Thomas H Gassert, MD, MSc Harvard University School of Public Health University of Massachusetts Medical School

1. InitiativePartners in Occupational & Environmental Health Vision for Training ofOEH Hygienists, Nurses, Doctors in Asia-PacificHong Kong28-29 October 2013 Thomas H Gassert, MD, MSc Harvard University School of Public Health University of Massachusetts Medical School

2. Overview • Why we are here • Legal Basis – O&E Health is a global • Human Right guaranteed by law • State and Employer Obligation • Burden of Occupational Disease (injuries & illnesses by country) • Capacity: now and future (country needs assessments) • Resources to identify: • Medical training capabilities (local, regional, international) • National regulatory and accreditation standards • Local and international labour and NGO guidance • Financial • Challenge: tasks, goals and timelines • Organization: name, mission, base, website, collaboration Vision of Partners in OEH Asia-Pacific

3. Why this meeting? • Other meetings, but what has been the practical outcome? • Other organizations (ICOH, AAOH, SPH, etc.) • Nothing unified or labour driven (but we are!) • Very little capacity building (little clinical substance) • Little regulatory movement; few dedicated resources • Our emphasis is preventive medicine and health protection • Primary, Secondary, Tertiary Prevention • OEH is needed for climate change, and clean water, air, soil • OEH means economic gain for all • We have strengths and a vision, a good base, and need a system that works to achieve OEH for all Vision of Partners in OEH Asia-Pacific

4. Preventive Medicine & Health Occupational & Environmental Health (OEH) is part of a specialty called Preventive Medicine Three levels of prevention in OEH: • Primary: prevent or control hazards at source • Hierarchy of controls (Occupational / Industrial Hygienist) • Wellness – health promotion with health protection (nurse, doctor) • Secondary: detect early disease risk by medical surveillance, health monitoring (doctors, nurses) • Tertiary: prompt medical care to prevent complications of death, disability, job loss (doctors, nurses) Vision of Partners in OEH Asia-Pacific

5. Define “Asia” – per U.N. nation listings • There are a total of 193 U.N. member nations (2013) • Asia list: Afghanistan (west) to Pacific islands (east) • Including Oceania (Australia, New Zealand, Pacific isles) • Does not at this time list: • Western Asian nations of the Middle East • Other “…stans” of Central Asia: • Kazakhstan • Kyrgyzstan • Tajikistan • Uzbekistan • Siberia (Russian Federation) • Guam (a U.S. territory) • Taiwan (ROC) membership was replaced by China (PRC) • North (PDRK) and South (ROK) Korea are both members Vision of Partners in OEH Asia-Pacific

6. Legal Basis: Human Rights • Entitlements because of being human, extends naturally to workers • Form: political, social and material claims • Guarantee protection of basic freedoms and dignity • Origin: to protect against abuse by those with power • Political rights extend to socio-economic realm • Implies a party with dutyto impart/honor those rights: • Governments • Employers, including Trans-National Corporations • Inter-Government Agencies • Banks and Aid Agencies Vision of Partners in OEH Asia-Pacific

7. Governments and Human Rights • Nation States are obligated (must…) • Protect (disability, pregnancy, gender, ethnicity, minorities, children) • Take active steps (budget, services, infrastructure) • Educate about Human Rights • Improve rights (progressive realization) • No constraint by int’l lenders (e.g., IMF, ADB) Vision of Partners in OEH Asia-Pacific

8. Health & Human Rights • Global (all workers, citizens, environment) • Double standards or constraints are forbidden • Rights as Enforceable Laws • Tied to Standards of Ethics • Dimensions of Gov’t and Corporate obligations: • Respect • Protect • Fulfill • Promote Vision of Partners in OEH Asia-Pacific

9. Brief History – Health and H.R. • ILO estab. 1919, first addressed global right to healthy work conditions • Franklin Roosevelt’s Four Freedoms speech 1941 proclaimed freedom from want, taken up by • UN Conference on International Organization, San Francisco, 1945 • Article 55 of UN Charter 1945 and WHO 1946 • “universal respect for and observance of human rights” • Articles 57 and 62 of UN Charter • “health” is the responsibility of the UN Economic and Social Council (ECOSOC) • Universal Declaration of Human Rights (UDHR) 1948 • Affirmed in Article 25(1) that “everyone has the right to a standard of living adequate for the health of himself and his family, including food, clothing, housing and medical care, and necessary social services.” • UN Commission on Human Rights 2002 • Appointed a Special Rapporteur on the right of everyone to the highest attainable standard of physical and mental health Vision of Partners in OEH Asia-Pacific

10. Basis of Legal Right to Health • United Nations Declaration of Human Rights (all members obliged) • WHO uses a voluntary policy approach (e.g., Covenants) • If adoptedor ratified, have legally binding authority • ILO uses a treaty approach (Conventions, Protocols, Recommendations) • Legally binding • Tripartite basis (Employee, Employer, Government) • Applies to ALL workers irrespective of age, gender, nationality, migration status • ILO Conventions for worker health rights (key ones): • No. 155 – Occupational Safety & Health (1981) • No. 161 – Occupational Health Services (1985) • No. 169 – Indigenous & Tribal Peoples (1989) • Equal but culturally sensitive health care and protection • ILO Convention re Child Labour • No. 182 – Child Labour • Article 3(d) – deems children’s health as an essential criterion for the definition of the term “worst forms of child labour.” Vision of Partners in OEH Asia-Pacific

11. U.N. International Covenants Civil & Political Rights (ICCPR) Economic, Social & Cultural Rights (ICESCR) To safe living and working environment To health protection and services • To organize independently • To bargain collectively • To information • Hazard Communication • Community Right-To-Know • Investigation and Surveillance Vision of Partners in OEH Asia-Pacific

12. UN ICESCR 1966 (in force 1976) • Article 12 • 1. “The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” • 2. “The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for: • (a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child; • (b) The improvement of all aspects of environmental and industrial hygiene; • (c) The prevention, treatment and control of epidemic, endemic occupational and other diseases; • (d) The creation of conditions which would assure to all medical service and medical attention in the event of sickness.” Vision of Partners in OEH Asia-Pacific

13. Dimensions of Right to Health • CESCR (Committee on ESC Rights) in 2000 • General Comment 14 details dimensions • Freedoms dimension: • To make decisions about one’s own health data • To make decisions about sexual and reproductive care • From being subject to non-consensual treatment • Entitlements dimension: • To a system of health care protection, including emergency care • To underlying determinants of health Vision of Partners in OEH Asia-Pacific

14. Health Determinants • Referenced in CESCR General Comment 14 (2000) • Underlying determinants of health: • Adequate sanitation • Safe and potable water • Adequate food and shelter • Safe and healthy work conditions • Healthy environment • If not met, right to health cannot be protected Vision of Partners in OEH Asia-Pacific

15. CESCR Definition • CESCR General Comment 14 on definition of “right to health” in ICESCR: • Restricts “right to health” to a right to enjoy a variety of facilities, goods, services and conditions needed to realize the right to health • Contains both freedoms and entitlements • Contains four elements (AAAQ): • Availability • Accessibility • Acceptability • Quality Vision of Partners in OEH Asia-Pacific

16. CESCR Definition (cont.) • CESCR General Comment 14 (continued) on the “right to health” states it requires of health facilities and practitioners that they must: • Respect medical ethics • Be culturally appropriate • Be gender sensitive • Offer health education of high quality Vision of Partners in OEH Asia-Pacific

17. State Obligations • ICECSR Article 2(1) • Progressive realization • States must show how they progressed in realization of rights protections between two reporting phases (4 yrs) • A clear and immediate legal obligation • If no progress, or worse, State must explain • Resource availability • Not a carte blanche for States to do what they please • Must take reasonable and targeted steps toward goals • Poorer States, if unable, must request help • Richer States must provide help Vision of Partners in OEH Asia-Pacific

18. ICESCR-12: Respect, Protect, Fulfill • ICESCR Article 12 obligations, three levels: • Respect (not interfere with) right to health • Protect (e.g., by legislation, access) right to health • Make sure medicines, facilities are regulated for access • Ensure practitioners meet appropriate standards of education, skills, and ethical codes of conduct • Fulfill right to health • Give sufficient recognition in political and legal systems • Adopt national health policy with detailed plans • Provide adequate health care facilities, vaccines • Formulate, implement and review periodically a coherent national policy to minimize risk of occupational accidents and diseases [CESCR 2000 General Comment 14, para 36] Vision of Partners in OEH Asia-Pacific

19. State Obligations for O&E Health Adapted from London L, IJOEH 2011;17:80-92 Vision of Partners in OEH Asia-Pacific

20. ICESCR • Art 7: just, safe, healthy work conditions • Art 12: improve all aspects of environment and industrial hygiene • Art 12: prevent, treat, control occup disease • Art 15: benefit from scientific progress • Many other global and regional rights conventions re OE health Vision of Partners in OEH Asia-Pacific

21. ICESCR • Right to health care: • “…not only…timely and appropriate but also…the underlying determinants of health” • Food, nutrition, sanitation, water, shelter and… • “healthy occupational conditions, and access to health related education and information” • “…benefits of scientific progress…” • Ensure the “diffusion of science” Vision of Partners in OEH Asia-Pacific

22. ICESCR Parties & Signatories 161 parties, 70 signatories (there are a total of 193 U.N. member nations) Dark green: signed and ratified Light green: signed but not ratified Grey: neither signed nor ratified* * in Asia: Brunei, Malaysia, Myanmar, Taiwan, some Pacific isles Vision of Partners in OEH Asia-Pacific

23. U.N. Declaration of Human Rights • All 193 member states are subject to the terms of the UNDHR Vision of Partners in OEH Asia-Pacific

24. Ratification of ILO OSH Conventions Convention Number, Name, Year of Adoption No. of Countries* (update) 45 Underground work (women) 1935 97 115 Radiation protection 1960 47 119 Guarding of machinery 1963 50 139 Occupational cancer 1974 35 148 Working env. (air pollution, noise and vibration) 1977 41 155 Occupational safety and health 1981 42 (60, 8 in A-P) 161 Occupational health services 1985 22 (31, none in A-P) 167 Safety and health in construction 1988 17 (24, 2 in A-P) 170 Chemicals 1990 11 174 Prevention of major industrial accidents 1993 9 176 Safety and health in mines 1995 20 (28, 1 in A-P) Safety and health in agriculture 2001 4 (15, 2 in A-P) P155 Protocol and 194-Rec to C155 2002 n.r. (9, none in A-P) Promotional Framework for OSH Convention 2006n.r. (25, 4 in A-P) *—number of countries (out of 193 members) that ratified the convention as of 2006 Source: http://www.ciop.pl/18286 Table A (JOSE, 2006, Vol. 12, No. 3, 255–266) Vision of Partners in OEH Asia-Pacific

25. ILO C155 OSH (1981) • To establish a national OSH policy and program • Asia-Pacific signatories (8 of 60 total): • Australia • China (PRC), incl. Hong Kong (2007) and Macau (1999) • Fiji • Kazakhstan • Mongolia • New Zealand • Tajikistan • Viet Nam Vision of Partners in OEH Asia-Pacific

26. ILO P155 Protocol (2002) to C155 • Establish periodic OSH program reviews, record and report occupational diseases, etc. • Asia-Pacific Signatories (1 of 9 globally): • Australia Vision of Partners in OEH Asia-Pacific

27. ILO C161 Occ Health Services (1985) • Establish OSH program services for/at enterprise levels • Asia-Pacific Signatories (None of 31 globally) • None Vision of Partners in OEH Asia-Pacific

28. Agriculture, Construction, Mines • ILO C184 Agriculture 2001 (2 of 15 globally): • Fiji • Kyrgyzstan • ILO C167 Construction 1988 (2 of 24 globally): • China (PRC) • Kazakhstan • ILO C176 Mining 1995 (1 of 28 globally): • Philippines Vision of Partners in OEH Asia-Pacific

29. Cancer and Chemicals • ILO C139 Occ. Cancer 1974 (3 of 39 globally) • Afghanistan • Japan • Korea (ROK) • ILO C___ Chemicals 1990 (2 of 17 globally) • China • Korea (ROC) Vision of Partners in OEH Asia-Pacific

30. Global Burden of Occupational and Environmental Death and Disease • 300,000 work injury deaths per year • 2 million work illness deaths per year • Environmental disaster M+M unknown • 10-20% workers have access to OH services • 10% developing nations have OSH laws • Globalization and Free Trade Agreements have protected some, but marginalized many Vision of Partners in OEH Asia-Pacific

31. Migrant Labour • “Regular vs. Irregular” • Both formal and informal sectors • Most jobs are low-skilled, labour-intensive • “3-D Jobs” – dirty, degrading, dangerous • Often: mining, textiles, agriculture, construction, heavy manufacturing, sweat shops, sex work • In Europe: migrants have 2-times rate of occupational injuries (Bollini, 1995) Vision of Partners in OEH Asia-Pacific

32. Migrant Labour Health Rights • Rights endorsed in U.N. 1985 “Health Rights of Individuals Who Are Not Nationals of the Country in Which They Live” - Article 8(1)(c) right to health protection and medical care • Right to access health care and preventive public health services • Cannot be returned home without treatment of an active medical condition • ILO Conventions apply to migrant workers, including work hour limits, maternity, paid holidays • “Non-discriminatory principle” – regardless of state status (including undocumented workers), employment establishes between migrant and employer a series of economic and social rights (including health protection and medical care for work injuries) • Rights include: prohibition of forced labour, freedom of association and right to organize and join union, right to adequate working conditions including OSH Vision of Partners in OEH Asia-Pacific

33. Obstacles to OEH Rights and Protections • Deregulation • Promotion of labourflexibility (anti-union, migrant) • Shift to informal sector employment • Outsourced production (SEZs, FTZs, EPZs) • Export of hazardous technologies and materials • Double standards, both national and TNCs • Government collusion and competition • Trade agreements that obstruct or inhibit rights Vision of Partners in OEH Asia-Pacific

34. ILO C187 Promotional Framework for OSH (2006) • Requires gov’ts to develop national policy, laws, programs with enterprise and labour representation (tripartite) per Article 4 of C155 • Asia-Pacific Signatories (4 of 25 globally) • Japan • Korea (ROK) • Malaysia • Singapore Also, Russia, if one considers Siberia is part of Asia Vision of Partners in OEH Asia-Pacific

35. Asia-Global OEH Activity • ILO technical training efforts • OEH (medical and hygiene) courses by western Universities • Mount Sinai Hospital (New York City) • 1-week OEH training in Bangkok, April 2013 • ~ 50 regional participants • Bhutan, Brunei, Cambodia, Indonesia, Laos, Nepal, Sri Lanka, Thailand, Viet Nam • Discussions with Myanmar Minister of Health • Finnish Institute of Occupational Health • Asia-Pacific Newsletter (quarterly; nation profiles) • Triennial Asia Conference Occupational Health (AAOH) since 1956 • NGOs – ANROEV (and GOSH); AMRC; Solidarity Center; Hesperian Foundation; others Vision of Partners in OEH Asia-Pacific

36. Taiwan OH Services • Problem: under-reporting of occupational injury and disease (OD) • Response: government founded and financed the Network of Occupational Diseases and Injuries Service (NODIS) for occupational disease and injury services and established a new Internet-based reporting system • NODIS comprised of: the Center for Occupational Disease and Injury Services and their local network hospitals • Objectives: (1) Analyze possible influence of NODIS on compensable OD; (2) Describe distribution of OD across occupations and industries (2005-2010) • Methods: Analyzed two datasets: (1) NODIS reporting dataset for demographics, OD distribution and time trends, and OD annual incidence; and (2) National Labor Insurance (NLI) scheme dataset of compensated OD for annual incidence • Results: After NODIS was established, both the reported (NODIS) and compensable (NLI) OD incidences increased 1.2 and 2.0 fold from 2007 to 2010, respectively; the most frequently reported OD (2008 to 2010) were carpal tunnel syndrome, lumbar disc disorder, upper limb musculoskeletal disorders, and contact dermatitis • Conclusions: NODIS system succeeded in providing more occupational health services, providing more workers with compensation for OD, and reducing under-reporting of OD Chu PC, et al. The impact of occupational health service network and reporting system in Taiwan. Int J OccEnv Health, 2013; 19(4): 352-362 Vision of Partners in OEH Asia-Pacific

37. OE Medical & Hygiene Training in Asia • Few for Occ Hygiene and Clinical Medicine • OEM Residencies; Occ Hygiene Master/Doctorate • Continuing Professional Education • OEM for Primary Care Doctors (none?) • Many turn out researcher MD/PhD • Mostly MPH degrees (not clinical; few OEH) • Training in OEM • Japan, Korea (ROK), Taiwan (ROC), Hong Kong, China (PRC), Singapore (other-?), • Australia (Monash Univ.) Vision of Partners in OEH Asia-Pacific

38. OH Nursing and Mid-Level Providers in Asia • Training of certified occupational nurses (none?) • Training of mid-level providers (none?) • Nurse Practitioners (Master/Doctorate levels) • Physician Assistant (separate training) • Can act like MD, with MD oversight collaboration • U.S. has OHN certification for RNs and NPs Vision of Partners in OEH Asia-Pacific

39. National OEH Associations in Asia • Few • Philippines College of Occupational Medicine • Offers a diploma course Vision of Partners in OEH Asia-Pacific

40. Trade and OEH • World Trade Organization (WTO) • 153 member nations • Diminish and regulate commerce barriers • Regional • NAFTA, EC, MERCOSUR (4 So. Amer.), bilateral • Trade rules restrict extent to which States can limit imports in order to protect public health, including OEH • Implications often for medications (patent protection; generic drug compulsory licenses) and pharmaceutical industry practices Vision of Partners in OEH Asia-Pacific

41. Needs Assessment and Tracking • Each nation baseline • See next slide • OEH goal setting to affect real change • Decrease occupational M&M (morbidity & mortality) • Decrease environmental degradation • Improve health and safety of work places and communities • Reverse man-made climate change • What is your country’s situation? • What OEH strengths does your country have? • What are the OEH needs? • What OEH priorities does your country have? • What plan could help solve some of them? • What long-range OEH goals for your country? Vision of Partners in OEH Asia-Pacific

42. Each Nation Need Determinants • Burden of occupational disease (injury, illness) • Labour force (by industry - union, gender, age) • Laws on OSH and environmental protection • Government agencies and institutes for OEH • Emergency preparedness and response for OEH • Public health, medical, laboratory services • OEH training programs (hygienists, nurses, doctors) • OEH support organizations (unions, NGOs, etc.) • Funding sources for OEH capacity building • Existing international partnerships (medical, NGO, etc.) • OEH links to community primary health care • Priority needs and vision Vision of Partners in OEH Asia-Pacific

43. OEH Clinical Training Structures • Core specialty • Medical residency • Post-graduate degree or clinical fellowship • Additional component to core training • OEM or OEHN curriculum added to basic medical or nursing degree program • Certification or Diploma courses • Comprehensive vs. Hot Topic • OEM for primary care doctors and nurses • Continuing education • Education credits for board certification maintenance Vision of Partners in OEH Asia-Pacific

44. Occupational Hygiene Training • Core degree program • Occ Hygiene and Safety Professional certification or diploma courses • Continuing professional education needed to maintain certification Vision of Partners in OEH Asia-Pacific

45. Training Modes • Regional and International established programs • Standardization • ACGME International (e.g., Ecuador) • Category 1 vs 2 level of continuing education credits • Internet learning (podcasts, curricula, videoconf) • Face-to-face • Field work and clinical work apprenticeships (these are essential!) • Work site visits • Occupational health clinical rotations • Goal: establish national capabilities after transfer of knowledge and skills to local core teams of professionals; integrate with community primary health care Vision of Partners in OEH Asia-Pacific

46. Training Topics – 1 • Lung disease • Asthma • Pneumoconioses (Coal, Silica, Asbestos) • See handout examples of resources • Simple spirometry (diagnosis restrictive & obstructive OD) • ILO digital radiography for pneumoconioses • Emergency/disaster preparedness and response • Conducting an occupational history and physical exam, lab testing, diagnosis, treatment plan • Disability management and return-to-work • OH Nurse case management • Leadership skills for OH Vision of Partners in OEH Asia-Pacific

47. Training Topics – 2 • Hazard identification, prevention and control: • Physical (temperature, pressure, vibration, noise, repetitive strain, falls, struck by/against) • Radiation (ionizing, non-ionizing • Chemicals, Gases, Metals Toxicology • Biological • Psychological & Social • Epidemiology and biostatistics • Medical surveillance for the more hazardous jobs • Running an occupational health service • Substance abuse, workplace violence, wellness at work • Regulations, recordkeeping, reporting • Privacy protection Vision of Partners in OEH Asia-Pacific

48. Training Topics – 3 • OSH for specific industries and/or jobs • Construction • Mining • Transport • Agriculture • Automobile • Electronics • Textiles, garments and shoes • Chemicals • Hospital and health care workers Vision of Partners in OEH Asia-Pacific

49. Institutional Partners in North America • US National Institutes of Occupational Safety and Health (NIOSH, International Support) • American College of Occupational & Environmental Medicine (ACOEM, International Section) • US Accreditation Committee for Graduate Medical Education (ACGME, International Standard Setting) • Harvard University School of Public Health, Department of Environmental Health, Environmental & Occupational Medicine and Epidemiology Program • Emory University, Mayo Clinic, Univ. of Washington, Stanford Univ., Univ. California San Francisco, MIT, etc. • Next Generation University (Univ. of British Columbia) Vision of Partners in OEH Asia-Pacific

50. Training Jump Start Proposal • New Generation University Preventive Occupational & Environmental Medicine Program • Links existing top OEH training institutions with local and regional participating OEH institutions in Asia-Pacific, or directly to students • Raises financial support from donor agencies (WHO, ILO, Africa Fund, independent foundations, governments, private Individuals) to: • Pay trainers and their institutions • Pay cost of curriculum development and delivery • Pay stipends and expenses for trainees • Thus, trainees pay nothing and earn something (no debt) Vision of Partners in OEH Asia-Pacific