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DOCUMENT RESUME 



ED 310 890 



RC 016 823 



AUTHOR 
TITLE 

INSTITUTION 



Greenwood, Judith 

Work Disability in Appalachia. 

West Virginia Univ., Morgantown. School of 

Medicine . 

Dec 87 

21p. 

Information Analyses (070) — Viewpoints (120) 



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PUB TYPE 



EDRS PRICE 
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IDENTIFIERS 



MF01/PC01 Plus Postage. 

*Coal; Labor Legislation; *Mining; Occupational 
Diseases; ^Occupational Safety and Health; ^Physical 
Disabilities; Social History; *Sociocultural 
Patterns; Socioeconomic Influences; Work 
Environment 

* Appalachia; ^Disability Payments; Labor Studies 



ABSTRACT 



This paper begins by examining the history of 



disability payments to disabled workers, specifically disability 
payments to coal workers. Efforts by the United Mine Workers of 
America made mine health and safety an issue in the 1960s, and 
continuing liberalization of the law continued through the 1970s. The 
identification of coal miners with disability is compounded by 
geographical and cultural barriers. Currently underscoring disability 
as a social construct among underground miners is the declining 
regional economy and rising unemployment, brought on by technological 
improvements in mining. The paper examines research about the effects 
of early health intervention among underground coal miners and 
describes other studies of physical disability in Appalachia. All 
cited research supports the same general finding: disability is part 
of an Appalachian life pattern, a natural consequence of work 
occurring before old age. It is common for work to be punctuated with 
periods of temporary disability and to end m disability retirement. 
The uncertainty of mining as long-term employment makes benefits such 
as Social Security and Workers 1 Compensation a necessary station in 
the career course. There can be no solution to disability if 
disability itself is a solution to narrow socioeconomic choices. Only 
long-term improvements in basic education and the economy would 
reduce work disability patterns. (TES) 



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* Reproductions supplied by EDRS are the best that can be made 



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11 



WORK DISABILITY IN APPAIACHIA 



— J. U S DEPARTMENT Or EDUCATION 

Office N Educational Research and Improvement 
EDUCATIONAL RESOURCES INFORMATION 
j CENTER (ERIC) 

Jo This <1ocumeni h,-»s been reproduced as 
'ece'ved from the oerson or organization 
originating it 

O Minor changes have been made to improve 
feproduction quality 



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MATERIAL HAS BEEN GRANTED BY 



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men! oo -»nt necessarily represent official 
OERi poiitio.i or policy 



TO THE EDUCATIONAL RESOURCES 
INFORMATION CENTER (ERIC)." 



WORK DISABILITY IN APPAIACHIA 




* 




WORK DISABILITY IN APPALACHIA 



Judith Greenwood, Ph. D., M.P.H. 
Director of Research and Development 
West Virginia Workers 1 Compensation Fund 

Clinical Associate Professor, Department 
of Comunity Medicine, Department of 
Behavioral Medicine and Psychiatry 
West Virginia University, Morgantown 
West Virginia 



December, 1987 



Coypright C 1986 by Judith G. Greenwood 



ACKNCWIEEGEMENTS 



I would like to thank Dr. R. John C. Pearson, Chairman of the Department 
of Ccmnunity Medicine of West Virginia University, and Dr. Peter S. Barth, 
Professor of Economics, at the University of Connecticut for their reviews. 



As noted in an earlier article: 



The term disability is relative and elastic, molded in 
usage by cultural, social/ economic, and political cir- 
cumstances. . . . Disability is fa] relativistic concept, 
refering to nothing sui generis. 

Yet, since the late 19th century, definitions of disability have been sought 

as Western governmental bodies have adopted social insurance programs to 

[2] 

address the needs of disabled persons over and beyond poverty alone. 



Beginning in Prussia under Bismark, the concept of disability became 
linked to monetary compensation for persons unable to work because of acci- 
dents and sickness or old age. This "model 11 compensation scheme spread across 
Europe. In the United States, federal and state governments moved more slow- 
ly and irregularly in addressing disability. Until 1911, practices in caring 
for the disabled differed from cxrinunity to comnunity with no semblance of any 
system.^ 

In 1911, the first state workers' compensation laws were passed in Wis- 
consin and New York, marking the first step in the emergence of a uniquely 
American disability system blending private, state, and federal obligations 
and responsibilities. The first component of the workers 1 compensation sys- 
tem rested on the philosophy that the government's role was limited to the 
states individually legislating minimum industrial standards, overseeing the 
obligation of employers paying injured workers some portion of pre-injury 
wages , and seeing to it that the worker received seme medical attention . 
There was a great deal of discretion left, up to employers as how to meet this 
obligation. By 1920, all but three states had workers' compensation in seme 
form. 

n 
O 



With the Social Security Act of 1935, states received federal funds for 
the relief of indigent dependent children whose parents were unable to work, 
often because of disability; also elderly adults, and blind persons. The 
concept of disability was thus linked to public welfare. Unemployment in- 
surance also began to meet seme temporary disability needs by paying benefits 
to workers unable to work for specified time periods. Then after two decades 
of federal planning and Congressional debate, in 1956 Social Security Disa- 
bility Insurance wc.s added to the Social Security system to allow a disabled 
worker to receive a pension before reaching retirement age. Entirely fed- 
erally administered, Social Security was built on both enployer and employee 
contributions. Unlike workers 1 compensation, coverage of disability under 
Social Security did not differentiate between whether or not disability arose 
out of a proveable v*ork-related injury or disease, but it did require the test 
of an impairment preventing "substantial gainful activity." 

Established in between the times of the first state workers 1 compensation 
programs and the later federal Social Security disability program was the 
federal-state vocational rehabilitation program. VSnile originally intended to 
relate closely to workers ' compensation programs and later intended to relieve 
any untoward financial inpact of long-term disability costs on Social Secur- 
ity, it, of all disability programs, has been subjected to interest group 
politics both internally - e.g. state agencies creaming the less severely 
disabled to shew program success and thus gaining more federal dollars - and 
externally - e.g. forceful lobby efforts of the United Mine Workers of America 
(described later), the blind, and other disabled groups, most recently those 
with severe neuromuscular disabilities seeking independent living. The fed- 



-2- 



eral state vocational rehabilitation program most clearly demonstrates hew 
"public policy runs counter to the intentions of the policy maker, be- 
cause the program did not develop in close relationship to either workers 1 
compensation or Social Security. 

Beyond the humanitarian intentions of policy makers, utilitarian goals 
have become welded to disability in any context: (i) benefit entitlement for 
individuals who can meet disability criteria, according to regulations, es- 
pecially When a local, regional, or national economy is poor and (ii) politi- 
cal clout for groups invested in the resource management for persons who are 
disabled or deemed to have disabilities. Beyond its origin in the western 
world as a legal and bureaucratic construct related to inability to work 
either on a tanporary or a permanent basis, disability has become an important 
social construct involving politics, economy, labor relations, and family 
relations . 

Underground Goal Mining and Work Related Disability 

Underground coal mining has always been an inherently dangerous occupa- 
tion from its early pick and shovel days to the automated mining of today. 
Contributing to fatalities and injuries have been roof falls, cave-ins, gases, 
dust, lew seams requiring tortuous body positioning; new machine noise and 
machinery that can - and does - sever body parts. While underground coal- 
miners are not a disabled group per se , they have become politically identi- 
fied as at high risk for disability. 

In the mid-20th century, the United Mine Workers of America (UMV™) pushed 
for miners 1 entitlement to rehabilitation. John L. Lewis, president of 



the UMWA worked closely with primary officials in the Social Security Admin- 
istration to set up the UMWA's Welfare and Retirement Fund in 1946/ and fed- 
eral officials worked for the Fund after that. One of the Fund's major goals 
was to provide medical and rehabilitation services to injured miners, services 
that prior to the Fund's establishment had been left up to mine owners and 
company doctors since mines were remote frcm centers of medical care. 

One of Lewis's first dramatic uses of the Fund was for the rehabilitation 
of paralyzed miners.^ Fund officials sent doctors and public health nurses 
into the hills, and they found miners who had lain bed-ridden for years. On 
stretchers they were brought out of the hollcws to roads then taken by ambu- 
lances to local hospitals, then taken on cots to train stations to wait for 
trains taking them to rehabilitation hospitals - Henry Kessler's ir A New Jersy, 
Hcward Rusk's in New York, Kabat-Kaiser in California. 

The continued focus of the UMWA on its most disabled miners brought it in 

conflict with the federal-state vocational rehabilitation program that wanted 

to focus on "better material.' The Fund officials lobbied and pressured 

federal agents to provide more dollars to state vocational rehabilitation 

agencies for union miners. Rehabilitation was not the cnly coal, hcwever; 

once the miners were accepted into the public program, the financial burden of 

caring for the miners was shifted frcm the private sector UMWA Rind. The 

pressure worked, and during the 1950 's it is reported that the "coal mining 

states developed larger and more advanced rehabilitation programs than other 
[6] 

states." This link between rehabilitation and disability promoted by the 
UMWA influence^ Congress in the 1950' s when it debated and then passed the 



Social Security Disability Insurance. As one researcher has pointed out, 
however, the much lobbied for UMWA rehabilitation program probably was not as 
dynamic and efficient as portrayed publicly, or the union would not have had 
to lobby as hard as it did. J 

The UMWA did not immediately lobby with any vigor for coal mine health 
and safety, hcwever, when that became an issue in the 1960's. Ralph Nader 
having achieved victory over the auto industry and unsafe cars, turned to the 
coal industry. To the industry's poor safety record, Nader added a new 
charge: dust exposure leading to occupational disease in miners . Nader's 
charge was based on a Public Health Service Report containing estimates that 
10 percent of active miners and 20 percent of inactive miners had lung di- 
sease. At the grass roots level the charge was supported by an outspoken West 
Virginia physician I.E. Buff who unremittingly attacked the coal industry and 
the dangers of dust exposure in the mines. It was Dr. Buff who coined the 
term "Black Lung." The UMWA, hcwever, was unmoved, by either Nader's or 
Buff's pronouncements. 

Then on November 20, 1968, a Consolodation Coal Conpany mine exploded in 

Farmington, West Virginia, entombing 78 miners. The Farmington disaster 

brought the issue of coal mine safety to the floor of Congress. Subsequent 

[8 91 

Congressional debate and action are well documented. ' J Nearly one year 
after the mine explosion, both the Senate and House had bills on the floor for 
coal mine health and safety, each containing provisions for the canpensation 
of "coal workers 1 pneumoconiosis," each, havever, restricting carpensatlon to 
"complicated pneumoconiosis" based on medical testimony. The bill that energ- 



-5- 

10 



ed frcm the conference camiittee ignored this area of agreement, deleting 
references to "ccrrplicated" frcm the legislation, thus allowing for far broad- 
er coverage. After sane sharp disagreement in the Houre regarding the integ- 
rity of the conference process, the bill passed and then passed in the Senate, 
and Title IV of the 1969 Coal Mine Health and Safety Act became a federalized 
workers' compensation program for miners who were or would beccme totally 
disabled because of pneumoconiosis and to dependent survivors of miners who 
died frcm the disease. 

The 1970' s saw a liberalization of the law. Union lobby new joined an 
active grass roots lobby and coupled with powerful and well-placed Congres- 
sional support gained amendments to the original legislation allowing for 
presumptive respiratory disability based on number of years spent in coal- 
mining; a positive X-ray was no longer necessary. Then came the most liberal 
version of the program with amendments passed in 1978. The new amendments 
mandated a review or reprocessing of all claims previously denied. "Miner" 
was redefined to include any worker in or around a coal mine. Continuing 
work, even continuing work in a coal mine, could not be used to refute a 
disability claim. 

Regarding the outcome of the liberalization of the Black Lung Program 

during the 1970' s, one writer has observed that "...the hundreds of thousands 

of successful beneficiaries actually exceeded the wildest possible goals set 

by the program's supporters in 1969. , ^ 10 -' Another writer observes: "Through a 

classic confluence of interest group politics and public relations, the Black 

Lung Program mushroomed into a billion dollar a year permanent federal pro- 
M [ll] 

gram." 1 " Both writers note that in many ways the Black Lung Program re- 



sembled a pension program responsive to social need . During the decade fol- 
lowing the Coal Mine Health and Safety Act, automation of the mines produced 
significant reductions in manpower requirements . Unemployment in mining 
counties was increasing; seme mine owners were moving toward operating non- 
union mines. To qualify for black lung benefits became the goal of many 
miners • 

Qiaract eristics of Appalachia 

The sociopolitical identification of coal miners with disability is 
compounded by geography and culture* In the United States much of the under- 
ground coal mining is located in Appalachia, a mountainous region running from 
northeast Alabama and northwest Georgia up through southwest South Carolina/ 
eastern Tennessee, eastern Kentucky, West Virginia, and southwestern Pennsyl- 
vania. Within that area, the bulk of the coal mining is in Kentucky and West 
Virginia. 

The mountainous nature of the region naturally restricts mobility and 
social interactions. Clay roads are common, and beccms mud roads in the 
winter and spring. Original settlers sold off the wealth of timber and miner- 
al rights, thus only the tof clay soil and rocks remained for any ownership . 
Then mining companies came in and bought up much of the land. The company 
towns have now gone, except for rews of identical small houses in some places, 
and trailers in Which many miners live are now often placed on rented land, 
Intellectual and cultural resource within the population is comparatively 
diminished , and educational opportunities and resources are circumscribed . 
Deprivation is a way of life in many of the hollows along the creek branches 



of Appalachia and has been sensitively described in detail by a nurse anthro- 
pologist^ 12 ^ 

If one who has been born and bred and worked in Appalachia becomes dis- 
abled by injury or disease, function Which has always been limited anyway is 
sinply further limited ♦ Within this geographical, cultural, and social con- 
text, disability does not controvert a pattern of life as it does in more 
mainstream middle-class America, but seems to magnify all the restrictions 
inherently present. 

Currently underscoring disability as a social construct among underground 

coal miners is the declining economy of the region in terms of unemployment 

brought about by mechanization of mining . In 1976. there were 9,050 mining 

jobs in the leading coal producing county in West Virginia; in 1986 there were 
[13] 

2,760, Unemployment in that county is over 25 percent* Weekly workers 1 

compensation disability benefits are almost $100 nore than unemployment 

benefits • Thus the awarding of disability benefits following injury or dust 

or noise exposure in the mines has become a matter of increasing controversy 

between workers and their employers . Despite the rich coal seams and the 

efficiency of machine mining, seme coal employers are finding the costs of 

disability impeding their ability to do business . Among enlightened coal 

employers, there is increased interest in intervening in what has been de- 

P141 

scribed elsewhere as "the disability process" 1 * following injury, 

-8- 



-3 



Studies on Disability in Appalachia 



A controlled demonstration project was undertaken by of the West Virginia 
Workers 1 Compensation Fund to assess the cost-effectiveness of early inter- 
vention among underground coal miners having back injuries resulting in time 
lost frcm work. The intervention consisted of a rehabilitation nurse making a 
health and psychosocial evaluation of injured workers within a week or two 
after injury followed by a nurse and a counselor providing guidance to workers 
deemed at risk for extended disability and coordinating primary care, spec- 
ialty, and physical therapy services. Unexpectedly, the findings from the 

study are not statistically significant and do not support this early inter- 
[15] 

vention approach. These findings counter other research and policy sup- 

Tl6l 

porting early intervention and raise questions regarding why this ap- 

proach failed to reduce the length and cost of workers 1 disability. Certain 
factors external to the intervention itself may help to explain the findings. 



First is the depressed socioeconomic condition in the geographical area 
from which the study sample came. Several small mining companies operating at 
the time of the study have closed, and two of the larger companies have closed 
mines and reduced personnel. There are few alternative employments in region. 



Second is the intimidation of health care providers by union officials 
and attorneys who are hostile toward overt return-to-work treatment inter- 
ventions. When confronted by staff involved in the early intervention study, 

a local hospital administrator responded, "We can't be known as an organi- 

[17] 

zation supporting a group that gets people back to work.' 



-9- 

>4 



Third, 47% of miners whose back injury had resulted in their entering the 
study had had previous injuries, and 30% had previous partial disability 
awards as a result of injury meaning that according to medical judgement, they 
had permanently lost a certain percentage of normal body function. These 
injury rates can be interpreted at two levels: first, to verify that coal 
mining is a high risk occupation; second, to shew that for an individual miner 
injuries and aggravations of previous injuries can make disability part of the 
pattern of life. 

Other studies have addressed disability in Appalachia. In 1952, Wiesel 

and Arny described "miners 1 syndrome" after studing 100 coal miners in Harlan 
[18] 

County Kentucky. The syndrome was characterized by numerous somatic 

complaints, a passive dependent attitude, a lack of anxiety with rationaliza- 
tions of being exposed to "bad air," hard work, and "nerves being run down." 
The researchers found both advantages and disadvantages to the then extant 
UMWA Welfare and Retirement Fund and noted that it fostered dependency and a 
chronic invalid reaction. 

Cock in assessing psychosocial barriers to rehabilitation in Appalachia 
in 1967 concluded that many individuals Who live in the restricted geograph- 
ical and social environments, the hollows and valleys and small rural mining 

tewns, have adapted to restriction and confinement, both of which are also 

[191 

elements of disability. J Cock noted dependency as a significant factor 
"that inhibits restoration to productivity," and that dependency is particu- 
larly evident among coal miners in Appalachia who have over decades had two 
major authority figures: the cenpany and the union. First, the ccmpany 



provided not only work for the miner/ but his house and the script for food 
and clothes at the company store. With the development of the UMWA, the miner 
transferred much dependency to the union for advocacy. In both cases, how- 
ever, autonomy and self-direction have been inhibited. 



Ludwig in 1982 described the conrrcn affliction of "nerves" and resulting 
disability among individuals, both men and vvomen, in Appalachia. "Nerves" 
appears to be 



. . .a conglomerate term to encompass chronic anxiety 
without panic, mild depression without despair, neu- 
rasthenia without malaise, a smattering of hypochond- 
riasis, and a surfeit of illness behavior, all 
superimposed on passive, dependent individuals with bor- 
derline normal intelligence and exposed to profound socio- 
cultural deprivation. ^ ^ 

Horton looked at patterns of illness in an Appalachian ocmmunity in 1984 
and noted: 



In this area of Appalachia [Lincoln County, West Virginia], 
disability is not experienced as it would be in the gen- 
eral middle-class United States, as a sharp insulting 
surprise . Dibability is not only inevitable, but it 
inevitably acocntpanies age. As one informant explained, 
that it is not a matter of 'if you'll be crippled, only 
'when. ' 



Human bodies, 'poor flesh at best,' are not presumed to 
function well, especially s they grew older. An invading 
set of ailments - 'arthuritis' (arthritis), 'sugar' (dia- 
betes), 'highblood* (hypertension) - are expected by the 
age of forty. As with injuries, these disorders are 
judged to be irremediable and irreversible. Even fit, 
healthy, hardvvorking young males are resigned to being 
'past it' by their thirtieth birthday. 



"ERIC 



-11- 



6 



Horton further speculates that back pain among men and headaches among women 

may be somatoform disorders, with belief in their inevitable occurrence as 
T221 

the pathogen. 



These separate studies, unrelated to cne another, all support the same 
general finding: disability is part of an Appalachian life pattern before old 
age. 

Discussion 

In light of the studies just cited and the politics of disability rela- 
tive to underground coal mining, one can conclude that in central Appalachia 
work and disability are related concepts with disability perceived as a natur- 
al consequence of work. It is common for work to be punctuated with periods 
of temporary disability and to end in disability retirement. 

At a systems level, disability is well supported. The Black Lung Pro- 
gram, while modified by amendment in 1981 to limit a number of the liberal 

provisions of the 1970' s amendments, was by no means "completely reform- 
[23] 

ed." It remains a quasi-pension program retaining essentially lenient 

definitions and procedures. In the broader system of workers ' compensation, 
when permanent total disability occurs as the result of the combined effects 
of a work-related injury and a pre-existing impairment frcm injury or di- 
sease, benefits to cover the pre-existing impairment portion of total dis- 
ability may be paid out of special set-aside funds. This method of disability 
coverage is prcminant in the two Appalachian coal mining states of West Virginia 
and Kentucky. The employer is held responsible only for benefits related to 



the subsequent work-related injury* Thus an employer can use pre-existing 
impairment as a way to dismiss any protracted litigation over a claim and to 
contain any future disability loss for one worker, and a worker can gain an 
honorable retirement. The question of whether the worker is truly totally 
disabled frcm work is relatively unirrportant. 

In other cases , Social Security benefits can be the next step after 

Workers 1 Compensation. And for many persons deemed unable to be gainfully 

employed for 12 months or longer, because of physical impairment, but who 

cannot claim a work-related injury, Social Security benefits may be the only 

recourse. West Virginia according to the most recent data available has 74 

disabled worker beneficiaries per 1,000 insured workers, the highest rate in 

the ration and quite significantly higher than the rational average of 35 

[24] 

disabled workers per 1,000 insured workers. Kentucky's rate of 48 dis- 

abled vorker beneficiaries per 1,000 workers, vtfiile considerably below West 
Virginia's rate, is still higher than the national average. 

What possibilities are there for change? First, it is clear that in West 
Virginia geography, high risk occupations (timbering and glass manufacturing 
in addition to mining), politics, and economy together with disability benefit 
administration systems backed by liberal court decisions can make disability a 
station in the career course, rather than an adverse interruption or an ad- 
versity to be mounted. In a region where the economy is limited and educa- 
tional levels are lew, vocational rehabilitation is generally not a premising 
alternative for disabled workers vho have worked in heavy labor* Early inter- 
vention in the course of disability may be more premising, but the lack of 



-13- 

i s 



cost-effectiveness in one research project leaves sane doubt . It would seen 
that only long term improvements in basic education and the economy would 
reduce work disability in Appalachian Lucwig frcm a study of Social Security 
Disability recipients in Kentucky, has observed: 



Any long-range remedy will have to be directed toward 
prevention both in the very young and future generations. 
In the education arena, special programs would have to be 
constructed for predisposed children at the pre-school and 
elementary school levels to make learning a more exciting 
process and to broaden their intellectual horizons . ... 



The presumed end product of this educational process will 
be psychologically minded individuals who can recognize 
the contributions of interpersonal and personal problems 
and their frustrations in resolving them to the distress- 
ing symptoms they experience. . . . Instead of a fatalistic 

world view of accepting their lot in life, social activism 

T251 

must beccme a credible alternative* 



Ludwig's solution through an improved educational process, however, cannot be 
realized without an economy that offers individuals job and career alterna- 
tives, that gives them a sense of control over their circumstances. Without 
economic options, disability _is a solution to unavailable or dissatisfactory 
jobs with both legal and bureaucratic accomodation of compensation. The Black 
Lung Program is the quintessential realization of such a solution. There can 
be no solution to disability if disability is itself a solution to a limited 
socioeconomic environment. 



-14- 



REFERENCES 



1. Greenv*xx3, J. G. Disability Dilemmas and Rehabilitation Tensions: A 
Twentieth Century Inheritance. Social Science and Medicine, 20 (12), p. 
1242, 1985. 

2. The "poor law" in England in 1601 first established secular and legal 
obligations beyond religious and moral to help individuals in unfortunate 
circumstances . 

3. Berkcwitz, E. D. The American Disability System in Historical Perspec- 
tive. In Disability Policies and Government Programs, E. D. Berkowitz, 
ed. p. 17, Praeger, New York, 1979. 

4. ibid. p. 67 

5. Berkcwitz, E. D. Growth of the U. S. Social Welfare System in the Post- 
World War II Era: The UMW, Rehabilitation, and the Federal Government. 
Research in Economic History, 5, p. 238, 1980. 

6. ibid. p. 242 

7. ibid. p. 244 

8. Barth, P. The Tragedy of Black Lung : Federal Compensation for Occupa- 
tional Disease . W. E. Upjohn Institute for Employment Research, Kala- 
mazoo, MI, 1987. 

9. Nelson, J. R. Black Lung: A Study of Disability Ccrrpensation Policy 
Formation. The School of Social Service Administration, University of 
Chicago, 1985. 

10. Barth, op. cit. p. 284. 

11. Nelson, op. cit. p. 155. 

12. Gazaway, R. The Longest Mile . Doubleday and Co., Garden City, N. Y. 
1969. 




13. Baker, N. Vanishing Coal Economy: McDowell Hopes fo r Repl acement . 
Sunday Gazette-Mail. Section D, p.l, Charleston, WV, Nov., 11-23, 1986. 

14. Weinstein, M. R. The Concept of the Disability Process. Psychosomatics, 
19 (2), 94-97, 1978. 

15. West Virginia Workers 1 Compensation Fund. Very Early Intervention Pro- 
ject: Management Report II. Charleston, WV, January, 1988. 

16. Hood, L. E. and Downs, J. D. Return to Work: A Literature Review. The 
Menninger Rehabilitation Research and Training Center. Preventing Disa- 
bility Dependence. The Menninger Foundaton. Topeka, KA, 1985 . 

17. Administrator, rural hospital in West Virginia, 1985 . 

18. Wiesel, C. and Amy, M. Psychiatric Study of Coal Miners in Eastern 
Kentucky Area. American Journal of Psychiatry, 108:617-624, 1952. 

19. Cook, T. D. Psychosocial Barriers to Rehabilitation in Appalachia. 
Rehabilitation Counseling Bulletin XL, 98-105, 1967. 

20. Ludwig, A,M. "Nerves": A Sociomedical Diagnosis . ..of Sorts. American 
Journal of Psychotherapy, 36(3) :350-357, 1982. 

21. Horton, C. F. Women Have Headaches, Men Have Backaches: Patterns of 
Illness in an Appalachian Community. Social Science and Medicine, 19(6) 
647-654, 1984. 

22. ibid . p. 653 

23. Barth, op.cit. p. 258. 

24. Social Security Administration. Notes and Brief Reports. Social Secur- 
ity Bulletin, 42(5), 1979 . 

25. Ludwig, op.cit. p. 354. 



'eric