Occupational Health and Occupational Medicine

1. Occupational Health and Occupational Medicine David A. Compton MD, MPH

2. Work Related Disease Issues Have Been Identified For A Long Time • Hippocrates (460-377 BC) • Described symptoms of lead poisoning among miners and metallurgists. • Pliny the Elder (23-70 AD) • Roman senator who wrote about workers who protected themselves from dust by tying animal bladders over their mouths. • He also noted hazards of asbestos and cinnabar (mercury ore) • Ulrich Ellenborg (1473) • A German physician, he recognized the dangers of metal fumes, described symptoms and preventive measures.

3. Influential People • Paracelsus (1493-1541) • Known by several names • Born Phillip von Hohenheim • A Swiss physician, he wrote a treatise on occupational diseases • Described lung diseases among miners and attributed the cause to vapors and emanation from metals • Paracelsus is best known today as the “Father of Toxicology” because of his observations of dose and response: “All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy.”

4. Observant People • Agricola (1494-1555) • Born Georg Bauer, he was a physician appointed to the mining town of Jochimstral in the Swiss mountains • Wrote De Re Metallica, a comprehensive discourse addressing every aspect of mining, smelting and refining. • He noted the need to provide ventilation for miners, and described “asthma” among workers who toiled in dusty mines:

5. De Re Metallica • “Some mines are so dry that they are entirely devoid of water and this dryness causes the workmen even greater harm, for the dust, which is stirred and beaten up by digging, penetrates into the windpipe and lungs, and produces difficulty in breathing and the disease the Greeks call asthma. If the dust has corrosive qualities, it eats away the lungs and implants consumption in the body. In the Carpathian mountains women are found who have married seven husbands, all of whom this terrible consumption has carried off to a premature death.”

6. Perceptive People • Bernardino Ramazzini (1633-1714) • Italian physician, known as the “patron saint of industrial medicine”. • His book De Morbis Artificium Diatriba (The Diseases of Workmen) described the symptoms of mercury and lead poisoning and other occupational diseases. • He wrote about the pathology of silicosis and recommended precautions to avoid hazards • Advised physicians to learn about occupational diseases by studying the work environment, and exhorted them to always ask their patients “Of what trade are you?”

7. Investigative People • Sir George Baker (1722-1809) • Discovered that “Devonshire colic” was caused by lead contamination in cider. • Percival Pott (1714-1788) • A London physician, he was the first to link occupational exposure to cancer. • Scrotal cancer among chimney sweeps, caused by soot • Later linked to Polycyclic Aromatic Hydrocarbons in Coal Soot • Sir Humphrey Davy (1788-1829) • Investigated problems of mine explosions and developed the first miner’s safety lamp.

8. American People • Dr. Alice Hamilton (1869-1970) • First woman faculty member at Harvard University (1919). • A social activist who worked to improve occupational health and safety. • Her autobiography “Exploring the Dangerous Trades” details her experiences in the mines and mills across America

9. Tragedies Stimulated Change • Workplace Disasters of the early 1900s led to outrage and subsequently to legislation to protect workers • The Triangle Shirtwaist Fire probably was the most important event leading to the regulation of occupational safety • The Triangle Shirtwaist Company was a New York City “sweatshop” where dozens of mostly young female immigrant workers crowded together to cut and sew shirtwaists • Shirtwaists were a popular ladies garment of the time, especially for working women • Sweatshops workers are paid low wages as they work excessively long hours in unsanitary and unsafe conditions

10. 1911 -The Triangle Shirtwaist Company Caught Fire 146 workers died from fire in the upper floors of this “fireproof” building Fire exits were inadequate or locked to keep the workers at their work stations Unable to flee, many victims jumped from the windows to their deaths The tragedy led to 36 laws reforming the state labor codes Triangle Shirtwaist Company

11. 1930 - Gauley Bridge Disaster Also known as the Hawks Nest tragedy, this was America’s worst industrial disaster Construction of the Hawks Nest tunnel near Gauley Bridge, West Virginia, caused massive exposures to silica dust At least 476 men died and 1500 disabled by silicosis. Silica exposures were so high men were dying from acute silicosis from only two months of exposure Pneumatic drilling equipment and rock high in silica content magnified the risk Economic factors of the Great Depression forced the men to work in unhealthy conditions I’ll Take Any Job That Pays…

12. Everyday Tragedies It took a tragedy to get attention, since death on the job was a normal every-day event. In this single Pennsylvania county, 524 workers died in one year. MMWR, June 11, 1999 / Vol. 48 / No. 22

13. Social Factors • Organized Labor • Labor unions did much to influence improvements in workplace health and safety by influencing legislation as well as forcing concessions from management. • The International Ladies Garment Workers Union (ILGWU) was established in1900 and took on the task of promoting comprehensive safety and workers’ compensation laws • Professional Organizations Were Formed • American Society of Safety Engineers, 1911 • National Safety Council, 1913 • American Industrial Hygiene Association, 1939

14. What Changed? • Other countries led the United States in adoption of workplace regulation • Laws in Great Britain regulated conditions and limited child labor • 1802 Factory Act • Health and Morals of Apprentices Act, it established minimum working conditions and regulated child labor • 1833 Factory Act • Further restricted child labor • 1842 Mines Act • Prohibited boys less than 10 years old and all females from working underground. Before this act, children as young as 7 years were harnessed with chains to haul heavy coal containers underground • 1844 Factory Act • Reduced work hours for children, extended coverage to women

15. US Laws and Regulations • Early U.S. Laws and Regulations • United States Bureau of Labor established in 1884 to study employment and labor • Laws and regulations to protect US workers first began to appear in the early 1900s • 1911- New York and New Jersey passed workmen’s compensation laws. • 1913 - New York State Department of Labor • Established a Division of Industrial Hygiene • 1916 - 1930 Forty-seven states enacted workmen’s compensation laws to guarantee wages and medical care for injured workers

16. More US Laws and Regulations • 1935 - The Social Security Act • Made funds available for public health programs. • 1936 - The Walsh Healey Public Contracts Act • Required organizations supplying goods or services to the U.S. government to maintain a safe and healthful working environment • 1948 - All states had workers compensation laws • 1970 - The Occupational Safety and Health Act • Established NIOSH and OSHA to carry out its mandate to ensure a workplaces free of recognized hazards. • 1977 - The Federal Mine Safety & Health Act • Consolidated all federal health and safety regulations of the mining industry, strengthened and expanded the rights of miners, established the Mine Safety and Health Administration (MSHA).

17. What About Medical Care For Workers? • By the 1930s, a medical specialty was formed: Industrial Medicine • Physicians in this area of practice were generally self-taught or taught on the job until the late 1940s when specialty training, testing, and board certification were developed and the resulting new specialty was renamed Occupational Medicine

18. What Do Occupational Medicine Practitioners Strive For In Daily Practice? “The highest degree of physical, mental and social well-being of workers in all occupations.” International Labor Organization Committee on Occupational Health, 1950

19. Occupational Medicine • Recognized Specialty For Over 50 Years, certification is under the American Board of Preventive Medicine • Combines Clinical Skills With Toxicology, Epidemiology, Safety, Rehabilitation, and Business Operations • “Tightrope Walker” Responsible to Patients, Business, and the Community

20. Detecting, Evaluating, and Treating Medical Conditions Emergency Response Medical Surveillance Chronic Disease Management Fitness and Wellness Work-Life Management Disability Management and Accommodation Employee Assistance and Advocacy Absence Management Training Consultant to Workers, Managers, Unions, and the Community Occupational Health Services

21. Occupational Medicine Staff Potential Ancillary Staff: • Certified Audiometric Technicians • Occupational Health Nurses • Medical Assistants • Physical Therapists • Radiology Technologists • Behavioral Health Counselors • Disability Case Managers • Certified Pulmonary Function Technicians • Emergency Responders (EMT or Paramedic) in manufacturing locations • In addition to the physician, physician assistant, or nurse practitioner who are the main providers of service, multiple other roles must be filled. • These can be filled by individuals with a single skill, or individuals who have been trained in multiple areas. • It is important to note that governmental regulations or industry standards prescribe many types of evaluations and require that they are performed by trained and certified staff.

22. Why a Special Practice Model? • Occupational Diseases are Hard to Distinguish From Ones Unrelated to the Workplace • Is the asthma arising from workplace dust, or tree pollen? • Absences from Work Have Multiple Causes (not all are medical) • See the CCH survey • Economic Implications of Maintaining a Healthy Workforce are Large CCH Group, Wolters and Kluver 2015

23. Since It Is Hard To Differentiate Occupational Diseases From Naturally Occurring Diseases, How Do You Know For Sure That The Disorder Is Or Is Not Associated To The Work Environment Or Activities?

24. Important Considerations When Considering Linkage Of A Disease To Work Activities • Strength of association - The greater the impact of an exposure on the occurrence or development of a disease, the stronger the likelihood of a causal relationship - dependent on epidemiologic and/or toxicological data • Consistency - Do all of the research reports have similar conclusions? • Specificity - Has it been shown that exposure to a specific risk factor results in a clearly defined pattern of disease or diseases? • Temporality or time sequence - Did the exposure precede the disease by a period of time consistent with proposed biological mechanisms?

25. More Considerations For Occupational Disease Linkage Biological gradient - Has it been shown that the greater the level and duration of exposure, the greater the severity of diseases or their incidence? Biological plausibility - Does it make biological sense to suggest that exposure leads to the disease? Coherence. Does review of the evidence lead to the conclusion that there is a cause–effect relationship in a broad sense and in terms of common sense? Interventional studies. Have there been trials where removing the hazard from the workplace eliminates the development of the disease?

26. What Does It Mean To Have An Occupational Health Program? • The Goal is to Enable Employees to Safely Attend Work and Successfully Perform Their Tasks Without Interference from Health Based Issues. Thus, a successful occupational health situation represents dynamic equilibrium between the worker and his or her occupational environment. • Health and safety consideration must be given to work processes and how they impact employees, their contacts, and the environment • If an employee is absent (for any reason), occupational health practitioners should facilitate receipt of effective and efficient medical interventions with a goal of return to work as soon as practicable

27. The 10,000 Foot View Of Occupational Health • Identification • recognition • assessment • Control • eliminate • manage • personal protection • Prevention Intervene and Treat

28. The 1000 Foot View of Occupational Health • Awareness Of Potential Hazards • Qualitative Assessment • Exposure • Health (Worker Eval) • Hazard Judgment • Acceptable • Unacceptable • Uncertain • Quantitative Assessment • Exposure • Health • Risk communication Interventions Medical Engineering Administrative

29. Employee Evaluations • Medical evaluations of employees should be conducted as prevention and health promotion sessions with special attention to health factors related to the job or to known hazards. They are NOT a substitute for controlling workplace hazards or using personal protective equipment. • Employers often view physical examinations, and purchase these services, as a commodity where low cost wins out –but the evaluations need to be so much more. . . • Can The Employee Physically do the Job? • Are There Medical Conditions Impacted by the Job’s Requirements? • Can We Control The Conditions in the Worksite or are They Better Controlled in the Employee? • Are There Regulatory Mandates? • What are Past Practices by This Employer and in Similar Industries?

30. If We Are To Intervene And Prevent, How Do We Know What To Address? • Remain vigilant for activity or incident trends, changes in people, worksites, or regulatory requirements. When all else fails - ask the workers • Develop relationships with people who control workplace change (engineers, supervisors, purchasing agents) • Evaluate potential or suspected issues early • Involve all stakeholders - management, safety, human resources, industrial hygiene, engineering, and medical personnel. • Balance the individual’s rights and needs with the rights and needs of the employer but injury and illness prevention is paramount.

31. Example - Firefighters • A 2007 Harvard study: heart disease kills more on duty firefighters than anything else (45% of on-duty deaths) • Epidemiologically, the majority of on-duty heart disease deaths in firefighters appear to be precipitated by physical and toxic factors • General reviews have shown that heart disease is less prevalent in firefighters than the general public • However – this is work in adverse environments, wearing cumbersome equipment, generating high levels of stress, and involving exposure to chemical toxins that may aggravate cardiac risk • Is this epidemiologic association plausible? Let’s look at some data: New England Journal of Medicine 2007;356:1207-15.

32. Firefighter Heart Disease Comparisons of on duty time and activities to Off Duty Time and Activities Revealed: • Firefighters are 12 to 136 times more likely to die of heart disease when putting out a fire. • Firefighters are 3 to 14 times more likely to die of heart disease while responding to an alarm. • Firefighters are 2 to 10.5 times more likely to die of heart disease while returning from an alarm. • Firefighters are 3 to 7 times more likely to die of heart disease during physical training.

33. What is The Occupational Medicine Response? • Based on the study findings, the best approach is to work with professional and volunteer (70% of firefighters) fire departments to educate firefighters and the medical community about the special issues involving firefighters and cardiac disease. Specifically – work to implement: • Wellness and fitness programs for firefighters and their families to reduce heart disease risk factors • Encourage adoption of a requirement for firefighters to undergo entrance and annual medical examinations by a provider well-versed in the requirements of firefighting • Encourage implementation of an annual physical performance test for all firefighters • A general understanding that, if heart disease is diagnosed in a firefighter, a very open and careful discussion must be undertaken in advising this person whether it is safe to return to duty NFPA [2003]. NFPA 1582: Standard on comprehensive occupational medical program for fire departments. Quincy, MA: National Fire Protection Association. NFPA [2000]. NFPA 1583: Standard on health-related fitness programs for fire fighters. Quincy, MA: National Fire Protection Association.

34. Even If You Have A Successful Program Of Prevention And Intervention, Employers Often Ask: “What About These Absences?” • Absences happen. An important point to remember is that even problem employees get sick. • Another important point is that each day an individual is out of work, they may lost income and the employer may lose productivity or have to hire a substitute • The medical providers must work within company policies, any regulatory requirements, and applicable privacy rules to address both points. • Programs must use competent and objective personnel for case evaluation and absence management. • Success occurs when you obtain optimum intervention for the individual and coordinate their return with the worksite. • Providers are not through when the individual returns to work, they should monitor outcomes and prevention efforts after full return to work.

35. Final Thoughts • Occupational Medicine practice is rooted in prevention. Workers who develop occupational diseases or receive injuries in the workplace represent a failure of prevention. • Many places that have Occupational Medicine listed as a service on their signage are frequently only practicing Workers Compensation Medicine and have little to offer in the way of prevention - know your service providers.