SUPPLEMENT TO COMMUNITY HEALTH STUDIES VIII, 3,1984

A NATIONAL INSTITUTE OF OCCUPATIONAL HEALTH AND SAFETY

David Ferguson

Professor of Occupational Health, Commonwealth Institute of Health, University of Sydney

The Case for an Institute An institute of occupational health was defined

in 1957 by the World Health Organization as “any organization in which specialists in the various aspects of occupational health act as a team to conduct research and teaching and to provide service in the field”’. Australia has no institute as such. However, the Occupational Health Section of the Commonwealth Institute of Health (CIH -from 1930 to 1980, known as the School of Public Health and Tropical Medicine) in the Commonwealth Department of Health and The University of Sydney, formed in 1949, fits the definition even if at a quite inadequate level, having regard to Australian needs, owing to its limited resources.

The idea of an institute of occupational health and safety based on the CIH is not new. Indeed the then Head of the Section, Dr Gordon Smith, in 1963 put forward proposals for such an institute in the (then) School at the request of the Director-General of Health. He made a further recommendation in 1972, and again in 1974 when, at the Whitlam Government’s request, the Department of Health was considering the role of the School in relation to a national occupation- al health program. In 1973, I also proposed an institute*, and again in 1976 in the plans for my new Section of Occupational and Environmental Health in the School. The matter has been canvassed informally in the past 15 years with some state government directors of occupational health, and has for years been a major item in the aims of the Australian and New Zealand Society of Occupational Medicine. Simson, after visiting many such institutes overseas in 1976, strongly urged establishment of one in Australia’. An institute of occupational health and safety is implicit in the recommendations in 1975 of the Committee of Review on the School‘. Dr M. El Batawi, Chief, Occupational Health, World Health Organization, Geneva, made representa-

tions in support of the proposal on his visit to Australia in 1975. My own visits to institutes in Asia‘ and Europe encourage me to believe that an Australian institute is long overdue.

Nor is the idea of a national institute of occupational health and safety new in other countries. The first such institute was formed in 1904 in Milan, since when institutes of which I am aware have been established in Algeria, Bolivia, Brazil, Bulgaria, Chile, Czechoslovakia, Finland, West and East Germany, Holland, India, Indonesia, Iran, Israel, Italy, Japan, Peru, Po- land, South Africa, Sri Lanka, Sweden, Switzer- land, United Kingdom, USA, USSR and Yugos- lavia. The list is by no means complete. The formation of national institutes of occupational health was recommended 27 years ago by a Joint Committee of the International Labour Orga- nization and World Health ,Organization’. Pro- fessor Sven Forssman, former President of the Permanent Commission and International Asso- ciation on Occupational Health, reported in 1978 on a survey he made of six national institutes on behalf of the Danish Government, in preparation for a Danish institute. In 1978 Canada estab- lished a new Centre for Occupational Health and Safety which embodies many of the functions of a national institute.

Institutes of occupational health and safety grew out of the need to bring together in centres of excellence the various disciplines and profes- sions concerned in this field which could fulfil teaching, research and service functions. The Joint ILOMrHO Committee in 1957’ suggested professional complements for minimum, average and complete establishments. Over twenty years later, Australia still does not have an institute, and my Section in the CIH still does not meet the Joint Committee’s minimum standard, despite attempts to attain that level.

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Initially, institutes were concerned only with occupational disease and injury, and some were specialised to deal with a particular problem, for example dust disease of the lungs. Ultimately, the scope widened to deal with “non- occupational” disease and injury in the worker as well as occupational disease and injury, and extended into such fields as occupational psychology, psychiatry, sociology, ergonomics, safety, physiology and human relations’; that is, the institutes became concerned with the total health of the worker and, despite increasing emphasis on scientific investigation, retained a strong clinical content. Indeed, the two Euro- pean institutes I visited in 1978 both had occupa- tional disease and injury hospitals attached to them. Most occupational health and safety insti- tutes also embrace environmental health and safety to a limited degree - for example, the effects of an industry’s operations on the health of its community, particularly the effects of environmental pollution, and the effects of its products on consumers.

Some institutes combine national with day-to- day service functions (such as are undertaken in Australian states by government divisions of occupational health) particularly in smaller coun- tries such as Central European nations. Larger countries, for example Japan, may have several national institutes as well as regional establish- ments in departments of health, schools of public health, or university departments of preventive and social or community medicine, which serve some of the functions of a national institute.

A national institute is not necessarily a purely geographic establishment, that is, a building or complex of buildings in one place. Rather it may represent a concept of integrated functions on a nationwide basis and at a national level. The institute may then constitute the national occupa- tional health and safety development centre, and thus contribute materially to national economic and social development. An example of the integration concept is presented by the National Institute of Occupational Safety and Health (NIOSH) in the United States which has its headquarters in Rockville, Maryland, and its main research labo.ratories in Cincinnati, Ohio. Special research stations in Morgantown, West Virginia (NIOSH’s Appalachian Center for Occupational Safety and Health) and Salt Lake City, Utah (NIOSH’s Western Area Occupa- tional Health Laboratories) deal respectively

with occupational respiratory disease, particular- ly coal pneumoconiosis, and health and safety hazards of uranium mining, together with some regional service. NIOSH also maintains staff in ten regional offices throughout the United States. These are focal points for special surveys and evaluations of existing occupational prob- lems, consultative services to states, and other activities. NIOSH is the federal agency for formulating new or improved standards under the Occupational Safety and Health Act of 1970. It is the principal agency engaged in research, education and training in this field, although it contracts out much of its work to state govern- ments, universities, industry, and private individuals.

The Canadian Occupational Health and Safety Centre represents a different concept, being a tripartitie, facilitatory, communicatory, suppor- tive concept designed to overcome industrial differences and unco-ordinated disparate provin- cial autonomy. It does nevertheless present also another example of need seen for national action in a federation.

Australia, as a federation, is in a similar position to the US if on a smaller scale. However, though there are divisions of occupational health or equivalent in each state health or labour ministry, all quite inadequately staffed and equipped, there has not, for the last 50 years, been a federal body in occupational health and safety formally constituted to undertake the national functions in this field. (As mentioned, the Occupational and Environmental Health Section of the CIH has since 1949 in effect fulfilled some of these national functions on a limited scale.)

The Commonwealth Department of Health had a small, though high quality, Division of Industrial Hygiene from 1921 to 1932 which was never reformed after the Depression. In recent years the Department has had one position of Medical Adviser in Occupational Health at Canberra, and administratively, occupational health had been seen as one of several areas of responsibility of the social health section. The Whitlam Government proposed setting up a unit in Canberra, in relation to an Australian Govern- ment employee health service and a national occupational health program. The plan included establishment of a research unit within the then School of Public Health and Tropical Medicine,

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which would also provide support to these services.

The Occupational Health Committee of the National Health and Medical Research Council, a Commonwealth Department of Health body, accepts some national functions in that it pre- pares codes of practice, model legislation, recom- mended standards and other such papers. Another of its valuable functions is to bring together the various state and territory divisions of occupational health for sharing of information and towards uniformity of legislation and prac- tice. Such functions, while proper to a national institute, do not thereby obviate the need for such a body. It is not enough to say that the state divisions of occupational health look after the field - the states have mainly a service role and there are clear state and federal responsibilities although, as made clear below, the state divisions have a role in the national institute concept. The role of the CIH as the national institute of health makes it the appropriate focus for an Australian institute of occupational health and safety.

A major barrier to progress in Australia has been the firm separation of occupational health and safety at all levels from government to shop floor. In both federal and state governments, occupational health has traditionally resided in ministries of health and safety in departments of labour. This wretched stultifying dichotomy has been a stumbling block to progress in many parts of the world. Various strategies have been used to overcome it, such as putting occupational health in the department of labour, as in Japan; creating a separate occupational health and safety commission as in Britain; or as in USA putting the research, standards development and educational aspects in the department of health and the administration of legislation in the department of labour. The anachronistic nature of the dichotomy is recognised by the combina- tion of health and safety in such titles as the National Institute of Occupational Safety and Health in USA, the British Health and Safety at Work etc. Act, and the Occupational Health and Safety Act of 1983 in New South Wales. The dichotomy is made worse by the isolation of special areas of occupational health and safety in departments of mines, agriculture, transport, environment and other ministries. The projected federal office, commission and institute of occu- pational health and safety will help to overcome the dichotomy.

The foregoing establishes a place for an institute of occupational health and safety in Australia. What follows is an outline of possible functions and organizations for such an institute, with particular reference to Australian needs. It is not an attempt to predict what will be decided in the near future, rather an opinion on a desirable arrangement.

Functions and Organization Aims and Scope

The aim.of a national institute of occupational health and safety should be to foster national activities in this field, in fulfilment of which it may undertake andor promote teaching and research, collect, collate and disseminate information, and provide service concerning:

1. Effects of exposure to haiardous physical, chemical, biological or psychosocial work conditions; Overall health of working populations; Health promotion, primary, secondary and tertiary prevention, and treatment as appropriate in working populations;

4. Public health and environmental health aspects of work and industry;

5. Occupational health and safety problems of particular importance to the nation, but without neglect of the world regional and global scene; and Broad labour issues related to occupational health and safety. '

To implement its functions a national institute

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would:

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Bring together a wide range of professional and research skills in such fields as occupa- tional medicine, hygiene, physiology, tox- icology, epidemiology, psychology, phy- siotherapy, nursing, engineering, safety, ergonomics and rehabilitation; Combine laboratory, epidemiological and clinical aspects; Maintain contact with clinical occupational medicine ; Integrate biological and environmental approaches; Develop the fields of occupational toxicolo- gy, occupational hygiene, safety engineer- ing, environmental control, ergonomics and occupational psychology.

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In addition to its own prime research function, an institute would collaborate in and co-ordinate national research on occupational health and safety. It would establish links with other institu- tions engaged in research into special areas of occupational health and safety.

An, institute’s research can be both basic and applied, its applied research being directed towards problems of national importance. A research committee would select projects with a priority based on national need, practicability of achievement, and likelihood of successful and worthwhile application. The projects could be generated by the institute or referred by govern- ment, industry, unions or other agencies. Co- ordination of occupational health and safety research at a national level presupposes a joint research council.

An institute should direct its research towards: Problems of injury, disease, fatigue, discom- fort and performance in working popula- tions;

2. Formulation of occupational health and safety standards;

3. Organization of occupational health ser- vices, and their integration with other com- munity health services; and

4. Evaluation of control measures. To ensure wide application, a national institute

should publish its research findings through its own or other outlets.

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Teaching and Training The amount and nature of the teaching under-

taken by a national institute will vary according to local circumstances. Nevertheless, an institute is normally the national focus and co-ordinator of professional training in occupational health and safety. It would thus collaborate with other teaching institutions in attempting to achieve uniformly high standards of instruction. While its own major teaching efforts would be at graduate level, it would engage also in undergraduate and postgraduate teaching and in continuing and public education nationally, and in teaching internationally.

There is currently a severe shortage of fully trained occupational health and safety profes- sionals in Australia. The main objective of an institute’s graduate program is to provide the academic aspects of vocational training for occu- pational physicians, occupational hygienists,

safety engineers, occupational nurses, occupa- tional physiotherapists, occupational physiolo- gists, occupational psychologists, and others in collaboration with appropriate professional bodies. These programs also provide a basis for academic careers in teaching and research in occupatibnal hdalth and safety.

A national institute offers and arranges accre- dited training posts which complement its formal academic programs, towards gaining of specialist status and recognition by professional institu- tions, registration boards and government employers. It should offer also doctoral and research programs towards academic advance- ment. The institute if necessary may constitute the specialist recognition body, on its own or in collaboration, depending on national develop ments in professional organization in this field. Though in the graduate programs there must be special (and flexibole) training in particular pro- fessional fields, there should also be common teaching across the disciplines in the more general areas of occupational health and safety and public health.

In collaboration with others, a national institute may provide, arrange and support appropriate basic education in the principles of occupational health and safety in undergraduate curricula in medicine, engineering, science, architecture, occupational therapy, physiotherapy, nursing and the social sciences.

Similarly, the institute may provide, arrange and foster postgraduate and continuing educa- tion in occupational health and safety by means of: 1. Refresher courses, seminars and confer-

ences for occupational health professionals and for other industrial and public and community health professional groups; Full-time courses of up to about 3 months’ duration, or part-time or correspondence equivalent, as an introduction tq occupation- al health and safety for general practitioners, community nurses, chemists and chemical safety industrial and other engineers; and Special courses of a few days to a few weeks in such subjects as ergonomics, industrial toxicology and carcinogenesis, noise, dust disease, occupational psychology, alcohol- ism and mental health in industry.

Postgraduate teaching in occupational health is arranged and conducted in collaboration with the

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3.

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professional associations of occupational physi- cians, hygienists, nurses, engineers, physiother- apists, ergonomists and other disciplines con- cerned. The institute gives assistance to relevant courses in other institutions. Postgraduate teaching includes the systematic training of the Institute’s own staff, and the development of teachers for other institutions.

In addition to academic teaching, it is proper for an institute to foster education of the public in occupational health and safety, for example by: 1. Giving or sponsoring lectures; 2. Making and providing films; 3. Disseminating educational material; 4. 5 . 6.

Organizing meetings and lay courses; Writing articles for popular journals; and Taking part in public debate.

An institute should also provide short courses for management and trade union groups.

Finally, it would be an appropriate teaching function of a national institute, through other national and international bodies, to arrange and take part in courses in and out of the country for its neighbours, in areas of occupational health and safety in which it had unique or well developed expertise in the region, for example occupational hygiene, in the case of Australia*. The institute could be a medium for promotion of exchange lectureships and professorships, and participation in regional professional confer- ences.

Service An institute should maintain a balance of

research, teaching and service, though any ser- vice must be at a level appropriate to a national body. The institute desirably should directly associate with a local group occupational health service for teaching and research in innovative programs, and for keeping in touch with current practice. Routine and lower level investigations and procedures proper to private, state and regional health establishments are better eschewed. Routine procedures can however be undertaken if they require a high professional skill, are of national importance, demand concur- rent assessment of effectiveness, or are in special areas in which skills elsewhere are limited or unavailable. An institute can share demands on its services with other regional and national bodies, letting out requests of a routine nature and taking on requests in its own special areas.

National institutes can make their resources available, on request, to governments, em- ployers, trade unions and others for investigation and solution of specific occupational health problems. Requests may range from matters capable of being dealt with over the telephone to those requiring full-scale applied research.

An institute’s comprehensive up-dated library affords service to staff, inquirers and public, in the forms of computerised literature search, catalogued system for easy retrieval, and re- sources for public enquiry and information pre- paration. The library accordingly needs adequate staff trained to handle requests on occupational health.

An institute is the focus of national activities in the preparation of occupational health and safety standards, exposure limits, codes of practice, model legislation and international agreements, in conjunction with such other bodies as the National Health and Medical Research Council and the Standards Association.

An institute constitutes also a national refer- ence centre and resource for collation and analysis of information on occupational health and safety. It is a demographic repository on occupational health, and may for example main- tain a registry of occupational diseases such as cancer, or of workers exposed highly to risk. To these ends it is equipped to undertake occupa- tional epidemiology research, may maintain a mobile occupational survey laboratory, and de- velops linkages with data sources, such as the Australian Bureau of Statistics.

As part of its service, research and teaching roles a national institute publicises its activities in the form of newsletter, handbook, brochures, journal, scientific monographs, textbooks, tech- nical and safety data sheets, codes of practice and information bulletins, in conjunction with other bodies.

For various clients an institute may undertake routine testing of a highly specialised nature, particularly where innovative procedures or cost- benefit issues, opportunities for research and teaching, and matters of national import are concerned. For example, an institute may be involved in testing for occupational mutagens and carcinogens, in monitoring for potential effects of uranium mining and milling and other

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toxicological hazards, in certain occupational hygiene analyses, and in psychological testing for effects of occupational stress.

Organization A national occupational health and safety

institute may be a unit of the national institute of health, or may be independent, but in either case, may be an establishment of the national ministry of health, and sited in and academically linked with a medical school and a university. Either way also, the institute should have effec- tive links with many other bodies: 1.

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Departments d occupational health and preventive, social and community medicine in medical schools; Divisions of occupational health in the states and territories; National committees, such as the Occupa- tional Health Committee of the National Health and Medical Research Council; The medical and other faculties of the home university; State and territory ministries of health; Federal and state departments of labour, agriculture, environment and mines; Rehabilitation units; Professional bodies; Industry and trade union organizations; Occupational health and safety divisions of the World Health Organization and Interna- tional Labour Organization regionally and in Geneva; and The Permanent Commission and Interna- tional Association on Occupational Health and the International Agency for Research on Cancer and other international bodies.

In these affiliations, the institute should avoid association with enforcement; political and industrial interference; inter-agency jealousies; external constraint on thought and publication and professional freedom; pre-occupation with financial support; fund raising by unworthy activities; and diversion to commercial ends.

The staff of a national institute are also the staff of the department of occupational health in the home university. The full-time staff should comprise experts in all the disciplines which constitute the broad field of occupational health and safety; and should form a team capable of fulfilling the functions of the institute. The staff include occupational physicians, hygienists, toxicologists, physiologists, engineers, psycho-

logists, nurses, physiotherapists, social workers, epidemiologists, statisticians and support staff. Part-time and visiting staff can include consul- tants in special branches of medicine and surgery, and professional people in physical and social sciences, in government and research, and in industry. Incorporation of an institute of occupa- tional health and safety in a national institute of health allows access to other staff and resources of the wider body which greatly expand its capacity. Equally, an occupational health and safety institute may have satellite units in other parts of the country, and in specialised areas of concern.

An institute of occupational health and safety can have units in occupational medicine, occupa- tional hygiene, ergonomics and safety, work and environmental physiology, industrial toxicology, occupational psychology and sociology, occupa- tional epidemiology and demography, and occupational health education and information. Desirably the units overlap extensively in person- nel, laboratory and survey work, and facilities. The medical unit can direct the institute’s group occupational health service, and the toxicology unit can direct an animal laboratory. Special . units in the field provide support and research and evaluation of occupational health and safety problems in major industrial undertakings and in specialised ventures such as uranium mining and off-shore oil and gas fields. The institute should maintain regional contact by arrangement with local divisions of occupational health and academic departments of occupational, social, or community medicine.

A national institute should have an advisory council which has representation from external authorities, institutions and organizations, including employers’ and employees’ groups, which can offer guidance on policy and objectives and directions of interest important to the community.

Finance A national institute can retain support from

the national ministry of health. However, there is no reason why it should not also derive additional funds or donations from other sources, to sup- port purchase of extra equipment, travel, and temporary employment of research assistance. These sources may include: 1. Charges for consultations, extramural

courses, and publications;

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2.

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Research funds from employers, trade un- ions and insurance companies; Research grants for specific projects through national research funding bodies such as the National Health and Medical Research Council; and A levy on workers’ compensation premiums. 4.

Conclusions This paper is concluded in the knowledge that

when it is delivered on 24th May, 1984, its outline above of an Australian institute of occupational health and safety will already be quite displaced by the recommendations of the Interim National Committee on Occupational Health and Safety; for at about the same time, the Committee is to report on the Government’s proposals for a national office, commission, institute and environmental contaminants authority.

Many people fear that the potential of an institute, so long awaited, will be vitiated by its being placed, instead of in the Commonwealth Department of Health as originally announced by the Government, rather in the Department of Employment and Industrial Relations. The insti- tute, it is feared, may then be subject to tripartite control, and its work to political, industrial and doctrinaire policies inimical to independent pro-

fessional judgement; and may become a mere handmaiden to the Commission.

There are compelling reasons why the institute should be placed within the Department of Health, and closely related to, if not part of, the CIH; and thus that it be located in Sydney, connected with the University of Sydney and major hospitals, and among the largest aggrega- tion of industry in Australia. If the institute is not made part of the CIH, it should not attempt to duplicate the postgraduate teaching functions of the latter but rather co-ordinate training at all levels. Fostering of the training of trainers is the most urgent function of the new office, commis- sion and institute. The great lack of trainers, and of trained professional practitioners and others in Australia will take many years to overcome.

Whatever the Interim Commission recom- mends and the Government decides, the new institute will need the support of institutions and professional groups around Australia if it is to achieve the national role seen for it and so long delayed. There can be no justification for sug- gested takeovers of existing units, particularly in the CIH and the National Health and Medical Research Council.

References

1. Joint ILOlWHO Committee on Occupation- al Health. Third Report; Tech. Rep. Ser. No. 135, 1957, Geneva.

2. Ferguson D. Teaching of Occupational Health in Relation to its Organization and Practice in some Western Pacific Countries. School of Public Health and Tropical Medi- cine, Univ of Syd, 1974. Simson R. E. Report to National Health and 3.

Medical Research Council on Travelling Fellowships in Occupational Health, 1977. Report of Committee of Inquiry into the School of Public Health and Tropical Medi- cine. Hospitals and Health Services Com- mission, Canberra, 1975. Forrsman S. Occupational health institutes: An international survey. Amer Ind Hyg

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ASSOC J , 1967; 28:197-203.

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