Goldsmith. The contributions to health care, HMOs started with occupational health care. They began to provide care to workers and their families. The patient-centered medical home, which we don't talk about as much now, but used to be a major issue in the narrative, was invented by an occupational physician. We already talked about railroads and their health care systems. The idea of health promotion in the workplace and wellness goes back to the 19th century. We have Jane Addams creating the settlement houses that trained and inculcated a sense of responsibility in Alice Hamilton, who then carried it over into hazards in the workplace, as well as the general well-being of workers and their families. We already talked about Harry Mock. I could talk about him for another hour, but I promise you I won't. That, of course, has moved into—he's the one smoking the pipe, by the way, so tobacco hazards hadn't quite reached the point of familiarity yet. And this led into the whole concept of health and productivity. So what can we learn, in summary, from this? One is that occupational environmental medicine is a creative field. We don't merely appropriate ideas and methods from other biomedical and scientific disciplines. We contribute. We're also a sociotechnical field, in which the technical aspects are combined with difficult social issues and our ability to deal with them. We give back to science. We also illuminate some of the social issues of the day. I think that we are an integral part of sustainable development, and that as we move forward to a sustainable society and economy, that that will be much more appreciated. And I believe that we are a critical science, as defined by Jerome Ravitz. Jerome Ravitz said there exist certain fields that have as their primary role to illuminate problems that are created by technology and science itself. Well, that's us. And so I think that this idea of us being a critical science illuminates a lot of what we do and informs a lot of what we do, and I think that it should make us proud that occupational environmental medicine gives back. Thank you. Thank you. 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There is also a small room on the second floor where they grind the plant parts. And so the plants are sort of dumped in the top of that white cone, and then they're ground, and then they sort of dumped out at the end. The second place where we found airborne CAN-S3 was where they loaded the cones, and that's all done by hand. So if you can see to the lower left of the left picture, there are a bunch of sort of cigarette cones that are loaded up into that machine, and we set up sampling right next to it. And then the worker kind of dumps cannabis into these cones, and then the cones just shake to sort of settle the marijuana until you have a set amount per cone. You can buy these off the internet. That's just a picture that I pulled off the internet to make these products. So the results from our preliminary sampling, we collected 18 area samples throughout the facility. They were not personal breathing zone, they were just area samples. So we collected for about seven hours. Only two areas had levels of CAN-S3 above the limit of detection. So it was a full shift in the machine packaging room where I saw them dumping the material into bags, and that was .73 nanograms per meter cubed. The other one was in the trim room where they're grinding and loading cones, and that had higher concentrations. This is interesting. The other piece, though, was two things. I think, one, we don't know what the personal exposures are, and number two, we have no idea what is a sensitizing level or not. So there's no limit, but this is the first step, I think, to collecting that information. So this is a complex bioaerosol exposure. So the direct handling of plants obviously exposes you to the plant allergens. There are four major plant allergens, CAN-S2, which is prophylline, CAN-S3, which is probably the major allergenic protein, nonspecific lipid transfer protein. Then there's OEEP, is CAN-S4, and then this protein 10 homolog is CAN-S5. What's interesting is that cannabis needs a lot of water, and because of the sequential watering requirements, you get secondary mold growth, which is a big concern in these essentially greenhouses. So I'm not sure I can pronounce this, Golovinomyces, anyway, that's powdery mildew, which is a big concern, and then gray mold is the Botrytis cinerea. There are other fungal species that are found in cannabis grow operations, which are the standard Aspergillus penicillium, Fusarium, and Trichoderma. In addition, there are airborne, mostly gram-positive bacteria, and including most of them actinobacteria there are fewer gram-negatives, although we do intend to measure endotoxin in the air in these operations. There are other cannabis exposures. Terpenes are probably responsible for the odor associated with marijuana, and there are different kinds. Terpene is actually a fairly common perfume allergen, which can also cause a contact dermatitis, but these are just a listing of some of the terpenes that have been reported. They will interact with some hydroxyl radicals, ozone, et cetera, to form formaldehyde and ultrafine particles, which are respiratory irritants as well. I just recently spoke to somebody yesterday who was, people are very interested in the terpenes in terms of either irritant exposure, but he had been doing some experiments with mice sort of repeatedly painting the skin with terpenes, and showed that you lose filaggrin, which is a skin protein that forms a barrier protection. So it's possible, I think it's interesting that in those exposures that can cause a dermatitis, it may start out with an irritant exposure, right, that sort of degrades the skin protective equipment. There are other VOCs that are formed when the plant material is heated, so I'm not going to talk about the processing that's involved, although some of it really is pretty specific organic chemistry, but there have been reported exposures to 2,3-pentadione and diacetyl, which Cecile will talk about later. There are pesticides, fungicides, insecticides, okay, I still have five minutes. I don't want to go through all of them. This is sort of a list for you to see. I will tell you an interesting story, though, about myclobutanil, because it is banned for legal cannabis cultivation. However, it is not banned for illegal cannabis cultivation. And I did have a patient that was sent down from Wyoming where cannabis cultivation is illegal. She was an evidence technician, and so whenever they would collect marijuana from illegal grow operations, they would be collected in bags, right? And so her job was to take out the bags, open up the bags, right, and they would take samples for the court case. And so she was sent down as maybe she's allergic to cannabis. But her symptoms didn't make sense, right? She did not have itching, tearing, stuffy nose, cough, nothing respiratory that would say, okay, this is an IgE-mediated allergy. What she did report was this sensation of a lump in her throat and globus that would last for a couple hours, right, and then resolved. And it was like, you know when you get patients that show up with nothing, with no information, with nothing? So it's like, all right, what do I do with this? But I did remember that cannabis does have a problem with mold. And I looked up some of the various fungicides that are available, and myclobutanil is one of them, and that's its side effect. Its side effect is that it causes this lump in your throat feeling like you can't swallow that lasts for a couple hours and then resolves. So just to sort of say that if you do have people exposed to cannabis, it's not just the allergen and the pesticide can cause some pretty significant symptoms. Related conditions associated with cannabis. So there are cases of bisinosis in industrial hemp production. Remember, hemp was used to make the ropes, especially for sailing ships. And so hemp was an important product for this industry. Because the hemp would sit around in big bags, you then got secondary sort of endotoxin production from gram-negative bacteria. Other reported conditions are asthma. I think many people have heard about the case of fatal asthma in a marijuana grow operation in Massachusetts. As it turns out, initially it was reported as a case of anaphylaxis, which is concerning, right? Because you need a lot of exposure to cause anaphylaxis. In this case, though, it was really a case of fatal asthma. Rhinosinusitis, irritant and allergic dermatitis, and contact urticaria. This is an example. This was a worker who was just walking out of the plant who said, oh, look what happened on my arm from dermal contact with a cannabis plant. And this is an example of contact urticaria. Okay. So cannabis is an allergen. Part of the problem that we have is that there is no commercial extract available for it. And there are people working on it. There are a lot of people working on ELISAs for the various cannabis allergens. I had somebody who really developed bad asthma and sinusitis from working in a dispensary because in the dispensaries, they sometimes have these big bins of plant leaves and buds that they then have to move. So I asked him to bring in sort of samples of the leaves of three of the different strains that bothered him and also three of the hemp oil, which is really extracted from the plant. And what was interesting here is that he was clearly positive to the marijuana leaves and had large wheel and flare to these different allergens. But when we tested him to the hash oil, he didn't react at all. It makes the point that it is the plant allergens most likely that are the cause of the problem. The hash oil retains very little to none of the allergens. These are some of the cross-reactive allergens. What makes this interesting is that because cannabis is a plant, there are many cross-reactive foods that have the same allergen. And so this is just a list of the four major allergens. If you ever see these lists of specific allergens, the way they're named, right, is the first three is the genus, cannabis. The second letter is the specific species, sativa. And then the number is the order in which they were discovered. But you can see that especially the stone fruits cross-react with cannabis. Peanut, banana, citrus, tobacco, latex, tomatoes as well. And also to birch pollen is closely related to the canis three. One of the things that we're interested in is probably, all right, I'll hurry up, is the cross-reactivity of the plant allergens with food allergens. And is this something that we need to be aware of? This is a really nice review, but it shows the cross-reactivity of the allergens based on the different epitopes, the different specific allergens. All right, so this is our proposed evaluation. We're going to do personal breathing zone monitoring for endotoxin, bacteria, fungi, et cetera. We're going to do a questionnaire, but we're also going to do skin testing. We're going to have to give blood for cannabis elizas because there is no commercial extract. All right, I'm almost done here. We've got three minutes for questions. Okay, sorry. Here are the conclusions. Cannabis grow operations are proliferating in response both to demand and legalization. There are sophisticated greenhouses that grind and process the plant product. Exposures are complex, and you also need to think about mold and pesticides. The exposure-related diseases are predominantly allergic, and better characterization of this relationship is what's needed if you want to limit or prevent disease. And there are a lot of people involved in this that I want to thank. I'll leave this up. Thank you. Thank you. Well, I want to open it up for questions, if you want to go to the mic with questions. But I'm hoping that this was a really good first episode because we got to look at the history and the various ways that occupational medicine has played into all these major events that affect the population. And then we got to see what are we doing nowadays, and how are we applying those concepts to look at new problems and new issues. So yes, we have a question. Thank you. So my name is Faiz Bajani. The question is for, thank you to both of you, Dr. Giroir. The question is for you. The last, or one of the last slides, you said OEM has a unique creative field, and et cetera, right? And I get that as a practitioner for a long time. But the counter-argument to that is that occupational health is a product of, or a crossbreed between basic medicine, internal family, whatever, public health, and public health, yeah? And it focuses on the causation, contribution, and remediation of occupational health problems. So the, and you know, many of the folks that you alluded to were first and foremost, in many instances, like you talk about pot, a surgeon, orthopedist, right? Then you talked about paraselsis, completely different stuff. So do you think, from your historical perspective, we respect you tremendously, that if you would have asked many of those professionals, would they have called themselves an occupational health physician, practitioner, scientist first, or a physician with some specialty first who had a unique ability to see through the relationship between occupation and health, and then produce their work in it? Thank you. I think, unfortunately, I can't move the mic. Yeah, this is really limiting some of the technical side of the way these rooms are put together. I think it doesn't matter. I think that we are a small field. We are a field that is unified by a particular concept. And that is how our environment, whether it's the built environment of the workplace, or whether it's the ambient environment in the community, affects health. We do not have an exclusive ownership of that field, but neither does anyone else. And public health, I think, is a predominantly, in terms of population health management, is one half of what we do. So we are not exclusive of public health. We are a public health specialty, and we are a clinical specialty. And that's partly what makes us unique. In my book, I like to say that we basically exist as a system. In other words, we're not a single, unitary mode of practice. We are a pyramid, if you will, and we are a system. If you look at the pyramid, you look on one side, and you see primary, secondary, and tertiary care, corresponding to treating the injured worker, dealing on a referral level with complicated problems, and doing IMEs and other technical evaluations. Then on the other side of that same pyramid, with a different face, we see the population health management side of occupational health. And that gets us into primary prevention, it gets in for the entire workforce, gets us into program management, and it gets us into higher level tracking, auditing, and program design that is all apart. And then the part of the pyramid that you can't see because you're looking in two dimensions is environmental medicine, which varies in terms of our direct engagement, depending on our career paths. So I see it as different facets of a unitary field, and I see us, in terms of the development of our careers, as essentially moving from one cell in that complicated, say, three by three system, and it depends on where we are at one point in our career. We give back to the specialties that we take from in terms of our knowledge. So I think that many people, like Irving Solikoff, would have considered himself to be a neurospecialist at the beginning of his career, and would have considered himself to be an occupational and environmental physician at the end. Thank you. Thank you. Yes? Hey, I have a question, you know, for Dr. Ghidotti. So the railroads in Portland, Oregon, the first black doctor in Portland, Oregon was brought by Union Pacific 100 years ago, and I'm interested to know, so, you know, you mentioned a moment for equity and social justice in occupational medicine, but, you know, there's an omission from the discussion, how often did this happen, as the railroads had a largely colored workforce, and the first black doctor in the state of Oregon that was recruited by Union Pacific, because they had this largely black and Asian population, but no white doctors because of the social strictures from the 19th century Oregon constitution that excluded blacks and Asians from owning land and being citizens of the state of Oregon. And also Jews. Yes, and this was not uncommon. So as the railroads expanded out west, they had to deal with their largely colored Irish workforce and recruit doctors that were willing to tend to these populations. I think that is a challenge, it's an omission here in 2023, but it's also a challenge for the transportation section, Dr. Hartenbaum and others, to get into the railroad archives and the history section to track down the extent to which transportation infrastructure recruited black doctors to fill this unmet need across the country as cities were built along the lines of our transportation infrastructure. Yes, and of course it's all intersectoral. So when you have a marginalized social... Oh, just a training timeout. So when I attend the National Medical Association meetings and I meet old gray-haired black doctors that still attend those annual conferences and with bitterness say that in their days, in the 1960s, they were never allowed into the AMA, it's almost like an alternate reality of the stories that they tell of a patchwork of black clinics and practitioners across the country because of a separate system. But will ACOM include those stories in the history of occupational medicine? Well, I think that the answer is, as those stories become known, yes, as ACOM and the members of ACOM learn about the deep history of our organization, of our society, and how it affects our own practice even today with carryover effects, sure. I think that we're committed to do that. I think that there's also an issue in terms of gender equality. Many of the railroad hospitals that were founded in the 19th century were exemplary in recruiting women surgeons and physicians as well. In fact, it was one of the few ways to get a medical education for women in some parts of the country at certain times. And occupational medicine has always had a disproportionate representation of women compared to other medical specialties. So I think that the whole issue in terms of self-identification, in terms of underserved groups, in terms of intersectoral equity, and the way in which these processes of marginalization intersect and complicate the lives of certain groups, it's all part of the unfortunately rich but sometimes negative history of occupational medicine and society overall. And I think if there's one thing that we learn from looking at the history of occupational medicine is that some of it's good, some of it's bad, a little bit of it is very bad, and some of it is exemplary. Some of it reflects society as a whole. Thank you very much for attending this section. We're going to do another part right after this, and that will give you even more of the type of information that you just heard from Dr. Pacheco about some of the newest things we're discovering, why occupational medicine makes a difference, and how we look at the world differently than many surgeons or internal medicine people, because that really they don't view it quite the same way we do, and they don't necessarily explore the same things. So thank you for attending this section, and we would love to see you back. Take a coffee break.

occupational medicine

contributions

health of workers

clinical practice

medical sciences

history

technology

science

occupational health risks

cannabis grow operations