Occupational health services in the United States have always been divided in function and control. The extent to which government at any level should make rules affecting working conditions has been a matter of continuing controversy. Furthermore, there has been an uneasy tension between the state and federal governments about which should take primary responsibility for preventive services based primarily upon laws governing workplace safety and health. Monetary compensation for workplace injury and illness has primarily been the responsibility of private insurance companies, and safety and health education, with only recent changes, has been left largely to unions and corporations.
It was at the state level that the first governmental effort to regulate working conditions took place. Occupational safety and health laws began to be enacted by states in the 1800s when increasing levels of industrial production began to be accompanied by high accident rates. Pennsylvania enacted the first coal mine inspection act in 1869, and Massachusetts was the first state to pass a factory inspection law in 1877.
By 1900 the more industrialized states had some laws in place regulating some workplace hazards. Early in the twentieth century, New York and Wisconsin led the nation in developing more comprehensive occupational safety and health programmes.
Most states adopted worker’s compensation laws mandating private no-fault insurance between 1910 and 1920. A few states, such as Washington, provide a state-run system allowing the collection of data and the targeting of research goals. The compensation laws varied widely from state to state, were generally not well enforced, and omitted many workers, such as agricultural workers, from coverage. Only railway, longshore and harbour workers, and federal employees have national worker’s compensation systems.
In the first decades of the twentieth century, the federal role in occupational safety and health was largely restricted to research and consultation. In 1910 the Federal Bureau of Mines was established in the Department of the Interior to investigate accidents; consult with industry; conduct safety and production research; and provide training in accident prevention, first aid and mine rescue. The Office of Industrial Hygiene and Sanitation was created in the Public Health Service in 1914 to conduct research and assist states in solving occupational safety and health problems. It was located in Pittsburgh because of its close association with the Bureau of Mines and its focus on injuries and illnesses in the mining and steel industries.
In 1913 a separate Department of Labor was established; the Bureau of Labor Standards and the Interdepartmental Safety Council were organized in 1934. In 1936, the Department of Labor began to assume a regulatory role under the Walsh-Healey Public Contracts Act, which required certain federal contractors to meet minimum safety and health standards. Enforcement of these standards was often carried out by the states with varying degrees of effectiveness, under cooperative agreements with the Department of Labor. There were many who felt that this patchwork of state and federal laws was not effective in preventing workplace injuries and illnesses.
The Modern Era
The first comprehensive federal occupational safety and health laws were passed in 1969 and 1970. In November 1968, an explosion in Farmington, West Virginia, killed 78 coalminers, providing impetus to the demands of the miners for tougher federal legislation. In 1969, the Federal Coal Mine Health and Safety Act was passed, which set mandatory health and safety standards for underground coal mines. The Federal Mine Safety and Health Act of 1977 combined and expanded the 1969 Coal Mine Act with other earlier mining laws and created the Mine Safety and Health Administration (MSHA) to establish and enforce safety and health standards for all mines in the United States.
It was not a single disaster, but a steady rise in injury rates during the 1960s that helped spur passage of the Occupational Safety and Health Act of 1970. An emerging environmental consciousness and a decade of progressive legislation secured the new omnibus act. The law covers the majority of workplaces in the United States. It established the Occupational Safety and Health Administration (OSHA) in the Department of Labor to set and enforce federal workplace safety and health standards. The law was not a complete break from the past in that it contained a mechanism by which states could administer their own OSHA programmes. The Act also established the National Institute for Occupational Safety and Health (NIOSH), in what is now the Department of Health and Human Services, to conduct research, train safety and health professionals and develop recommended safety and health standards.
In the United States today, occupational safety and health services are the divided responsibility of a number of different sectors. In large companies, services for treatment, prevention and education are primarily provided by corporate medical departments. In smaller companies, these services are usually provided by hospitals, clinics or physicians’ offices.
Toxicological and independent medical evaluations are provided by individual practitioners as well as academic and public sector clinics. Finally, governmental entities provide for the enforcement, research funding, education and standard setting mandated by occupational safety and health laws.
This complex system is described in the following articles. Drs. Bunn and McCunney from the Mobil Oil Corporation and the Massachusetts Institute of Technology, respectively, report on corporate services. Penny Higgins, RN, BS, of Northwest Community Healthcare in Arlington Heights, Illinois, delineates the hospital-based programmes. The academic clinic activities are reviewed by Dean Baker, MD, MPH, the Director of the University of California, Irvine’s Centre for Occupational and Environmental Health. Dr. Linda Rosenstock, Director of the National Institute for Occupational Safety and Health, and Sharon L. Morris, Assistant Chair for Community Outreach of the University of Washington’s Department of Environmental Health, summarize government activities at the federal, state and local levels. LaMont Byrd, the Director of Health and Safety for the International Brotherhood of Teamsters, AFL-CIO, describes the various activities provided to the membership of this international union by his office.
This division of responsibilities in occupational health often leads to overlapping, and in the case of workers’ compensation, inconsistent requirements and services. This pluralistic approach is both the strength and weakness of the system in the United States. It promotes multiple approaches to problems, but it can confuse all but the most sophisticated user. It is a system that often is in flux, with the balance of power shifting back and forth among the key players—private industry, labour unions, and state or federal governments.
Every employer is contractually obligated to take precautions to guarantee the safety of his employees. The labour-related rules and regulations to which attention must be paid are of necessity just as various as the dangers present in the workplace. For this reason, the Occupational Safety Act (ASiG) of the Federal Republic of Germany includes among the duties of employers a legal obligation to consult specialist professionals on matters of occupational safety. This means that the employer is required to appoint not only specialist staff (particularly for technical solutions) but also company doctors for medical aspects of occupational safety.
The Occupational Safety Act has been in effect since December 1973. There were in the FRG at that time only about 500 doctors trained in what was called occupational medicine. The system of statutory accident insurance has played a decisive role in the development and construction of the present system, by means of which occupational medicine has established itself in companies in the persons of company doctors.
Dual Occupational Health and Safety System in the Federal Republic of Germany
As one of five branches of social insurance, the statutory accident insurance system makes a priority the task of taking all appropriate measures to ensure prevention of work accidents and occupational diseases through detection and elimination of work-related health hazards. In order to fulfil this legal mandate, legislators have granted extensive authority to a self-governing accident insurance system to enact its own rules and regulations concretizing and shaping the requisite preventive precautions. For this reason, the statutory accident insurance system has—within the bounds of existing public law—taken over the role of determining when an employer is required to take on a company doctor, what expert qualifications in occupational medicine the employer may demand of the company doctor and how much time the employer may estimate that the doctor will have to spend on the care of his employees.
The first draft of this accident prevention regulation dates from 1978. At that time, the number of available doctors with expertise in occupational medicine did not appear sufficient to provide all businesses with the care of company doctors. Thus the decision was made at first to establish concrete conditions for the larger businesses. At that time, to be sure, the businesses belonging to large-scale industry had often already made their own arrangements for company doctors, arrangements which already met or even exceeded the requirements stated in the accident prevention regulations.
Employment of a Company Doctor
The hours allocated in firms for the care of employees—called assignment times—are established by the statutory accident insurance system. Knowledge available to insurers concerning the existing risks to health in the various branches formed the basis for the calculation of the assignment times. The classification of firms with regard to particular insurers and the evaluation of possible health risks undertaken by them were thus the basis for the assignment of a company doctor.
Since the care rendered by company doctors is an occupational safety measure, the employer must cover the costs of assignment for such doctors. The number of employees within each of the several areas of hazard multiplied by the time allocated for care determine the sum of financial expenses. The result is a range of different forms of care, since it can pay—depending on the size of a firm—either to employ a doctor or doctors full-time, that is as the company’s own, or part-time, with services rendered on an hourly basis. This variety of requirements has led to a variety of organizational forms in which occupational medical services are offered.
The Duties of a Company Doctor
In principle, a distinction should be made, for legal reasons, between the provisions made by companies to provide care for employees and the work done by the doctors in the public health system responsible for the general medical care of the population.
In order to differentiate clearly which services of occupational medicine employers are responsible for, which are given in figure 1, the Occupational Safety Act has already anchored in law a catalogue of duties for company doctors. The company doctor is not subject to the orders of the employer in the fulfilment of these tasks; still, company doctors have had to fight the image of an employer-appointed doctor up to the present day.
Figure 1. The duties of occupational physicians employed by companies in Germany
One of the essential duties of the company doctor is the occupational medical examination of employees. This examination can become necessary according to the specific features of a given concern, if particular working conditions exist which lead the company doctor to offer, of his own accord, an examination to the employees involved. He cannot, however, force an employee to allow himself to be examined by him, but must rather convince him through trust.
Special Preventive Checkups in Occupational Medicine
There exists, in addition to this kind of examination, the special preventive check-up, participation in which by the employee is expected by the employer on legal grounds. These special preventive checkups end in the issuance of a doctor’s certificate, in which the examining doctor certifies that, based on the examination conducted, he has no objection to the employee’s engaging in work at the workplace in question. The employer may assign the employee only once for each certificate issued.
Special preventive checkups in occupational medicine are legally prescribed if exposure to particular hazardous materials occurs in the workplace or if particular hazardous activities belong to job practice and such health risks cannot be excluded through appropriate occupational safety precautions. Only in exceptional circumstances—as is the case, for example, with radiation protection checkups—is the legal requirement that an examination be performed supplemented by legal regulations concerning what the doctor carrying out the examination must pay attention to, which methods he must apply, which criteria he must use to interpret the outcome of the examination and which criteria he must apply in judging health status with regard to work assignments.
This is why in 1972 the Berufsgenossenschaften, made up of commercial trade associations which provide the accident insurance for trade and industry, authorized a committee of experts to work out commensurate recommendations to doctors working in occupational medicine. Such recommendations have existed for more than 20 years. The Berufsgenossenschaften Guidelines for Special Preventive Checkups, listed in figure 2, now show a total of 43 examination procedures for the various health hazards which can be countered, on the grounds of present knowledge, with appropriate medical precautionary measures so as to prevent diseases from developing.
Figure 2. A summary information on external services of the Berufgenossenschaften in the German building industry
The Berufsgenossenschaften deduce the mandate to make available such recommendations from their duty to take all appropriate measures to prevent occupational diseases from arising. These Guidelines for Special Preventive Checkups are a standard work in the field of occupational medicine. They find application in all spheres of activity, not only in enterprises in the sphere of trade and industry.
In connection with the provision of such occupational medical recommendations, the Berufsgenossenschaften also took steps early on to ensure that in businesses lacking their own company doctor the employer would be required to arrange for these preventive checkups. Subject to certain basic requirements having to do primarily with the specialized knowledge of the doctor, but also with the facilities available in his or her practice, even doctors without expertise in occupational medicine can acquire the authority to offer companies their services in performing preventive checkups, contingent on a policy administered by the Berufsgenossenschaften. This was the precondition for the current availability of the total of 13,000 authorized doctors in Germany who perform the 3.8 million preventive checkups performed annually.
It was the supply of a sufficient number of doctors that also made it possible legally to require that employers initiate these special preventive checkups in complete independence of the question of whether or not the company employs a doctor prepared to do such checkups. In this way, it became possible to use the statutory accident insurance system to ensure enforcement of certain measures of health protection at work, even at the level of small businesses. The relevant legal regulations may be found in the Ordinance on Hazardous Substances and, comprehensively, in the accident prevention regulation, which regulates the rights and duties of the employer and the examined employee and the function of the licensed doctor.
Care Provided by Company Doctors
The statistics released annually by the Federal Board of Doctors (Bundesärztekammer) show that for the year 1994 more than 11,500 doctors fulfil the prerequisites, in the form of specialist knowledge in industrial medicine, to be company doctors (see table 1). In the Federal Republic of Germany, the organization Standesvertretung representing the medical profession regulates autonomously which qualifications must be met by doctors as regards study and subsequent professional development before they may become active as doctors in a given field of medicine.
Table 1. Doctors with specialist knowledge in occupational medicine
Field designation “occupational medicine”
Additional designation “corporate medicine”
Specialist knowledge in occupational medicine
* As of 31 December 1995.
The satisfaction of these prerequisites for the activity of a company doctor represents either the attainment of the field designation “occupational medicine” or of the additional designation “corporate medicine”—that is, either four years’ further study after the licence to practice in order to be active exclusively as a work physician, or three years’ further study, after which activity as a company doctor is allowed only in so far as it is connected with medical activity in another field (e.g., as an internist). Doctors tend to prefer the second variant. This means, however, that they themselves see the chief emphasis of their professional work as physicians in a classical field of medical activity, not in occupational medical practice.
For these doctors, occupational medicine has the significance of an auxiliary source of income. This explains at the same time why the medical element of the examination by doctors continues to dominate the practical exercise of the profession of company doctor, although the legislature and the statutory accident insurance system themselves emphasize inspection of companies and medical advice given to employers and employees.
In addition, there still exists a group of doctors who, having acquired specialist knowledge in occupational medicine in earlier years, met different requirements at that time. Of particular significance in this regard are the standards which doctors in the former German Democratic Republic were required to meet in order to be allowed to practice as company doctors.
Organization of Care Provided by Company Doctors
In principle, it is left up to the employer to choose freely a company doctor for the firm from among those offering occupational medical services. Since this supply was not yet available subsequent to the establishment, in the early 1970s, of the relevant legal preconditions, the statutory accident insurance system took the initiative in regulating the market economy of supply and demand.
The Berufsgenossenschaften of the building industry instituted their own occupational medical services by engaging doctors with specialist knowledge in occupational medicine in contracts to provide care, as company doctors, to the firms affiliated with them. Via their statutes, the Berufsgenossenschaften arranged for each of their firms to be cared for by its own occupational medical service. The costs incurred were distributed among all the firms through appropriate forms of financing. A summary of information concerning external occupational medical services of the Berufsgenossenschaften of the building industry is given in table 2.
Table 2. Company medical care provided by external occupational medical services,1994
Doctors providing care as primary occupation
Doctors providing care as secondary occupation
Employees cared for
83 mobile: 46
175 mobile: 7
1 ARGE Bau = Workers’ Community of the Berufgenossenschaften of Building Industry Trade Associations.
2 BAD = Occupational Medical Service of the Berufgenossenschaften.
3 IAS = Institute for Occupational and Social Medicine.
4 TÜV = Technical Control Association.
5 AMD Würzburg = Occupational Medical Service of the Berufgenossenschaften.
The Berufsgenossenschaften for the maritime industry and that for domestic shipping also founded their own occupational medical services for their businesses. It is a characteristic of all of them that the idiosyncrasies of the businesses in their trade—non-stationary enterprises with special vocational requirements—were a decisive factor in their taking the initiative to make clear to their companies the necessity for company doctors.
Similar considerations occasioned the remaining Berufsgenossenschaften to unite themselves in a confederation in order to found the Occupational Medical Service of the Berufsgenossenschaften (BAD). This service organization, which offers its services to every enterprise in the market, was enabled at an early stage by the financial collateral provided by the Berufsgenossenschaften to be present over the entire area of the Federal Republic of Germany. Its broad coverage, as far as representation goes, was meant to ensure that even those businesses located in the Federal states, or states of relatively poor economic activity, of the Federal Republic would have access to a company doctor in their area. This principle has been maintained up to the present time. The BAD is considered, meanwhile, the largest provider of occupational medical services. Nonetheless, it is forced by the market economy to assert itself against competition from other providers, particularly within urban agglomerations, by maintaining a high level of quality in what it provides.
The occupational medical services of the Technical Control Association (TÜV) and of the Institute for Occupational and Social Medicine (IAS) are the second- and third-largest transregional providers. There are in addition numerous smaller, regionally active enterprises in all of the Federated States of Germany.
Cooperation with Other Providers of Services in Occupational Health and Safety
The Occupational Safety Act, as a legal foundation for care provided to companies by company doctors, provides also for professional supervision of occupational safety, particularly in order to ensure that aspects of occupational safety be handled by personnel schooled in technical precautions. The requirements of industrial practice have changed meanwhile to such an extent that technical knowledge regarding questions of occupational safety must now be supplemented more and more by familiarity with questions of the toxicology of materials used. In addition, questions of ergonomic organization of work conditions and of the physiological effects of biological agents play an increasing role in evaluations of stresses in a place of work.
The requisite knowledge may be mustered only through interdisciplinary cooperation of experts in the field of health and safety at work. Therefore, the statutory accident insurance system supports particularly the development of forms of organization which take such interdisciplinary cooperation into account at the organizational stage, and creates within its own structure the preconditions for this cooperation by redesigning its administrative departments in a suitable fashion. What was once called the Technical Inspection Service of the statutory accident insurance system turns into a field of prevention, within which not only technical engineers but also chemists, biologists and, increasingly, physicians are active together in designing solutions for problems of labour safety.
This is one of the indispensable prerequisites for creating a basis for the type of organization of interdisciplinary cooperation—within businesses and between safety technology service organizations and company doctors—required for efficient solution of the immediate problems of occupational health and safety.
In addition, supervision in respect of safety technology should be advanced, in all companies, just as much as supervision by company doctors. Safety specialists are to be employed by businesses on the same legal basis—the Occupational Safety Act—or appropriately trained personnel affiliated with the industry are to be supplied by the businesses themselves. Just as in the case of the supervision provided by company doctors, the accident prevention regulation, Specialists for Occupational Safety (VBG 122), has formulated the requirements according to which businesses must employ safety specialists. In the case of safety-technical supervision of businesses as well, these requirements take all necessary precautions to incorporate each of the 2.6 million firms currently comprising the commercial economy as well as those in the public sector.
Around two million of these firms have fewer than 20 employees and are classed as small industry. With the full supervision of all enterprises, that is, including the smaller and smallest of businesses, the statutory accident insurance system creates for itself a platform for the establishment of occupational health and safety in all areas.
The coverage of workers in small-scale enterprises (SSEs) is perhaps the most daunting challenge to systems for delivering occupational health services. In most countries, SSEs comprise the vast majority of the business and industrial undertakings—reaching as high as 90% in some of the developing and newly industrialized countries—and they are found in every sector of the economy. They employ on average nearly 40% of the workforce in the industrialized countries belonging to the Organization for Economic Cooperation and Development and up to 60% of the workforce in developing and newly industrialized countries. Although their workers are exposed to perhaps an even greater range of hazards than their counterparts in large enterprises (Reverente 1992; Hasle et al. 1986), they usually have little if any access to modern occupational health and safety services.
Defining Small-Scale Enterprises
Enterprises are categorized as small-scale on the basis of such characteristics as the size of their capital investment, the amount of their annual revenues or the number of their employees. Depending on the context, the number for the last category has ranged from one to 500 employees. In this article, the term SSE will be applied to enterprises having 50 or fewer employees, the most widely accepted definition (ILO 1986).
SSEs are gaining importance in national economies. They are employment-intensive, flexible in adapting to rapidly changing market situations, and provide job opportunities for many who would otherwise be unemployed. Their capital requirements are often low and they can produce goods and services near the consumer or client.
They also present disadvantages. Their lifetime is often brief, making their activities difficult to monitor and, frequently, their small margins of profits are achieved only at the expense of their workers (who are often also their owners) in terms of hours and intensity of workloads and exposure to occupational health risks.
The Workforce of SSEs
The workforce of SSEs is characterized by its diversity. In many instances, it comprises the manager as well as members of his or her family. SSEs provide entry to the world of work for young people and meaningful activities to elderly and redundant workers who have been separated from larger enterprises. As a result, they often expose such vulnerable groups as children, pregnant women and the elderly to occupational health risks. Further, since many SSEs are carried out in or near the home, they often expose family members and neighbours to the physical and chemical hazards of their workplaces and present public health problems through contamination of air or water or of food grown near the premises.
The educational level and socio-economic status of SSE workers vary widely but are often lower than the averages for the entire workforce. Of particular relevance is the fact that their owners/managers may have had little training in operation and management and even less in the recognition, prevention and control of occupational health risks. Even where appropriate educational resources are made available, they often lack the time, energy and financial resources to make use of them.
Occupational Hazards in SSEs and the Health Statusof their Workers
Like all other aspects of SSEs, their working conditions vary widely depending on the general nature of the enterprise, the type of production, the ownership and location. In general, the occupational health and safety hazards are much the same as those encountered in larger enterprises, but as noted above, the exposures to them are often substantially higher than in large enterprises. Occasionally, however, the working conditions in SSEs may be much better than those in larger enterprises with a similar type of production (Paoli 1992).
Although very few studies have been reported, it is not surprising that surveys of the health of workers in SSEs in such industrialized countries as Finland (Huuskonen and Rantala 1985) and Germany (Hauss 1992) have disclosed a relatively high incidence of health problems, many of which were associated with lowered capacity for work and/or were work-related in origin. In SSEs in developing countries an even higher prevalence of occupational diseases and work-related health problems has been reported (Reverente 1992).
Barriers to Occupational Health Services for SSEs
There are formidable structural, economic and psychological barriers to the provision of occupational health services to SSEs. They include the following:
International Instruments Covering OccupationalSafety and Health Services
In some countries, occupational safety and health activities are in the jurisdiction of labour ministries and are regulated by a special occupational safety and health authority; in others, this responsibility is shared by their ministries of labour, health and/or social affairs. In some countries, such as Italy, regulations covering occupational health services are embodied in health legislation or, as in Finland, in a special act. In the United States and in England, provision of occupational health services rests on a voluntary basis, while in Sweden, among others, it was once regulated by collective agreement.
The ILO Occupational Safety and Health Convention (No. 155) (ILO 1981a) requires governments to organize a policy for occupational safety and health to be applicable to all enterprises in all sectors of the economy that is to be implemented by a competent authority. This Convention stipulates the responsibilities of the authorities, employers and workers and, supplemented by the concomitant Recommendation No. 164, defines the key occupational safety and health activities of all relevant actors at both national and local levels.
The ILO supplemented these in 1985 by the International Convention No. 161 and Recommendation No. 171 on Occupational Health Services. These contain provisions on policy design, administration, inspection and collaboration of occupational health services, activities by occupational safety and health teams, conditions of operation, and responsibilities of employers and workers, and they furthermore offer guidelines for organizing occupational health services at the level of the enterprise. While they do not specify SSEs, they were developed with these in mind since no size limits were set for occupational health services and the necessary flexibility in their organization was emphasized.
Unfortunately, ratification of these ILO instruments has been limited, particularly in developing countries. On the basis of experience from the industrialized countries, it is likely that without special actions and support by government authorities, the implementation of the ILO principles will not take place in SSEs.
The WHO has been active in promoting the development of occupational health services. Examination of the legal requirements was carried out in a consultation in 1989 (WHO 1989a), and a series of about 20 technical documents on various aspects of occupational health services has been published by WHO headquarters. In 1985 and again in 1992, the WHO Regional Office in Europe carried out and reported surveys of occupational health services in Europe, while the Pan American Health Organization designated 1992 as a special year for occupational health by promoting occupational health activities in general and conducting a special programme in Central and South America.
The European Union has issued 16 directives concerning occupational safety and health, the most important of which is Directive 391/1989, which has been called the “Framework Directive” (CEC 1989). These contain provisions for specific measures such as requiring employers to organize health risk assessments of different technical facilities or to provide health examinations of workers exposed to special hazards. They also cover the protection of workers against physical, chemical and biological hazards including the handling of heavy loads and working at video display units.
While all of these international instruments and efforts were developed with SSEs in mind, the fact is that most of their provisions are practical only for larger enterprises. Effective models for organizing a similar level of occupational health services for SSEs remain to be developed.
Organizing Occupational Health Services for SSEs
As noted above, their small size, geographic dispersion and wide variation in types and conditions of work, coupled with great limitations in economic and human resources, make it difficult to efficiently organize occupational health services for SSEs. Only a few of the various models for delivering occupational health services described in detail in this chapter are adaptable to SSEs.
Perhaps the only exceptions are SSEs that are dispersed operating units of large enterprises. These usually are governed by policies established for the entire organization, participate in company-wide educational and training activities, and have access to a multidisciplinary team of specialists in occupational health located in a central occupational health service that is usually based at the headquarters of the enterprise. A major factor in the success of this model is having all of the costs of occupational safety and health activities covered by the central occupational health unit or the general corporate budget. When, as is increasingly common, the costs are allocated to the operating budget of the SSE, there may be difficulty in enlisting the full cooperation of its local manager, whose performance may be judged on the basis of the profitability of that particular enterprise.
Group services organized jointly by several small or medium-sized enterprises have been successfully implemented in several European countries—Finland, Sweden, Norway, Denmark, the Netherlands and France. In some other countries they have been experimented with, with the help of government subsidies or private foundations, but they have not survived after termination of subsidies.
An interesting modification of the group service model is the branch-oriented service, which provides services for a high number of enterprises operating all in the same type of industry, such as construction, forestry, agriculture, food industry and so on. The model enables the service units to specialize in the problems typical for the branch and thus accumulate high competence in the sector that they serve. A famous example of such a model is the Swedish Bygghälsan, which provides services for construction industries.
A notable exception is the arrangement organized by a trade union whose members are employed in widely scattered SSEs in a single industry (e.g., health care workers, meat cutters, office workers and garment workers). Usually organized under a collective agreement, they are financed by employers’ contributions but are usually governed by a board comprising representatives of both employers and workers. Some operate local health centres providing a broad range of primary and specialist clinical services not only for workers but often for their dependants as well.
In some instances, occupational health services are being provided by hospital outpatient clinics, private health centres and community primary care centres. They tend to focus on the treatment of acute work-related injuries and illnesses and, except perhaps for routine medical examinations, provide little in the way of preventive services. Their staffs often have a low level of sophistication in occupational safety and health, and the fact that they are usually paid on a fee-for-service basis provides no great incentive for their involvement in the surveillance, prevention and control of workplace hazards.
A particular disadvantage of these “external services” arrangements is that the customer or client relationship with those using them generally precludes the participation and collaboration of employers and workers in the planning and monitoring of these services that are stipulated in the ILO Conventions and the other international instruments created to guide occupational safety and health services.
Another variant is the “social security model”, in which occupational health services are provided by the same organization that is responsible for the cost of compensation for occupational diseases and injuries. This facilitates the availability of resources to finance the services in which, although curative and rehabilitative services are featured, preventive services are often prioritized.
An extensive study carried out in Finland (Kalimo et al. 1989), one of the very few attempts to evaluate occupational health services, showed that municipal health centres and private health centres were the dominant providers of occupational health services to SSEs, followed by the group or shared centres. The smaller the enterprise, the more likely it was to use the municipal health centre; up to 70% of SSEs with one to five workers were served by municipal health centres. Significant findings of the study included verification of the value of workplace visits by the personnel of the centres serving the SSEs to gain knowledge (1) of the working conditions and the particular occupational health problems of the client enterprises, and (2) of the need to provide them with special training in occupational safety and health before they undertake the provision of the services.
Types of Activities for Occupational Health Services for SSEs
The occupational health services designed for SSEs vary widely according to national laws and practices, the types of work and work environments involved, the characteristics and health status of the workers and the availability of resources (both in terms of the ability of the SSEs to afford the occupational health services and the availability of health care facilities and personnel in the locality). Based on the international instruments cited above and regional seminars and consultations, a list of activities for comprehensive occupational health services has been developed (Rantanen 1989; WHO 1989a, 1989b). A number of key activities that should always be found in an occupational health services programme, and that are relevant for SSEs, can be picked up from those reports. They include for example:
Assessment of occupational health needs of the enterprise
Prevention and control activities in the workplace
Preventive activities oriented to workers
Record keeping and evaluation
Implicit in the above list of core activities is the appropriate availability of advice and consultations in such occupational safety and health specialities as occupational hygiene, ergonomics, work physiology, safety engineering, occupational psychiatry and psychology and so on. Such specialists are not likely to be represented in the personnel of the facilities providing occupational health services to SSEs but, when needed, they can usually be provided by governmental agencies, universities and private consulting resources.
Because of their lack of sophistication and time, owners/managers of SSEs are forced to rely more heavily on the purveyors of safety equipment for the effectiveness and reliability of their products, and on the suppliers of chemicals and other production materials for complete and clear information (e.g., data sheets) about the hazards they may present and how these may be prevented or controlled. It is important, therefore, that there be national laws and regulations covering proper labelling, product quality and reliability, and the provision of easily understood information (in the local language) about equipment use and maintenance as well as product use and storage. As a backup, the trade and community organizations of which SSEs are often members should feature information about the prevention and control of potentially hazardous exposures in their newsletters and other communications.
In spite of their importance for the national economy and their role as employer of a majority of the nation’s workforce, SSEs, the self-employed and agriculture are sectors that are typically underserved by occupational health services. ILO Convention No. 161 and Recommendation No. 171 provide relevant guidelines for the development of such services for SSEs and should be ratified and implemented by all countries. National governments should develop the requisite legal, administrative and financial mechanisms to provide all workplaces with occupational safety and health services that will effectively identify, prevent and control exposures to potential hazards and promote the enhancement and maintenance of optimal levels of health status, well-being and productive capacity of all workers. Collaboration at international, regional and subregional levels, such as that provided by the ILO and the WHO, should be encouraged to foster the exchange of information and experience, the development of appropriate standards and guidelines and the undertaking of relevant training and research programmes.
SSEs may in many instances be reluctant to seek actively the services of occupational health units even though they might be the best beneficiaries of such services. Considering this, some governments and institutions, particularly in Nordic countries, have adopted a new strategy by starting wide-scale interventions for establishment or development of services. For instance the Finnish Institute of Occupational Health currently implements an Action Programme, for 600 SSEs employing 16,000 workers, aimed at the development of occupational health services, maintenance of work ability, prevention of environmental hazards in the neighbourhood and improving the competence of SSEs in occupational health and safety.
In the 1930s, the application in France of certain clauses of the labour code concerning occupational hygiene demonstrated the value of providing workplace inspectors with access to consulting physicians.
The laws of 17 July 1937 and 10 May 1946 (articles L 611-7 and R 611-4) empowered the Department of Workplace Inspection to order temporary medical interventions. Over time, these interventions, originally conceived of as intermittent, evolved into ongoing activities complementary to and conducted simultaneously with workplace inspection.
The promulgation of the law of 11 October 1946 concerning occupational medicine was soon followed by the establishment of a permanent technical framework for the medical inspection of workplaces and workers. The decree of 16 January 1947 established the context, pay scales, status and functions of medical inspectors of workplaces and workers.
Since 1947, however, technical development in this area has been irregular and sporadic, and the number of medical inspectors has sometimes failed to keep pace with the number of inspection tasks; the latter has also been true of workplace inspections. Thus, while medical departments created in accordance with the law of 11 October 1946 increased in prevalence and importance, the number of medical inspectors was gradually reduced from 44, the number originally called for in 1947, to 21. These contradictory trends partially explain some of the criticism the occupational medicine system has had to face.
However, since 1970, and particularly since 1975, there has been a significant effort to create a Department of Workplace Medical Inspection capable of responding to the needs of the approximately 6,000 physicians responsible for over 12 million workers. In 1980, inspection services were allocated 39 paid positions, of which 36 were actually filled. In 1995, 43 positions were available. Priority Action Plan Number 12 of the VIIth Plan provides for 45 medical inspectors; this will bring staffing levels up to the levels originally envisaged in 1947.
At the same time that French officials were recognizing the necessity of establishing a specialized inspection department responsible for the application of legislative and regulatory directives concerning occupational hygiene and medicine, identical conclusions were being drawn in other countries. In response to this growing consensus, the ILO, in collaboration with the WHO, convened an international colloquium on the medical inspection of workplaces, in Geneva in 1963. Among the noteworthy outcomes of the colloquium were the definition of the responsibilities, duties, and knowledge and training requirements of medical inspectors, and the techniques and methods of medical inspection.
The central office of the Department of Workplace and Worker Medical Inspection is part of the Industrial Relations Department and reports directly to the Regional Director of Industrial Relations and Medical Inspection. The Regional Director, in turn, is part of the Regional Labour and Employment Board and reports directly to the Regional Director of Labour and Employment. The number of professionals and workers in France in 1995 were:
The number of medical inspectors in each region depends on the number of salaried occupational medicine positions in that region. In general, each regional medical inspector should be responsible for approximately 300,000 workers. This general rule is, however, subject to modification in either direction, depending on the size and geography of each region.
Although many of its clauses are no longer relevant or have lapsed, it is nevertheless useful to review the responsibilities of medical inspectors prescribed by the aforementioned decree of 16 January 1947.
The physician in charge of the department is responsible, among other things, for the coordination of all medical problems in the various departments of the Ministry of Labour and Social Security. His or her functions can be extended by decree.
The Medical Inspector of Workplaces and Workers will:
The Medical Inspector of Workplaces will communicate information he or she possesses concerning the risk of occupational disease and accidents in different companies to the Technical Committees of the Social Security Credit Unions. The note of 15 September 1976 concerning the organization of Industrial Relations Departments assigns the following responsibilities to the Department of Workplace and Worker Medical Inspection:
Management of medical inspectors involves:
In addition to these core activities, the Department of Workplace and Worker Medical Inspection also collaborates with industrial relations and human resources departments in all cases involving medical aspects of work (especially those involving handicapped workers, candidates for continuing education and job applicants) and is responsible for managing, coordinating, recruiting and training regional medical inspectors and ensuring their continuing technical education. Finally, the central office of the Department also engages in consulting activities and is the government’s official representative in matters concerning occupational medicine.
The Department of Labour’s central or regional Departments of Workplace and Worker Medical Inspection may be called upon to intervene when other governmental departments without their own medical inspection services (most notably the Department of Health and Social Security) find themselves faced with problems related to the prevention or correction of occupational health hazards; these departments of the Department of Labour may also assist in the establishment of a department of medical prevention. Except in cases where the requesting party is another governmental work-inspection service, the Department’s role is usually limited to an advisory one.
From 7 to 10 June 1994, almost 1,500 people attended the XIIIth Journées nationales de médecine du travail (the 23rd National Occupational Medicine Conference) organized by the Société et l’Institut de médecine du travail et d’ergonomie de Franche-Comté (the Society and Institute of Occupational Medicine and Ergonomics of Franche-Comté). The following subjects were discussed:
The Department is the government’s representative in medicosocial, scientific and professional agencies or institutions in the field of occupational medicine. These include the Conseil National de l’Ordre des Médecins (the National Council of the Order of Physicians), le Haut Comité d’Études et d’Information contre l’alcoolisme (the High Commission for Alcoholism Research and Information) and various university and scientific institutions. In addition, the central Department of Workplace and Worker Medical Inspection is frequently called upon to present the French government’s position on medical questions to the European Economic Community, the WHO and the ILO. Regional departments have similar responsibilities, in accordance with Circular DRT No. 18-79, of 6 July 1979, on the role of cooperation between workplace inspectors and medical inspectors of workplaces in the prevention of occupational hazards. The circular identifies orientation, informational, supervisory, management and intervention activities to be carried out, as needed, in collaboration with the regional, departmental or local workplace inspection departments.
Although both workplace inspectors and medical inspectors share common goals—the prevention of occupational health ha-zards—their specific interventions may differ, depending on the technical expertise required. Other circumstances may, on the other hand, require their collaboration.
Proposed New Circular
A circular in preparation reiterates and updates the clauses of the circular of 6 July 1979. It should be noted that on 1 January 1995, the Departments of Occupational Training assumed the responsibilities of the regional Departments of Labour and Employment. The function, role and mission of medical inspectors of workplaces must therefore be reviewed.
In summary, we can say that by 1980, medical inspection departments had, for all intents and purposes, regained the role and functions originally foreseen for them in the period 1946-47. The most likely next step in medical inspection is towards increasing emphasis on promotion, management and research in workplaces. This evolution, it should be noted, parallels that of occupational medicine itself. Following a long period of development and implementation that may now be considered practically completed, occupational medicine must now embark upon a new era of qualitative improvement and scientific advance.
Infrastructures, Practice and Approaches in Occupational Health
While much progress has been made since the 1980s towards a comprehensive approach in occupational health where the protection and promotion of workers’ health are pursued together with the maintenance and promotion of their working capacity, with a special emphasis on the establishment and maintenance of a safe and healthy working environment for all, there is much room for discussion as to the manner in which occupational health is actually implemented. The expression occupational health practice is currently used to cover the whole spectrum of activities undertaken by employers, workers and their organizations, designers and architects, manufacturers and suppliers, legislators and parliamentarians, labour and health inspectors, work analysts and work organization specialists, standardization organizations, universities and research institutions to protect health and to promote occupational safety and health.
The expression occupational health practice includes the contribution of occupational health professionals, but it is not limited to their practice of occupational health.
Confusion often occurs because the term occupational health services may be used to denote:
In order to overcome this difficulty and several other common causes of misunderstanding, the following wording was used for the second point on the agenda of the Twelfth Session of the Joint ILO/WHO Committee on Occupational Health: “Infrastructures for occupational health practice: options and models for national policies, primary health care approaches, strategies and programmes, and functions of occupational health services” (1995b) with the following understanding of the terms:
The use of the key words infrastructures, practice and approaches permits the various actors and partners in prevention to play their individual roles in their respective fields of competence and to act jointly, as well.
Occupational health services contribute to the occupational health practice, which is intrinsically multidisciplinary and intersectoral and involves other specialists both in the enterprise and outside in addition to occupational health and safety professionals, as well as the appropriate governmental authorities, employers, workers and their representatives. Functionally, occupational health services must be considered both a part of country-level health infrastructures as well as of the infrastructures that exist for the implementation of relevant legislation on occupational safety and health. It is a national decision to determine whether such services should be under the supervision of the ministry of labour, the ministry of health, the social security institutions, a tripartite national committee or other bodies.
There are a large number of models for occupational health services. One of them enjoys the support of a large consensus at the international level: the model proposed by the ILO Occupational Health Services Convention (No. 161) and Recommendation (No. 171) adopted by the International Labour Conference in 1985. Countries should consider this model as an objective towards which progress should be made, taking into account, of course, local differences and the availability of specialized personnel and financial resources. A national policy should be adopted to develop progressively occupational health services for all workers, taking into account the specific risks of the undertakings. Such policy should be formulated, implemented and periodically reviewed in the light of national conditions and practice in consultation with the most representative organizations of employers and workers. Plans should be established indicating the steps which will be taken when occupational health services cannot be immediately established for all undertakings.
Multidisciplinary Cooperation and Intersectoral Collaboration: An Overall Perspective
The ILO and the WHO have a common definition of occupational health (see box), which was adopted by the Joint ILO/WHO Committee on Occupational Health at its first session (1950) and revised at its twelfth session (1995).
Governments, in collaboration with employers’ and workers’ organizations and professional organizations concerned, should design adequate and appropriate policies, programmes and plans of action for the development of occupational health with multidisciplinary content and comprehensive coverage. In each country, the scope and content of programmes should be adapted to national needs, should take into account local conditions and should be incorporated into national development plans. The Joint ILO/WHO Committee emphasized that the principles embodied in the ILO Conventions No. 155 and No. 161 and their accompanying Recommendations, as well as WHO resolutions, guidelines and approaches related to occupational health, provide a universally accepted guide for design of such policies and programmes (Joint ILO/WHO Committee on Occupational Health 1992).
Definition of occupational health adopted by the Joint
ILO/WHO Committee on Occupational Health (1950)
Occupational health should aim at the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities and; to summarize: the adaptation of work to man and of each man to his job.The main focus in occupational health is on three different objectives: (i) the maintenance and promotion of workers’ health and working capacity; (ii) the improvement of working environment and work to become conducive to safety and health and (iii) development of work organizations and working cultures in a direction which supports health and safety at work and in doing so also promotes a positive social climate and smooth operation and may enhance productivity of the undertakings. The concept of working culture is intended in this context to mean a reflection of the essential value systems adopted by the undertaking concerned. Such a culture is reflected in practice in the managerial systems, personnel policy, principles for participation, training policies and quality management of the undertaking.
There are similar features between the ILO strategy for the improvement of the working conditions and environment and the WHO general principle of primary health care. Both rest on similar technical, ethical and social considerations and they both:
The main focus of ILO activity has been on the provision of international guidelines and a legal framework for the development of occupational health policies and infrastructures on a tripartite basis (including governments, employers and workers) and the practical support for improvement actions at the workplace, while the WHO has concentrated on the provision of scientific backgrounds, methodologies, technical support and on the training of health and related manpower for occupational health (Joint ILO/WHO Committee on Occupational Health 1992).
For the WHO, occupational health includes safety at work. Hygiene is conceptualized as directed towards disease prevention while safety is thought of as the discipline that prevents bodily injuries due to accidents. For the ILO, occupational safety and health is considered as a discipline aiming at the prevention of work injuries (both occupational diseases and accidents) and at the improvement of working conditions and the environment. The terms occupational safety, occupational health, occupational medicine, occupational hygiene and occupational health nursing are used to acknowledge the contribution of different professions (e.g., engineers, physicians, nurses, hygienists) and in recognition of the fact that the organization of occupational safety and health at the enterprise level very often comprises separate occupational safety services and occupational health services, as well as safety and health committees.
To some extent, occupational safety and primary prevention are more directly linked to the technology which is used, to the process of production and to daily management than is occupational health, which focuses more on the relationships between work and health, in particular on the surveillance of the working environment and of workers’ health (secondary prevention), as well as on human factors and ergonomic aspects. Further, at the enterprise level, engineers are a necessary presence and are inte-gral to the management line (production engineers, maintenance, technicians and so on), while occupational health and hygiene requires the intervention of specialists in the health field who need not be present for the enterprise to function, but can be consultants or belong to an external occupational health service.
Whatever organizational arrangements and terminology are used, the most important thing is that occupational safety and health professionals work as a team. They need not necessarily be in the same unit or service, although this may be desirable where appropriate. The emphasis should not be on the structure of services but on the execution of their functions at the enterprise level in a sound manner (from a scientific, technical and ethical point of view). The emphasis should be on cooperation and coordination in the elaboration and implementation of a programme of action, as well as on the development of unifying concepts, such as “working cultures” (safety culture, labour protection culture, corporate culture) that are conducive to safety and health at work and “continuing quality improvement” of the working conditions and environment.
In 1992, the Joint ILO/WHO Committee emphasized that the scope of occupational health is very broad (as shown in table 1), encompassing disciplines such as occupational medicine, occupational nursing, occupational hygiene, occupational safety, ergonomics, engineering, toxicology, environmental hygiene, occupational psychology and personnel management. Collaboration and participation of employers and workers in occupational health programmes is an essential prerequisite for successful occupational health practice.
Table 1. Six principles and three levels for a sound occupational health practice
Personal protective equipment
Scientific organization of work
Employee assistance programmes
Groups (exposed groups, special needs)
Safe and healthy working environment
Ergonomics including design
Workers’ health promotion programmes
Emergency planning and preparedness
Society and all workers
Environmental health management
Preventive health care
Health education and promotion programmes
Note: The times (1910, 1920, etc.) are arbitrary. Dates are merely given to provide an idea of the time scale for the progressive development of a comprehensive approach in occupational health. Dates will vary from country to country and may indicate the beginning or the full development of a discipline or the appearance of new terms or approaches for a practice which has been carried out for many years. This table does not intend to delineate exact disciplines involved in the process but to present in a concise manner their relationships within the framework of a mutlidisciplinary approach and intersectoral cooperation, towards a safe and healthy working environment and health for all, with a participatory approach and the objective of new forms of development which should be equitable if they are to be sustainable.
The definition of a common goal is one of the solutions to avoid the trap of an excessive compartmentalization of disciplines. Such compartmentalization of disciplines may sometimes be an asset since it allows for a specialized in-depth analysis of the problems. It may often be a negative factor, because it prevents the development of a multidisciplinary approach. There is a need to develop unifying concepts which open fields of cooperation. The new definition of occupational health adopted by the Joint Committee in 1995 serves this purpose.
Sometimes there can be heated arguments as to whether occupational health is a discipline in itself, or is part of labour protection, of environmental health or of public health. When the issue is more than academic and involves such decisions as which organization or ministry is competent for specific subject areas, the outcome can have significant consequences with regard to the allocation of funds and distribution of resources available in the form of expertise and equipment.
One of the solutions to such a problem is to advocate convergent approaches based on the same values with a common objective. The WHO approach of primary health care and the ILO approach of improving the working conditions and environment can serve this purpose. With common values of equity, solidarity, health and social justice in mind, these approaches can be translated into strategies (the WHO’s strategy of occupational health for all) and programmes (the ILO International Programme for the Improvement of Working Conditions and Environment) as well as into plans of action and activities implemented or carried out at the enterprise, national and international levels by all partners in prevention, protection and promotion of workers’ health, independently or jointly.
There are other possibilities. The International Social Security Association (ISSA) proposes the “concept of prevention” as a golden path to social security to address “safety worldwide” at work and at home, on the road and during leisure time. The International Commission on Occupational Health (ICOH) is developing an approach of ethics in occupational health and catalyses a rapprochement and cross-fertilization between occupational health and environment health. A similar trend can be seen in many countries where, for example, professional associations now get together occupational health and environmental health specialists.
In 1984, the ILO’s annual International Labour Conference adopted a resolution concerning the improvement of working conditions and environment incorporating the concept that the improvement of the working conditions and environment is an element essential to the promotion of social justice. It stressed that improved working conditions and environment are a positive contribution to national development and represent a measure of success of any economic and social policy. It spelled out three fundamental principles:
During the 1980s a shift occurred from the concept of development towards the concept of “sustainable development”, which includes “the right to a healthy and productive life in harmony with nature” as indicated in the first principle of the Rio Declaration (United Nations Conference on Environment and Development—UNCED 1992). The objective of a safe and healthy environment has thus become an integral part of the concept of sustainable development, which also implies balancing environment protection with generation of opportunity for employment, improved livelihoods and health for all. Both environmental health and occupational health contribute to make development sustainable, equitable and sound not only from an economic but also from a human, social and ethical point of view. This paradigm shift is illustrated in figure 1.
Figure 1. A multidisciplinary approach towards a sustainable and equitable development
The purpose of this figure is to illustrate the interaction between occupational health and environmental health and their mutually supportive contribution to a sustainable development. It identifies an area which represents the integration of the economic and social objectives which can be met while at the same time taking account of the environment, employment and health.
The WHO Commission on Health and Environment has further recognized that “the kind of development needed to safeguard health and welfare will depend on many conditions, including respect for the environment, while development without regard for the environment would inevitably result in impairment of human health” (WHO 1992). In the same vein, occupational health should be recognized as an “added value”, that is, a positive contribution to national development and a condition of its sustainability.
Of particular significance to the work of the ILO and the WHO are the Declaration and Programme of Action adopted by the World Summit for Social Development held in Copenhagen in 1995. The Declaration commits the nations of the world to pursuing the goal of full, productive and freely chosen employment as a basic priority of their economic and social policies. The Summit clearly indicated that the goal must not be to create just any sort of jobs, but quality jobs that safeguard the basic rights and interests of workers. It made clear that the creation of good quality jobs must include measures to achieve a healthy and safe working environment, to eliminate environmental health hazards and provide for occupational health and safety. This is an indication that the future of occupational health may well be active partnership in reconciling employment, health and environment towards an equitable and sustainable development.
The primary health care approach emphasizes social equity, affordability and accessibility, participation and community involvement, as noted by the Joint ILO/WHO Committee on Occupational Health in 1995. These basic moral and ethical values are common to the ILO and the WHO. The primary health care approach is innovative because it applies social values to preventive and curative health care. This complementarity has not always been clearly understood; sometimes confusion is due to the interpretation of common words, which has led to a degree of misunderstanding in discussing actual roles and activities to be undertaken by the ILO and the WHO, which are complementary and mutually supportive.
Primary health care can be considered to be based on principles of social equity, self-reliance and community development. It may also be considered to be a strategy for reorienting health systems, in order to promote individual and community involvement and collaboration between all sectors concerned with health. A general principle should be that primary health care should incorporate an occupational health component and specialized occupational health services should apply the general principle of primary health care, regardless of the structural model in place.
There are many partners in prevention, sharing the philosophy of both the ILO and the WHO, who should provide the necessary inputs to implement a good occupational practice. The Joint ILO/WHO Committee has indicated that the ILO and the WHO should promote an inclusive approach to occupational health in their member countries. If such an approach is used, occupational health can be seen as a multidisciplinary and integrated subject. Taken in this light, activities of different organizations and ministries will not be competitive or contradictory but will be complementary and mutually supportive, working towards an equitable and sustainable development. The emphasis should be on common goals, unified concepts and basic values.
As pointed out by the Joint ILO/WHO Committee in 1995, there is a need to develop occupational health indicators for the promotion and monitoring of the progression towards health and sustainable development. Forms of development which jeopardize health cannot claim the quality of being equitable or sustainable. Indicators towards “sustainability” necessarily include health indicators, since UNCED emphasized that the commitment of “protecting and promoting human health” is a fundamental principle for sustainable development (Agenda 21, Chapter 6). The WHO has taken a leading role in developing both the concept and use of environmental health indicators, some of which concern health and the working environment.
The WHO and the ILO are expected to develop occupational health indicators which could help countries in the evaluation, both retrospective and prospective, of their occupational health practice, and assist them in monitoring the progress made towards the objectives set by national policies on occupational safety, occupational health and the working environment. The development of such indicators focusing on the interactions between work and health could also assist occupational health services in evaluating and guiding their programmes and their activities to improve the working conditions and environment (i.e., in monitoring the efficiency and the manner in which they carry out their functions).
Standards and Guidance
The ILO Conventions and Recommendations on occupational safety and health define the rights of the workers and allocate duties and responsibilities to appropriate authorities, to the employers, and to the workers in the field of occupational safety and health. The ILO Conventions and Recommendations adopted by the International Labour Conference, taken as a whole, constitute the International Labour Code which defines minimum standards in the labour field.
The ILO policy on occupational health and safety is essentially contained in two international Conventions and their accompanying Recommendations. The ILO Occupational Safety and Health Convention (No. 155) and its Recommendation (No. 164), 1981, provide for the adoption of a national occupational safety and health policy at the national level and describe the actions needed at the national and at the enterprise levels to promote occupational safety and health and to improve the working environment. The ILO Occupational Health Services Convention (No. 161) and its Recommendation (No. 171), 1985, provide for the establishment of occupational health services which will contribute to the implementation of the occupational safety and health policy and will perform their functions at the enterprise level.
These instruments provide for a comprehensive approach to occupational health that includes primary, secondary and tertiary prevention and is consistent with general principles of primary health care. They indicate the manner in which occupational health care should ideally be delivered to the working populations, and propose a model that channels towards the workplace organized activities which require expert staff in order to catalyse an interaction between various disciplines to promote cooperation between all partners in prevention. These instruments also provide an organizational framework wherein occupational health professionals can deliver efficiently quality services to ensure workers’ health protection and promotion and contribute to the health of enterprises.
Convention No. 161 defines occupational health services as services dedicated to essentially preventive functions and responsible for advising employers, workers and their representatives at the enterprise on the requirements for establishing and maintaining a safe and healthy working environment that will optimize physical and mental health in relation to work and on the adaptation of work to the capabilities of workers, taking into consideration their state of physical and mental health.
The Convention specifies that occupational health services should include those of the following functions that are adequate and appropriate to the occupational risks at the worksite:
The ILO Convention and Recommendation are very flexible with regard to the forms of organization of occupational health services. The establishment of occupational health services may be done by laws or regulations, by collective agreements, or in any other manner approved by the appropriate authority, after consultation with the representative organizations of concerned employers and workers. Occupational health services may be organized as a service for a single enterprise or as a service common to a number of enterprises. As far as possible, the occupational health services should be located near the place of employment or should be organized to ensure their proper functioning at the place of employment. They may be organized by the concerned enterprises, by the public authorities or official services, by social security institutions, by any other bodies authorized by the authorities or, indeed, by combination of any of these. This offers a large degree of flexibility and, even in the same country, several or all of these methods may be used, according to local conditions and practice.
The flexibility of the Convention demonstrates that the spirit of the ILO instruments on occupational health services is to place more emphasis on its objectives rather than on the administrative rules for achieving them. It is important to ensure occupational health to all workers, or at least to make progress towards this objective. Such progress is usually achievable by degrees but it is necessary to make some progress towards achieving these aims and to mobilize resources in the most efficient manner for this purpose.
Various methods of financing occupational health exist. In many countries the obligation of establishing and maintaining occupational health services rests with employers. In other countries they are part of national health schemes or public health services. Staffing, financing and training of personnel are not detailed in the Convention but are individual national approaches.
Many examples exist of occupational health services set up by social security institutions or financed by special workers’ insurance schemes. Sometimes their financing is governed by an arrangement agreed upon by the ministry of labour and the ministry of health or by the social security institutions. In some countries trade unions run occupational health services. There are also special arrangements wherein funds are collected from employers by a central institution or tripartite body and then disbursed to provide occupational health care or distributed to finance the functioning of occupational health services.
The sources of financing occupational health services may also vary according to their activities. For example, when they have curative activities, social security may contribute to their financing. If occupational health services take part in public health programmes and in health promotion or in research activities, other funding sources may be found or become available. Financing will depend not only on the structural model chosen to organize the occupational health services, but also on the value that society concedes to health protection and promotion and its willingness to invest in occupational health and in the prevention of occupational hazards.
Conditions of Operation
A special emphasis is placed on the conditions of operation of occupational health services. It is not only necessary for the occupational health services to execute a number of tasks but it is equally important that these tasks should be performed in an appropriate manner, taking into consideration technical and ethical aspects.
There are some basic requirements as regards the operation of occupational health services which are spelled out in the ILO Convention, and especially in the Recommendation on Occupational Health Services. These may be summarized as follows:
Ethical dimensions of occupational health are increasingly taken into account, and emphasis is placed on the need for both quality and on-going evaluation of occupational health services. It is not only necessary to determine what should be done but also for which purpose and under which conditions. The ILO Recommendation on Occupational Health Services (No. 171) introduced a first set of principles in this respect. Further guidance is given by the International Code of Ethics for Occupational Health Professionals adopted by the International Commission on Occupational Health (ICOH 1992).
In 1995, the Joint ILO/WHO Committee on Occupational Health emphasized that “quality assurance of services must be an integral part of the occupational health services development. It is unethical to give poor quality of service”. The ICOH Code of Ethics prescribes that “occupational health professionals should institute a programme of professional audit of their own activities in order to ensure that appropriate standards have been set, that they are being met and that deficiencies, if any, are detected and corrected”.
Common Goals and Values
The role of institutionalized occupational health services should be seen within the broader framework of health and social policies and infrastructures. The functions of occupational health services contribute to the implementation of the national policies on occupational safety, occupational health and the working environment advocated by the ILO Occupational Safety and Health Convention (No. 155) and Recommendation (No. 164), 1981. Occupational health services contribute also to the attainment of the objectives embodied in the “Health For All” strategy advocated by the WHO as a policy for equity, solidarity and health.
There are signs of an increasing trend to mobilize expertise and resources within the framework of networking arrangements and joint ventures. At the international level, such is already the case for chemical safety, where there is an interorganization me-chanism for chemical safety: the Inter-Organization Programme for the Sound Management of Chemicals (IOMC). There are many other fields where new flexible forms of international cooperation among countries and international organizations are emerging or could be developed, such as radiation protection and biological safety.
Networking arrangements open new fields of cooperation which may be adapted in a flexible manner to the theme which is to be addressed, such as occupational stress, coordinating research or updating this Encyclopaedia. The emphasis is placed on interactions and not any more on vertical compartmentalization of disciplines. The concept of leadership gives way to active partnership. International networking for occupational safety and health is developing rapidly and could be further developed on the basis of existing structures which could be interconnected. The roles of the ILO and the WHO may well be to initiate international networks designed to fulfil the needs and demands of their constituents and to meet the common goal of protecting the people at work.
The social and ethical values agreed upon by the international community are incorporated into the ILO Conventions and Recommendations, as well as in the WHO policy on “Health For All”. Since the 1980s the concept of sustainable development has progressively emerged and, after the Rio Conference and the Social Summit in Copenhagen, now takes into account the interrelationships between employment, health and the environment. The common goal of a safe and healthy working environment for all will reinforce the determination of all those involved in occupational safety and health to better serve the health of workers and to contribute to a sustainable and equitable development for all. One of the main challenges in occupational health may well be to resolve the conflict between values such as the right to health and the right to work at the level both of the individual and all workers, with the aim of protecting health and allowing employment.
This article is based on the standards, principles and approaches embodied in the ILO Occupational Health Services Convention, 1985 (No. 161) and its accompanying Recommendation (No. 171); ILO Occupational Safety and Health Convention, 1981 (No. 155) and its accompanying Recommendation (No. 164); and the Working Document of the Twelfth Session of the Joint ILO/WHO Committee on Occupational Health, 5-7 April 1995.
The ILO Occupational Health Services Convention (No. 161) defines “occupational health services” as services entrusted with essentially preventive functions and responsible for advising the employer, the workers and their representatives in the undertaking on the requirements for establishing and maintaining a safe and healthy working environment which will facilitate optimal physical and mental health in relation to work and the adaptation of work to the capabilities of workers in the light of their state of physical and mental health.
Provision of occupational health services means carrying out activities in the workplace with the aim of protecting and promoting workers’ safety, health and well-being, as well as improving working conditions and the working environment. These services are provided by occupational health professionals functioning individually or as part of special service units of the enterprise or of external services.
Occupational health practice is broader and consists not only of the activities performed by the occupational health service. It is multidisciplinary and multisectoral activity involving in addition to occupational health and safety professionals other specialists both in the enterprise and outside, as well as competent authorities, the employers, workers and their representatives. Such involvement requires a well-developed and well-coordinated system at the workplace. The necessary infrastructure should comprise all the administrative, organizational and operative systems that are needed to conduct the occupational health practice successfully and ensure its systematic development and continuous improvement.
The most elaborate infrastructure for occupational health practice is described in the ILO Occupational Safety and Health Convention, 1981 (No. 155) and the Occupational Health Services Convention, 1985 (No. 161). The establishment of occupational health services according to the models advocated by the Convention No. 161 and its accompanying Recommendation No. 171 is one of the options. It is however evident that the most advanced occupational health services are in concordance with the ILO instruments. Other types of infrastructures may be used. Occupational medicine, occupational hygiene and occupational safety may be practised separately or together within the same occupational health service. The occupational health service may be a single integrated entity or a composite of different occupational health and safety units unified by a common concern for workers’ health and well-being.
Availability of Occupational Health Services
Occupational health services are unevenly distributed in the world (WHO 1995b). In the European Region, about half of the working population remains uncovered by competent occupational health services; the variation among countries is very wide, with coverage figures ranging between 5% and 90% of the workforce. The Central and Eastern European countries now in transition are having problems in providing services due to reorganization of their economic activities and the break-up of the large centralized industries into smaller units.
Lower coverage figures are found on other continents. Only a few countries (United States, Canada, Japan, Australia, Israel) show coverage figures comparable to those in Western Europe. In typical developing regions, the coverage by employee health services ranges from 5% to 10% at best, with services being found mainly in manufacturing enterprises, while some sectors of industry, agriculture, the self-employed, small-scale enterprises and the informal sector are usually not covered at all. Even in countries where coverage rates are high, there are gaps, with small-scale enterprises, certain mobile workers, construction, agriculture and the self-employed being underserved.
Thus, there is a universal need to increase the coverage of workers by occupational health services throughout the world. In a number of countries, intervention programmes to increase the coverage have demonstrated that it is possible to substantially improve the availability of occupational health services in a relatively short time and at a reasonable cost. Such interventions have been found to improve both the workers’ access to the services and the cost effectiveness of the services provided.
Policy Impact of International Instruments
The so-called work environment reform which took place in most of the industrialized countries in the 1970s and 1980s saw the production of important international instruments and guidelines. They reflected the responses of occupational health policies to the new needs of working life, and the achievement of an international consensus on the development of occupational safety and health.
The International Programme for the Improvement of Working Conditions and Environment (PIACT) was launched by the ILO in 1976 (Improving Working Conditions and Environment: An International Programme (PIACT) 1984; 71st Session of the International Labour Conference 1985). The ILO Occupational Safety and Health Convention, 1981 (No. 155), with its accompanying Recommendation (No. 164), and the ILO Occupational Health Services Convention, 1985 (No. 161) and its accompanying Recommendation (No. 171), amplified the impact of the ILO in the development of occupational safety and health. By 31 May 1995, 40 ratifications of these Conventions had been registered, but their practical impact was much wider than the number of ratifications, since many countries had implemented the principles embodied in these instruments, although they had not been able to ratify them.
Simultaneously, the WHO Global Strategy Health for All by the Year 2000 (HFA) (1981), first launched in 1979, was followed in the 1980s by introduction and implementation of regional and national HFA strategies in which workers’ health constituted an essential part. In 1987, WHO launched a Programme of Action for Workers’ Health, and in 1994 the WHO Collaborating Centres in Occupational Health developed the Global Strategy for Occupational Health for All (1995), which was endorsed by the WHO Executive Board (EB97.R6) and unanimously adopted by the World Health Assembly in May 1996 (WHA 49.12).
The most important features of the international consensus on occupational safety and health are:
The United Nations Summit on Environment and Development in Rio de Janeiro in 1993 touched on several aspects of human environment which have relevance to occupational health (WHO 1993). Its Agenda 21 contains elements on providing services for underserved workers and ensuring chemical safety at the workplace. The Rio Declaration emphasized peoples’ right to lead “healthy and productive lives in harmony with nature”, which would require work and working environment to meet certain minimum health and safety standards.
Such instruments and international programmes directly or indirectly stimulated the inclusion of the provision of occupational health services in the national Health for All by the Year 2000 programmes and other national development programmes. Thus, the international instruments have served as guidelines for the development of national legislation and programmes.
A significant role in the global development of occupational health has been played by the Joint ILO/WHO Committee on Occupational Health, which, in its twelve meetings held since 1950, has made important contributions toward the definition of concepts and their transfer into national and local practices.
Legislative Structures for Occupational Health Practice
Most countries have laws governing the provision of occupational health services, but the structure of the legislation, its content and the workers covered by it vary widely (Rantanen 1990; WHO 1989c). The more traditional laws consider occupational health services as a group of specialized and separate activities such as occupational health care, occupational safety and hygiene services, workplace health promotion programmes and so on. In many countries, instead of stipulating what might be regarded as programmes, the legislation stipulates the responsibility of employers to provide health risk assessments, health examinations of workers or other individual activities related to workers’ health and safety.
More recent laws reflecting international guidelines such as those contained in the ILO Convention on Occupational Health Services (No. 161) consider the occupational health service as an integrated, comprehensive, multidisciplinary team containing all the elements needed for the improvement of health at work, improvement of the working environment, promotion of workers’ health, and the overall development of the structural and managerial aspects of the workplace needed for health and safety.
The legislation usually delegates the authority to establish, implement and inspect occupational health services to such ministries or agencies as Labour, Health or Social Security (WHO 1990).
There are two main types of legislation regulating occupational health services:
One views the occupational health service as an integrated multidisciplinary service infrastructure and stipulates the objectives, activities, obligations and rights of the various partners, the conditions of operation, as well as the qualifications of its personnel. Examples include the European Union Framework Directive No. 89/391/EEC on Occupational Safety and Health (CEC 1989; Neal and Wright 1992), the Dutch ARBO Act (Kroon and Overeynder 1991) and the Finnish Act on Occupational Health Services (Translation of the Occupational Health Care Act and the Council of the State Decree No. 1009 1979). There are only a few examples of the organization of systems of occupational health services in the industrialized world that are in accord with this type of legislation, but their number is expected to grow with progressive implementation of the European Union Framework Directive (89/391/EEC).
The other type of legislation is found in most industrialized countries and is more fragmented. Instead of a single act stipulating the occupational health service as an entity, it involves a number of laws that simply oblige employers to carry out certain activities. These may be stipulated quite specifically or merely in general, leaving issues of their organization and conditions of operation open (WHO 1989c). In many developing countries, this legislation is applicable only to main industrial sectors, while large numbers of other sectors as well as agriculture, small-scale enterprises and the informal sector remain uncovered.
During the 1980s, particularly in industrialized countries, social and demographic developments such as ageing of the working population, increase in disability pensions and sickness absenteeism, and difficulty in controlling social security budgets led to some interesting reforms of national occupational health systems. These focused on the prevention of both short-term and long-term disability, preservation of working capacity, particularly of older workers, and reducing early retirement.
For example, the amendment of the Dutch ARBO Act (Kroon and Overeynder 1991) together with three other social laws aimed at the prevention of short- and long-term disability stipulated important new requirements for occupational health and safety services at the plant level. They included:
This new system will be implemented stepwise and should be mature before the end of the 1990s.
Amendments of the Finnish Act on Occupational Health Services in 1991 and 1994 introduced the maintenance of working capacity, particularly of ageing workers, as a new element in the legislation-based preventive activities of occupational health services. Implemented through the close collaboration of all the actors in the workplace (management, workers, health and safety services), it involves improvement and adaptation of work, working environment and equipment to the worker, improving and maintaining the physical and mental working capacity of the worker, and making the work organization more conducive to maintaining the work capacity of the worker. Currently, efforts are being directed at the development and evaluation of practical methods to achieve these goals.
The adoption in 1987 of the Single European Act gave new impetus to the occupational health and safety measures taken by the European Communities. This was the first time health and safety at work had been directly included in the EEC Treaty of 1957 and was done through the new Article 118a. Of significant importance to the level of protection is that directives adopted by the Member States under Article 118a lay down minimum requirements concerning health and safety at work. According to this principle, the Member States must raise their level of protection if it is lower than the minimum requirements set by the directives. Beyond this, they are entitled and encouraged to maintain and introduce more stringent protective measures than required by the directives.
June 1989 saw the adoption of the first and probably the most important Directive providing for minimum requirements concerning health and safety at work under Article 118a: Framework Directive 89/391/EEC on the introduction of measures to encourage improvements in the safety and health of workers at work. It is the core strategy on health and safety on which all subsequent directives will be built. The Framework Directive is to be supplemented by individual directives covering specific areas and also sets the general framework for future directives related to it.
The Framework Directive 89/391/EEC contains many features of the ILO Conventions Nos. 155 and 161 which the 15 countries of the European Union will implement in their national laws and practices. Main provisions that are relevant to occupational health practice include:
During the past years, a large amount of European Union legislation has been introduced, including a series of individual directives based on the principles formulated in the Framework Directive, some supplementing those which had been subject to technical harmonization measures in preparation, and others covering specific risks and high-risk sectors. Examples of the first group are directives concerning the minimum safety and health requirements for the workplace, for the use of work equipment by workers at work, for the use of personal protective equipment, for the manual handling of loads, for work with display screen equipment, for the provision of safety and health signs at work, and the implementation of the minimum safety and health requirements at temporary or mobile construction sites. The second group includes such directives as the protection of workers from the risks related to exposure to vinyl chloride monomer, metallic lead and its ionic compounds, asbestos at work, carcinogens at work, biological agents at work, the protection of workers by the banning of certain specified agents and/or certain work activities, and some others (Neal and Wright 1992; EC 1994).
Proposals have been made recently for the adoption of other directives (namely, the directives on physical agents, chemical agents, transport activities and workplaces, and work equipment) in order to consolidate some existing directives and rationalize the overall approach to the safety and health of workers in these fields (EC 1994).
Many new elements in the national legislation and practices respond to today’s emerging problems of working life and contain provisions for further development of occupational health infrastructures. This especially concerns programming, at the national and enterprise level, more comprehensive activities in respect of psychosocial, organizational and work capacity aspects and particular emphasis on the principle of participation. They also provide for the application of quality management systems, auditing and certification of both the competence of the experts and services to meet the requirements of occupational safety and health legislation. Thus, such national laws, by absorbing the substantive content of the ILO instruments, no matter whether the instruments are ratified or not, lead to the stepwise implementation of the objectives and principles embodied in the ILO Conventions Nos. 155 and 161 and in the WHO HFA Strategy.
Objectives of Occupational Health Practice
The objectives of occupational health practice that were originally defined in 1950 by the Joint ILO/WHO Committee on Occupational Health stated that:
Occupational health should aim at the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities; and, to summarize: the adaptation of work to man and of each man to his job.
In 1959, based on discussions of the special ILO tripartite committee (representing governments, employers and workers), the Forty-third Session of the International Labour Conference adopted Recommendation No. 112 (ILO 1959) which defined an occupational health service as a service established in or near a place of employment for the purposes of:
In 1985, the ILO adopted new international instruments—the Occupational Health Services Convention (No. 161) and its accompanying Recommendation (No. 171) (ILO 1985a, 1985b)— which defined occupational health services as services entrusted with essentially preventive functions and responsible for advising the employer, the workers and their representatives in the undertaking on: the requirements for establishing and maintaining a safe and healthy working environment which will facilitate optimal physical and mental health in relation to work; and the adaptation of work to the capabilities of workers in light of their state of physical and mental health.
In 1980, the WHO/Euro Working Group on Evaluation of Occupational Health and Industrial Hygiene Services (WHO 1982) defined the ultimate goal of such services as “promoting conditions at work that guarantee the highest degree of quality of working life by protecting workers’ health, enhancing their physical, mental and social well-being, and preventing ill-health and accidents”.
The extensive survey of occupational health services in the 32 countries in the European Region carried out in 1985 by the WHO Regional Office for Europe (Rantanen 1990) identified the following principles as objectives of occupational health practice:
Such principles can still be considered to be relevant with respect to the new developments in countries’ policies and legislation. On the other hand, the formulation of objectives of occupational health practice as they stand on recent national laws and the development of new needs for working life seem to emphasize the following trends (WHO 1995a, 1995b; Rantanen, Lehtinen and Mikheev 1994):
Thus, there certainly exists a tendency for expansion of the scope of the objectives of occupational health practice towards new types of issues entailing social and economic consequences for workers.
Functions and Activities of Occupational Health Services
To protect and promote the health of workers, an occupational health service has to meet the special needs of the enterprise it serves and the workers employed in it. With the enormous range and scope of industrial, manufacturing, commercial, agricultural and other economic activities, it is not possible to lay down a detailed programme of activity or pattern of organization and conditions of operation for an occupational health service which should be suitable for all enterprises and in all circumstances. According to the ILO Occupational Safety and Health Convention (No. 155) and the ILO Occupational Health Services Convention (No. 161), the prime responsibility for health and safety of workers rests with the employers. The functions of an occupational health service are to protect and promote the health of workers, improve working conditions and the working environment and maintain the health of the enterprise as a whole by providing occupational health services to workers and expert advice to the employer on how to achieve the highest possible standards of health and safety in the interests of the particular working community of which it is a part.
ILO Convention No. 161 and its accompanying Recommendation No. 171 envisage occupational health services as multidisciplinary, comprehensive and, although essentially preventive, also allow for carrying out curative activities. The WHO documents calling for services for small-scale enterprises, the self-employed and agricultural workers encourage the provision of services by primary health care units (Rantanen, Lehtinen and Mikheev 1994). The documents described above and national laws and programmes recommend a stepwise implementation so that the occupational health activities can be adjusted to the national and local needs and the prevailing circumstances.
Ideally, an occupational health service should establish and act in accordance with a programme of activities adapted to the needs of the enterprise where it operates. Its functions should be adequate and appropriate to the occupational hazards and health risks of the enterprise it serves, with particular attention given to the problems specific to the branch of economic activity concerned. The following represent the basic functions and most typical activities of an occupational health service.
Preliminary orientation to the enterprise
If occupational health services have not been previously provided or when new occupational health service staff members are recruited, a preliminary orientation to the occupational safety and health situation of the enterprise is needed. This involves the following steps:
Surveillance of the working environment
The quality of the working environment through compliance with safety and health standards has to be ensured by surveillance at the workplace. According to ILO Convention No. 161, surveillance of the working environment is one of the main tasks of the occupational health services.
On the basis of the information obtained through the preliminary orientation to the enterprise, a walk-through survey of the workplace is conducted, preferably by a multidisciplinary occupational health team supplemented by employers’ and workers’ representatives. This should include interviews with managers, foremen and workers. When needed, special safety, hygiene, ergonomic or psychological checks can be performed.
Special checklists and guidelines are available and are recommended for such surveys. The observations may indicate a need for specific measurements or checks which should be performed by specialists in occupational hygiene, ergonomics, toxicology, safety engineering or psychology who may be members of the occupational health team of the enterprise or may have to be procured externally. Such special measurements or checks may be beyond the resources of small-scale enterprises, which would have to rely on observations made during the survey supplemented by qualitative or, in the best case, by semi-quantitative data as well.
As a basic checklist for the identification of potential health hazards, the List of Occupational Diseases (amended 1980) appended to the ILO Employment Injury Benefits Convention, 1964 (No. 121), may be recommended. It lists the major known causes of occupational diseases, and although its main purpose is to provide guidance for compensation of occupational diseases, it can also serve for their prevention. Hazards not mentioned in the list can be added according to national or local conditions.
The scope of surveillance of the working environment as defined by the ILO Occupational Health Services Recommendation (No. 171) is as follows:
As a result of the walk-through survey a hazard inventory should be prepared, identifying each hazard inherent in the enterprise. This inventory is necessary for estimating a potential for exposure and suggesting control measures. For purposes of this inventory and to facilitate designing, implementing and evaluating of controls, hazards should be cross-classified by the risks they present for workers’ health with acute or chronic outcomes and by type of hazard (i.e., chemical, physical, biological, psychological or ergonomic).
The next step is a quantitative assessment of exposure, which is necessary for more exact health hazard evaluation. It consists of measuring the intensity or concentration, the variation in time, the total duration of exposure, as well as the number of workers exposed. Measurement and evaluation of exposure are usually conducted by occupational hygienists, ergonomists and specialists in injury control. They are based on the principles of environmental monitoring and should include, where necessary, ambient monitoring to collect data on exposure in a given working environment, and personal exposure monitoring of an individual worker or a group of workers (e.g., exposed to specific hazards). Measurement of exposure is necessary whenever hazards are suspected or reasonably predictable, and should be based on the completed hazard inventory combined with an assessment of work practices. Knowledge of potential effects caused by each hazard should be used to establish priorities for intervention.
The evaluation of health hazards in the workplace should be accomplished by considering the complete picture of exposures in comparison with established occupational exposure standards. Such standards are expressed in terms of permissible levels and exposure limits and are set up through numerous scientific studies correlating exposure with produced health effects. Some of them have become state standards and are legally enforceable according to national law and practice. Examples are Maximum Allowable Concentrations (MAKs in Germany, MACs in the East European countries) and Permissible Exposure Limits (PELs, United States). There are PELs for about 600 chemical substances commonly found in the workplace. There are also limits on time-weighted average exposure, short-term exposure limits (STELs), ceilings, and for some hard conditions that might result in skin absorption.
Surveillance in the working environment includes monitoring both the hazardous exposures and the health outcomes. If exposure to hazards is excessive, it should be controlled regardless of outcome, and the health of exposed workers should be evaluated. Exposure is considered excessive if it approaches or exceeds established limits such as those mentioned above.
Surveillance of the work environment provides information on the occupational health needs of the enterprise and indicates the priorities for preventive and control actions. Most of the instruments guiding occupational health services emphasize the need to carry out the surveillance before initiating services, periodically during the course of the activities, and always when substantial changes in work or the working environment have taken place.
The results obtained provide the necessary data to estimate whether preventive actions taken against health hazards are effective, as well as whether workers are placed in jobs adequate to their capacities. These data are also used by the occupational health service to ensure that reliable protection against exposures is maintained and to formulate advice on how to implement controls in order to improve the working environment. In addition, the accumulated information is used for epidemiological surveys, for the revision of permissible exposure levels, as well as for the evaluation of the effectiveness of the engineering control measures and other methods of various preventive programmes.
Informing employer, enterprise managementand workers about occupational health hazards
As information about potential workplace health hazards is obtained, it should be communicated to those responsible for implementing preventive and control measures as well as to the workers exposed to these hazards. The information should be as precise and quantitative as possible, describing the preventive measures being taken and explaining what the workers should do to ensure their effectiveness.
The ILO Occupational Health Services Recommendation, 1985 (No. 171) provides that in accordance with national law and practice, data resulting from surveillance of the working environ-ment should be recorded in an appropriate manner and be available to the employer, the workers and their representatives, or to the safety and health committee, where one exists. These data should be used on a confidential basis solely to provide guidance and advice on measures to improve the working en-vironment and the safety and health of workers. The competent authority should also have access to these data. They may be communicated to others by the occupational health service only with the agreement of the employer and the workers. Workers concerned should be informed in an adequate and appropriate manner of the results of the surveillance and should have the right to request the monitoring of the working environment.
Assessment of health risks
To assess occupational health risks, information from surveillance of the work environment is combined with information from other sources, such as epidemiological research on particular occupations and exposures, reference values like occupational exposure limits and available statistics. Qualitative (e.g., whether the substance is carcinogenic) and, where possible, quantitative (e.g., what is the degree of exposure) data may demonstrate that workers face health hazards and indicate a need for preventive and control measures.
The steps in an occupational health risk assessment include:
Surveillance of workers’ health
Due to limitations of a technological and economic nature, it is often not possible to eliminate all health hazards in the workplace. It is in these circumstances that surveillance of workers’ health plays a major role. It comprises many forms of medical evaluation of health effects developed as a result of workers’ exposure to occupational health hazards.
The main purposes of health examinations are to assess the fitness of a worker to carry out certain jobs, to assess any health impairment which may be related to the exposure to harmful agents inherent in the work process and to identify cases of occupational diseases in accordance with national legislation.
Health examinations cannot protect workers against health hazards and they cannot substitute for appropriate control measures, which have the first priority in the hierarchy of actions. Health examinations help to identify conditions which may make a worker more susceptible to the effects of hazardous agents or detect early signs of health impairment caused by these agents. They should be conducted in parallel with surveillance of the working environment, which provides information on potential exposure in the workplace and is used by occupational health professionals to assess results obtained through health surveillance of the exposed workers.
Health surveillance of workers may be passive and active
In case of passive health surveillance, ill or affected workers are required to consult occupational health professionals. Passive surveillance usually detects only symptomatic disease and requires that occupational health professionals be able to differentiate the effects of occupational exposures from the similar effects of non-occupational exposures.
In case of active health surveillance, occupational health professionals select and examine workers who are at high risk of work-related disease or injury. It may be conducted under many forms, including periodic medical examinations for all workers, medical examinations for workers exposed to specific health hazards, screening and biological monitoring of selected groups of workers. Specific forms of health surveillance depend largely upon possible health effects resulting from a particular occu-pational exposure. Active surveillance is more appropriate for workers with a history of multiple exposures and those at higher risk for disease or injury.
Details about health surveillance are given in the ILO Convention No. 161 and Recommendation No. 171. These instruments specify that surveillance of workers’ health should include, in the cases and under the conditions specified by the competent authority, all assessments necessary to protect the health of workers, which may include:
Evaluation of the health status of workers is of utmost importance when occupational health practice is initiated, when new workers are recruited, when new working practices are adopted, when new technologies are introduced, when special exposures are identified, and when individual workers display health characteristics that need follow-up. A number of countries have special regulations or guidelines specifying when and how health examinations should be carried out. Health examinations should be monitored and continuously developed to identify the work-related health effects at their earliest stage of development.
Pre-assignment (pre-employment) health examinations
This type of health assessment is carried out before the job placement of workers or their assignment to specific tasks which may involve a danger to their health or that of others. The purpose of this health assessment is to determine whether a person is physically and psychologically fit to perform a particular job and to ensure that his or her placement in this job will not represent a danger to his or her health or to the health of other workers. In most instances, a review of the medical history, a general physical examination and routine laboratory tests (e.g., simple blood count and urinalysis) will suffice, but in some cases the presence of a health problem or the unusual requirements of a particular job will require extensive functional examinations or diagnostic testing.
There are a number of health problems that may make a certain job hazardous for the worker or incur a risk for the public or other workers. For these reasons, it may be necessary, for example, to exclude workers with uncontrolled hypertension or unstable diabetes from certain hazardous jobs (e.g., air and sea pilots, drivers of public service and heavy goods vehicles, crane drivers). Colour blindness may justify an exclusion from jobs requiring colour discrimination for safety purpose (e.g., reading traffic signals). In jobs demanding a high standard of general fitness like deep-water diving, fire fighting, police service and aircraft piloting, only workers able to meet the performance requirements would be acceptable. A possibility that chronic diseases may be aggravated by the exposures involved in a particular job should also be considered. It is essential, therefore, that the examiner have a detailed knowledge of the job and the work environment and be aware that standardized job descriptions may be too superficial or even misleading.
After finishing a prescribed health assessment, the occupational physician should communicate the results in writing to both the worker and the employer. These conclusions communicated to the employer should contain no information of a medical nature. They should contain a conclusion about the fitness of the examined person for the proposed or held assignment and specify the kinds of jobs and the conditions of work which are medically contra-indicated either temporarily or permanently.
The pre-employment medical examination is important to the worker’s subsequent occupational history since it provides the necessary clinical information and laboratory data on the worker’s health status at the moment of entering the employment. It also represents an indispensable baseline for the subsequent evaluation of any changes in health status that may occur later on.
Periodic health examinations
These are performed at periodic intervals during employment which involves exposure to potential hazards that could not be entirely eliminated by preventive and control measures. The purpose of periodic health examinations is to monitor the health of workers during the course of their employment. It aims at verifying workers’ fitness in relation to their jobs and at detecting as early as possible any sign of ill-health which may be due to work. They are often supplemented by other examinations in accordance with the nature of hazards observed.
Their objectives include:
These objectives will determine the frequency, content and methods of the periodic health examinations, which may be conducted as frequently as every one to three months or every few years, depending on the nature of the exposure, the biological response expected, the opportunities for preventive measures and the feasibility of the examination method. They may be comprehensive or limited to just a few tests or determinations. Special guidelines on the purpose, frequency, content and methodology of these examinations are available in a number of countries.
Return-to-work health examinations
This type of health assessment is required to authorize the resumption of work after a long absence for health reasons. This health examination determines the workers’ suitability for the job, recommends appropriate actions to protect them against future exposures, and identifies whether there is a need for a reassignment or a special rehabilitation.
Similarly, when a worker changes jobs, the occupational physician is required to certify that the worker is fit to carry out the new duties. The objective of the examination, the need and the use of the results determine its content and methods and the context in which it is performed.
General health examinations
In many enterprises, general health examinations may be performed by the occupational health service. They are usually voluntary and may be available to the entire workforce or only to certain groups determined by age, length of employment, status in the organization and so on. They may be comprehensive or limited to screenings for particular diseases or health risks. Their objectives determine their frequency, contents and methods used.
Health examinations after the ending of service
This type of health assessment is performed after the termination of assignment involving hazards which could cause or contribute to future health impairment. The purpose of this health assessment is to make a final evaluation of workers’ health, compare it with previous medical examinations and to assess how the prior job assignments may have affected their health.
The general observations summarized below apply to all types of health examinations.
Health examinations of workers should be conducted by professionally qualified personnel trained in occupational health. These health professionals should be familiar with the exposures at work, physical requirements and other conditions of work in the enterprise and experienced in using appropriate medical examination techniques and instruments, as well as in keeping correct record forms.
The health examination is not a substitute for action to prevent or control hazardous exposures in the working environment. If prevention has been successful, fewer examinations are needed.
All data collected in connection with health examinations are confidential and should be recorded by the occupational health service in a personal confidential health files. Personal data relating to health assessments may be communicated to others only with the informed consent of the worker concerned. When the worker wishes the data to be forwarded to a personal physician, he or she provides formal permission for this.
Conclusions about the suitability of a worker for a particular job or about the health effects of the job should be communicated to the employer in a form that does not violate the principle of the confidentiality of personal health data.
Use of health examinations and their results for any kind of discrimination against workers cannot be tolerated and must be strictly prohibited.
Initiatives for preventive and control measures
Occupational health services are responsible not only for the identification and evaluation of potential risks for the health of workers but also for providing advice on preventive and control measures which will help to avoid risks.
After analysing the results of surveillance of the working environment, including where necessary workers’ personal exposure monitoring, and the results of workers’ health surveillance, including where necessary the results of biological monitoring, occupational health services should be in a position to assess possible connections between the exposure to occupational hazards and resulting health impairments and to propose appropriate control measures to protect workers’ health. These measures are recommended together with other technical services in the enterprise after consulting the enterprise management, employers, workers or their representatives.
Control measures should be adequate to prevent unnecessary exposure during normal operating conditions as well as during accident and emergencies. Planned modifications in work processes should also be taken into account, and recommendations should be adaptable to future needs.
Measures of control of health hazards are used to eliminate occupational exposure, minimize or in any case reduce it to permissible limits. They include primarily engineering, engineering controls in the work environment, changes in technology, substances and materials and as secondary preventive measures, human behaviour controls, personal protective equipment, integrated control and others.
The formulation of recommendations for control measures is a complicated process that includes the analysis of information on existing health risks in the enterprise and the consideration of occupational safety and health requirements and needs. For analysis of feasibility and costs versus benefits one should consider the fact that the investments made for health and safety may pay back during long periods in the future, but not necessarily immediately.
The ILO instruments include a requirement that the employers, workers and their representatives should cooperate and participate in the implementation of such recommendations. They are usually discussed by the safety and health committee at large-scale enterprises, or in smaller enterprises by the representatives of the employers and workers. It is important to document the proposed recommendations so that there can be a follow-up of their implementation. Such documentation should emphasize the responsibility of management for preventive and control actions at the enterprise.
Occupational health services have an important task to perform by providing advice to the enterprise management, the employers, the workers, and health and safety committees in their collective as well as individual capacities. This needs to be recognized and used in the decision-making processes as it often happens that occupational health professionals are not directly involved in the decision-making.
The ILO Occupational Health Services Convention (No. 161) and Recommendation (No. 171) promote the advisory role of occupational health professionals in the enterprise. To promote the adaptation of work to the workers and improve working conditions and environment, occupational health services should act as advisers on occupational health, hygiene, ergonomics, collective and individual protective equipment to the employers, the workers and their representatives in the enterprise, and to the safety and health committee, and should collaborate with other services already operating as advisers in these fields. They should advise on the planning and organization of work, the design of workplaces, on the choice, maintenance and condition of machinery and other equipment, as well as on the substances and materials used in the enterprise. They should also participate in the development of programmes for the improvement of working practices, as well as in the testing and evaluation of health aspects of new equipment.
Occupational health services should provide workers with personal advice concerning their health in relation to work.
Another important task is to provide advice and information related to the integration of workers who have been victims of work accidents or diseases in order to help them in their rapid rehabilitation, protect their working capacity, reduce absenteeism and restore a good psychosocial climate in the enterprise.
Educational and training activities are closely linked to the advisory task that occupational health professionals perform vis-à-vis the employers and workers. They are of particular importance when the modification of existing installations or the introduction of new equipment are envisaged, or when there may be changes in the layout of workplaces, workstations and in the organization of work. Such activities have an advantage when started at the right time because they provide for better consideration of human factors and ergonomic principles in the improvement of working conditions and environment.
Technical advisory services at the workplace constitute an important preventive function of occupational health services. They should give priority to the awareness of occupational hazards and to the involvement of the employers and workers in hazard control and the improvement of the working environment.
First aid services and emergency preparedness
The organization of first aid and emergency treatment is a tradi-tional responsibility of occupational health services. ILO Convention No. 161 and Recommendation No. 171 stipulate that the occupational health service should provide first aid and emergency treatment in cases of accident or indisposition of workers at the workplace and should collaborate in the organization of first aid.
This covers preparedness for accidents and acute health conditions in individual workers, as well as readiness for response in collaboration with other emergency services in cases of serious accidents affecting the entire enterprise. Training in first aid is a primary duty of occupational health services, and the personnel of these services are among the first to respond.
The occupational health service should make appropriate preliminary arrangements for ambulance services and with community fire, police and rescue units and local hospitals in order to avoid delays and confusion that may threaten the survival of critically injured or affected workers. These arrangements, supplemented by drills when feasible, are particularly important in preparing for major emergencies such as fire, explosions, toxic emissions and other catastrophes that may involve many individuals in the enterprise as well as in the neighbourhood and may result in a number of casualties.
Occupational health care, general preventiveand curative health services
Occupational health services may be involved in the diagnosis, treatment and rehabilitation of occupational injuries and diseases. The knowledge of occupational diseases and injuries coupled with the knowledge of the job, the working environment and occupational exposures present in the workplace enable the occupational health professionals to play a key role in the management of work-related health problems.
According to the scope of activities and as required by national legislation or based on national practice, occupational health services fall into three main categories:
The ILO Occupational Health Services Recommendation (No. 171) promotes the provision of curative and general health care services as functions of occupational health services where they are found to be appropriate. Based on national legislation and practice, the occupational health service may undertake or participate in one or more of the following curative activities with regard to occupational illnesses:
The provision of general preventive and curative health care services includes the prevention and treatment of non-occupational illnesses and other relevant primary health care services. Usually, general preventive health care services include immunizations, maternity and child care, general hygiene and sanitary services, whereas general curative health care services include conventional general-practitioner-level practice. Here, ILO Recommendation No. 171 prescribes that the occupational health service may, taking into account the organization of preventive medicine at the national level, fulfil the following functions:
Occupational health services set up by large enterprises, as well as those operating in remote or medically underserved areas, may be called upon to provide general non-occupational health care not only for workers but for their families as well. The extension of such services depends on the infrastructure of the health services in the community and on the capacity of the enterprises. When industrial enterprises are established in poorly developed areas, it may even be expedient to provide such services together with occupational health care.
In some countries, occupational health services provide ambulatory treatment during working hours which is normally provided by a general practitioner. It usually concerns simple forms of treatment, or it may be more comprehensive medical care if the enterprise has an agreement with the social security or other insurance institutions providing reimbursement of the cost of workers’ treatment.
The participation of occupational health services is particularly crucial in guiding workers’ rehabilitation and their return to work. This is becoming more and more important owing to a large number of occupational accidents in developing countries and the ageing of the working populations in industrialized societies. Rehabilitation services are usually provided by external units which may be free-standing or hospital-based and staffed by rehabilitation specialists, occupational therapists, vocational counsellors and so on.
There are some important aspects concerning the participation of occupational health services in the rehabilitation of injured workers.
First, the occupational health service may play an important role in seeing that workers recovering from injury or disease are referred to them promptly. It is greatly preferable, when practicable, for a worker to return to his or her original place of employment, and it is an important function of the occupational health service to maintain contact during the period of incapacity with those responsible for treatment during the acute stages in order to identify the time when a return to work can be envisaged.
Second, the occupational health service can facilitate an early return to work by collaborating with the rehabilitation unit in planning. Its knowledge of the job and work environment will be helpful in exploring the possibilities of modifying the original job (e.g., changes in work assignment, limited hours, rest periods, special equipment and so on) or arranging an alternative temporary substitute.
Finally, by following the worker’s progress, the occupational health service can keep management informed of the probable duration of absence or limited capacity, or the extent of any residual disability, so that arrangements for alternative staffing may be made with minimal impact on production schedules. On the other hand, the occupational health service maintains a link with the workers and often with their families, facilitating and better preparing their return to work.
Adaptation of work to the workers
To facilitate the adaptation of work to the workers and improve the working conditions and environment, occupational health services should advise the employer, the workers and the safety and health committee in the enterprise on matters of occupational health, occupational hygiene and ergonomics. Recommendations may include modifications of the job, the equipment and the working environment that will allow the worker to perform effectively and safely. This may involve reducing the physical workload for an ageing worker, providing special equipment for workers with sensory or locomotor impairments or fitting equipment or work practices to the anthropometric dimensions of the worker. The adaptations may be required temporarily in the case of workers recovering from an injury or disease. A number of countries have legal provisions requiring workplace adaptations.
Protection of vulnerable groups
The occupational health service is responsible for recommendations that will protect vulnerable groups of workers, such as those with hypersensitivities or chronic diseases and those with certain disabilities. This may include selection of a job that minimizes adverse effects, provision of special equipment or protective devices, prescription of sick leave and so on. The recommendations must be feasible in the light of the circumstances in a particular workplace, and workers may be required to undertake special training in appropriate working practices and the use of personal protective equipment.
Information, education and training
Occupational health services should play an active role in providing relevant information and organizing education and training in relation to work.
The ILO Occupational Health Services Convention (No. 161) and Recommendation (No. 171) provide for the participation of occupational health services in designing and implementing programmes of information, education and training in the field of occupational safety and health for the personnel of the enterprise. They should participate in the progressive and continuing training of all workers in the enterprise who contribute to occupational safety and health.
Occupational health professionals can help increase workers’ awareness of occupational hazards to which they are exposed, discuss with them existing health risks and advise workers on the protection of their health, including protective measures and proper use of personal protective equipment. Every contact with workers offers an opportunity to provide useful information and to encourage healthful behaviour in the workplace.
Occupational health services should provide all information on occupational hazards present in the enterprise as well as on safety and health standards relevant to the local situation. This information should be written in language understandable by the workers. It should be provided on a periodic basis and especially when new substances or equipment are being introduced or changes are being made in the working environment.
Education and training can play a key role in the improvement of working conditions and environment. Efforts to improve safety, health and welfare at work are often substantially limited due to lack of awareness, technical expertise and know-how. Education and training in specific fields of occupational safety and health and working conditions can facilitate both the diagnosis of problems and the implementation of solutions, and can therefore help overcome these limitations.
ILO Conventions Nos. 155 and 161 and their accompanying Recommendations emphasize the key role of education and training in the enterprise. Training is essential to fulfil the obligations of both the employers and the workers. Employers are responsible for the organization of in-plant occupational safety and health training, and workers and their representatives in the enterprise should fully cooperate with them in this respect.
Training in occupational safety and health should be organized as an integral part of the overall efforts for improving working conditions and environment, and occupational health services should play a major role in this respect. It should aim at solving various problems affecting the physical and mental well-being of workers and should address adaptation to technology and equipment, improvement of working environment, ergonomics, working time arrangements, the organization of work, job content and workers’ welfare.
Health promotion activities
There is some tendency, particularly in North America, to incorporate wellness promotion activities in the form of occupational health programmes. These programmes are, however, essentially general health promotion programmes that may include such elements as health education, stress management and assessment of health risks. They usually aim at changing personal health practices such as alcohol and drug abuse, smoking, diet and physical exercise, with a view to improving overall health status and reducing absenteeism. Although such programmes are supposed to improve productivity and reduce health care costs, they have not been properly evaluated so far. These programmes, designed as health promotion programmes, though valuable as such are not usually considered as occupational health programmes, but as public health services delivered in the workplace, because they focus attention and resources on personal health habits rather than on protection of workers against occupational hazards.
It should be recognized that the implementation of health promotion programmes is an important factor contributing to the improvement of the health of workers in the enterprise. In some countries, “health promotion in the workplace” is regarded as a separate discipline on its own and is carried out by completely independent groups of health workers other than occupational health professionals. In this case, their activities should be coordinated with the activities of the occupational health service, whose staff can ensure their relevance, feasibility and sustainable effect. The participation of occupational health services in the realization of health promotion programmes should not limit the performance of their main functions as specialized health services created to protect workers against harmful exposures and unhealthy working conditions in the workplace.
A very recent development in some countries (e.g., the Netherlands, Finland) is the establishment of occupational health promotion activity within occupational health services. Such activities aim at promotion and maintenance of work ability of workers by targeting early prevention and promotion actions to workers and their health, to work environment, and to work organization. The results of such activities are found to be highly positive.
Data collection and record-keeping
It is important that all medical contacts, evaluations, assessments and surveys be properly documented and the records safely stored so that, if necessary for follow-up health examinations, legal or research purposes, they may be retrieved years and even decades later.
The ILO Occupational Health Services Recommendation (No. 171) provides that occupational health services should record data on workers’ health in personal confidential files. These files should also contain information on jobs held by the workers, on exposure to occupational hazards involved in their work, and on the results of any assessment of workers’ exposure to these hazards. Personal data relating to health assessments may be communicated to others only with the informed consent of the worker concerned.
The conditions under which and time during which records containing workers’ health data should be kept, communicated or transferred, and the measures necessary to keep them confidential, especially when these data are computerized, are usually prescribed by national laws or regulations or by the competent authority, and governed by recognized ethical guidelines.
According to the ILO Occupational Health Services Recommendation (No. 171), occupational health services, in consultation with the employers’ and workers’ representatives, should contribute to research within the limits of their resources by participating in studies in the enterprise or in the relevant branch of economic activity (e.g., to collect data for epidemiological purposes or participate in national research programmes). Occupational physicians involved in the implementation of research projects will therefore be bound by the ethical considerations applied to such projects by the World Medical Association (WMA) and the Council for International Organizations of Medical Sciences (CIOMS). Research in the working environment may involve healthy “volunteers”, and the occupational health service should fully inform them about the purpose and the nature of the research. Each participant should give individual consent to the participation in the project. The collective consent provided by the workers’ trade union in the enterprise is not enough. Workers must feel free to withdraw from the investigation at any time and the occupational health service should be responsible that they will not be subjected to undue pressure to remain within the project against their will.
Liaison and Communications
A successful occupational health service is necessarily involved in communications of many kinds.
The occupational health service is an integral part of the productive apparatus of the enterprise. It must closely coordinate its activities with occupational hygiene, occupational safety, health education and health promotion, and other services directly related to workers’ health, when these operate separately. In addition, it must collaborate with all services in the operation in the enterprise: personnel administration, finance, employee relations, planning and design, production engineering, plant maintenance and so on. There should be no obstacles in reaching out to any department in the enterprise when issues of worker health and safety are involved. At the same time, the occupational health service should be responsive to the needs and sensitive to the constraints of all other departments. And, if it does not report to a most senior executive, it must have the privilege of direct access to top management in cases when important recommendations relating to workers’ health are denied appropriate consideration.
In order to function effectively, the occupational health service needs the support of the enterprise management, the employer, workers and their representatives. The ILO instruments (ILO 1981a, 1981b, 1985a, 1985b) require the employer and the workers to cooperate and participate in the implementation of the organizational and other measures relating to occupational health services on an equitable basis.
The employer should collaborate with the occupational health service in achieving its objectives particularly by:
Where a special plant-level programme for occupational health activities is required, the collaboration between the employer and the occupational health service is crucial in the preparation of such a programme and the activity report.
Occupational health services are established to protect and promote workers’ health by preventing work injuries and occupational diseases. Many functions of occupational health services cannot be carried out without cooperation with workers. According to the ILO instruments, workers and their organizations should cooperate with occupational health services and provide support to these services in the execution of their duties (ILO, 1981a, 1981b, 1985a, 1985b). The workers should cooperate with occupational health services in particular by:
The ILO instruments recommend the collaboration between the employers and workers on matters of occupational safety and health (ILO 1981a,1981b,1985a,1985b). This collaboration is carried out in the occupational safety and health committee of the enterprises, which comprises the representatives of workers and the employer and constitutes a forum for the discussion of matters relating to occupational health and safety. The establishment of such a committee may be prescribed by legislation or collective agreements in enterprises with 50 or more workers. In smaller enterprises, its functions are intended to be fulfilled by less formal discussions between the workers’ safety delegates and the employer.
The committee has a broad range of functions (ILO 1981b) which may include:
The principle of workers’ participation in decisions concerning their own health and safety, on changes in jobs and working environments, and on safety and health activities is emphasized in recent guidelines on occupational health practice. It also requires that workers should have access to information on the activities of the enterprise concerning occupational safety and health and on any potential health hazard that they may encounter at the workplace. Accordingly, the principle of “right to know” and transparency principles have been established or strengthened by legislation in many countries.
Occupational health services should establish close relations with external services and institutions. Foremost among these are relationships with the public health care system of the country as a whole and the institutions and facilities in the local communities. This starts at the level of primary health care units and extends to the level of hospital-based specialized services, some of which may also be providing occupational health services. Such relationships are important when it is necessary to refer workers to specialized health services for appropriate evaluation and treatment of occupational injuries and diseases, and also to provide opportunities for mitigating the possible adverse effects of non-occupational health problems on attendance and work performance. Collaboration with public health as well as environmental health services is important. Inviting general practitioners and other health professionals to visit the occupational health service and familiarize themselves with the demands made on their patients by occupations or the hazards to which they are exposed will not only help to establish friendly relations, but also provide an opportunity to sensitize them to the particulars of occupational health issues that ordinarily would be ignored in their treatment of workers for whom they provide general health care services.
Rehabilitation institutes are a frequent collaborative partner, particularly in the case of workers with handicaps or chronic disabilities who may require special efforts to enhance and maintain their work capacities. Such collaboration is especially important in recommending temporary job modifications that will accelerate and facilitate the return to work of individuals recovering from serious injuries or illnesses, with occupational or non-occupational aetiology.
Emergency response organizations and first aid providers such as ambulance services, hospital outpatient and emergency clinics, poison control centres, police and fire brigades, and civic rescue organizations can ensure the expeditious treatment of acute injuries and illnesses and assist in planning for and response to major emergencies.
Appropriate links with social security and health insurance institutions can facilitate the administration of benefits and functioning of the workers’ compensation system.
The competent safety and health authorities and labour inspectorates are key collaborative partners for the occupational health services. In addition to expediting formal inspections, appropriate relationships may provide support for internal occupational health and safety activities and offer opportunities to input to the formulation of regulations and methods of enforcement.
Participation in professional societies and in activities of educational/training institutes and universities is valuable for arranging continuing education for professional staff members. Ideally, the time and expenses should be subsidized by the enterprise. In addition, the collegial contacts with occupational health professionals serving other enterprises can provide strategic information and insights and may lead to partnerships for meaningful data collection and research.
The kinds of collaboration described above should be initiated from the very beginning of the operation of the occupational health service and be continued and expanded as appropriate. They may not only facilitate achievement of the objectives of the occupational health service, but may also contribute to the community and public relations efforts of the enterprise.
Infrastructures for Occupational Health Services
Infrastructures for the provision of occupational health services are insufficiently developed in most parts of the world, including developed and developing countries. The need for occupational health services is particularly acute in the developing and newly industrialized countries, which contain eight out of ten of the world’s workers. If organized appropriately and effectively, such services would contribute significantly not only to workers’ health, but also to the overall socio-economic development, productivity, environmental health, and the well-being of countries, communities and families (WHO 1995b; Jeyaratnam and Chia 1994). Effective occupational health services can not only reduce avoidable-sickness absenteeism and work disability, but also help to control the costs of health care and social security. Thus, the development of the occupational health services covering all workers is fully justified with regard to both workers’ health and the economy.
Infrastructures for the provision of occupational health services should permit effective implementation of activities needed to meet the objectives of occupational health (ILO 1985a, 1985b; Rantanen, Lehtinen and Mikheev 1994; WHO 1989b). To allow the necessary flexibility, Article 7 of ILO Convention No. 161 provides that occupational health services may be organized as a service for a single undertaking or as a service common to a number of undertakings. Or, in accordance with national conditions and practice, occupational health services may be organized by the undertakings or groups of undertakings concerned, public authorities or official services, social security institutions, any other bodies authorized by the competent authority, or any combination of the above.
Some countries have regulations relating the organization of occupational health services to the size of the enterprise. For example, larger enterprises have to establish their own in-plant occupational health service while medium-sized and small enterprises are required to join group services. As a rule, legislation allows flexibility in the choice of structural models of occupational health services in order to meet local conditions and practices.
Models of Occupational Health Services
To meet the occupational health needs of enterprises which vary widely with respect to type of industry, size, type of activity, structure and so on, a number of different models of occupational health services have been developed (Rantanen, Lehtinen and Mikheev 1994; WHO 1989). In developing and newly industrialized countries, for example, where health care for the general population may be deficient, the occupational health service may provide primary non-occupational health care to the employees and their families as well. This has also been successfully implemented in Finland, Sweden and Italy (Rantanen 1990; WHO 1990). On the other hand, the high level of worker coverage in Finland has been made possible by organizing municipal health centres (PHC units) providing occupational health services for workers in small-scale enterprises, the self-employed and even small worksites operated by large enterprises that are scattered throughout the country.
In-plant (in-company) model
Many large industrial and non-industrial enterprises in both the private and public sectors have an integrated, comprehensive occupational health service on their premises that not only provides a full range of occupational health services, but may also provide non-occupational health services to workers and their families, and may carry out research. These units usually have multidisciplinary staff that may include not only occupational physicians and nurses, but also occupational hygienists, ergonomists, toxicologists, occupational physiologists, laboratory and x-ray technicians, and possibly physiotherapists, social workers, health educators, counsellors and industrial psychologists. Occupational hygiene and safety services may be provided by the staff of the occupational health service or by separate units of the enterprise. Such multidisciplinary units are usually afforded only by large (often multinational) enterprises and their quality of services and impact on health and safety is most convincing.
Smaller enterprises may have an in-plant unit that is staffed by one or more occupational health nurses and a part-time occupational physician who visits the unit for several hours a day or several times a week. A variant is the unit staffed by one or more occupational health nurses with an “on-call” physician who visits the unit only when summoned and usually provides “standing orders” which authorize the nurse to perform procedures and dispense medications that are normally the prerogative of licensed physicians only. In some instances in the United States and England, these units are operated and supervised by an external contractor such as a local hospital or a private entrepreneurial organization.
Due to various reasons, the occupational health staff may sometimes become more and more separated from the central operating structure of the enterprise, and, as result, the range of services it provides tends to shrink to first aid and treatment of acute occupational injuries and illnesses and the performance of routine medical examinations. Part-time and particularly on-call physicians often do not acquire the necessary familiarity with details of the kinds of jobs being performed or the working environment, and may not have enough contact with managers and the safety committee or do not have enough authority to effectively recommend appropriate preventive measures.
As part of the reductions in workforce seen at times of recession, some large enterprises are shrinking their occupational health services and, in some instances, eliminating them entirely. The latter may occur when an enterprise with an established occupational health service is acquired by an enterprise that had not maintained one. In such cases, the enterprise may contract with external resources to operate the in-plant facility and employ consultants on an ad hoc basis to provide such specialized services as occupational hygiene, toxicology and safety engineering. Some enterprises choose to retain an expert in occupational and environmental health to serve as an in-house medical director or manager to coordinate the services of the external providers, monitor their performance, and provide advice to top management on matters relating to employee health and safety and environmental concerns.
Group or inter-enterprise model
Sharing of occupational health services by groups of small or medium-sized enterprises has been widely used in industrialized countries such as Sweden, Norway, Finland, Denmark, the Netherlands, France and Belgium. This enables enterprises that are individually too small to have their own services, to enjoy the advantages of a well-staffed, well-equipped comprehensive service. The Slough Plan, organized some decades ago in an industrial community in England, pioneered this type of arrangement. In the 1980s, interesting experiments with regional occupational health centres organized in Sweden were found to be feasible and particularly useful for mid-sized enterprises, and some countries, such as Denmark, have made efforts to increase the size of the shared units to allow them to provide a broader range of services instead of splitting them into smaller monodisciplinary units.
A frequently encountered disadvantage of the group model compared to the in-plant model of larger enterprises is the distance between the worksite and the occupational health service. This is important not only in cases requiring first aid for more serious injuries (it is sometime more prudent to send such cases directly to a local hospital, bypassing the occupational health unit) but because more time is usually lost when workers are forced to go off the premises when seeking health services during working hours. Another problem arises when the participating enterprises are unable to contribute sufficient funds to sustain the unit which is forced to close down when the government or private foundation grants that may have subsidized its start-up are no longer available.
Industry-oriented (branch-specific) model
A variant of the group model is the joint use of an occupational health service by a number of enterprises in the same industry, trade or economic activity. Construction, food, agriculture, banking and insurance are examples of sectors that have made such arrangements in Europe; such models are found in Sweden, the Netherlands and France. The advantage of this model is the opportunity for the occupational health service to concentrate on the particular industry and accumulate special competence in addressing its problems. Such a model for the construction industry in Sweden provides sophisticated, high-quality, multidisciplinary services for the entire country and has been able to conduct research and develop programmes dealing with problems specific to that industry.
Hospital outpatient clinics
Hospital outpatient clinics and emergency rooms have traditionally provided services to injured or sick workers who seek care. A notable disadvantage is the lack of familiarity with occupational diseases on the part of the usual staff and attending physicians. In some instances, as noted above, occupational health services have made arrangements with local hospitals to provide certain specialized services and fill the gap either by collaborating in the care or educating the hospital staff about the kinds of cases that may be referred to them.
More recently, hospitals have begun to operate special occupational health clinics or services that are compared favourably to the large in-plant or group services described above. They are staffed by physicians specialized in occupational health who may also conduct research involving the kinds of problems they see. In Sweden, for example, there are eight regional clinics of occupational medicine, several of which are affiliated with a university or medical college, each providing services to enterprises in several communities. Several have a special unit to serve small enterprises.
A significant difference between the group services and the hospital-based activity is that in the case of the former, the participating enterprises usually share ownership of the occupational health service and have the decision-making authority over how it operates, while the latter operates as a private or public polyclinic that has a provider-customer relationship with the client enterprises. This limits, for example, the extent to which participation and collaboration between employers and workers can influence the operation of the unit.
Private health centres
The private health centre model is a unit usually organized by a group of physicians (it may be organized by a private entrepreneurial organization that employs the physicians) to provide several types of outpatient and sometimes also hospital-based health services. The larger centres often have a multidisciplinary staff and may offer occupational hygiene and physiotherapy services, while smaller units usually supply only medical services. As in the hospital clinic model, the provider-client relationship with participating enterprises may hinder implementation of the principle of employer and worker involvement in formulating policies and procedures.
In some countries, private health centres have been criticized for being too much oriented to curative clinical services provided by the physicians. Such criticism is justified in the case of smaller centres where the services are provided by general practitioners instead of health professionals experienced in occupational health practice.
Primary health care units
Primary health care units are usually organized by municipal or other local authorities or by the national health service, and usually provide both preventive services and primary health care. This is the model strongly recommended by the WHO as a means of providing services to small-scale enterprises and, particularly, to agricultural enterprises, the informal sector and the self-employed. Since general physicians and nurses usually lack specialization and experience in occupational health, the success of this model critically depends on how much training in occupational health and occupational medicine can be arranged for the health professionals.
An advantage of this model is its good coverage of the country and its location in the communities where the people it serves work and live. This is a particular advantage in serving agricul-tural workers and the self-employed.
A weakness is its concentration on general curative health services and treatment of emergencies with only limited ability to carry out surveillance of the working environment and to institute preventive measures needed in the workplace. Experience in Finland, where large primary health care units employ teams of trained specialists to provide occupational health services is, however, highly positive. Interesting new models for providing occupational health services by primary health care units have been tried in the Shanghai area of China.
Social security model
In Israel, Mexico, Spain and some African countries, for example, occupational health services are provided by special units organized and operated by the social security system. In Israel, this model is essentially similar in structure and operation to the group model, while elsewhere it is usually oriented more to curative health care. The specific feature of this model is that it is operated by the organization responsible for workers’ compensation for occupational injuries and diseases. While curative and rehabilitative services are provided, the emphasis on controlling social security costs has led to priority being given to preventive services.
Selecting a Model for Occupational Health Services
The primary decision of whether or not to have an occupational health service may be determined by law, by a labour-management contract, or by management’s concerns about employees’ health and safety. While many enterprises are motivated toward a positive decision by awareness of the value of an occupational health service in maintaining their productive apparatus, others are impelled by such economic considerations as controlling the costs of workers’ compensation benefits, avoidable sickness absenteeism and disability, early retirement for health reasons, regulatory penalties, litigation and so on.
The model for providing occupational health services may be dictated by laws or regulations which may be general or applicable only to certain industries. This is generally the case with the social security model, in which the client enterprises have no other option.
In most instances, the model selected is determined by such factors as the size of the workforce and its demographic characteristics, the kinds of work they do and the workplace hazards they encounter, the location of the worksite(s), the kind and quality of health services available in the community and, perhaps most important, the affluence of the enterprise and its ability to provide the requisite financial support. Sometimes, an enterprise will launch a minimal unit and enlarge and expand its activities as it proves its worth and earns the acceptance of the workers. Only a few comparative studies have been conducted so far on the operation of various models of occupational health services in different situations.
Occupational hygiene services
International instruments and guidelines strongly recommend the inclusion of occupational hygiene services in the multidisciplinary occupational health service. In some countries, however, occupational hygiene is traditionally carried out as a separate and independent activity. Under such circumstances, collaboration with other services involved in occupational safety and health activities is necessary.
Safety services are traditionally carried out as a separate activity either by safety officers or safety engineers who are employees of the enterprise (ILO 1981a; Bird and Germain 1990) or by some form of consulting arrangement. In the in-plant safety service, the safety officer is often also the chief responsible for safety in the enterprise and represents the employer in such matters. Again, the modern trend is to integrate safety along with occupational hygiene and occupational health and other services involved in occupational health activities in order to form a multidisciplinary entity.
Where safety activities are carried out in parallel with those of occupational health and occupational hygiene, the collaboration is necessary particularly as regards the identification of accident hazards, risk assessment, planning and implementation of preventive and control measures, education and training of managers, supervisors and workers, and collecting, maintaining and registering records of accidents, and the operation of any control measures that are instituted.
Staffing of the Occupational Health Service
Traditionally, the occupational health service is staffed by an occupational health physician only, or a physician and a nurse who, perhaps with the addition of an industrial hygienist, may be designated as the “core” staff. The most recent provisions, however, require that whenever possible the occupational health staff should be multidisciplinary in composition.
The staff may be enlarged to a full multidisciplinary team depending on the model of the service, the nature of the industry and the types of work involved, the availability of the various specialists or of programmes for training them, and the extent of the available financial resources. When not actually on the staff, the supplementary staff positions may be filled in by external support services (WHO 1989a, 1989b). They may include safety engineers, mental health specialists (e.g., psychologists, counsellors), work physiologists, ergonomists, physiotherapists, toxicologists, epidemiologists and health educators. Most of these are rarely included in the full-time staff of the occupational health service and are involved on a part-time or an “as needed” basis (Rantanen 1990).
Since quantitative needs for occupational health staff vary widely depending on the enterprise in question, the organization model and the services provided by the occupational health service, as well as on the availability of support and parallel services, it is not possible to be categorical about the numerical size of the staff (Rantanen 1990; Rantanen, Lehtinen and Mikheev 1994). For example, 3,000 workers in one large enterprise require a smaller staff than would be needed to provide a similar range of services for 300 workplaces with 10 employees each. It has been noted, however, that at present in Europe, the usual proportion is one physician and two nurses to serve from 2,000 to 3,000 workers. The variation is wide, ranging from 1 per 500 to 1 per 5,000. In some countries, decisions on the staffing of the occupational health service is made by the employer on the basis of the kinds and volume of services provided, whereas in a number of countries the number and composition of occupational health staff are stipulated by legislation. For example, recent legislation in the Netherlands requires that the occupational health team must consist at least of a physician, a hygienist, a safety engineer and an expert in labour/organization relations (Ministerial Order on the Certification of SHW Services and Expertise Requirements for SHW Services 1993).
Many countries have formulated official or semi-official competence criteria for occupational physicians and nurses, but those for the other disciplines have not been established. The new European Union principles call for confirmation of the competence of all occupational health specialists, and some countries have established certification systems for them (CEC 1989; Ministerial Order on the Certification of SHW Services and Expertise Requirements for SHW Services 1993).
Training curricula for occupational health specialists are not well developed, apart from those for occupational physicians, nurses and, in some countries, occupational hygienists (Rantanen 1990). The establishment of curricula at all levels for all of the specialist categories, including programmes for basic, postgraduate and continuing education, has been encouraged. It is also deemed desirable to include training elements of occupational health at the level of basic education, not only in medical schools but also in other institutions such as technical universities, faculties of science and so on. In addition to the background in science and practical skills needed for occupational health practice, the training should include development of appropriate attitudes towards protection of workers’ health. Training in collaboration with specialists in other disciplines would enable a multidisciplinary approach. Training in collaboration with competent authorities and employers is also deemed necessary.
The professional identity of occupational health specialists needs to be supported on an equitable basis among the various disciplines. Strengthening their professional independence is crucial for efficient performance of their duties and may increase interest of other health professionals in developing lifelong careers in occupational health. It is important that the training curricula be reorganized while countries are developing new competence and certification criteria for occupational health specialists.
Infrastructures for Support Services
The majority of enterprises cannot afford the comprehensive multidisciplinary occupational health service needed for their occupational health and safety programmes. In addition to basic services provided for the enterprise, the occupational health service itself may need technical expertise in such areas as (Kroon and Overeynder 1991; CEC 1989; Rantanen, Lehtinen and Mikheev 1994):
Countries have used different approaches to the organization of such services. For example, Finland has an Institute of Occupational Health with six regional institutes to supply expert support for front-line occupational health services. Most of the industrialized countries have such a national institute or a comparable structure with research, training, information and consultation services as its main functions; they are rare in the developing countries. Where such an institute does not exist, these services may be provided by university research groups, social security institutions, national health service systems, governmental occupational health and safety authorities and private consultants.
Experiences from industrialized countries have demonstrated the advisability of creating in each industrializing and newly developing country a special centre for occupational health research and development that can:
When an individual institute is not able to supply all of the needed services, networking among several service units such as universities, research institutions and other such organizations may be needed.
Financing of Occupational Health Services
According to the ILO instruments, the primary responsibility for financing occupational health and safety services rests with the employer, with no charge being made to the workers. In some countries, however, there are modifications of these principles. For example, costs for the provision of occupational health services may be substantially subsidized by the social security institution. A case in point is Finland, where the primary financial responsibility is on the employer but 50% of the costs will be reimbursed by the social insurance institution provided there is evidence of compliance with the occupational health and safety regulations and the occupational safety and health committee of the enterprise confirms that the occupational health services have been properly provided.
In most countries, such national systems of reimbursement are available. In the community health centre model for the delivery of occupational health services, the start-up costs for facilities, equipment and personnel are met by the community, but operating costs are met by collecting fees from employers and from the self-employed.
The reimbursement or subsidy systems are intended to encourage the availability of services to enterprises with economic constraints, and particularly to small-scale enterprises which rarely can command adequate resources. The effectiveness of such a system is shown by the experience in Sweden in the 1980s, in which the allocation of substantial amounts of government financing to subsidize occupational health service for enterprises in general and particularly for small-scale enterprises increased the proportion of covered workers from 60% to over 80%.
Quality Systems and Evaluation of OccupationalHealth Services
The occupational health service should continually evaluate for itself its objectives, activities and results achieved as regards the protection of workers’ health and the improvement of the working environment. Many enterprises have arrangements for periodic independent audits by specialists in the organization or by external consultants. In some countries, there are governmental or private mechanisms for periodic recertification based on formal audit protocols. In some enterprises, periodic employee surveys provide useful indications of workers’ regard for the occupational health service and their satisfaction with the services it provides. To be truly valuable, there must be a feedback of the results of such surveys to participating employees, and evidence that appropriate actions are being taken to address any problems they disclose.
Many of the industrialized countries (e.g., the Netherlands and Finland) have initiated the use of the ISO 9000 series standards in developing quality systems for health services in general as well as for occupational health services. This is particularly appropriate because many client enterprises are applying such standards to their production processes. Some enterprises which have included their occupational health services in the application of Total Quality Management (also known as Continuous Quality Improvement) throughout their organizations have reported a positive experience in terms of improved quality and smoother operation of services.
In practice, the application of a programme of continuous quality improvement means that each department or unit of the enterprise analyses its functions and performance, and institutes any changes needed to bring their quality to an optimal level. The occupational health service should not only be a willing participant in this effort but should make itself available to ensure that considerations of workers’ health and safety are not overlooked in this process.
Evaluation of the quality of occupational health services not only serves the interests of the employers, workers and the competent authorities, but also the interests of the providers of the services as well. Several schemes for such evaluation have been developed in a number of countries. For practical purposes, the self-evaluation by the occupational health service staff itself may be the most practical, particularly when there is a health and safety committee to assess the results of such evaluation.
There is a growing interest in examining the economic aspects of occupational health and safety services and validating their cost-effectiveness, but few such studies have yet been reported.
Stepwise Development of Occupational Health Services
The ILO Occupational Health Services Convention, 1985 (No. 161) and its accompanying Recommendation (No. 171) encourage countries to develop progressively occupational health services for all workers, in all branches of economic activity and in all undertakings, including those in the public sector and the members of production cooperatives. Some countries have already developed well-organized services based on provisions stipulated by their legislation.
Starting with established services, there are three strategies for further development: extending the full spectrum of activities to cover more enterprises and more workers; expanding the content of occupational health services offering only core services; and stepwise expansion of both the content and the coverage.
There have been discussions of the minimum activities that should be provided by an occupational health service. In some countries, they are limited to health examinations conducted by specially authorized physicians. In 1989, the WHO/European Consultation on Occupational Health Services (WHO 1989b) proposed that the minimum should comprise the following core activities:
In practice, there exist a large number of workplaces around the world that have not yet been able to provide any services to their workers. Consequently, the first step for a national programme may be limited just to establishing occupational health services providing these core activities for those most in need.
Future Perspectives for Occupational Health Services Development
The future development of occupational health services depends on a number of factors in the world of work and on national economies and policies as well. The most important trends in industrialized countries include ageing of the workforce, increase of irregular employment patterns and working schedules, distant work (telework), mobile workplaces and the steady increase in small-scale enterprises and the self-employed. New technologies are introduced, new substances and materials are used, and new forms of work organization appear. There is pressure for simultaneously increasing productivity and quality, resulting in the need to maintain strong motivation for work in the face of the increasing tempo of change, and the need to learn new work practices and methods grows apace.
While measures to combat traditional occupational hazards have been successful, particularly in industrialized countries, these hazards are not likely to totally disappear in the near future and they will still represent danger even though for smaller populations of workers. Psychological and psychosocial problems are becoming dominant occupational hazards. The globalization of the world economy, the regionalization and the growth of multinational economies and enterprises are creating an internationally mobile workforce and resulting in the exportation of occupational hazards to areas in which protective regulations and constraints are weak or non-existent.
In response to these trends, the Second Meeting of the WHO Collaborating Centres in Occupational Health (the Network of 52 National Institutes of Occupational Health) held in October 1994 developed the Global Strategy on Occupational Health for All with particular relevance to future development of occupational health practice. With regard to further development of occupational health services, the following emerging issues will have to be met in the future:
To summarize, occupational health services will face formidable challenges during the next decade and beyond in addition to the economic, political and social pressures inherent in changing national and industrial configurations. They include the occupational health problems linked with new information technologies and automation, new chemical substances and new forms of physical energy, the hazards of new biotechnologies, relocation and international transfer of hazardous technologies, ageing of the workforce, the special problems of such vulnerable groups as the chronically ill and the handicapped, as well as the unemployment and relocations forced by job-seeking, and the appearance of new and hitherto unrecognized diseases that may affect the workforce.
Occupational health infrastructures are insufficiently developed to meet the needs of workers in all parts of the world. The need for effective occupational health services is growing rather than decreasing. The ILO instruments on occupational health services and the parallel WHO strategies provide a valid basis for the significant development of occupational health services, and should be used by each country as it sets policy objectives to ensure the health and safety of workers in the country.
The developing and newly industrialized countries contain approximately 8 out of 10 of the world’s workers, and no more than 5 to 10% of this working population has access to adequate occupational health services. In many industrialized countries this proportion rises to no higher than 20 to 50%. If such services could be organized and provided for all workers it would not only favourably influence workers’ health, but also have a positive influence on the well-being and economic status of the countries, their communities and their whole populations. This would also help to control the costs of avoidable sickness absenteeism and disability and restrain the escalation of health care and social security costs.
International guidelines for effective occupational health policies and programmes are available but insufficiently applied on national and local levels. Collaboration between countries and the international organizations and among the countries themselves should be fostered to provide the necessary financial, technical and professional support needed to increase access to occupational health services.
The range and quantity of occupational health services required by an enterprise vary widely depending on conditions in the country and the community, the nature of the industry and the processes and materials used, as well as on the characteristics of the workforce. Preventive services should be given highest priority and an acceptable level of quality should be ensured.
A variety of models are available for organizing occupational health services and creating the associated infrastructures. The choice should be determined by the characteristics of the enterprise, the available resources in terms of finances, facilities, qualified personnel, the kinds of problems anticipated, and what is available in the community. Further research on the suitability of various models in different situations is needed.
Providing high-quality occupational health services often requires the involvement of a broad range of occupational health and safety, general health and psychosocial disciplines. The ideal service is staffed by a multidisciplinary team in which a number of these specialities are represented. However, even such services must turn to external sources when infrequently used specialists are required. To meet the growing need for such specialists, adequate numbers must be recruited, trained and provided with the specialization in occupational health needed for optimal effectiveness in the world of work. International collaboration should be encouraged in the collection of available information and design of its application under varied circumstances, and its dissemination through already established networks widely promoted.
Research activities in occupational health have traditionally been focused on such areas as toxicology, epidemiology and the diagnosis and treatment of health problems. More research is needed on the effectiveness of various models and mechanisms for delivering occupational health services, on their cost-effectiveness and their adaptability to different circumstances.
There are a number of goals and objectives of occupational health services, some of which may need to be reconsidered because of the constantly changing world of work. These should be reviewed and revised by the most authoritative international bodies in the light of new and emerging problems of occupational health and safety and the new modes of promoting and protecting the health of workers.
The ILO Occupational Health and Safety Conventions and Recommendations, approaches and standards embodied in them, the WHO strategies and resolutions, as well as international programmes of both organizations constitute a solid basis for national work and wide international cooperation in the further development and improvement of occupational health services and practice. Such instruments and their due implementation are particularly needed throughout the world in times of rapidly changing working life; in implementation of new technologies; and under the growing risk of setting the short-term economic and material objectives ahead of the health and safety values.
Outplacement is a professional consulting service that helps organizations plan and implement individual terminations or reductions in their workforces so as to minimize disruptions and avoid legal liability, and counsels terminated employees in order to minimize the trauma of separation while orienting them towards seeking alternative employment or new careers.
The economic downturn of the 1980s, which continues in the 1990s, has been characterized by a virtual pandemic of job terminations reflecting the closing down of obsolescent or unprofitable units, plants and businesses, the elimination of redundancies created by mergers, takeovers, consolidations and reorganizations, and the trimming of staff to reduce operating costs and produce a “lean and mean” workforce. Although less striking than in private industry thanks to the protection of civil service regulations and political pressures, the same phenomenon has also been seen in government organizations struggling to cope with budget deficits and a philosophy that less government is desirable.
For the terminated employees, job loss is a potent stressor and source of trauma, especially when the manner of dismissal is sudden and brutal. It generates anger, anxiety and depression and may cause decompensation in persons with marginal adjustment to chronic mental illness. Rarely, the anger may express itself in sabotage or violence aimed at the supervisors and managers responsible for the termination. Sometimes, the violence is directed at spouses and family members.
The trauma of job loss has also been associated with physical ailments ranging from headaches, gastrointestinal disturbances and other functional complaints to stress-related disorders such as heart attacks, bleeding peptic ulcers and colitis.
In addition to the financial impact of loss of earnings and, in the United States, loss of employer-sponsored health insurance, job loss also affects the health and well-being of the families of the terminated employees.
Employees who are not terminated are also affected. Despite employers’ reassurances, there often is concern over the possibility of additional layoffs (threatened job loss has been found to be an even more potent stressor than actual loss of the job). In addition, there is the stress of adjusting to changes in work load and job content as relationships with co-workers are reshuffled. “Downsizing”, or reduction in the size of a workforce, may also be traumatic to the employer. It may take significant time and effort to smooth out the resultant organizational disruptions and achieve the desired productive efficiency. Valuable employees not scheduled for termination may leave for other, ostensibly more secure jobs and better-organized firms. There is also the potential of legal liability stemming from discharged employees’ allegations of breach of contract or unlawful discrimination.
Outplacement—A Preventive Approach
Outplacement is a professional service offered to prevent, or at least minimize, the trauma of staff reduction for terminated employees, those who remain and the employer.
Not all discharged employees require assistance. For some, the termination precipitates an opportunity to seek new work that might provide welcome relief from a job that had become stultifying and offered little hope of advancement. For most, however, professional counselling in working through the almost inevitable disappointment and anger of dismissed employees and help in finding new jobs can facilitate the restoration of their sense of self-worth and their well-being. Even those who accept the lure of the “golden handshake” (a package of enhanced severance and retirement benefits) and leave voluntarily may benefit from help in making the necessary readjustments.
It is generally agreed that outplacement services are most inexpensively provided by in-house staff. However, even a large organization with a competent and well-functioning staff may not have had much experience with the sensitive work of downsizing and may be too busy planning the restructuring of the organization following the exodus to attend to the niceties that may be involved. Even hardened executives often find it difficult to deal with their erstwhile co-workers. Furthermore, the departing employees are more likely to give credibility to advice from a “neutral” resource.
Accordingly, the vast majority of organizations find it expedient to contract with an outplacement consultant or consulting firm. This neutrality is reinforced by having all possible outplacement contacts located offsite in separate quarters occupied even temporarily by the consultant(s).
The outplacement process for terminated employees needs to be individualized depending on their attitudes, capabilities and circumstances, and the nature of the job market locally or in other regions. For non-exempt production workers and first-line supervisors, it involves an inventory of the worker’s skills and, where there is a market for them, assistance in placement. Where no suitable jobs exist, it involves assessment of the potential for retraining, referral for retraining, and assistance in marketing the new skills. An unfortunate complication that is difficult to overcome arises when the pay scales for the available new jobs do not measure up to the earnings of the former employment.
For employees in managerial and “creative” positions, the process generally involves a number of phases that are frequently overlapping. These phases are considered under the following heads.
Leaving the past employer.
The object is to help the candidate through the stages of reaction, understanding and acceptance of his or her predicament. Occasionally, this may require the intervention of a mental health professional.
This usually involves a reevaluation of the termination event. To earn the candidate’s confidence and assist in establishing a desirable rapport, the consultant generally reviews the circumstances of the termination and makes certain that the candidate understands them and, furthermore, has received all of the monetary and other benefits to which he or she may be entitled.
This phase concludes when the candidate is able to deal constructively with the immediate problems and responsibilities and is ready to start preparing for the future with a positive attitude. Ideally, some measure of reconciliation has been established with the past employer and the candidate is willing to accept whatever support may be offered. Such support may include temporary use of an office with a business address and telephone, supplemented by the services of a secretary who can provide typing and photocopying services, take messages, confirm appointments, etc. Most candidates function more effectively from an business-like office environment than from their own homes. Also, the consultant helps formulate a mutually satisfactory reason for the termination and arrange a mutually acceptable response to requests for references from potential employers.
Preparation for new employment.
This phase is intended to provide the focus and structure for positive thinking and action. It involves a start of the recovery of self-confidence (which continues throughout the process) by building a personal data base of the candidate’s skills, abilities, knowledge and experience, and learning to communicate it in clear, functional terms. Simultaneously, the candidate begins to identify and confirm suitable job objectives and to consider the nature of the jobs for which his or her background might be particularly suitable. Through it all, the candidate acquires the knack of accumulating and organizing information that will highlight the range and depth of his or her experience and level of competence.
Here, the candidate learns to develop a flexible tool that will present his or her objectives, qualifications, and background, arouse the interest of potential employers, help obtain interviews, and serve as an aid during job interviews. Rather than being restricted to a fixed format, the résumé is varied to “package” skills and experiences to make them most attractive for particular job opportunities.
Assessing job opportunities.
The consultant guides the candidate to an assessment of the availability of potential jobs that might be suitable. This includes a survey of different industries, the job market in different localities, opportunities for growth and advancement, and likely earning potential. Experience indicates that about 80% of job opportunities are “hidden,” that is, they are not readily apparent on the basis of industry designation or job title. Where appropriate, the assessment also includes an appraisal of the potential of self-employment.
This involves identifying and exploring existing and potential opportunities through direct approaches to potential employers and developing and making use of contacts and intermediaries. The campaign entails obtaining interviews with the “right” people on a right basis, and using letters both to obtain interviews and as a follow-up to interviews.
The consultant will, as part of enhancing the candidate’s job-hunting skills, improve his or her writing and interview techniques. Practice in letter writing is aimed at polishing a communication skill that is uniquely helpful in defining job opportunities, in identifying the “right” people and developing contacts with them, obtaining interviews with them and in following up on interviews. The candidate is further trained by interview coaching, which involves role playing and critiquing videotapes of practice interviews in order to maximize the effectiveness with which his or her personality, experience and desires are presented. The candidate’s chances of coming away from an interview, with, at least, an appointment for the next interview, if not an actual job offer, are by this means enhanced.
The consultant will help candidates overcome their dislike or even fear of discussing compensation in negotiating a potential position so that they can obtain the best compensation package possible under the existing circumstances, avoiding the possibility of over-selling or under-selling themselves or antagonizing the interviewer.
Within the limits of the consulting contract, regular contact with the candidate is maintained until a new position is maintained. This involves gathering and organizing information to track how the campaign is progressing and to ensure optimal use of time and effort. It will help the candidate to avoid errors of omission and provide a signal to correct errors of commission.
When a new position is obtained, the candidate notifies the consultant and the old employer as well as other prospective employers with whom he or she may have been negotiating.
Again, within the limits of the contract, the consultant maintains contact to assist the candidate’s adjustment to the new position to aid in overcoming any adverse factors and to encourage continuing career growth and development. Finally, at the close of the programme, the consultant provides the employer with an aggregate report of the results (personal and/or sensitive information is usually held confidential).
It is rare for the outplacement consultant to be involved in designating specifically which employees are to be separated and which will remain — that is a decision usually made by the organization’s top management, often in consultation with department heads and line supervisors and in the light of the structure envisioned for the revised organization. The consultant, however, does provide guidance on the planning, timing and staging of the downsizing process and on the communications with both those who will leave and those who will remain. Since the “grapevine” (i.e., rumors circulating in the workforce) is usually active, it is imperative that these communications be timely, complete and accurate. Proper communications will also help address potential allegations of discrimination. The consultant also often assists with public relations communications to the industry, customers and the community.
The extent of downsizing during the last decade, at least in the United States, has given impetus to development of a veritable industry of outplacement consultants and firms. A number of search firms devoted to identifying candidates for job vacancies have taken up outplacement as a side-line. A variety of semiprofessionals, including former personnel directors, have become outplacement counsellors.
Until recently, there was no formally adopted code of practice and ethical standards. However, in 1992, the International Association of Outplacement Professionals (IAOP) sponsored the creation of the Outplacement Institute, membership in which requires meeting a set of criteria based on educational background and personal experience, evidence of continuing participation in programs of personal and professional development, and a commitment to uphold and observe the published IAOP Standards for Ethical Practice.
Reduction in the size of a workforce is, at best, a trying experience for the employees being terminated or forced into retirement, and for those remaining and for the organization as a whole. It is invariably traumatic. Outplacement is a professional consulting service designed to prevent or minimize the potential adverse effects and promote the health and well-being of those involved.
It is increasingly being recognized that the last third of life—the “third age”—requires as much thought and planning as do education and training (the “first age”) and career development and retraining (the “second age”). About 30 years ago, when the movement to address the needs of the retired began, the average male employee in the United Kingdom, and in many other developed countries as well, retired at the age of 65 as a rather worn-out worker with a limited life expectancy and, especially if he was a blue collar worker or labourer, with an inadequate pension or none at all.
This scene has been changing dramatically. Many people are retiring younger, voluntarily or at ages other than those dictated by mandatory retirement regulations; for some, early retirement is being forced upon them by illness and disability and by redundancy. At the same time, many others are electing to continue to work long past the “normal” retirement age, in the same job or in another career.
By and large, today’s retirees generally have better health and longer life expectancies. Indeed, in the United Kingdom, the over-80s are the fastest growing group in the population, while more and more people are living into their 90s. And with the surge of women into the workforce, a growing number of the retirees is female, many of whom, owing to longer life expectancies than their male counterparts, will be single or widowed.
For a time—two decades or longer for some—most retirees retain mobility, vigour and functional capacities honed by experience. Thanks to higher living standards and advances in medical care, this period continues to extend. Sadly, however, many live longer than their biological structures were designed for (i.e., some of their bodily systems give up efficient service while the rest struggle on), causing increasing medical and social dependency with ever fewer compensatory enjoyments. The goal of retirement planning is to enhance and extend enjoyment of the period of well-being and ensure to the extent possible the resources and support systems needed during the final decline. It goes beyond estate planning and the disposition of property and assets, although these are often important elements.
Thus, retirement today can offer immeasurable compensations and benefits. Those who retire in good health can expect to live another 20 to 30 years, enjoying potentially purposeful activity for at least two-thirds of this period. This is far too long to drift about doing nothing in particular or rotting away on some sunny “Costa Geriatrica”. And their ranks are being swelled by those who retire early by choice or, sadly, because of redundancy, and by women, too, more of whom are retiring as adequately pensioned workers expecting to remain purposefully active rather than to live as dependants.
Fifty years ago, pensions were inadequate and economic survival was a struggle for most of the elderly. Now, employer-provided pensions and general welfare benefits supplied by government agencies, although still inadequate for many, do allow a not too unreasonable existence. And, because the skilled workforce is shrinking in many industries while employers are recognizing that older workers are productive and often more reliable employees, opportunities for third-agers to get part-time employment are improving.
Further, the “retired” now form about a third of the population. Being sound in mind and limb, they are an important and potentially contributory segment of society which, as they recognize their importance and potential, can organize themselves to pull much more weight. An example in the United States is the American Association of Retired Persons (AARP), which offers to its 33 million members (not all of whom are retired, since membership in the AARP is open to anyone aged 50 or over) a broad range of benefits and exercises considerable political influence. At the first Annual General Meeting of the United Kingdom’s Pre-Retirement Association (PRA) in 1964, Lord Houghton, its president, a member of the Cabinet, said, “If only pensioners could get their act together, they could swing an election.” This has not yet happened, and probably never will in these terms, but it is now accepted in most developed countries that there is a “third age”, comprising a third of the population that has both expectations and needs along with an enormous potential for contributing to the benefit of its members and to the community as a whole.
And with this acceptance, there has been a growing realization that adequate provision and opportunity for this group is vital to social stability. Over the last few decades, politicians and governments have begun to respond through extension and improvement of the variety of “social security” and other welfare programmes. These responses have been handicapped both by fiscal exigencies and by bureaucratic rigidities.
Another, major, handicap has been the attitude of the pensioners themselves. Too many have accepted the stereotyped personal and social image of retirement as both the end of recognition as a useful or even deserving member of society and the expectation of being shunted into a backwater where one can be conveniently forgotten. Overcoming this negative image has been, and to a degree still is, the main objective of training for retirement.
As more and more retirees accomplished this transformation and looked to fulfil the needs that emerged, they became aware of the shortcomings of government programmes and began to look to employers to fill the gap. Thanks to accumulated savings and employer-provided pension programmes (many of which were shaped through collective bargaining with unions), they discovered financial resources that were often considerable. To enhance the value of their private pension schemes, employers and unions began to arrange for (and even offer) programmes providing advice and support in managing them.
In the United Kingdom, credit for this is largely due to the Pre-Retirement Association (PRA) which, with government support through the Department of Education (initially, this programme was shunted among the Departments of Health, Employment, and Education), is being accepted as the mainstream of retirement preparation.
And, as the thirst for such guidance and assistance has grown, a veritable industry of voluntary and for-profit organizations has come into existence to meet the demand. Some function quite altruistically; others are self-serving, and include insurance companies that wish to sell annuities and other insurance, investment firms that manage accumulated savings and pension income, real estate brokers selling retirement homes, operators of retirement communities seeking to sell memberships, charities that offer advice on the tax benefits of making contributions and bequests, and so on. These are supplemented by an army of publishers offering “how-to” books, magazines, audiotapes and videotapes, and by colleges and adult education organizations that offer seminars and courses on relevant topics.
While many of these providers focus primarily on coping with financial, social or family problems, recognition that well-being and productive living are dependent on being healthy has led to the increasing prominence of health education and health promotion programmes intended to avert, defer or minimize illness and disability. This is particularly the case in the United States, where employers’ financial commitment for the escalating costs of health care for retirees and their dependants has not only become a very weighty burden but now must be projected as a liability on the balance sheets included in corporation annual reports.
Indeed, some of the categorical voluntary health organizations (e.g., heart, cancer, diabetes, arthritis) produce educational materials specifically designed for employees approaching retirement age.
In short, the third age has arrived. Pre-retirement and retirement programmes offer opportunities both for maximizing personal and social well-being and function and for providing the necessary understanding, training and support.
Role of the Employer
Although far from universal, the main support and funding for pre-retirement programmes has come from employers (including local and central governments and the armed forces). In the United Kingdom, this was in large part due to the efforts of the PRA, which, early on, initiated company membership through which employees are provided with encouragement, advice and in-house courses. It has, in fact, not been difficult to convince commerce and industry that they have a responsibility far beyond the mere provision of pensions. Even there, as pension schemes and their tax implications have become more complicated, detailed explanations and personalized advice have become more important.
The workplace provides a convenient captive audience, making the presentation of programmes more efficient and less costly, while peer pressure enhances employee participation. The benefits to the employees and their dependants are obvious. The benefits to the employers are substantial, albeit more subtle: improved morale, the enhancement of the company’s image as a desirable employer, encouragement for retaining older employees with valuable experience, and retaining the good will of retirees, many of whom, thanks to profit-sharing and company-sponsored investment plans, are also shareholders. When workforce reductions are desired, employer-sponsored pre-retirement programmes are often presented to enhance the attractiveness of the “golden handshake,” a package of inducements for those accepting early retirement.
Similar benefits accrue to trade unions who offer such programmes as an adjunct to union-sponsored pension programmes: making union membership more attractive and enhancing good will and esprit de corps among union members. It should be noted that interest among the trade unions in the United Kingdom is only beginning to develop, primarily among the smaller and professional unions, like that of the airline pilots.
The employer may contract for a complete, “pre-packaged” programme or assemble one from the list of individual elements offered by organizations like the PRA, assorted adult educational institutions and the many investment, pension and insurance firms that offer retirement training courses as a commercial venture. Although generally of a high standard, the latter have to be monitored to be sure that they provide straightforward, objective information rather than promotion of the provider’s own products and services. The employer’s departments of personnel, pension and, where there is one, education, should be involved in assembling and presenting the programme.
The programmes may be given entirely in-house or at a conveniently located facility in the community. Some employers offer them during working hours but, more often, they are made available during lunch periods or after hours. The latter are more popular because they minimize interference with work schedules and they facilitate the attendance of spouses.
Some employers cover the entire cost of participation; others share it with the employees while some rebate all or part of the employee’s share on successful completion of the programme. While faculty should be available for answers to questions, participants are usually referred to appropriate experts when individualized personal consultations are needed. As a rule, these participants accept responsibility for any costs that may be required; sometimes, when the expert is affiliated with the programme, the employer may be able to negotiate reduced fees.
For many people, especially those who have been workaholics, separation from work is a wrenching experience. Work provides status, identity and association with other people. In many societies, we tend to be identified and to identify ourselves socially by the jobs we do. The work context that we are in, especially as we grow older, dominates our lives in terms of what we do, where we go and, particularly for professional people, our daily priorities. Separation from co-workers, and a sometimes unhealthy level of preoccupation with minor family and household affairs, indicate a need for developing a new frame of social reference.
Well-being and survival in retirement depend on understanding these changes and setting out to make the most of the opportunities they present. Central to such understanding is the concept of maintenance of health in the widest sense of the World Health Organization definition and a more modern acceptance of a holistic approach to medical problems. Establishment of and adherence to a healthful life style must be supplemented by properly managing finances, housing, activities and social relationships. Preserving financial resources for the time when increasing disability requires special care and assistance that may increase the cost of living is often more important than estate planning.
Organized courses which provide information and guidance may be considered the keystone of pre-retirement training. It is sensible for the course organizers to realize that the aim is not to provide all the answers but to delineate possible problem areas and point the way to the best solutions for each individual.
Pre-retirement programmes may include a variety of elements; the following briefly described topics are the most fundamental and should be assured a place among any programme’s discussions:
Vital statistics and demography.
Life expectancies at relevant ages—women live longer than men—and trends in family composition and their implications.
The lifestyle, motivational and opportunity-based changes to be required over the next 20 to 30 years.
Understanding the physical and mental aspects of ageing and elements of the lifestyle that will promote optimal well-being and functional capacity (e.g., physical activity, diet and weight control, coping with failing vision and hearing, increased sensitivity to cold and hot weather, and use of alcohol, tobacco and other drugs). Discussions of this topic should include dealing with doctors and the health care system, periodic health screening and preventive interventions, and attitudes toward illness and disability.
Understanding the company’s pension plan as well as potential social security and welfare benefits; managing investments to preserve resources and maximize income, including the investment of lump sum payments; managing home ownership and other properties, mortgages, and so on; continuation of employer/union-sponsored and other health insurance, including consideration of long-term care insurance, if available; how to select a financial advisor.
Estate planning and making a will; executing a living will (i.e., the setting forth of “medical directives” or naming a health care proxy) containing wishes about what treatments should or should not be administered in the event of potentially terminal illness and inability to participate in decision-making; relationships with spouse, children, grandchildren; coping with constriction of social contacts; role reversal in which the wife continues a career or outside activities while the husband takes more responsibility for cooking and homemaking.
Home and garden may become too large, costly and burdensome as financial and physical resources shrink, or it may be too small as the retiree recreates an office or workshop in the home; with both spouses at home, it is helpful, if possible, to arrange for each to have his and her own territory to provide a modicum of privacy for activities and reflection; consideration of moving to another area or country or to a retirement community; availability of public transportation if automobile driving becomes imprudent or impossible; preparing for eventual frailty; assistance with homemaking and social contacts for the single person.
How to find opportunities and training for new jobs, hobbies and volunteer activities; educational activities (e.g., completion of interrupted diploma and degree courses); travel (in the United States, Elderhostel, a voluntary organization, offers a large catalogue of year-round one-week or two-week adult education courses given at college campuses and vacation resorts throughout the United States and internationally).
Developing a schedule of meaningful and enjoyable activities that balance individual and joint involvement; while new opportunities for “togetherness” are a benefit of retirement, it is important to realize the value of independent activities and to avoid “getting in each other’s way”; group activities including clubs, church and community organizations; recognizing the motivational value of ongoing paid or voluntary work commitments.
Organizing the course
The type, content and length of the course are usually determined by the sponsor on the basis of the available resources and expected costs, as well as the level of commitment and the interests of employee participants. Few courses will be able to cover all of the above topic areas in exhaustive detail, but the course should include some discussion of most (and preferably all) of them.
The ideal course, educators tell us, is of the day-release type (employees attend the course on company time) with about ten sessions in which participants can get to know each other and instructors can explore individual needs and concerns. Few companies can afford this luxury, but Pre-Retirement Associations (of which the United Kingdom has a network) and adult education centres run them successfully. The course may be presented as a short-term entity—as a two-day course which allows participants more discussion and more time for guidance in activities is probably the best compromise, rather than as a one-day course in which condensation requires more didactic than participative presentations—or it may involve a series of more or less brief sessions.
It is prudent that the course be open to spouses and partners; this may influence its location and timing.
Clearly, every employee facing retirement should be given the opportunity to attend, but the problem is the mix. Senior executives have very different attitudes, aspirations, experiences and resources than relatively junior executives and line staff. Widely differing educational and social backgrounds may inhibit the free-wheeling exchanges that make the courses so valuable to participants, particularly with respect to finances and post-retirement activities. Very large classes dictate a more didactic approach; groups of 10 to 20 facilitate valuable exchanges of concerns and experiences.
Employees in large companies which emphasize corporate identity, like IBM in the United States and Marks & Spencer in the United Kingdom, often find it difficult to fit into the wide world without the “big brother” aura to support them. This is particularly true of the separate services in the armed forces, at least in the United Kingdom and the United States. At the same time in such tightly-knit groups, employees sometimes find it difficult to express concerns that might be construed as company disloyalty. This does not appear as much of a problem when courses are given off-site or include employees of number of companies, a necessity when smaller organizations are involved. These “mixed” groups are often less formal and more productive.
It is essential that the instructors have the knowledge and, especially, the communication skills required to make the course a useful and pleasurable experience. While the company’s personnel, medical and education departments may be involved, qualified consultants or academicians are often considered to be more objective. In some instances, qualified instructors recruited from among the company’s retirees can combine greater objectivity with knowledge of the company environment and culture. Since it is rare for any one individual to be expert in all of the issues involved, a course director supplemented by several specialists is usually desirable.
The course sessions are usually supplemented by workbooks, videotapes and other publications. Many programmes include subscriptions to pertinent books, periodicals, and newsletters, which are most effective when addressed to the home, where they may be shared by spouses and family members. Membership in national organizations, like PRA and AARP or their local counterparts, provides access to useful meetings and publications.
When is the course given?
Pre-retirement programmes generally begin about five years before the scheduled retirement date (recall that AARP membership becomes available at age 50, regardless of planned retirement age). In some companies, the course is repeated every one or two years, with employees invited to take it as often as they wish; in others, the curriculum is divided into segments given in successive years to the same group of participants with content varying as the retirement date approaches.
The number of eligible employees electing to participate and the rate of drop-out are perhaps the best indicators of the utility of the course. However, a mechanism should be introduced so that participants can feed back their impressions of the course content and the quality of the instructors as a basis for making changes.
Courses with uninspired presentations of largely irrelevant material are not likely to be very successful. Some employers use questionnaire surveys or conduct focus groups to probe the interests of potential participants.
An important point in the decision-making process is the state of employer/employee relations. When hostility is overt or just beneath the surface, employees are not likely to assign great value to anything the employer offers, especially if it is labelled “for your own good”. Employee acceptance can be enhanced by having one or more staff committees or union representatives involved in the design and planning.
Finally, as retirement approaches and becomes a way of life, circumstances change and new problems arise. Accordingly, periodic repetition of the course should be planned, both for those who might benefit from a rerun and those who are newly approaching the “third age”.
Many companies continue contact with retirees throughout their lives, often together with their surviving spouses, especially when employer-sponsored health insurance is continued. Periodic health screenings and health education and promotion programmes designed for “seniors” are provided and, when needed, access to individual consultations on health, financial, domestic and social problems is made available. An increasing number of larger companies subsidize pensioner clubs which may have more or less autonomy in programming.
Some employers make a point of rehiring retirees on a temporary or part-time basis when extra help is needed. Other examples from New York City include: the Equitable Life Assurance Society of the United States, which encourages retirees to volunteer their services to non-profit-making community agencies and educational institutions, paying them a modest stipend to offset commuting and incidental out-of-pocket expenses; the National Executive Service Corps, which arranges to provide the expertise of retired executives to companies and government agencies around the world; the International Ladies Garment Workers Union (ILGWU), which has instituted the “Friendly Visiting Program,” which trains retirees to provide companionship and useful services to members beset by problems of ageing. Similar activities are sponsored by pensioner clubs in the United Kingdom.
Except for employer/union-sponsored pensioner clubs, most post-retirement programmes are carried out by adult education organizations through their offerings of formal courses. In the United Kingdom, there are several nationwide pensioner groups like PROBUS which holds regular local meetings to provide information and social contacts to their members, and the PRA which offers individual and corporate membership for information, courses, tutors and general advice.
An interesting development in the United Kingdom, based on a similar organization in France, is the University of the Third Age, which is centrally coordinated with local groups in the larger towns. Its members, mostly professionals and academics, work to broaden their interests and extend their knowledge.
Through their regular intramural publications as well as in materials specifically prepared for retirees, many companies and unions provide information and advice, often spiced with anecdotes about retirees’ activities and experiences. Most developed countries have at least one or two general circulation magazines aimed at retirees: France’s Notre Temps has a large circulation among third agers and, in the United States, AARP’s Modern Maturity goes to its more than 33 million members. In the UK there are two monthly publications for the retired: Choice and SAGA Magazine. The European Commission is currently sponsoring a multi-language retirement workbook, Making the Most of Your Retirement.
In the many developed countries, employers are becoming increasingly aware of the impact of the problems faced by employees with elderly or disabled parents, in-laws and grandparents. Although some of these may be pensioners of other companies, their needs for support, attention, and direct services may be significant burdens for the employees who must contend with their own jobs and personal affairs. To ease those burdens and reduce the consequent distraction, fatigue, absenteeism and lost productivity, employers are offering “eldercare programmes” to these caregivers (Barr, Johnson and Warshaw 1992; US General Accounting Office 1994). These provide various combinations of education, information and referral programmes, modified work schedules and respite leaves, social support, and financial aid.
It is abundantly clear that demographic and social workforce trends in the developed countries are producing increasing awareness of the need for information, training and advice across the whole spectrum of “third age” problems. This awareness is being appreciated by employers and labour unions—and by politicians, as well—and is being translated into pre-retirement programmes and post-retirement activities which offer potentially great benefits to the ageing, their employers and unions, and society at large.
Employers may recruit workers and trade unions may enlist members, but both get human beings who bring to the workplace all the concerns, problems and dreams characteristic of the human condition. As the world of work has become increasingly conscious that the competitive edge in a global economy depends on the productivity of its work force, the key agents in the workplace—management and labour unions—have devoted significant attention to meeting the needs of those human beings. Employee Assistance Programmes (EAPs), and their parallel in unions, Membership Assistance Programmes (MAPs) (hereafter referred to jointly as EAPs), have developed in workplaces around the world. They constitute a strategic response to meeting the diverse needs of a working population and, more recently, to meeting the humanist agenda of organizations of which they are a part. This article will describe the origins, functions and organization of EAPs. It is written from the point of view of the social worker’s profession, which is the major profession driving this development in the United States and one which, because of its worldwide interconnections, appears to be playing a major role in establishing EAPs worldwide.
The extent of development of employee assistance programmes varies from country to country, reflecting, as David Bargal has pointed out (Bargal 1993), the differences in degree of industrialization, state of the professional training available for appropriate personnel, degree of unionization in the employment sector and societal commitment to social issues, among other variables. His comparison of EAP development in Australia, the Netherlands, Germany and Israel leads him to suggest that although industrialization may be a necessary condition to achieve a high rate of EAPs and MAPs in a country’s workplaces, it may not be sufficient. The existence of these programmes also is characteristic of a society with significant unionization, labour/management cooperation and a well-developed social service sector in which government plays a major role. Further, there is need for a professional culture, supported by an academic specialization that promotes and disseminates social services at the workplace. Bargal concludes that the greater the aggregate of these characteristics in a given nation, the more likely that there will be extensive availability of EAP services in its workplaces.
Diversity is also apparent among programmes within individual countries in relation to structure, staffing, focus and scope of programme. All EAP efforts, however, reflect a common theme. The parties in the workplace seek to provide services to remediate the problems that employees experience, often without causal relationship to their work, that interfere with employees’ productivity on the job and sometimes with their general well-being as well. Observers have noted an evolution in EAP activities. Although the initial impetus may be the control of alcoholism or drug abuse among workers, nevertheless, over time, interest in individual workers becomes more broadly based, and the workers themselves become only one element in a dual focus that embraces the organization as well.
This organizational focus reflects an understanding that many workers are “at risk” of being unable to maintain their work roles and that the “risk” is as much a function of the way the work world is organized as it is a reflection of the individual characteristics of any particular worker. For example, ageing workers are “at risk” if the workplace technology changes and they are denied retraining because of their age. Single parents and caretakers of the elderly are “at risk” if their work environment is so rigid that it does not provide time flexibility in the face of the illness of a dependant. A person with a disability is “at risk” when a job changes and accommodations are not offered to enable the individual to perform in keeping with the new requirements. Many other examples will occur to the reader. What is significant is that, in the matrix of being able to change the individual, the environment, or some combination thereof, it has become increasingly clear that a productive, economically successful work organization cannot be achieved without consideration of the interaction between organization and individual at a policy level.
Social work rests on a model of individual in environment. The evolving definition of “at risk” has enhanced the potential contribution of its practitioners. As Googins and Davidson have noted, the EAP is exposed to a range of problems and issues affecting not only individuals, but also families, the corporation and the communities in which they are located (Googins and Davidson 1993). When a social worker with an organizational and environmental outlook functions in the EAP, that professional is in a unique position to conceptualize interventions that promote not only the EAP’s role in delivery of individual service but in advising on organizational policy in the workplace as well.
History of EAP Development
The origin of social service delivery at the workplace dates back to the time of industrialization. In the craft workshops that marked an earlier period, work groups were small. Intimate relationships existed between the master craftsman and his journeymen and apprentices. The first factories introduced larger work groups and impersonal relationships between employer and employee. As problems that interfered with the workers’ performance became apparent, employers began to provide helping individuals, often called social or welfare secretaries, to assist workers recruited from rural settings, and sometimes new immigrants, with the process of adjusting to formalized workplaces.
This focus on using social workers and other human service providers to achieve acculturation of new populations to the demands of factory labour continues internationally to this day. Several nations, for example Peru and India, legally require that work settings that exceed a particular employment level provide a human service worker to be available to replace the traditional support structure that was left behind in the home or rural environment. These professionals are expected to respond to the needs presented by the newly recruited, largely displaced rural residents in relation to concerns of everyday living such as housing and nutrition as well as those involving illness, industrial accidents, death and burial.
As the challenges involved in maintaining a productive work force evolved, a different set of issues asserted itself, warranting a somewhat different approach. EAPs probably represent a discontinuity from the earlier welfare secretary model in that they are more clearly a programmatic response to the problems of alcoholism. Pressed by the need to maximize productivity during the Second World War, employers “attacked” the losses resulting from alcohol abuse among workers by establishing occupational alcoholism programmes in the major production centres of the Western Allies. The lessons learned from the effective efforts at containing alcoholism, and the concomitant improvement in the productivity of the workers involved, received recognition after the War. Since that time, there has been a slow but steady increase in service delivery programmes worldwide that make use of the employment site as an appropriate location and centre of support for remediating problems that are identified as causes of major drains in productivity.
This trend has been aided by the development of multinational corporations that tend to replicate an effective effort, or a legally required system, in all their corporate units. They have done so almost without regard to the programme’s relevance or cultural appropriateness to the particular country in which the unit is located. For example, South African EAPs resemble those in the United States, a state of affairs accountable in part by the fact that the earliest EAPs were established in the local outposts of multinational corporations that are headquartered in the United States. This cultural crossover has been positive in that it has fostered replication of the best of each country on a worldwide scale. An example is the sort of preventive action, in relation to sexual harassment or labour force diversity issues that have come to prominence in the United States, that has become the standard to which American corporate units around the world are expected to adhere. These provide models for some local firms to establish comparable initiatives.
Rationale for EAPs
EAPs may be differentiated by their stage of development, programme philosophy or definition of what problems are appropriate to address and what services are acceptable responses. Most observers would agree, however, that these occupational interventions are expanding in scope in the countries that have already established such services, and are incipient in those nations that have yet to establish such initiatives. As already indicated, one reason for expansion can be traced to the widespread understanding that drug and alcohol abuse in the workplace is a significant problem, costing lost time and high medical care expenses and seriously interfering with productivity.
But EAPs have grown in response to a wide array of changing conditions that cross national boundaries. Unions, pressed to offer benefits to maintain the loyalty of their members, have viewed EAPs as a welcome service. Legislation on affirmative action, family leave, worker’s compensation and welfare reform all involve the workplace in a human service outlook. The empowerment of working populations and the search for gender equity that are needed for employees to function effectively in the team environment of the modern production machine, are aims that are well served by the availability of destigmatized, universal social service delivery systems that can be established in the world of work. Such systems also help with the recruitment and retention of a quality labour force. EAPs have also filled the gap in community services that exists, and seems to be increasing, in many nations of the world. The spread of, and desire to contain HIV/AIDS, as well as the growing interest in prevention, wellness and safety in general, have each contributed support to the educational role of EAPs in the world’s workplaces.
EAPs have proven a valuable resource in helping workplaces respond to the pressure of demographic trends. Such changes as the increase in single parenthood, in the employment of mothers (whether of infants or of young children), and in the number of two-worker families have required attention. The ageing of the population and the interest in reducing welfare dependency through maternal employment—facts that are apparent in most industrialized countries—have involved the workplace in roles that require assistance from human service providers. And, of course, the ongoing problem of drug and alcohol abuse that has reached epidemic proportions in many countries, has been a major concern of work organizations. A survey examining public perception of the drug crisis in 1994 as compared with five years earlier found that 50% of respondents felt it was much greater, an additional 20% felt it was somewhat greater, only 24% considered it the same and the remaining 6% felt it had declined. While each of these trends varies from country to country, all exist across countries. Most are characteristic of the industrialized world where EAPs have already developed. Many can be observed in the developing countries that are experiencing any significant degree of industrialization.
Functions of EAPs
The establishment of an EAP is an organizational decision that represents a challenge to the existing system. It suggests that the workplace has not attended adequately to the needs of individuals. It confirms the mandate for employers and trade unions, in their own organizational interest, to respond to the broad social forces at work in society. It is an opportunity for organizational change. Though resistance may occur, as it does in all situations where systemic change is attempted, the trends described earlier provide many reasons why EAPs can be successful in their quest for offering both counselling and advocacy services to individuals and policy advice to the organization.
The kinds of functions EAPs serve reflect the presenting issues to which they seek to respond. Probably every programme extant deals with drug and alcohol abuse. Interventions in this connection usually include assessment, referral, training for supervisors and operation of support groups to maintain employment and encourage abstinence. The service agenda of most EAPs, however, is more broadranging. Programmes offer counselling to those experiencing marital problems or difficulties with children, those needing help with finding day care or those making decisions concerning elder care for a family member. Some EAPs have been asked to deal with work environment issues. Their response is to give help to families adjusting to relocation, to bank employees who experience robberies and need trauma debriefing, to disaster crews, or to health care workers accidentally exposed to HIV infection. Assistance in coping with “downsizing” is supplied, too, to both those laid off and the survivors of such lay-offs. EAPs may be called on to assist with organizational change to meet affirmative action goals or to serve as case managers in achieving accommodation and return to work for employees who become disabled. EAPs have been enlisted in preventive activities as well, including good nutrition and smoking cessation programmes, encouraging participation in exercise regimes or other parts of health promotion efforts, and offering educational initiatives that can range from parenting programmes to preparation for retirement.
Although these EAP responses are multifaceted, they typify EAPs as widespread as Hong Kong and Ireland. Studying a non-random sample of American employers, trade unions and contractors who deliver EAP drug and alcohol abuse services, for example, Akabas and Hanson (1991) found that plans in a variety of industries, with different histories and under various auspices, all conform to each other in important ways. The researchers, expecting that there would be a wide variety of creative responses to dealing with workplace needs, identified, on the contrary, an astounding uniformity of programme and practice. At an International Labour Organization (ILO) international conference convoked in Washington, D.C. to compare national initiatives, a similar degree of uniformity was confirmed throughout western Europe (Akabas and Hanson 1991).
Respondents in the surveyed work organizations in the United States agreed that legislation has had a significant impact on determining the components of their programmes and the rights and expectations of client populations. In general, programmes are staffed by professionals, more often social workers than professionals of any other discipline. They respond to a broad constituency of workers, and often their family members, with services that provide diverse care for a range of presenting problems in addition to their focus on rehabilitation of alcohol and drug abusers. Most programmes overcome general inattention by top management and inadequate training for and support from supervisors, to achieve penetration rates of between 3 and 5% of the total workers at the target site. The professionals who staff the EAP and MAP movements seem to agree that confidentiality and trust are the keys to effective service. They claim success in dealing with the problems of drug and alcohol abuse although they can point to few evaluative studies to confirm the efficacy of their intervention in relation to any aspect of service delivery.
Estimates suggest that there are as many as 10,000 EAPs now in operation in settings throughout the United States alone. Two main types of service delivery systems have evolved, the one directed by an inhouse staff and the other provided by an outside contractor that offers service to numerous work organizations (employers and trade unions) at the same time. There is a raging debate as to the relative merits of internal versus external programmes. Claims of increased protection of confidentiality, greater diversity of staff and clarity of role undiluted by other activities, are made for external programmes. Advocates of internal programmes point to the advantage conferred by their position within the organization with respect to effective intervention at the systems level and to the policy-making influence that they have gained as a result of their organizational knowledge and involvement. Since organization-wide initiatives are increasingly valued, internal programmes are probably better for those worksites that have sufficient demand (at least 1,000 employees) to warrant a full-time staffer. This arrangement allows, as Googins and Davidson (1993) point out, improved access to employees because of the varied services that can be offered and the opportunity it affords to exert influence on policymakers, and it facilitates collaboration and integration of the EAP function with others in the organization—all of these capabilities strengthen the authority and role of the EAP.
Work and Family Issues: A Case in Point
The interaction of EAPs, over time, with work and family issues provides an informative example of the evolution of EAPs and of their potential for individual and organizational impact. EAPs developed, historically speaking, parallel with the period during which women entered the labour market in increasing numbers, especially single mothers and mothers of infants and young children. These women often experienced tension between their family demands for dependant care—whether children or the elderly—and their job requirements in a work environment in which the roles of work and family were considered to be separate, and management was inhospitable to the need for flexibility with respect to work and family issues. Where there was an EAP, the women brought their problems to it. EAP staffers identified that women under stress became depressed and sometimes coped with this depression by drug and alcohol abuse. Early EAP responses involved counselling on drug and alcohol abuse, education about time management, and referral to child and elder care resources.
As the number of clients with similar presenting problems mounted, EAPs carried out needs assessments that pointed to the importance of moving from case to class, that is, they began to look for group rather than individual solutions, offering, for example, group sessions on coping with stress. But even this proved to be an inadequate approach to problem resolution. With an understanding that needs differ across the life cycle, EAPs began thinking about their client population in age-related cohorts that had different requirements. Young parents needed flexible leave to care for sick children and easy access to child care information. Those in their middle thirties to late forties were identified as the “sandwich generation”; at their time of life, the twofold demands of adolescent children and ageing relatives increased the need for an array of support services that included education, referral, leave, family counselling and abstinence assistance, among others. The mounting pressures experienced by ageing workers who face the onset of disability, the need to accommodate to a work world in which almost all one’s associates, including one’s supervisors, are younger than oneself, while planning for retirement and dealing with their frail elderly relatives (and sometimes with the parenting demands of the children of their children), create yet another set of burdens. The conclusion drawn from monitoring these individual needs and the service response to them was that what was required was a change in workplace culture that integrated the work and family lives of employees.
This evolution has led directly to the emergence of the EAP’s current role with respect to organizational change. During the process of meeting individual needs, it is probable that any given EAP has built up credibility within the system and is regarded by the key people as the source of knowledge about work and family issues. Likely, it has served an educational and informational role in response to questions raised by managers in numerous departments affected by the problems that occur when these two aspects of human life are experienced in conflict with each other. The EAP has probably collaborated with many organizational actors, including affirmative action officers, industrial relations experts, union representatives, training specialists, safety and health personnel, the medical department staff, risk managers and other human resource personnel, and fiscal workers, and line managers and supervisors.
A force field analysis, a technique suggested in the 1950s by Kurt Lewin (1951), provides a framework for defining the activities necessary to undertake to produce organizational change. The occupational health professional should understand where there will be support within the organization to resolve work and family issues on a systemic basis, and where there might be opposition to such a policy approach. A force field analysis should identify the key actors in the corporation, union or government agency who will influence change, and the analysis will summarize the promoting and restraining forces that will influence these actors in relation to work and family policy.
A sophisticated outcome of an organizational approach to work and family issues will have the EAP participating in a policy committee that establishes a statement of purpose for the organization. The policy should recognize the dual interests of its employees in being both productive workers and effective family participants. Expressed policy should indicate the organization’s commitment to establishing a flexible climate and work culture in which such dual roles can exist in harmony. Then an array of benefits and programmes may be specified to fulfil that commitment including, but not limited to, flexible work schedules, job sharing and part-time employment options, subsidized or onsite child care, an advice and referral service to assist with other child and eldercare needs, family leave with and without pay to cover demands deriving from illness of a relative, scholarships for children’s education and for employees’ own development, and individual counselling and group support systems for the variety of presenting problems experienced by family members. These manifold initiatives related to work and family issues would combine to allow a total individual and environmental response to the needs of workers and their work organizations.
There is ample experiential evidence to suggest that the provision of these benefits assists workers to their goal of productive employment. Yet these benefits have the potential to become costly programmes and they offer no guarantee that work will be performed in an effective and efficient manner as a result of their implementation. Like the EAPs that foster them, work and family benefits must be assessed for their contribution to the organization’s effectiveness as well as to the well-being of its many constituencies. The uniformity of development, described earlier, can be interpreted as support for the fundamental value of EAP services across work places, employers and nations. As the world of work becomes increasingly demanding in the era of a competitive global economy, and as the knowledge and skill that workers bring to the job becomes more important than their mere presence or physical strength, it seems safe to predict that EAPs will be called upon increasingly to provide guidance to organizations in fulfilling their humanist responsibilities to their employees or members. In such an individual and environmental approach to problem solving, it seems equally safe to predict that social workers will play a key role in service delivery.
Throughout history human beings have sought to alter their thoughts, feelings and perceptions of reality. Mind-altering techniques, including reduction of sensory input, repetitive dancing, sleep deprivation, fasting and prolonged meditation have been employed in many cultures. However, the most popular method for producing mood and perception changes has been the use of mind-altering drugs. Of the 800,000 species of plants on earth, about 4,000 are known to produce psychoactive substances. Approximately 60 of these have been used consistently as stimulants or intoxicants (Malcolm 1971). Examples are coffee, tea, the opium poppy, coca leaf, tobacco and Indian hemp, as well as those plants from which beverage alcohol is fermented. In addition to naturally occurring substances, modern pharmaceutical research has produced a range of synthetic sedatives, opiates and tranquillizers. Both plant-derived and synthetic psychoactive drugs are commonly used for medical purposes. Several traditional substances are also employed in religious rites and as part of socialization and recreation. In addition, some cultures have incorporated drug use into customary workplace practices. Examples include the chewing of coca leaves by Peruvian Indians in the Andes and the smoking of cannabis by Jamaican sugar cane workers. The use of moderate amounts of alcohol during farm labour was an accepted practice in the past in some Western societies, for example in the United States in the eighteenth century and the early nineteenth century. More recently, it was customary (and even required by some unions) for employers of battery burners (workers who incinerate discarded storage batteries to salvage their lead content) and house painters using lead-based paints to provide each worker with a daily bottle of whisky to be sipped during the work day in the belief—an erroneous one—that it would prevent lead poisoning. In addition, drinking has been a traditional part of certain occupations, as, for example, among brewery and distillery salespeople. These sales representatives are expected to accept the hospitality of the tavern owner on completing their order-taking.
Customs that dictate alcohol use persist in other work too, such as the “three martini” business lunch, and the expectation that groups of workers will stop at the neighbourhood pub or tavern for a few convivial rounds of drinks at the end of the work day. This latter practice poses a particular hazard for those who then drive home.
Mild stimulants also remain in use in contemporary industrial settings, institutionalized as coffee and tea breaks. However, several historical factors have combined to make the use of psychoactive substances at the workplace a major social and economic problem in contemporary life. The first of these is the trend towards employing increasingly sophisticated technology in today’s workplace. Modern industry requires alertness, unimpaired reflexes and accurate perception on the part of workers. Impairments in these areas can cause serious accidents on one hand and can interfere with the accuracy and efficiency of work on the other. A second important trend is the development of more powerful psychoactive drugs and more rapid means of drug administration. Examples are the intranasal or intravenous administration of cocaine and the smoking of purified cocaine (“freebase” or “crack” cocaine). These methods, delivering much more powerful cocaine effects than the traditional chewing of coca leaves, have greatly increased the dangers of cocaine use on the job.
Effects of Alcohol and Other Drug Usein the Workplace
Figure 1 summarizes the various ways in which the use of psychoactive substances can influence the functioning of employees in the workplace. Intoxication (the acute effects of drug ingestion) is the most obvious hazard, accounting for a wide variety of industrial accidents, for example vehicle crashes due to alcohol-impaired driving. In addition, the impaired judgement, inattention and dulled reflexes produced by alcohol and other drugs also interferes with productivity at every level, from the board room to the production line. Furthermore, workplace impairment due to drug and alcohol use often lasts beyond the period of intoxication. The alcohol-related hangover may produce headache, nausea and photophobia (light sensitivity) for 24 to 48 hours after the last drink. Workers suffering from alcohol dependence may also undergo alcohol withdrawal symptoms on the job, with shaking, sweating and gastrointestinal disturbances. Heavy cocaine use is characteristically followed by a withdrawal period of depressed mood, low energy and apathy, all of which interfere with work. Both intoxication and the after-effects of drug and alcohol use also characteristically lead to lateness and absenteeism. In addition, the chronic use of psychoactive substances is implicated in a wide range of health problems that increase society’s medical costs and time lost from work. Cirrhosis of the liver, hepatitis, AIDS and clinical depression are examples of such problems.
Figure 1. Ways in which alcohol/drug use can cause problems in the workplace.
Workers who become heavy, frequent users of alcohol or other drugs (or both) may develop a dependency syndrome, which characteristically includes a preoccupation with obtaining the drug or the money needed to buy it. Even before other drug or alcohol-induced symptoms begin to interfere with work, this preoccupation may already have started to impair productivity. Furthermore, as a result of the need for money, the employee may resort to stealing items from the workplace or selling drugs on the job, creating another set of serious problems. Finally, the close friends and family members of drug and alcohol abusers (often referred to as “significant others”) are also affected in their ability to work by anxiety, depression and a variety of stress-related symptoms. These effects may even carry over into later generations in the form of residual work problems in adults whose parents suffered from alcoholism (Woodside 1992). Health expenditures for employees with serious alcohol problems are about twice as high as health costs for other employees (Institute for Health Policy 1993). Health costs for members of their families are also increased (Children of Alcoholics Foundation 1990).
Costs to Society
For the above reasons and others, drug and alcohol use and abuse have created a major economic burden on many societies. For the United States, the societal cost estimated for the year 1985 was US$70.3 billion (thousand millions) of for alcohol and $44 billion for other drugs. Of the total alcohol-related costs, $27.4 billion (about 39% of the total) was attributed to lost productivity. The corresponding figure for other drugs was $6 billion (about 14% of the total) (US Department of Health and Human Services 1990). The remainder of the cost accruing to society as a result of drug and alcohol abuse includes the costs for the treatment of medical problems (including AIDS and alcohol-related birth defects), vehicle crashes and other accidents, crime, property destruction, incarceration and the social welfare costs of family support. Although some of these costs may be attributed to the socially acceptable use of psychoactive substances, the vast majority are associated with drug and alcohol abuse and dependence.
Drug and Alcohol Use, Abuse and Dependence
A simple way to categorize the patterns of use of psychoactive substances is to distinguish among non-hazardous use (use in socially accepted patterns that neither create harm nor involve a high risk of harm), drug and alcohol abuse (use in high risk or harm-producing ways) and drug and alcohol dependence (use in a pattern characterized by signs and symptoms of the dependence syndrome).
Both the International Classification of Diseases, 10th edition (ICD-10) and the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th edition (DSM-IV) specify diagnostic criteria for drug and alcohol-related disorders. The DSM-IV uses the term abuse to describe patterns of drug and alcohol use that cause impairment or distress, including interference with work, school, home or recreational activities. This definition of the term is also meant to imply recurrent use in physically hazardous situations, such as repeatedly driving while impaired by drugs or alcohol, even if no accident has yet occurred. The ICD-10 uses the term harmful use instead of abuse and defines it as any pattern of drug or alcohol use that has caused actual physical or psychological harm in an individual who does not meet the diagnostic criteria for drug or alcohol dependence. In some cases drug and alcohol abuse is an early or prodromal stage of dependence. In others, it constitutes an independent pattern of pathological behaviour.
Both the ICD-10 and the DSM-IV use the term psychoactive substance dependence to describe a group of disorders in which there is both interference with functioning (in job, family and social arenas) and an impairment in the individual’s ability to control the use of the drug. With some substances, a physiological dependence develops, with increased tolerance to the drug (higher and higher doses required to obtain the same effects) and a characteristic withdrawal syndrome when use of the drug is abruptly discontinued.
A definition recently prepared by the American Society of Addiction Medicine and the National Council on Alcoholism and Drug Dependence of the United States describes the features of alcoholism (a term usually employed as a synonym for alcohol dependence) as follows:
Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic. (Morse and Flavin 1992)
The definition then goes on to explain the terms used, for example, that the qualification “primary” implies that alcoholism is a discrete disease rather than a symptom of some other disorder, and that “impaired control” means that the affected person cannot consistently limit the duration of a drinking episode, the amount consumed or the resulting behaviour. “Denial” is described as referring to a complex of physiological, psychological and culturally-influenced manoeuvres that decrease the recognition of alcohol-related problems by the affected individual. Thus, it is common for persons suffering from alcoholism to regard alcohol as a solution to their problems rather than as a cause.
Drugs capable of producing dependence are commonly divided into several categories, as listed in table 1. Each category has both a specific syndrome of acute intoxication and a characteristic combination of destructive effects related to long-term heavy use. Although individuals often suffer from dependency syndromes relating to a single substance (e.g., heroin), patterns of multiple drug abuse and dependence are also common.
Table 1. Substances capable of producing dependence.
Category of drug
Examples of general effects
Alcohol (e.g., beer, wine, spirits)
Impaired judgement, slowed reflexes, impaired motor function, somnolence, coma-overdose may be fatal
Withdrawal may be severe; danger to foetus if used excessively in pregnancy
Depressants (e.g., sleeping medicines, sedatives, some tranquillizers)
Inattention, slowed reflexes, depression, impaired balance, drowsiness, coma-overdose may be fatal
Withdrawal may be severe
Opiates (e.g., morphine, heroin, codeine, some prescription pain medications)
Loss of interest, “nodding”-overdose may be fatal. Subcutaneous or intravenous abuse may spread Hepatitis B, C and HIV/AIDS via needle-sharing
Stimulants (e.g., cocaine, amphetamines)
Elevated mood, overactivity, tension/anxiety, rapid heartbeat, constriction of blood vessels
Chronic heavy use may lead to paranoid psychosis. Use by injection may spread Hepatitis B, C and HIV/AIDS via needle-sharing
Cannabis (e.g., marijuana, hashish)
Distorted time sense, impaired memory, impaired coordination
Hallucinogens (e.g., LSD (lysergic acid diethylamide), PCP (phencyclidine), mescaline)
Inattention, sensory illusions, hallucinations, disorientation, psychosis
Does not produce withdrawal symptoms but users may experience “flashbacks”
Inhalants (e.g., hydrocarbons, solvents, gasoline)
Intoxication similar to alcohol, dizziness, headache
May cause long- term organ damage (brain, liver, kidney)
Nicotine (e.g., cigarettes, chewing tobacco, snuff)
Initial stimulant, later depressant effects
May produce withdrawal symptoms. Implicated in causing a variety of cancers, cardiac and pulmonary diseases
Drug and alcohol-related disorders often affect the employee’s family relationships, interpersonal functioning and health before obvious work impairments are noticed. Therefore, effective workplace programmes cannot be limited to efforts at achieving drug and alcohol abuse prevention on the job. These programmes must combine employee health education and prevention with adequate provisions for intervention, diagnosis and rehabilitation as well as long-term follow-up of affected employees after their reintegration into the workforce.
Approaches to Drug and Alcohol-relatedProblems in the Workplace
Concern over the serious productivity losses caused by drug and alcohol abuse and dependence have led to several related approaches on the part of governments, labour and industries. These approaches include so-called “drug-free workplace policies” (including chemical testing for drugs) and employee assistance programmes.
One example is the approach taken by the United States Military Services. In the early 1980s successful anti-drug policies and drug testing programmes were established in each branch of the US military. As a result of its programme, the US Navy reported a dramatic fall in the proportion of random urine tests of its personnel that were positive for illicit drugs. The positive test rates for those under age 25 fell from 47% in 1982, to 22% in 1984, to 4% in 1986 (DeCresce et al. 1989). In 1986 the President of the United States issued an executive order requiring that all federal government employees refrain from illegal drug use, whether on or off the job. As the largest single employer in the United States, with over two million civilian employees, the federal government thereby assumed the lead in developing a national drug-free workplace movement.
In 1987, following a fatal railway accident linked to marijuana abuse, the US Department of Transportation ordered a drug and alcohol testing programme for all transportation workers, including those in private industry. Managements in other work settings have followed suit, establishing a combination of supervision, testing, rehabilitation and follow-up in the workplace that has shown consistently successful results.
The case-finding, referral and follow-up component of this combination, the employee assistance programme (EAP), has become an increasingly common feature of employee health programmes. Historically, EAPs evolved from more narrowly-focused employee alcoholism programmes that had been pioneered in the United States during the 1920s and expanded more rapidly in the 1940s during and after the Second World War. Current EAPs are customarily established on the basis of a clearly enunciated company policy, often developed by joint agreement between management and labour. This policy includes rules of acceptable workplace behaviour (e.g., no alcohol or illicit drugs) and a statement that alcoholism and other drug and alcohol dependence are considered treatable diseases. It also includes a statement of confidentiality, guaranteeing the privacy of sensitive personal employee information. The programme itself conducts preventive education for all employees and special training for supervisory personnel in identifying job performance problems. Supervisors are not expected to learn to diagnose drug and alcohol-related problems. Rather, they are trained to refer employees who show problematic job performance to the EAP, where an assessment is made and a plan of treatment and follow-up is formulated, as appropriate. Treatment is usually provided by community resources outside the workplace. EAP records are kept confidentially as a matter of company policy, with reports relating only to the subject’s degree of cooperation and general progress released to management except in cases of imminent danger.
Disciplinary action is usually suspended as long as the employee cooperates with treatment. Self-referrals to the EAP are also encouraged. EAPs that help employees with a wide range of social, mental health and drug and alcohol-related problems are known as “broad-brush” programmes to distinguish them from programmes that focus only on drug and alcohol abuse.
There is no question of the appropriateness of employers’ prohibiting the use of alcohol and other drugs during working hours or in the workplace. However, the right of the employer to prohibit the use of such substances away from the workplace during off hours has been disputed. Some employers have said, “I don’t care what employees do off the job as long as they report on time and are able to perform adequately,” and some labour representatives have opposed such a prohibition as an intrusion on the worker’s privacy. Yet, as noted above, excess use of drugs or alcohol during off-hours can affect work performance. This is recognized by airlines when they prohibit all use of alcohol by air crews during a specified number of hours prior to flight time. Although the prohibitions of alcohol use by an employee before flying or driving a vehicle are generally accepted, blanket prohibitions of tobacco, alcohol or other drug use outside of the workplace have been more controversial.
Workplace drug testing programmes
Along with EAPs, increasing numbers of employers have also instituted workplace drug testing programmes. Some of these programmes test only for illicit drugs, while others include breath or urine testing for alcohol. Testing programmes may involve any of the following components:
Drug testing programmes create special responsibilities for those employers who undertake them (New York Academy of Medicine 1989). This is discussed more fully under “Ethical Issues” in the Encyclopaedia. If employers rely on urine tests in making employment and disciplinary decisions in drug-related cases, the legal rights of both employers and employees must be protected by meticulous attention to collection and analysis procedures and to the interpretation of laboratory results. Specimens must be collected carefully and labelled immediately. Because drug users may attempt to evade detection by substituting a sample of drug-free urine for their own or by diluting their urine with water, the employer may require that the specimen be collected under direct observation. Because this procedure adds time and expense to the procedure it may be required only in special circumstances rather than for all tests. Once the specimen is collected, a chain-of-custody procedure is followed, documenting each movement of the specimen to protect it from loss or misidentification. Laboratory standards must ensure specimen integrity, with an effective programme of quality control in place, and staff qualifications and training must be adequate. The test used must employ a cut-off level for the determination of a positive result that minimizes the possibility of a false positive. Finally, positive results found by screening methods (e.g., thin-layer chromatography or immunological techniques) should be confirmed to eliminate false results, preferably by the techniques of gas chromatography or mass spectrometry, or both (DeCresce et al. 1989). Once a positive test is reported, a trained occupational physician (known in the United States as a medical review officer) is responsible for its interpretation, for example, ruling out prescribed medication as a possible reason for the test results. Performed and interpreted properly, urine testing is accurate and may be useful. However, industries must calculate the benefit of such testing in relationship to its cost. Considerations include the prevalence of drug and alcohol abuse and dependence in the prospective workforce, which will influence the value of pre-employment testing, and the proportion of the industry’s accidents, productivity losses and medical benefit costs related to the abuse of psychoactive substances.
Other methods of detecting drug and alcohol-related problems
Although urine testing is an established screening method for detecting drugs of abuse, there are other methods available to EAPs, occupational physicians and other health professionals. Blood alcohol levels may be estimated by means of breath testing. However, a negative chemical test of any kind does not rule out a drug or alcohol problem. Alcohol and some other drugs are metabolized rapidly and their aftereffects may continue to impair work performance even when the drugs are no longer detectable on a test. On the other hand, the metabolites produced by the human body after the ingestion of certain drugs may remain in the blood and urine for many hours after the drug’s effects and aftereffects have subsided. A positive urine test for drug metabolites therefore does not necessarily prove that the employee’s work is drug-impaired.
In making an assessment of employee drug and alcohol-related problems a variety of clinical screening instruments are used (Tramm and Warshaw 1989). These include pencil-and-paper tests, such as the Michigan Alcohol Screening Test (MAST) (Selzer 1971), the Alcohol Use Disorders Identification Test (AUDIT) developed for international use by the World Health Organization (Saunders et al. 1993), and the Drug Abuse Screening Test (DAST) (Skinner 1982). In addition, there are simple sets of questions that can be incorporated into history-taking, for example the four CAGE questions (Ewing 1984) illustrated in figure 2. All of these methods are used by EAPs to evaluate employees referred to them. Employees referred for job performance problems such as absences, lateness and decreased productivity on the job should additionally be evaluated for other mental health problems such as depression or compulsive gambling, which may also produce impairments in job performance and are often associated with drug and alcohol-related disorders (Lesieur, Blume and Zoppa 1986). With respect to pathological gambling, a paper-and-pencil screening test, the South Oaks Gambling Screen (SOGS) is available (Lesieur and Blume 1987).
Figure 2. The CAGE questions.
Treatment of Disorders Related to theUse of Drugs and Alcohol
Although each employee presents a unique combination of problems to the addiction treatment professional, the treatment of disorders related to drug and alcohol use usually consists of four overlapping phases: (1) identification of the problem and (as necessary) intervention, (2) detoxification and general health assessment, (3) rehabilitation, and (4) long-term follow-up.
Identification and intervention
The first phase of treatment involves confirming the presence of a problem caused by the use of drugs or alcohol (or both) and motivating the affected individual to enter treatment. The employee health programme or company EAP has the advantage of using the employee’s concern both for health and job security as motivational factors. Workplace programmes are also likely to understand the employee’s environment and his or her strengths and weaknesses, and can thus choose the most appropriate treatment facility for referral. An important consideration in making a referral for treatment is the nature and extent of workplace-based health insurance coverage for the treatment of drug and alcohol-induced disorders. Policies with coverage of the full range of inpatient and outpatient treatments offer the most flexible and effective options. In addition, the involvement of the employee’s family at the intervention stage is often helpful.
Detoxification and general health assessment
The second stage combines the appropriate treatment needed to help the employee attain a drug and alcohol-free state with a thorough evaluation of the patient’s physical, psychological, family, interpersonal and work-related problems. Detoxification involves a short period—several days to several weeks—of observation and treatment for the elimination of the drug of abuse, recovery from its acute effects, and control of any symptoms of withdrawal. While detoxification and the assessment activities are progressing, the patient and “significant others” are educated about the nature of drug and alcohol dependence and recovery. They and the patient are also introduced to the principles of self-help groups, where this modality is available, and the patient is motivated to continue in treatment. Detoxification may be carried out in an inpatient or outpatient setting, depending on the needs of the individual. Treatment techniques found useful include a variety of medications, augmented by counselling, relaxation training and other behavioural techniques. Pharmacological agents used in detoxification include drugs which can substitute for the drug of abuse to relieve withdrawal symptoms and then be gradually reduced in dosage until the patient is drug-free. Phenobarbital and the longer-acting benzodiazepines are often used this way to achieve detoxification in the case of alcohol and sedative drugs. Other medicines are used to relieve withdrawal symptoms without substituting a similarly-acting drug of abuse. For example, clonidine is sometimes used in the treatment of opiate withdrawal symptoms. Acupuncture has also been used as an aid in detoxification, with some positive results (Margolin et al. 1993).
The third phase of treatment combines helping the patient establish a stable state of ongoing abstinence from all substances of abuse (including those prescription drugs which may cause dependence) and treating whatever associated physical and psychological conditions accompany the drug-related disorder. Treatment may begin on an inpatient or intensive outpatient basis, but characteristically continues in an outpatient setting for a number of months. Group, individual and family counselling and behavioural techniques may be combined with psychiatric management, which may include medication. The goals include helping patients understand their patterns of drug or alcohol use, identifying triggers for relapse after past efforts at recovery, helping them to develop drug-free coping patterns in dealing with life problems, and helping them integrate into a clean and sober social support network in the community. In some cases of opiate dependence, long-term maintenance on a long-acting synthetic opiate (methadone) or an opiate receptor blocking drug (naltrexone) is the treatment of choice. Maintenance on a daily dose of methadone, a long-acting opiate, is recommended by some practitioners for individuals with long-term opiate addiction who are unwilling or unable to achieve drug-free status. Patients stably maintained on methadone over long periods are able to function successfully in the workforce. In many cases, such patients are eventually able to detoxify and become drug free. In these cases, maintenance is combined with counselling, social services and other rehabilitative treatment. Recovery is defined in terms of stable abstinence from all drugs other than the drug of maintenance.
The final phase of treatment continues on an outpatient basis for a year or more after a stable remission is attained. The goal of long-term follow-up is preventing relapse and helping the patient internalize new patterns of coping with life problems. The EAP or employee health service can be a great help during the rehabilitation and follow-up phases by monitoring cooperation in treatment, encouraging the recovering employee to maintain abstinence and assisting him/her in readjusting to the workplace. Where self-help or peer assistance groups are available (for example, Alcoholics Anonymous or Narcotics Anonymous), these groups provide a life-long supportive programme for sustained recovery. Since drug or alcohol dependence is a chronic disorder in which there may be relapses, company policies often require follow-up and monitoring by the EAP for a year or more after abstinence is established. If an employee relapses the EAP usually re-evaluates the situation and a change in treatment plan may be instituted. Such relapses, if brief and followed by a return to abstinence, usually do not signal overall treatment failure. Employees who do not cooperate with treatment, deny their relapses in face of clear evidence or cannot maintain stable abstinence will continue to show poor work performance and may be terminated from employment on that basis.
While social changes in some areas have narrowed the differences between men and women, substance abuse has traditionally been seen as a man’s problem. Substance abuse was felt to be incompatible with women’s role in society. Consequently, while men’s abuse ot substances could be excused, or even condoned, as an acceptable part of manhood, women’s abuse of substances attracted a negative stigma. While this latter fact may be claimed to have prevented many women from abusing drugs, it has also made it extremely difficult for substance-dependent women to seek assistance for their dependence in many societies.
Negative attitudes to women’s substance abuse, coupled with the reluctance of women to admit their abuse and dependence have resulted in scanty data being available specifically on women. Even in countries with considerable information about drug abuse and dependence, it is often hard to find data relating directly to women. In cases where studies have examined women’s role in substance abuse the approach has by no means been gender-specific, so that conclusions may have been clouded by viewing women’s involvement from a male perspective.
Another factor related to the concept of substance abuse as a male problem is the lack of services for women substance abusers. ... Where services, such as treatment and rehabilitation services, do exist, they frequently have an approach based on male role models of drug dependence. Where services are provided for women, it is clear that they must be accessible. This is not always easy when women’s drug dependence is stigmatized and when cost of treatment is beyond the means of the majority of women.
Quoted from: World Health Organization 1993.
Effectiveness of Workplace-based Programmes
An investment in workplace programmes to deal with drug and alcohol problems has been profitable in many industries. An example is a study of 227 employees of a large US manufacturing company who were referred for the treatment of alcoholism by the company’s EAP. Employees were randomly assigned to three treatment approaches: (1) mandatory inpatient care, (2) mandatory attendance at Alcoholics Anonymous (AA) or, (3) a choice of inpatient care, outpatient care or AA. At follow-up, two years later, only 13% of the employees had been discharged. Of the remainder, less than 15% had job problems and 76% were rated “good” or “excellent” by their supervisors. Time absent from work fell by more than a third. Although some differences were found between initial treatment approaches the two-year job outcomes were similar for all three (Walsh et al. 1991).
The US Navy has calculated that its inpatient drug and alcohol rehabilitation programmes have produced an overall ratio of financial benefit to cost of 12.9 to 1. This figure was calculated by comparing the cost of the programme with the costs that would have been incurred in replacing the successfully rehabilitated programme participants with new personnel (Caliber Associates 1989). The Navy found that the benefit to cost ratio was highest for those over 26 years of age (17.8 to 1) as compared to younger personnel (8.2 to 1) and found the greatest benefit for alcoholism treatment (13.8 to 1), versus other drug (10.3 to 1) or polydrug dependence treatment (6.8 to 1). Nevertheless, the programme produced financial savings in all categories.
In general, workplace-based programmes for the identification and rehabilitation of employees who suffer from alcohol and other drug problems have been found to benefit both employers and workers. Modified versions of EAP programmes have also been adopted by professional organizations, such as the medical societies, nursing associations and bar associations (associations of lawyers). These programmes receive confidential reports about possible signs of impairment in a professional from colleagues, families, clients or employers. Face-to-face intervention is performed by peers, and if treatment is required the programme makes the appropriate referral. It then monitors the recovery of the individual and helps the recovering professional deal with practice and licensing problems (Meek 1992).
Alcohol and other psychoactive drugs are significant causes of problems in the workplace in many parts of the world. Although the type of drug used and the route of administration may vary from place to place and with the type of industry, the abuse of drugs and alcohol creates health and safety hazards for users, for their families, for other workers and, in many cases, for the public. An understanding of the types of drug and alcohol problems that exist within a given industry and the intervention and treatment resources available in the community will allow rehabilitative programmes to be developed. Such programmes bring benefits to employers, employees, their families and the larger society in which these problems arise.