COMMUNITY HEALTH STUDIES VOLUME V , NUMBER I , 1981

David Ferguson

OCCUPATIONAL HEALTH IN AUSTRALIA - DEBIT AND CREDIT

Department of Environmental and Occupational Health Sydney, N.S.W. 2006.

Introduction This paper examines occupational health* in

Australia, and considers possible improvement. It also examines obstacles to progress, and urges national priorities and objectives.

The usual concept of health care at work is of a casualty, clinical or compensation service, conducted in factories by physicians and nurses. Such services constitute medicine in industry, not occupational medicine. Occupational health services deal with health promotion and maintenance (well people care), with prevention of disease and injury (threatened people care), and with some treatment (sick people care). The workplace affords the best community opportunity for health promotion and maintenance in working adults. In countries with community treat- ment services, sick people care is not the usual province of health services at work.’ However, many companies in Europe, Japan and some developing countries provide total health care including that of family illness.

Occupational health draws upon various non- medical disciplines including science, engineering and psychology.* Support comes from professions such as statistics, economics and law. Occupational health has clinical, administrative, investigative, epidemiological and laboratory aspect^.^ It is con- cerned with biological and environmental evalution and control, the biological approach being particularly that of occupational physicians and the environmental of occupational hygienists.

Occupational health services differ from services of clinicians and hospitals. The former are devoted mainly to well and threatened people care, the latter to sick people care. Services on lines of International Labour Office recommendations‘ provide, in addition to occupational disease and injury prevention, a wide general health cover. For example, they may offer activities relating to personal and public hygiene, diet, physical fitness, mental health, alcohol, smoking and other drug taking, family planning, use of leisure, preparation for retirement, immunisation, road safety, - *In this paper ‘occuptiond health’ gemnllr includes oecuptional safety. ‘Industry’ inclt!&s v. see- ud muy industry. indkd MY gainful employment. Occupauonal mcdrmm’ rcfm to thc rrnctice of occupuiolul health by physicians. nurses ud physiahcmpiur

The Commonweulth Institute of Health, The University of

environmental health, chronic disease and venereal disease. The functions of an occupational health service thus apply to the effects both of health on work and work on health.

Occupational Health in Australia Occupational disease

Occupational injuries in Australia are unaccept- ably common, and are a far greater source of death and disability than occupational disease.

The incidence of occupational disease in Australia is unknown. There are no official statistics other than compensation and death certificate data, which are not a true record of occurrenc,e. Little study of occupational disease has been undertaken, with some notable exceptions.’ Probably much undis- covered or unreported disease exists.e Estimates overseas are high, for example 390,000 new cases of occupational disease are thought to occur annually in the United States, and 100,000 deaths.’

Some estimate of dust disease can be gained from the reports of the New South Wales Dust Diseases Board. Of the two commonest diseases, silicosis is decreasingly reported whereas asbestos-related dis- ease is increasing. Systemic disease, mainly acute and chronic poisoning by toxic agents absorbed through skin or lungs, appears to be uncommon, but the occurrence of mild degrees is unknown. Three commonly compensated disorders-occupational hearing loss, lumbar intervertebral disc degeneration, and process work strains of the hand and arm-are more repetition injuries than diseases, although differentiation between disease and injury in such cases is tenuous. Zoonoses and decompression sickness are still serious occupational diseases in Australia. Generally, however, legislative, industrial and public concern for rare or potential specific poisonings and irradiations is misplaced in priority in relation to the far more common physical trauma at work.

Far greater morbidity and mortality result in workers also from work-related ‘non-work’ disease. Such disease includes particularly common chronic disorders-hypertension, coronary heart disease, some cancers, bronchitis, asthma, arthritis. mental illhealth and alcoholism-in whose occurrence often

VOLUME V , NUMBER I , 1981 63 COMMUNITY HEALTH STUDIES

large occupational group differences can be noted. Social, geographic and other environmental influ- ences obviously operate,* but factors in work may contribute. Few employers, unions or community health services attempt control of occupational factors in these important chronic diseases, except perhaps in the case of alcoholism.

Even a single case of occupational harm is unacceptable. Yet industry and the community still accept occupational disease and injury with apparent equanimity. This general preparedness to risk low probability high harm contingencies also reflects social acceptance of the harmful nature of work.' Risks are accepted at a higher rate for workers than for the community (if one excepts self-destructive indulgence).

Strangely, enormous compensation costs appear to be accepted also, while investment in the far less expensive prevention is scarcely even contemplated until coercion looms. Noise-induced hearing loss is an example. Perhaps this anomaly occurs because prevention costs are immediate and often of a capital nature and their return is usually delayed, while compensation casts are deferred and are a deductible item. .

There is apparent unconcern also over such possible indices of or contributors to illhealth and unsafeness in work as sickness absence,s turnover, fatigue," anxiety, tension, neurosis, boredom and dissatisfaction." Equally, physical unfitness of the workforce, with its attendant inefficiency, unsafeness and predisposition to disease, causes no concern. Unfitnest commonly accompanies a drugged state from alcohol, tobacco, other social poisons and prescribed potions. Further, alcohol and tobacco abuse are often work-related habits and are responsi- ble for far more death, disease and malaise than are all other industrial toxic agents combined.

Whether from work, or from faulty nutrition, physical unfitness or drugs, the many biological differences between occupational groups reflect relative health disadvantage short of 'disease'." Further, mortality and morbidity in the community generally correlate with living and working conditions and occupational status,13 and poor work conditions degrade workers as well as contribute to community degradation. An unrecognised state of non-specific work and society-contributed 'unhealth' exists."

Yet all this is negative occupational health. There is now, elsewhere, a mood of rejection of the negative approach, of merely controlling risk, in favour of work conditions which actively promote optimum wellbeing, satisfaction, realisation of potential creativity and physical and mental ability, and 'adaptability to changing circumstances of work and life'.'' This concept includes design of work for human abilities and limitations (ergonomics). Such an approach barely exists in Australia today, being perhaps overshadowed by the weight of occupational disease and injury.

Organisation

Development of occupational health in Australia has been neglected. With isolated exceptions covering specific occupational diseases or hazards, no federal or state laws relate to promotion and maintenance of worker health, although New South Wales is conducting an inquiry therein, and the National Health and Medical Research Council is preparing draft model legislation. Few occupational health profes- sionals are trained and fewer specialists practise in the field. Most workers have no health service at work, and most existing services fail to meet requirements of the International Labour Conference in 1959.' Little research goes on, and almost none is funded by national research grants. Australia has no national institute in this field, virtually no central secretariat, no national policy or program, and no central data system.

In Australia the federal system and parochial assertion of state rights ensure lack of uniformity in law and practice. The many national industries must conform to seven different sets of rules. As in Canada, there are disparate policies, programs and priorities.'O As in United States, state pre-emption of federal authority means unequal protection of the worker.s

Within the central government and within each state, control of occupational health is fragmented in many departments. Occupational safety, sited in labour ministries, is divorced from occupational health in health ministries, yet their essential oneness is recognised overseas in such titles as the Occupa- tional Safety and Health Act of the United States and the Health and Safety at Work Act of the United Kingdom. State labour ministries embody little professional expertise in modem scientific safety and ergonomics, and none in occupational health. Yet they aspire to take over occupational health divisions.

Each state division of occupational health is inadequately equipped to handle the investigatory, regulatory, consultative and educational service functions for its region. The Division of Industrial Hygiene in the Commonwealth Department of Health, initiated in 1921, undertook much worthy investiga- tion and publication before it was disbanded during the Depression in 1932. Its first director, D. G. Robertson, made many forward-looking recommen- dations on the organisation of occupational health which are still applicable but still not applied." Munitions factory services, the Occupational Health Committee of the National Health and Medical Research Council, and the Occupational Health Unit of the School of Public Health and Tropical Medicine (now the Commonwealth Institute of Health-a Commonwealth Department of Health establishment in The University of Sydney) formed in 1949, were the only major central government activities in occupa- tional health in the 40 years following the federal division's demise in 1932.

COMMUNITY HEALTH STUDIES 64 VOLUME V , NUMBER I , 198i

The Whitlam government planned many initia-

A central government executive; a code of general principles on occupational safety and health of Australian Government employees;1B a national occupational health program; a national research unit, to be based on the Institute; research and travelling fellowships; training fellowships for occupational physicians and nurses; and codes of practice.

tives to promote worker health and safety, including:

A few physicians and nurses were trained and three travelling fellowships were granted. The code of general principles was endorsed by the Fraser government in May 1978, and codes of practice have been generated by the Commonwealth Departments of Health and hoductivity (now Science). In the 7 years that one-year postgraduate courses have been availa- ble in the school, only three physicians havc been fully supported to attend by a state govennent and only one by private industry. Most occupational medicine is practised outside industry by physicians untrained in the subject.

Until the annual 13-week courses in occupational hygiene began in the Institute in 1977, trained practitioners in this field in private industry numbered less than five in all Australia. Many more nurses are employed but few are trained in occupational nursing. Only in recent years has any training in ergonomics been a~ai lab le . '~ But almost no engineers, chemists, physicists, architects, industrial designers, psychologists, economists, lawyers, managers and union officials, in whose hands health protection eventually lies, are trained in occupational health appropriate to their responsibilities. Those few occupational health professionals in practice waste much time on fruitless required routines such as medical examinations intended to protect compensa- tion and superannuation funds.

Cost and the community. Community health services are rarely appraised

for their health effectiveness or for their cost effectiveness. Yet the real health priorities - for example, prevention and control of cardiovascular disease, cancer, mental illhealth, self-damaging behaviour (on the road and in dietary, alcohol and tobacco habits), and hazardous inhuman work condi- tions - are starved by diversion of funds to treatment. Of the $8 OOO million spent on "health care" in Australia less than 0.2 per cent goes into research; almost none of this goes into prevention research, and even less into research of occupational disease and injury. The sick return from hospitals to the unchanged environment, including the workplace, which bred their illness. The treatment on which so much is lavished does little to improve health."'

There are both benefits and costs to the community from employee health programs:2i.22 industry subsidises community health care, for example in health education, health screening and nutrition;13 poor community health planning is a load

on industry, in that absence and morbidity of workers are unnecess, -ily high;*' benefits of sickness absence prevention extend far beyond mitigation of overt costs; workers' compensation does not cover the ill health (as distinct from occupational disease and injury) consequences of work; and chronic occupa- tional disease may lead to early death or retirement, or at least to failing efficiency, together with family and community consequences, all of which are costly to society. Indeed much cost of occupational disease and injury falls on the subjects thereof and on society generally, not on the industry moiety of society. Thus, no incentive is placed on industry to internalise these external costs. Incentive at least occurs with compen- sation, after the event.'

Most workers compensation insurance com- panies pay only lip service to prevention, yet prevention costs far less than compensationz3 which in New South Wales in 1975 ran at $295 million. Unreasonable, inequitable inefficiency is incurred in a separate compensation system for workers, with all the bias and perjury and needless incapacity it creates. The National Compensation and Rehabilitation Scheme (the Woodhouse plan)." shelved in 1975, was more equitable and embodied support for prevention, while recognising the inseparability of health into different life compartments, work and other.

The cost of occupational disease and injury is passed on to the community in higher prices, and in involvement of community resources in their investi- gation and control; and community failure to promote health in the worker is costly to industry. For these and other arguments adduced above. it is unproductive to consider occupational health in isolation from com- munity health. Yet while ill-health institutions and community services largely remain ignorant of and thus ignore occupational health, and fail to promote worker health generally, S U @ I S community health manpower could well be retramed to undertake health promotion through the workplace.

Action for Improvement The gloomy picture painted above is only slowly

improving. What can be done to increase the rate? Present disparate halting efforts need coordination and purpose by a national policy and program and by setting of targets. Though modem legislation is necessary, legislation alone will fail without funding, education, occupational health manpower training, research and standards backed by a national institute. The activities called for should be coordinated with activities towards better community health generally. They involve government, management, labour, universities and professions.

Government action Government' activities in occupational health

concern legislation and its implementation, insti- tutes,2S.26 education, training, information, demog- raphy, research, investigation, consultation, stan-

VOLlJME V . NUMBER I . 1981 65 COMMUNITY HEALTH STUDIES

dards, coordination and funding. At both federal and state level, an effective central executive is needed. The executive needs to sit high enough, whether in health or labour ministries. A separate executive independent of both these ministries overcomes present barriers.s Federal-state barriers can come down by establishment of national functions to which states contribute; as, for example; a national institute and a national multipartite federal-state advisory committee, in addition to the existing expert federal- state committee which the Occupational Health Committee of the National Health and Medical Research Council constitutes.

State governments can greatly extend the advis- ory, investigative, laboratory and educational services of their divisions of occupational health. How legislation is enforced and with what compliance can be assessed; relevant government agencies and their policies monitored; support given to information dissemination in industry, unions, the professions and the public; conferences sponsored; options for com- munity organisation of occupational health and safety explored; and so on.

Regionalised specialised consultative, inves- tigatory and laboratory support, particularly in occupational medicine, occupational nursing, occu- pational physiotherapy, occupational hygiene, er- gonomics, occupational health economics and sys- tems, and occupational health psychology,2 should be the state governments’ forte. Governments can foster private initiative and self help in worker health but should also consider whether distribution and use of scarce resources are inefficient, enough that the state should supplement or subsidise services where necessary. Governments can also set an example to private industry by instituting comprehensive health services for their own employees.

bdustry action What option does an employer have? The

employer can make use of a regional government service (scarcely established yet in Australia), or can hire professionals on a salaried or contract or goup basis.’ No group service on the private cooperative contributory model yet operates in Australia. A few trained occupational physicians supply contract ser- vices, each physician attending to several firms, for a variety of (usually limited) purposes.

Only large firms can justify employing an occupational physician fulltime, and only moderately large firms (over 300 employees, say) an occupational nurse fulltime. For most small industries, arranging with a local physician remains the only source of medical advice, an unsatisactory option unless the physician is trained in occupational health.

Whatever governments and other outsiders may do, nothing effective will happen unless management and labour agree on joint consultation and self-help towards worker health and safety. The trend towards management labour colloquy and collective bargain- ing in this field and towards higher union priority is too slow without legislation. Managements have to

assume responsibility for the hazards of their operations, warn employees and monitor their work- places. Unions need informed opinion rather than danger money.

However, small firms lack resources for in- formed action and unorganised labour lacks muscle; both need public assistance.’ Lobbying and legal action by labour and’ public interest groups and activities of the media stimulate industry to get informed, and create community demand for educa- tion, services, standards and resources. The informing of industry is hastened by formal training of managers and union officials. Even so, joint consultation and health and safety committees suffer without profes- sional occupational health input.

Obstacles Ignorance and conflict

Why is Australia so relatively backward in occupational health and safety programs? Lack of knowledge can be only part of the reason. Employers cannot be totally ignorant of the effects of their operations on workers and community. Nor can unions blame ignorance for their failure to act for safer conditions. Though access to information by employers and unions is unequal, most unions can now tap international health data networks.

There is failure to use known information. Industrial secrecy of many employers amounts to paranoia and bars effective monitoring of processes. Cost is another excuse for not monitoring. Employers say that improved health and safety can only be at cost of wage constraint, and that insistence on standards will force closure. They focus on short-term costs and ignore long-term benefits in prevention and in promotion of workers’ health. Unions in turn regard health and safety as management’s responsibility.

Even if a work health service is adopted, merely to employ physician, hygienist and nurse will not guarantee all the advantages claimed. A service succeeds only if comprehensive and preventive; if professional staff are well-trained, dedicated and adequately paid, and have appropriate facilities and direct access to top management; and if the service gets full support from management and unions.p7 A service fails if it does not achieve a delicate balance between employer and employee needs. It may be seen by the worker as a denier of employment, an adversary in workmen’s compensation, and a watch- dog for management. Conflict or misconception of objectives prevents acceptance of a service. Functions are often unstated, as is also the company’s policy towards health and safety. Even where a policy exists, employees’ concurrence is usually unsought.

Industry is not a charitable institution. Its prime concern is to remain solvent. Thus, it rejects services not up to expectations, which may include: efficient, economical operation; benefits related to costs; trained occupational health professionals; guidance on medi- cal policies; mutual benefit to management and employees; contribution to interpersonal relations;

COMMUNITY HEALTH STUDIES 66 VOLUME V , NUMBER I , 1981

responsibility for camers, handlers and users of products and services; and leadership in community environmental health contr01.'~

Why, if they confer such benefits, are effective work health services still so rare? Data on real reasons why employers do provide a service are unobtainable. Ostensible reasons may include: altruism and pater- nalism; keeping up with the Joneses; union demands; control of sickness absence and protection of superannuation and worker's compensation funds; casualty treatment; protection from government or community pressure; medical in-laws of managing director; and recognition of contribution to wellbeing and safety and thus to efficiency and profitability of the company.28

Costing Despite stimulus of the profit motive there are

few Australiandataoncost benefiton whichacasecan be made for establishing an occupational health service. Various reasons are given: accurate cost benefit analysis seems impossible; few benefits are strictly costable; some benefits claimed are contri- buted to by other influences, whose share is inseparable; diversity of practice between and even within organisations dooms comparative analyses; costs are commonly submerged in the welfare or personnel budget (though are nevertheless estima- b1e).21*22.29.30 The employee's benefit (which is to the employer's benefit) and cost (which may be to the employer's benefit) are usually ignored.'

It can be argued, first, that one should not try to cost such benefits as lengthening (even quality) of working life and early identification of disease but rather hold them inestimable and unassailably jus- tified, and, second, that costs are recoupable from the few accountable benefits, the less tangible benefits then constituting a bonus.

Some major savings wrought by occupational health services are claimed in such "accountable" areas as sickness absence, injury occurrence and hospital insurance. Rates of these indices dropped to half those of other industry in North Carolina after a worker health program started in 1950.'* Eich estimated the cost-return ratio tor his large service (staff of 5 2 , looking after 300000 Ford workers in Cologne) to be l:2.3' Savings on individual items alone could amply justify a service financially. The Philips Eindhoven plant claimed a reduction of 40 per cent in absenteeism attributable to their service.3p Even a smaller fraction of the $1500 million that sickness absence was estimated to cost Australian employers in 1970-71 would be worth saving.33

An occupational health program can be examined by profit and loss like any other industrial a~t ivi ty ,~ ' even if some questions are unanswerable in cash terms. Benefits may be hard (accruement understood by the company, clearly identified, allocated to particular service activities, and quantifiable) and soft (the opposite). Hard and soft benefits do not essentially differ; soft benefits become hard as understanding increases.

Though theoretically it is possible to quantitate

benefits, the attempt is not made. Clearly, much more needs to k done to record costs and to estimate savings.

Eflecfiveness Difficultv in resolvine effectiveness thus further ~~

obstructs proiress. Cost-effectiveness analysis, which to economists compares the costs of various ways of reaching some assumed outcome, has to be distin- guished from cost-benefit study, which attempts to express costs and benefits of a procedure in some measurable units, usually money.3s Most medical cost-benefit studies concern clinical procedures such as hysterectomy, cardiac surgery, renal transplants or the CAT scanner,"6 rather than primary or secondary prevention. Strict evaluation demands controlled trials, whose performance is difficult, often expensive and prolonged and beyond resources of all except large industries, in collaboration with universities, or through group industry research units.

Yet another obstacle is uncritical adoption of safety procedures that do not meet occupational hygiene, ergonomic and motivational design. Simi- larly inappropriate unproductive use of occupational health manpower discredits their services. It is wasteful also to hire expensive professionals if they are not given opportunity and resources to do work for which they were trained. However, expensive methods, equipment, and staff do not guarantee effectiveness. Much prevention and health promotion is cheap-choice of method can be selective on an item and cost basis.

Y

Legislation One obstacle is lack of modem legislation. Most

state legislation comprises unpolicearble mandatory minimum standard outmoded factories and shops and other acts and regulations that, have multiplied over the years and that differ in every state. Canada recently found it had over 150 laws and 400 sets of regulations relating to occupational health and safety, adminis- tered by over 70 departments and agencies." In Victoria some years ago about 25 different sets of regulations governed pesticide usage.

Competitive disadvantage (in short term) of spending health money without legal obligation discourages provision of occupational health cover. Compulsion, whether by law or industrial agreement, is necessary if only to remove commercial advantage to unenlightened employers who do not add preven- tion costs to price of p r o d ~ c t . ~ However, compliance with worthy legislation should not create loss. Eventually compliance enhances safety and effi- ciency, and failure to comply may be costly in fines and shutdowns as well as in loss of prestige. Short term competitive disadvantage of legislation extends also to states and countries. If Australian States do not act in concert industries will go where constraints are least.

New legislation will not automatically remove the obstacle of outmoded laws. Of recent world models the United States' Occupational Safety and Health Act of 1970(OSHA) and the British Health and Safety at' Work etc. Act of 1974 (HASAWA) exemplify contrasting styles. OSHA has been a relative failure, being crisis inspired and hazard

VOLUME V , NUMBER I , I981 67 COMMUNITY HEALTH STUDIES

oriented, and based on rigid constraints that have bred an army of uninformed officials and an obstructive adversary system. However, the act has caused introduction of occupational hygiene, preventive medicine, more highly qualified occupational physi- cians, safety into the medical section, alcohol and drug programs, psychological evaluation and coun- selling, computering of records and environmental health prog~ams.~' Moreover the legislation has stimulated community interest in this previously neglected field.

The British HASAW Act based on industry self control of hazard,with government support and oversight, seems more likely to succeed but has not yet been adequately eval~ated.~ '

Legislation is counterproductive if it has an adverse effect on gross national product, small firms, employment and international competitive ability;s and if it isolates worker health control from the community health system. National health insurance legislation can recognise industry's contribution to community health and can encourage prevention and early rehabilitation to work, as in the proposals of the Australian National Compensation and Rehabilitation Commiqion."

There are thus various obstacles in Australia to introduction and effective operation of occupational health services. Some obstacles are major and others unreal or minor. To assert that removal of grosser obstacles is essential to effective progress is to assert the obvious, yet their obvious nature has proved little incentive to removal. More stimulus is needed. Priorities

It is not a matter of knowing what to do about better worker health and safety-that has been known-but of knowing how to persuade people to get it done. If not all that is known can be remedied, certainly not all at once, some priority must be set, as in the European Economic Community, which has fixed successive occupational health target^.^' Be- cause data are scarce on safe exposures, first priority must go to getting information on disease and injury and on their environmental concomitants.

What of new toxic substances and processes which flood industry and the community every year? Should one prohibit till found safe, or use till found dangerous? And should one accept legal (or media) proof rather than scientific proof? In setting standards for environmental agents and criteria for positive health, should one aim at no-effect levels, or accept levels where compensatory adjustment occurs, short of disease? Biological and environmental monitoring for early effects are called for.

Yet needs for worker health are not just prevention of occupational disease and injury, but also improvement of the occupational and community environment," lifestyle and nutrition, humanisation of work,38 and urban improvement,' measures which enhance the length or quality of life.

Even if employers, including governments, would provide a work health cover, they could not for years find the occupational health manpower needed. Nothing much can happen without government support of manpower development, yet no govern- ment appears to have a policy on the subject. Data are lacking on which to base manpower development, though fulltime trained occupational physicians, occupational nurses, occupational hygienists, er- gonomists, occupational health psychologists and safety engineers are so few as to warrant a great increase in all of them. This means first adequate training resources and viable training programs. However, it is no use training all these professionals unless employers are persuaded to employ them.

Inducement is probably best as financial incen- tive to initiate services and other self help activities, and to maintain them effectively and efficiently. A I per cent lien on workers' compensation premiums has been used elsewhere to finance occupational health activities, including research institutes. The New Zealand government has long subsidised work health services to the extent of 60 per cent of staff salaries, in recognition of their contribution to community health.

Unresolved is whether governments should merely locate occupational health professionals in community health regions as statutory outsiders, leaving small industry to make private group arrangements (with government encouragement and support); or whether governments should actively participate in the setting up and conduct of group services, as South Australia has recently done in the Port Adelaide area. Strictly evaluated pilot projects under community health service grants would help resolve the issue. There is place for more than one style, according to local needs.

Strategies are needed for the obstacles identified above. Many activities suggest themselves. The patent priorities of gathering information, new legislation and manpower development have been mentioned. In addition, management and labour and the health professions can be represented on govern- ment occupational health and safety agencies; key government activities can be regrouped; national practices can be developed on hygienic standards, biological and environmental monitoring, engineering methods, diagnostic criteria and notification of disease and injury. These activities are costly; pious statements of concern do no good if not backed by money.

No single approach will be effective. A national commitment to improve worker health and safety, as in the European Economic Community, and a shift in principle and attitude throughout the economy, industry and government, are necessary in Australia. But even if obstacles were removed and planning started now, better worker health and safety Would still be 5 to 10 years ahead.

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