This article discusses some of the currently specific concerns and issues relating to occupational health in the developing world and elsewhere. The general technical subjects common to both the developed and the developing world (e.g., lead and pesticides) are not dealt with in this article as they have been addressed elsewhere in the Encyclopaedia. In addition to the developing countries, some of the emerging occupational health issues of the Eastern European nations too have been addressed separately in this chapter.
It is estimated that by the year 2000 eight out of ten workers in the global workforce will be from the developing world, demonstrating the need to focus on the occupational health priority needs of these nations. Furthermore, the priority issue in occupational health for these nations is a system for the provision of health care to their working population. This need fits in with the World Health Organization (WHO) definition of occupational health, which expresses the concern for the total health of the worker and is not confined merely to occupational diseases. As shown in figure 1 the worker may be affected by the general diseases of the community which may occur among workers, such as malaria, as well as multi-factorial work-related diseases, in which work may contribute to or aggravate the condition. Examples are cardiovascular diseases, psychosomatic illnesses and cancers. Finally, there are the occupational diseases, in which exposure at the workplace is essential to causation, such as with lead poisoning, silicosis or noise-induced deafness.
Figure 1. Categories of disease affecting workers
The WHO philosophy recognizes the two-way relationship between work and health, as represented in figure 2. Work may have an adverse or beneficial effect on health, while the health status of the worker has an impact on work and productivity.
Figure 2. Two-way relationship between work and health
A healthy worker contributes positively to productivity, quality of products, work motivation and job satisfaction, and thereby to the overall quality of life of individuals and society, making health at work an important policy goal in national development. To achieve this goal, the WHO has recently proposed the Global Strategy on Occupational Health for All (WHO 1995), in which the ten priority objectives are:
- strengthening of international and national policies for health at work and developing the necessary policy tools
- development of healthy work environment
- development of healthy work practices and promotion of health at work
- strengthening of occupational health services
- establishment of support services for occupational health
- development of occupational health standards based on scientific risk assessment
- development of human resources for occupational health
- establishment of registration and data systems, development of information services for experts, effective transmission of data and raising of public awareness through public information
- strengthening of research
- development of collaboration in occupational health and with other activities and services.
Occupational Health and National Development
It is useful to view occupational health in the context of national development as the two are intimately linked. Every nation wishes to be in a state of advanced development, but it is the countries of the developing world which are most anxious—almost demanding—for rapid development. More often than not, it is the economic advantages of such development which are most sought after. True development is, however, generally understood to have a wider meaning and to encompass the process of improving the quality of human life, which in turn includes aspects of economic development, of improving self-esteem and of increasing people’s freedom to choose. Let us examine the impact of this development on the health of the working population, i.e., development and occupational health.
While the global gross domestic product (GDP) has remained almost unchanged for the period 1965-89, there has been an almost tenfold increase in the GDP of the developing world. But this rapid economic growth of the developing world must be seen in the context of overall poverty. With the developing world constituting three quarters of the world’s population, it accounts for only 15% of the global domestic product. Taking Asia as a case in point, all of the countries of Asia except for Japan are categorized as part of the developing world. But it needs to be recognized that there is no uniformity of development even among the developing nations of Asia. For instance, today, countries and areas such as Singapore, Republic of Korea, Hong Kong and Taiwan (China) have been categorized as newly industrialized countries (NICs). Though arbitrary, this implies a transition stage from developing country status to industrialized nation status. However, it must be recognized that there are no clear criteria defining a NIC. Nevertheless, some of the salient economic features are high sustained growth rates, diminishing income inequality, an active government role, low taxes, underdeveloped welfare state, high savings rate and an economy geared to exports.
Health and Development
There exists an intimate relationship between health, development and the environment. Rampant and uncontrolled development measures purely in terms of economic expansion could, under certain circumstances, be considered to have an adverse impact on health. Usually, though, there exists a strong positive relationship between a nation’s economic status and health as indicated by life expectancy.
As much as development is positively linked to health, it is not adequately recognized that health is a positive force driving development. Health must be considered to be more than a consumer item. Investing in health increases the human capital of a society. Unlike roads and bridges, whose investment values dwindle as they deteriorate over time, the returns on health investments can generate high social returns for a lifetime and well into the next generation. It should be recognized that any health impairment that the worker may suffer is likely to have an adverse effect on work performance, a matter of considerable interest particularly to nations in the throes of rapid development. For instance, it is estimated that poor occupational health and reduced working capacity of workers may cause an economic loss of up to 10 to 20% of gross national product (GNP). Furthermore, the World Bank estimates that two-thirds of occupationally determined disability adjusted life years (DALYS) could be prevented by occupational health and safety programmes. As such, the provision of an occupational health service should not be viewed as a national expense to be avoided, but rather as one that is necessary for the national economy and development. It has been observed that a high standard of occupational health correlates positively with a high GNP per capita (WHO 1995). The countries investing most in occupational health and safety show the highest productivity and strongest economies, while countries with the lowest investment have the lowest productivity and the weakest economies. Globally, each worker is said to contribute US$9,160 to the annual domestic product. Evidently the worker is the engine of the national economy and the engine needs to be kept in good health.
Development results in many changes to the social fabric, including the pattern of employment and changes in the productivity sectors. In the early stages of development, agriculture contributes extensively to national wealth and the workforce. With development, the role of agriculture begins to decline and the contribution of the manufacturing sector to national wealth and the workforce becomes dominant. Finally, there comes a situation where the service sector becomes the largest income source, as in the advanced economies of industrialized countries. This is clearly evident when a comparison is made between the group of NICs and the group of Association of Southeast Asian (ASEAN) nations. The latter could be categorized as middle income nations of the developing world, while the NICs are countries straddling the developing and the industrialized worlds. Singapore, a member of ASEAN, is also a NIC. The ASEAN nations, though deriving approximately a quarter of their gross domestic product from agriculture, have almost half of their GDP drawn from industry and manufacturing. The NICs, on the other hand, particularly Hong Kong and Singapore, have approximately two-thirds of their GDP from the service sector, with very little or none from agriculture. The recognition of this changing pattern is important in that occupational health services must respond to the needs of each nation’s workforce depending on their stage of development (Jeyaratnam and Chia 1994).
In addition to this transition in the workplace, there also occurs a transition in disease patterns with development. A change in disease patterns is seen with increasing life expectancy, with the latter indicative of increasing GDP. It is seen that with development or an increase in life expectancy, there is a large decrease in death from infectious diseases while there are large increases in deaths from cardiovascular diseases and cancers.
Occupational Health Concerns and Development
The health of the workforce is an essential ingredient for national development. But, at the same time, adequate recognition of the potential pitfalls and dangers of development must be recognized and safeguarded against. The potential damage to human health and the environment consequent to development must not be ignored. Planning for development can avert and prevent harms associated therewith.
Lack of adequate legal and institutional structure
The developed nations evolved their legal and administrative structure to keep pace with their technological and economic advancements. In contrast, the countries of the developing world have access to the advanced technologies from the developed world without having developed either legal or administrative infrastructure to control their adverse consequences to the workforce and the environment, causing a mismatch between technological development and social and administrative development.
Further, there is also careless disregard of control mechanisms for economic and/or political reasons (e.g., the Bhopal chemical disaster, where an administrator’s advice was overruled for political and other reasons). Often, the developing countries will adopt standards and legislation from the developed countries. There is, however, a lack of trained personnel to administer and enforce them. Furthermore, such standards are often inappropriate and have not taken into account differences in nutritional status, genetic predisposition, exposure levels and work schedules.
In the area of waste management, most developing countries do not have an adequate system or a regulatory authority to ensure proper disposal. Although the absolute amount of waste produced may be small in comparison to developed countries, most of the wastes are disposed of as liquid wastes. Rivers, streams and water sources are severely contaminated. Solid wastes are deposited on land sites without proper safeguards. Furthermore, developing countries have often been the recipients of hazardous wastes from the developed world.
Without proper safeguards in hazardous waste disposal, the effects of environmental pollution will be seen for several generations. Lead, mercury and cadmium from industrial waste are known to contaminate water sources in India, Thailand and China.
Lack of proper planning in siting of industries and residential areas
In most countries, the planning of industrial areas is undertaken by the government. Without the presence of proper regulations, residential areas will tend to congregate around such industrial areas because the industries are a source of employment for the local population. Such was the case in Bhopal, India, as discussed above, and the Ulsan/Onsan industrial complex of the Republic of Korea. The concentration of industrial investment in the Ulsan/Onsan complex brought about a rapid influx of population to Ulsan City. In 1962, the population was 100,000; within 30 years, it increased to 600,000. In 1962, there were 500 households within the boundaries of the industrial complex; in 1992, there were 6,000. Local residents complained of a variety of health problems that are attributable to industrial pollution (WHO 1992).
As a result of such high population densities in or around the industrial complexes, the risk of pollution, hazardous wastes, fires and accidents is greatly multiplied. Furthermore, the health and future of the children living around these areas are in real jeopardy.
Lack of safety-conscious culture among workers and management
Workers in developing countries are often inadequately trained to handle the new technologies and industrial processes. Many workers have come from a rural agricultural background where the pace of work and type of work hazards are completely different. The educational standards of these workers are often much lower as compared to the developed countries. All these contribute to a general state of ignorance on health risks and safe workplace practices. The toy factory fire in Bangkok, Thailand, discussed in the chapter Fire, is an example. There were no proper fire safety precautions. Fire exits were locked. Flammable substances were poorly stored and these had blocked all the available exits. The end result was the worst factory fire in history with a death toll of 187 and another 80 missing (Jeyaratnam and Chia 1994).
Accidents are often a common feature because of a lack of commitment of management to the health and safety of the workers. Part of the reason is the lack of skilled personnel in maintaining and servicing industrial equipment. There is also a lack of foreign exchange, and government import controls make it difficult to obtain proper spare parts. High turnover of workers and the large readily available labour market also make it unprofitable for management to invest heavily in workers’ training and education.
Transfer of hazardous industries
Hazardous industries and unsuitable technologies in the developed countries are often transferred to the developing countries. It is cheaper to transfer the entire production to a country where the environmental and health regulations are more easily and cheaply met. For example, industries in the Ulsan/Onsan industrial complex, Republic of Korea, were applying emission control measures in keeping with local Korean legislation. These were less stringent than in the home country. The net effect is a transfer of potentially polluting industries to the Republic of Korea.
High proportion of small-scale industries
Compared to the developed countries, the proportion of small-scale industries and the proportion of workers in these industries are higher in the developing countries. It is more difficult in these countries to maintain and enforce compliance in occupational health and safety regulations.
Lower health status and quality of health care
With economic and industrial development, new health hazards are introduced against a backdrop of poor health status of the population and a less than adequate primary health care system. This will further tax the limited health care resources.
The health status of workers in the developing countries is often lower compared to that of workers in developed countries. Nutritional deficiencies and parasitic and other infectious diseases are common. These can increase the susceptibility of the worker to developing occupational diseases. Another important observation is the combined effect of workplace and non-workplace factors on the health of the worker. Workers with nutritional anaemias are often very sensitive to very low levels of inorganic lead exposure. Significant anaemias are often seen with blood lead levels of around 20 μg/dl. A further example is seen among workers with congenital anaemias like thalassaemias, the carrier rate for which in some countries is high. It has been reported that these carriers are very sensitive to inorganic lead, and the time taken for the haemoglobin to return to normal is longer than in non-carriers.
This situation reveals a narrow dividing line between traditional occupational diseases, work-related diseases and the general diseases prevalent in the community. The concern in the countries of the developing world should be for the overall health of all people at work. In order to achieve this objective, the nation’s health sector must accept responsibility for organizing a programme of work for the provision of health care services for the working population.
It must also be recognized that the labour sector has an important role in ensuring the safety of the work environment. In order to achieve this, there is a need to review legislation so that it covers all workplaces. It is inadequate to have legislation limited to factory premises. Legislation should not only provide a secure and safe workplace, but also ensure the provision of regular health services to the workers.
Thus it would be evident that two important sectors, namely the labour sector and the health sector, have important roles to play in occupational health. This recognition of the intersectoriality of occupational health is an extremely important ingredient for the success of any such programme. In order to achieve proper coordination and cooperation between these two sectors, it is necessary to develop an intersectorial coordinating body.
Finally, legislation for the provision of occupational health services and ensuring the safety of the workplace is fundamental. Again, many Asian countries have recognized this need and have such legislation today, although its implementation may be wanting to some extent.
In developing countries, industrialization is a necessary feature of economic growth and development. Although industrialization can bring about adverse health effects, the accompanying economic development can have many positive effects on human health. The aim is to minimize the adverse health and environmental problems and maximize the benefits of industrialization. In the developed countries, experience from the adverse effects of the Industrial Revolution has led to regulation of the pace of development. These countries have generally coped fairly well and had the time to develop all the necessary infrastructure to control both health and environmental problems.
The challenge today for the developing countries who, because of international competition, do not have the luxury of regulating their pace of industrialization, is to learn from the mistakes and lessons of the developed world. On the other hand, the challenge for the developed countries is to assist the developing countries. The developed countries should not take advantage of the workers in developing countries or their lack of financial capacity and regulatory mechanisms because, at the global level, environmental pollution and health problems do not respect political or geographical boundaries.