NIOSH doctor dismissed; says he was fired for protecting patients

His research links Navy jobs to silicosis

In a case that evokes every occupational health provider’s worst nightmare, a physician with the National Institute for Occupational Safety and Health (NIOSH) in Morgantown, WV, has been fired from his job.

The dismissal occurred after a longstanding and volatile dispute over thousands of Navy veterans who may have undiagnosed silicosis related to their military work. The doctor says he was fired for trying to protect his patients, but others suggest that perhaps he did not handle the dispute as diplomatically as he should have.

Regardless of the clinical outcome, the experience may hold a lesson for other occupational health providers who, inevitably, will face a similar situation at some point in their careers. Such disputes always are difficult, but a careful approach can help you get your patients the help they need.

The NIOSH case concerns Philip Jajosky, MD, MPH, a 23-year veteran of the U.S. Public Health Service. He recently was ordered to leave his post as a public health researcher with NIOSH in what the institute calls "an involuntary retirement."

The dismissal came two months after closed hearings in Rockville, MD, in which a panel determined that Jajosky had defied the NIOSH chain of command and performed poorly.

NIOSH officials did not return calls seeking comment on the dismissal, but Jajosky has plenty to say about it. He is adamant that NIOSH fired him for doing the right thing for his patients, and says the government has nefarious motives for getting rid of him.

He makes repeated comparisons to the notorious Tuskegee experiments of 1932, in which the federal government promised 400 poor black men in Macon County, AL, free treatment for syphilis. The Tuskegee Study, which lasted until 1972, actually had nothing to do with treatment. The public health service was using the men to study the long-term effects of untreated syphilis, and the incident has since become known as one of the worst failings of health care providers to protect their patients.

"I see a direct comparison to Tuskegee," Jajosky says. "We should tell the veterans with sarcoidosis that they might have work-induced lung disease, and the others who did dusty jobs that they might have work-induced lung disease. We have medical information that they do not have, and that’s the way it was with the Tuskegee incident. The government knew and didn’t tell them."

Navy work may be tied to silicosis

Jajosky entered the dispute in 1992, 17 years after a Navy veteran initially approached NIOSH to suggest that his lung disease might be tied to the work he did in the Navy, specifically his work in grinding the rough surface off of aircraft carrier decks. NIOSH had said there was no evidence to support a connection between his Navy work and the lung disease he was suffering years later, but then the dispute came to Jajosky’s attention. He immediately thought there was merit to the veteran’s claim.

"I thought somehow I could handle the situation," Jajosky says. "I was very excited and optimistic in the beginning, but at the same time, I had a sick feeling about the controversy. There were 17 years of conflict between the U.S. government and this black Navy enlisted man."

Jajosky contends that there is a racial element in the government’s refusal to admit a connection between the man’s Navy work and his lung disease. He adds, however, that the main motivation for NIOSH refusing the claim is to avoid a precedent that would change the way future claims are made.

NIOSH and the Public Health Service both operate on a policy that, essentially, requires the military veteran to prove his or her claim that military service led to an occupational disorder, Jajosky says. Since the veteran in this dispute came to NIOSH with his suspicions, NIOSH officials do not want to confirm them and set a precedent in which future claims would have to be investigated and possibly confirmed as the responsibility of the government.

Jajosky also says the government does not want to be responsible for the thousands of potential cases of silicosis that would be uncovered by the response he contends is necessary. NIOSH officials have stated publicly in the past that there is no such motivation and that Jajosky’s superiors merely disagree with him about what the clinical evidence shows.

There is no disputing that thousands of veterans worked in dusty conditions that now would be considered a risk for silicosis, and NIOSH does not deny that many of those men were diagnosed previously with sarcoidosis, a granulomatous disorder of unknown cause. Jajosky says his research proves that many, if not most, of those diagnoses should be changed to silicosis induced by their work in the Navy. (See article on p. 15 for more on Jajosky’s research.)

"Sarcoidosis, by definition, means we have no idea what caused your lung disease," he says. "We have known from the 1940s that sarcoidosis diagnoses have been some of the most important sentinel events for lung disease in American workers. That is the initial diagnosis, and then you find the real cause."

NIOSH refuses to consider the sarcoidosis rates among Navy veterans in dusty jobs as a sentinel event and to follow up with all those who might be suffering from silicosis, he says.

"By and large, the veterans who may have been misdiagnosed don’t know it and can’t be expected to make that connection on their own," he says. "It’s just like the Tuskegee experiment. If you tell a veteran he has sarcoidosis, he thinks it has meaning and you’re telling him it’s not work-related. That’s not necessarily true."

Jajosky says it seems that "even in the post-Tuskegee era, the government wants to preserve a system in which the burden of proof is on the veteran. That is contrary to everything I was taught as a military physician."

A prominent occupational health leader says Jajosky’s dismissal raises disturbing questions about the issue of silicosis diagnoses. The issue may need further study, says Robert McCunney, MD, MPH, director of environmental medicine at the Massachusetts Institute of Technology in Boston and president of the American College of Occupational and Environmental Medicine (ACOEM) in Arlington Heights, IL.

While he says he cannot weigh in on whether Jajosky or NIOSH ultimately is right about whether to pursue the silicosis diagnoses with the veterans, he tells Occupational Health Management that the case is a good study of what happens when an occupational health provider butts heads with an employer or client.

McCunney says he is skeptical of Jajosky’s claims that NIOSH flatly turned down his efforts to pursue the silicosis diagnoses and wonders how well he handled the dispute. It is entirely possible that Jajosky is right about the research but failed in the diplomatic aspects of his job, McCunney says.

"That certainly is a dim view of the situation he has, and I’m not sure that’s reality," he says. "I would be surprised if NIOSH would stonewall his efforts like that, and I’d be shocked if they stonewalled because of the money involved."

McCunney says he is sympathetic to any occupational health provider who has to fight an employer or client to do the right thing for patients, and he says it is not at all a rare occurrence. Most providers will encounter such a problem more than once in a career, he says.

"Absolutely, I can relate to that problem," he says. "I’m aware of situations in which physicians were fired for being overzealous, or sometimes just for being accurate and trying to do the right thing. Unfortunately, it’s not a rare situation for physicians in this specialty."

McCunney says he is a bit surprised to hear of such allegations against a federal agency because he would expect them more from private industry, where the effort to save money on medical care is more intense. He says the Jajosky situation makes him wonder if perhaps Jajosky somehow did not react well to the dispute, even if he was right about the clinical facts.

"He may have been right on the science and sincere about helping the patients, but sometimes that’s not the whole story in terms of getting things done," he says. (See article on p. 17 for McCunney’s advice on dealing with similar disputes.)

Jajosky says he eventually went over his bosses’ heads because he felt the information had to be released, making another allusion to how the Tuskegee experiment was not stopped until it was revealed in an article in The New York Times. Now that he’s out of a job, Jajosky says he was outmaneuvered by a powerful government agency.

"I actually thought things were going to work better; I guess I was delusional there," he says. "When the Surgeon General explained [in a public ceremony] that it was The New York Times that stopped the withholding of medical information from the Tuskegee participants, I just couldn’t get that out of my mind. I thought that if we released the information, we’d do a lot of good.

"I still feel I did the right thing. There’s no doubt in mind about that."

[For more information, contact:

• American College of Occupational and Environ-mental Medicine, 1114 N. Arlington Heights Road, Arlington Heights, IL 60004. Telephone: (847) 818-1800. Fax: 847/818-9266. Web site: http://www. acoem.org.]