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Ministerial Inquiry into the Management of Certain Hazardous Substances in Workplaces

Speech notes: Denis Clifford - Inquiry Chair

Launch of the Ministerial Inquiry into the Management of Certain Hazardous Substances in Workplaces Report

Executive Foyer, The Beehive - 10.30am Friday, 25 July 2003

Minister, ladies and gentlemen

I am honoured to be asked to speak at this morning's launch of the report of the Ministerial Inquiry into certain Hazardous Substances in Workplaces.

The Hazardous Substances in question were glutaraldehyde, other aldehydes and solvents. The Inquiry focussed on workplaces in the health, printing and manufacturing sectors.

This morning I will first make a number of observations on the submissions the Inquiry received, particularly from individuals who had experienced adverse health effects associated with or caused by workplace exposure to the Hazardous Substances. I will then summarise some of the key elements of the Report itself.

For many of the individuals who made submissions to the Inquiry, preparation of those submissions and, particularly, appearing at hearings, involved revisiting very painful memories and carried an emotional toll. No one who read the submissions, or listened to individual submitters speak in person, would have remained unmoved by the events described or have been left in any doubt as to the very real pain and suffering those events had involved. Whilst there is debate about proper diagnosis, and cause and effect, that fact should not be overlooked.

Speaking very personally, prior to my involvement in the Inquiry, I certainly had not appreciated the potential severity of the adverse health effects that can be associated with exposure to Hazardous Substances used relatively commonly in New Zealand. This I think was particularly so in the case of the condition known as chronic solvent neurotoxicity. As the Report notes, the instances of individuals who were suffering from neurotoxicity caused by long term exposure to solvents, and also neurotoxicity as recognised now in New Zealand as being associated with exposure to x-ray processing chemicals and glutaraldehyde in particular, were some of the most difficult the Inquiry encountered. Neurotoxicity involves damage to the nervous system. It can have a significant, and sometimes severe, general debilitating effect on a person's life. Symptoms include headache, fatigue, irritability, sleep disturbance, memory and intellectual function impairment, emotional instability and depression. In extreme cases, dementia can result. The potential impact of neurotoxicity on a person's life should not be underestimated.

It is appropriate, at this point, to also acknowledge the severity for the individuals involved of the adverse health effects associated with the condition known as multiple chemical sensitivity or MCS. For the people involved, the symptoms associated with MCS can have severe and debilitating effects on their wellbeing, and their quality of life, similar, it would appear, to those caused by chronic solvent neurotoxicity.

If the Inquiry results in there being a greater understanding of the potential severity of the adverse effects of exposure to the Hazardous Substances, then it should contribute to better occupational health outcomes.

The other aspect of the individual submissions that I would like to comment on relates to the willingness of the people involved to reflect on their own experiences, and to make recommendations for the future, in a positive and commonsense way. As you may be aware, the Inquiry was not about allocating blame or accountability for past incidents. There was some disappointment with this. Notwithstanding that disappointment, the great majority of individual submitters did seek to draw from their own personal experiences more general lessons on workplace health and safety issues, and to recommend improved practices for the future. These recommendations reflected a great deal of commonsense. They focussed particularly on the importance of identifying hazards, and providing appropriate information to both employers and employees as to the nature of the hazards in question, and as to how the risks associated with those hazards can best be managed. The Inquiry acknowledges the very positive and practical way in which individual submitters who had suffered adverse health effects from exposure to the Hazardous Substances responded to the Terms of Reference.

The principal object of the Inquiry was to identify any gaps in the availability and adoption of best practice systems for the management of the Hazardous Substances in the health, printing and manufacturing sectors, and to identify why those gaps exist.

To achieve that principal objective, the Inquiry was directed to:

In my comments this morning, I will focus on issues relating to the nature and extent of adverse health consequences associated with the Hazardous Substances, and to the management of the Hazardous Substances in workplaces.

The Inquiry was marked by two contrasting features regarding the availability of relevant information.

On the one hand, there is virtually unlimited information available, some from New Zealand sources, but much more from international sources via the internet, relating to the nature of the Hazardous Substances, their potential to cause adverse health effects and how in a general sense they should be managed in workplaces.

At the same time, there is relatively little information available regarding the actual incidence and prevalence of adverse health effects from exposure to the Hazardous Substances and how the Hazardous Substances are, in fact, being managed in workplaces.

OSH currently relies on high-level estimates to make an overall assessment of occupational ill health. It has also carried out a number of audits, which provide some information on the management of safety and health in workplaces, and adverse health effects associated with workplace exposure. Some information on these matters is also provided by OSH's Notifiable Occupational Disease system, but less than might be expected. ACC is not able to provide much information at all in this area.

The Inquiry is not alone in facing a lack of broad and reliable occupational health data. Such a lack is an ongoing issue for OSH and other regulators in New Zealand, and for health and safety regimes around the world.

The best information the Inquiry received related to past experiences in the health sector with glutaraldehyde. Here, the position can be summarised in the following way:

In summary, the gap that existed as regards glutaraldehyde related to the adoption of, rather than to the availability of information about, best practice. There was also a recognition in the submissions that the situation was now much improved and that the health sector is far better at managing, and indeed eliminating, the risk from glutaraldehyde than was the case in the 1990s and earlier. That general sense was confirmed by the visits the Inquiry made to a number of hospitals and other health sector workplaces. It could not be said, however, that the Inquiry was confident that the issues associated with the use of glutaraldehyde in the health sector have been completely dealt with.

The position as regards the other Hazardous Substances is more complex.

There is reasonably comprehensive information available about the toxic effects of exposure to these Hazardous Substances, and their associated potential adverse health effects. There would appear to be little controversy as to the nature of those adverse effects or, in general terms, as to causal links with exposure. Information regarding best management practices is not, however, available for all the other Hazardous Substances, and their wide range of uses in New Zealand, to the extent it is for glutaraldehyde. Whilst there is certainly a significant amount of such information, the level of generality at which much of it is expressed reduces its usefulness.

The Inquiry received less information on the actual incidence of adverse effects associated with exposure to the other Hazardous Substances than it did for glutaraldehyde. The information that was received, together with existing sources of information - principally OSH audits and the NODS system - clearly indicates failures to implement appropriate management practices. Based on the information available to it, the Inquiry was not in a position to draw any new conclusions on the extent of those instances, or of associated adverse health effects. The Inquiry's conclusion as regards the other Hazardous Substances is, therefore, that there would appear to be gaps in both the availability of information about, and the adoption of, best practice, but the significant of those gaps it not clear.

What, then, can this Inquiry say as to why those gaps occurred, and what lessons can be learnt from this Inquiry for the future?

The issues raised by this Inquiry are complex. Any occupational health issue is influenced by a multiplicity of factors, and a temptation to over simplify has to be avoided.

Nevertheless, having carefully considered the information available, the Inquiry's view is that the lessons to be learnt appear to relate to two issues in particular. These are:-

Both of these factors, in the case of the management not only of glutaraldehyde but also of the Hazardous Substances generally, make the preventative aspect of the duties under the Health and Safety in Employment Act of special significance. These factors of latency and individual susceptibility serve to emphasise the importance of the behaviour patterns called for by that Act relating to the systematic identification and assessment of hazards. If, as a first step, a hazard has not been identified and assessed in a formal way, and relevant information communicated to employees, it is much less likely that appropriate hazard control strategies will be adopted in a timely fashion.

These issues were central to many of the submissions the Inquiry received. In many of those submissions, it was the failure to identify the hazard in the workplace, and to provide employees with relevant information following on from that identification, that was central to the concerns of individuals. There was also the concern that, even when the adverse health effects were realised, the fact that only one or two employees may have been affected seemed to count against acceptance of the reality of the problem for those employees. The lack of awareness of occupational health issues amongst doctors was also a concern.

These factors also emphasise the care with which workplace exposure standard levels must be treated. Whilst workplace exposure standards provide a guide to acceptable exposure levels, the objective under the Health and Safety in Employment Act is still to reduce actual and potential exposures as far as practicable below the workplace exposure standard by elimination, isolation, minimisation and protection.

The Inquiry therefore considers that the general issue relating to the way in which employers and others manage the Hazardous Substances is not the availability - at least in theory - of information relating to the Hazardous Substances, adverse health effects associated with them and best or acceptable management practices. Rather the issue is one of the application of that information. Within that, there are issues relating to the provision of that information to employers and employees in a more usable form. These issues, furthermore, are of particular relevance to small to medium enterprises. In the context of the latency and individual sensitivity issues associated with occupational ill health, the approach taken by OSH to the enforcement of the Health and Safety in Employment Act is of particular significance.

Based on those general lessons, the Report concludes a number of specific recommendations. I do not intend to go into the detail of those recommendations this morning. Suffice to say, the recommendations have as their focus:

In concluding, I would like to express my thanks to the Inquiry team.

The Inquiry's expert advisers, Doctors Hilda Firth and Ian Laird, provided me with invaluable support and guidance.

The Inquiry secretariat of John Gilbert, Nick Matsas, Jill Thomson, Joanne Brown and Jo-Anne Lundon performed their roles with skill and dedication.

Finally, I would like to take this opportunity to thank you, Minister, for hosting this function and, in that way, drawing attention to the Inquiry and its report. I think it is appropriate that I express those thanks, not so much on behalf of the Inquiry team itself, but rather on behalf of the many individuals and organisations who both made submissions to and appeared before the Inquiry, and also more generally supported the work of the Inquiry. There is, I think, a general recognition that the issues raised by the Inquiry are complex, and ones to which there are no easy answers. Progress in dealing with those issues will be incremental. An important part of achieving such progress is to increase informed understanding of the issues involved. If the Inquiry can contribute to that improved understanding, my sense is that those who have contributed to it will feel that their contribution has been worthwhile.