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17. Occupational Safely and Health For some of the nearly 104 million men and women in our nation's work force, Living is hazardous to your health. Working is even more hazardous to your health. (#337) An estimated 10 million traumatic injuries occur on the job each year. In addition, about 400,000 workers become ill from exposure to hazardous substances in the workplace, and some 100,000 die prematurely from this exposure." Many of the 43 testifiers on occupational health issues call for improved or stepped-up cooperative efforts between public and private sectors to help achieve the nation's occupational safety and health objectives. Stronger regulatory measures and, equally important, stronger and more consistent implementa- tion of existing regulations are high on many wit- nesses' agenda. The Occupational Safety and Health Administration (OSHA), the Food and Drug Admini- stration, and the Environmental Protection Agency, along with numerous state agencies, are seen as the governmental groups with the greatest responsibility for improving occupational safety and health in the next decade. However, many testifiers recognize that these groups can be only as effective as their funding allows. A Detroit Department of Health spokesperson identifies several trends that will have some impact on the year 2000 objectives, Including continued cigarette smoking, which greatly magnifies the effects of toxic agents; excessive government regulatory programs that have led to an inhibition of new technologies for hazardous waste treatment; more women in the workplace, which has led to the emerging importance of possible mutagens and teratogens; and illegal dumping of toxic wastes, which has led to an increase in the probability of contact with toxic agents. (#210J Among the worker protection issues discussed were toxic agent exposure, injury control, reproductive effects (for both women and men), and noise reduc- tion. Human immunodeficiency virus (HIV) infections and AIDS were identified as an important occupa- tional health focus for the year 2000, especially for health care workers and law enforcement officers. A compelling case was made for directing some objec- tives to the special plight of farm workers, including migrant workers. Farmers tend to work alone and Do not have a collective voicer to represent their complaints to equipment manufacturers or to govern- ment regulatory agencies. (#540) They are excluded from many laws and regulations such as some state workers' compensation laws. Other occupations singled out for special attention were construction workers, fire fighters, working children, and retired workers who could benefit from improved notification procedures regarding hazards inherent in their former jobs. The need for more research into both the cause and the effects of occupationally related diseases, and the need for better data collection and analysis, were common themes throughout much of the testimony. Testimony on occupational safety and health issues covers two separate but interrelated issues: the pro- tection of workers from injuries and illness attribut- able to the workplace itself, and the workplace as a site for health promotion and disease prevention activities. This chapter deals primarily with the former; the latter issue is dealt with in more detail in Chapter 9. The first section of this chapter examines the spe- cial needs of particular groups of workers: agricul- tural workers, health professionals, and so on. The second section highlights some particular problems to be addressed in workplace protection: toxic agents, injury control, etc. The third section describes briefly the testimony on the workplace as a site for health promotion and disease prevention activities. The final section deals with implementation issues, including surveillance and manpower needs. GROUPS WITH PARTICULAR NEEDS Several witnesses addressed specific occupations at high risk for particular problems, including agricul- tural workers, health care workers, construction workers, law enforcement officers, and fire fighters. Others were concerned about those who have retired from occupations that may have exposed them to risk and about children who are employed. Agricultural Workers David Pratt of the New York Center for Agricultural Medicine and Health, at Bassett Hospital in New Occupational Safer and Health 141

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York, reports that agriculture has become the most dangerous occupation in the United States. Individuals who work in agriculture are injured or killed at a rate that is substantially higher than the mean for all U.S. workers. Pratt sees a problem of social equity here. Why do these men and women not deserve the same safe working conditions on the job as other Americans? How can we allow those who produce the food we eat to finance it by squan- dering human capital? Why should they pay with their lives for the right to work? (#540) A number of testifiers, such as Mary Ellis of the Iowa Department of Public Health, believe that the 1990 Objectives focused primarily on industrial hazards and injury control with little attention to farm-related injuries and hazards. (#569J In Colora- do, rural areas have a higher occupational mortality rate than do urban areas, according to William Marine of the University of Colorado School of Medi- cine; from 1982 to 1984, for example, 20 percent of the work force employed in rural areas suffered 48 percent of the occupational injury deaths in the state.2 (#382) Chuck Stout, Director of the Colorado Migrant Program in the Colorado Department of Health, is particularly concerned about the conditions under which migrant workers labor. He cites a lack of access to potable water, toilets, and hand-washing facilities as serious and common problems in such settings. Although OSHA recently (under court order) set standards of basic hygiene conditions for agricultural workers, Stout charges that the agency has not developed mechanisms for inspection, enforce- ment, handling of complaints, or informing growers of their new responsibilities. nAmerica's farm workers still suffer from diseases that may be controlled very easily by the application of the most basic sanitation measures that have been taken for granted for de- cades by the rest of this country's labor forces." #710) Paul Monahan of the Yakima Valley Farm Workers Clinic in Washington State recommends the identification and elimination of legislative and regulatory policies that discriminate against farm workers. Exclusionary features of many laws and regulations, he says, "have an adverse impact on the health of farm workers." For example, some 20 states provide no protection for farm workers under their workers' compensation laws, and another 15 states 142 Healthy People 2000: Citizens Chart the Course protect only restricted categories of temporary workers. Unemployment benefits also are limited for workers on small farms, according to Monahan; in the off season, medical care for these workers is often inaccessible because of the cost. (~330J Health Care Workers The American Society of Hospital Pharmacists is concerned with the frequent use of pytotoxic and hazardous substances in health care settings, with a concomitant potential for toxicity to pharmacists, nurses, and other health care personnel. The society's Director of Clinical Affairs, Marie Smith, says that employees who come in contact with such materials should be made more aware and should adhere more strictly to procedures for the safe handling of these substances. (#574J William Wilkinson of the University of Washington addresses the risk of HIV infection to health care workers: needlestick injuries and handling blood or blood products are the primary sources of HIV infec- tion for health workers. Wilkinson calls for more research to determine the level of risk and for more education of workers about research findings. (#319) Similarly, the American Association of Occupational Health Nurses (AAOHN) points to hepatitis B as a major infectious occupational health hazard in the health care industry. They cite unpublished data from the Centers for Disease Control (CDC) indicating that each year 500-600 health care workers whose jobs involve exposure to blood are hospitalized with acute hepatitis B and that more than 200 deaths occur among health workers from this cause. Use of the universal barrier precautions recommended by the CDC should greatly diminish the risk of infection from blood-borne pathogens, including both hepatitis B and the HIV virus. In addition, the AAOHN indicates that significant numbers of at-risk health workers do not take advantage of the available vac- cine against hepatitis B. (#558) Other Hazardous Occupations Several occupations, including construction, law enforcement, and fine fighting, require workers to undertake tasks on a daily basis that are both physi- cally and emotionally hazardous. The Laborers' International Union of North America (LIUNA) reports that construction workers suffer significantly more injuries, fatalities, and diseases than other workers. At the same time,

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according to LIUNA, federal government efforts to protect construction workers have been lagging. The union believes that specific objectives should be established to eliminate the differential in injury and illness rates between these workers and others. (#586) Some construction workers also have been exposed to very high levels of lead. For example, according to Harvey Collins of the California Depart- mer~t of Health Services, well over 3,000 individuals in that state are reported each year to have blood lead levels higher than 40 milligrams per deciliter. It is suggested that these workers be included in the standards for general workplace exposure to lead. (#783) Fred Toler, Executive Director of the Texas Com- mission on Law Enforcement Officer Standards and Education, is concerned with the health of law enforcement workers. People frequently view the felon as the greatest threat to the law enforcement officer's health and safety, when he or she actually is much more likely to die from heart disease, stroke, automobile accident, cancer, or suicide," he says. Law enforcement officers are widely perceived as heavier users of tobacco than many other professionals, and Toler calls for research to determine the accuracy of this perception and to identify approaches that would reduce such use. Law officers often are less physically fit than is good for their health, which makes them more susceptible to stress-related illnesses that may result in premature death or a reduced quality of life. Toler recommends training for this group in coping and stress reduction to help reduce the incidence of suicide, in handling hazardous substances, and in proper techniques for protecting themselves against AIDS and other contagious diseases. (~297) Fire fighters, too, face high-stress situations daily and encounter work-related hazards such as heat stress, threat of physical injury, and exposure to toxic gases emitted from the combustion of synthetic materials in fires. (#108) Retired Workers Rebecca Richards of the North Woods Health Careers Consortium in Michigan notes that a number of the 1990 Objectives relate to identification, notification, and follow-up of workers at risk "while employedn; she suggests that this be extended to retirees as well. (~183) Because retired workers may have been ex- posed to materials capable of inducing diseases of long latency, LIUNA also urges that retirees be included in any programs of information and educa tion about occupational risks. Prevention-oriented health programs aimed at retirees, LIUNA notes, may mitigate the adverse health effects attributable to prior workplace exposures and help workers with work-related disease to avoid further disability and complications. (#586) Working Children The health and safety of children who work on family farms, in family businesses, or in other parts of the economy not covered by federal requirements for occupational safety and health are also of concern to LIUNN Child labor under the age of 14 is legally prohibited in the United States and should be elimi- nated in those segments of the economy where it still exists. At a minimum, LIUNA suggests a goal to eradicate job-related injuries and illnesses in children under age 14, and states that there were hundreds of such claims under workers' compensation in a recent year. (#586J WORKPLACE PROTECTION ISSUES From among the many specific workplace protection issues, most witnesses focused on exposure to toxic agents. Some, however, did address injury control, reproductive effects, and noise. Occupationally re- lated dermatitis was also noted as among the most commonly occurring illnesses in the workplace. (#569) Toxic Agent Exposure Robert Spear of the University of California, Berkeley submits that the greatest risks to health from exposure to chemical agents occur in the workplace, with rare exceptions involving accidental releases to the general environment. Therefore, toxic agent con- trol in the workplace should be emphasized. We must face the fact that, whatever the toxic hazard, the odds are very high that workers will or have experi- enced it first, and it is only sensible to have a strong preventive program focussed on the occupational envi- ronment." (#275) George Gaines, representing the Detroit Depart- ment of Health, reports that toxic agents that produce acute or chronic illness are not new to the workplace, but the rapid growth of new technologies and new, potentially toxic, substances has led to a situation in which "what we do know continues to be far outweighed by what we do not know concerning all of Occupational Safely and Health 143

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the effects produced by toxic agents." He further notes that, although the specific effects of some individual materials are known, very little information is available about the synergistic effects of toxic agents on workers. It has become clear, for example, that smoking tends to magnitr the effects of other toxic agents. Gaines recommends the increased use of multiphasic health testing to aid in identifying possible and multiple effects of toxic agents. (#210) Employee right-to-know programs are vital in instructing employees about the procedures for handling a tone substance and the actions to take in the event of accident with such a substance. (#210) Bernard Turnock of the Illinois Department of Public Health says that worker right-to-know legislation should be extended to include on-thejob instruction about occupational hazards. He feels that it is unreasonable to expect a prospective employee to research workplace hazards, and applicants believe that asking too many questions may result in being denied a job. (~215) Lawrence Kenney, President of the Washington State Labor Council, AFL-CIO, reports that millions of workers are exposed to neurotoxic agents In the workplace and that many die or are disabled as a result of this exposure. (~345) Raymond Singer of the Mount Sinai School of Medicine notes that the effects of neuroto~city are subtle and when symptoms caused by exposure to these agents appear, they may be attributed to "normal aging. Few U.S. workers are currently monitored for signs of neurotoxicity, although most of those who work with toxic chemicals are exposed to neurotoxic substances; if toxicity is detected early, permanent brain and nerve damage can be prevented, according to Singer. (#638J Kenney believes that worker education is the most effective means of reducing the rate of occupational disease and injury. (~345) Turnock suggests a revision of a 1990 objective to reduce occupational lung diseases because "assessing [achievement of] the objectives in 1990 might create a false sense of security. The current objective calls for no new cases of asbestosis, byssinosis, silicosis, and coal worker's pneumoconiosis by 1990. Because of the long latency period between exposure and devel- opment of the disease, Turnock believes that many cases would not be detectable by 1990. He suggests that the deadline for assessing this objective should be 2010. (~215) 144 Healthy People 2000: Citizens Chart the Course Injury Control Jeanette Winfree, representing the American Physical Therapy Association, suggests that ergonomically designed jobs can prevent injuries. She reports, however, that employers are often reluctant to rede- sign tasks due to the cost, although Data are begin- ning to reveal ergonomically-designed jobs do prevent costly injuries and allow the worker a safe environ- ment.n (#313) Michael Jarrett, Commissioner of the South Carolina Department of Health and Environmental Control, comments that as the work force ages, occupational injuries or days lost due to injury may increase. He suggests that specific objectives about occupational injuries to those over 50 may be appropriate. (#108) Many industries report that the greatest number of work days lost are due to back complaints, according to Marilyn Gossman and Jane Walter of the American Physical Therapy Association. They suggest that fitness programs could serve as a preventive mea- sure against these injuries. (~248) Kenneth Kizer of the California Department of Health Services reports that carpal tunnel syndrome "is second only to back injury as a cause of lost time from repetitive motion injuriesH and suggests that model reporting systems and an intervention system be expanded to 50 percent of the counties in the country. (#591) Reproductive Effects Several witnesses addressed the occupational effects on reproductive health. According to the Centers for Disease Control, at least 50 chemicals widely used in industry have been shown to impair reproductive function in animals; these chemicals include heavy metals such as lead and cadmium, glycol ethers, organohalide pesticides, and organic solvents. Studies have shown increased rates of spontaneous abortion among laboratory and chemical workers and other workers exposed to lead, ethylene oxide, and anesthetic gases.3 Joan Berlin and others from the American Civil Liberties Union Foundation suggest that occupational exposures may account in part for the large propor- tion of infertility, miscarriages, infant mortality, and birth defects that are labeled as idiopathic or "cause unknown." They underscore the importance of look

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ing at reproductive effects in men as well as women. "The practice of using selective data to ban one group of employees, always women, from an occupational hazard that is deleterious to the health of both sexes creates only the illusion of workplace safe. (~617) Noise Reduction The American Occupational Medical Association (AOMA) reports that many U.S. production workers have been exposed to high levels of noise and, as a result, have varying degrees of hearing impairment. In the future, noisy industries such as steel mills, machine shops, and foundries will make up a smaller proportion of jobs in the country; because of this fact, as well as improved technology, acoustic engineering, and better enforcement of laws, a lower rate of hearing loss from such causes is to be expected. (~071) THE WORKPLACE AS A SITE FOR HEALTH PROMOTION AND DISEASE PREVENTION ACTIVITIES When programs are properly designed, says Leon Warshaw of the New York Business Group on Health, the workplace is a uniquely advantageous site for health promotion; employers may undertake such programs to improve employees' well-being, morale, and work performance, as well as to minimize the company's costs for health services. (~448J Jill F-loberg of Olympia Physical Therapy Service is less certain about the economic value of worksite preven- tion programs. Although there are some data availa- ble, follow-up studies of in-house programs are as yet inconclusive in showing long-term decreases in health- related time loss and injury costs." (#317J Pat Joseph, a representative of the American Association of Occupational Health Nurses, says that the degree of voluntary participation in workplace health promotion programs is often higher than in similar community-based programs. According to Joseph, the increased participation is due to employee con- venience, the presumption that programs are of good quality if they are sponsored by the employer, the employees' viewing the programs as a benefit, and the availability of social support for a desired change in behavior. (#385) Any objectives requiring more oc- cupational safety and health services from businesses should also recognize that smaller businesses may need "ready access" to resources in order to provide the services, according to Dorothea Johnson of AT&T. f#450) Workplace health promotion and disease prevention are discussed in greater detail in Chapter 9. IMPLEMENTATION The AOMA stresses the importance of a collaborative effort between government and the private sector toward reaching occupational health goals. This effort should indude jointly designed and sponsored edllca- tional programs, plant health and safety committees, and jointly designed and operated employee assistance programs. (#071) noberg, who represented the American Physical Therapy Association, would like to see the development of a labor-management relation- ship that removes health and safety issues from the politics of contract negotiation. (~317) Givens and Floberg agree that, in general, rewards are more effective than punitive measures. Thus, the AOMA wants to see rewards that encourage win-win attitudes between management and labor applied to the development and implementation of environmental hazard controls. (#071) Floberg specifically suggests that financial incentives through insurance or tax measures be used to reward companies and individuals for successful prevention and promotion programs. (#317J Harvey Checkoway of the University of Washington suggests that the primary targets for occupational safen,r and health objectives be those diseases and injuries that have unambiguous occupational etiologies and are truly preventable. He urges concentration on selecting objectives that can be met realistically; developing methods for monitoring the occurrence of occupational diseases and injuries; and developing approaches for remediation of unacceptable risks. Among the conditions or diseases that should be monitored, he includes occupational asthma, lead poisoning, silicosis, carpal tunnel syndrome, noise- induced hearing loss, disabling injuries at the work- site, asbestosis, byssinosis, coal workers' pneumo- coniosis, occupational hepatitis, solvent-induced encephalopathy, and peripheral nellropathy. (#245) Surveillance A number of people testified about the inadequacy of statistics on occupational health, which LIUNA refers to as "the failure to recognize the woeful inadequacy of occupational injury and illness statistics." The union cites a 1987 National Academy of Sciences Occupational Safety and Health 145

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report in support of its claim that the United States does not have a timely, accurate assessment of mor- bidity or mortality associated with job-related injuries, occupational diseases, and work-related disorders.4 (#586) Joseph suggests a standardized, ongoing occupation- al health hazard injury and illness coding system. (#385J Checkoway would establish regional centers for disease surveillance and research, because ~workers' compensation claims, hospital discharge summaries and death certificates vary in quality and quantity of information" and "some of the important adverse health events occur in small workplaces where exposures often are not monitored and may be excessive." With good regional centers, nationwide monitoring is possible, and surveillance should then be supplemented by specifically designed industrial hygiene and safety remediation programs, he says. f#245) Marine suggests a computerized linkage of state workers' compensation data with state death certificate files to provide a more complete count of fatalities than either source alone. (~382) Ellis recommends the expansion of statistical, surveillance, and epidemiological studies related to farm injuries and diseases. She also advocates the use of hospital discharge data-including E-coding and information about a patient's occupation and industry for occupa- tional illness and injury surveillance. (#569) This type of information tracking requires that health workers take occupational histories and correctly interpret their findings. Kizer cautions, "There is no REFERENCES easy way to determine whether health care providers currently do this." (#591 J Manpower Kenney urges increased emphasis in medical schools on the identification of occupational diseases. Many workers' compensation claims go unfired each year, he says, because neither the doctor nor the patient can identify the cause of a particular condition. (~345) Steven Levine of the University of Michigan also calls for more training In occupational fields. He advo- cates developing an adequate supply of qualified personnel to carry out the purposes of the Occupa- tional Safety and Health Act by maintaining and expanding the Educational Resource Centers program, which trains various occupational safety and health specialists. (~392) Bernard Goldstein of the Uni- versi~ of Medicine and Dentistry of New Jersey calls for more trained public health professionals and better geographic distribution and outreach of existing graduate-training facilities in public health. (#625) Wilkinson would like to see the number of occupa- tional health professionals at industry sites increased and suggests that occupational health nurses assume the majority of these positions. (#319) The AAOHN agrees that occupational health nurses are well suited to be worksite health promotion pro- fessionals and recommends that every state health department hire at least one occupational health nurse as a consultant to local industries. (#558) 1. U.S. Department of Health and Human Services: The 1990 Health Objectives for the Nation: A Midcourse Review. Washington, D.C.: U.S. Government Printing Office, November 1986 2. Colorado Department of Health, Health Statistics Section: Colorado Population-based Occupational Injury and Fatality Surveillance System Report, 1982-1984. Denver, n.d. 3. Centers for Disease Control: Leading work-related diseases and injuries-United States. Morbid Mortal Wkly Rep 34~35~:537-540, 1985 4. Pollack ES, Keimig DG (Eds.~: Counting Injuries and Illnesses in the Workplace: Proposals for a Better System. Washington D.C.: National Academy Press, 1987 TESTIFIERS CITED IN CHAPTER 17 071 Givens, Austin; American Occupational Medical Association 108 Jarrett, Michael; South Carolina Department of Health and Environmental Control 183 Richards, Rebecca; North Woods Health Careers Consortium (Wausau, Wisconsin) 146 Healthy People 2000: Citizens Chart the Course

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210 Gaines, George; Detroit Department of Health 215 Turnock, Bernard; Illinois Department of Public Health 245 Checkoway, Haney; University of Washington 248 Gossman, Marilyn and Walter, Jane; American Physical Therapy Association 275 Spear, Robert; University of California, Berkeley 297 Toter, Fred; Texas Commission on Law Enforcement Officer Standards and Education 313 Winfree, Jeanette; Physical Therapy Services (Galveston, Texas) 317 Floberg, Jill; Olympia Physical Therapy Service 319 Wilkinson, William; University of Washington 330 Monahan, Paul; Yakima Valley Farm Workers Clinic (Toppenish, Washington) 337 Sugarman, Jute; Washington State Department of Social and Health Services 345 Kenney, Lawrence; Washington State Labor Council, AFL-CIO 382 Marine, William; University of Colorado Health Sciences Center 385 Joseph, Pat; United States Air Force, Lowly Air Force Base, Denver 392 Levine, Steven; University of Michigan 448 Warshaw, Leon; New York Business Group on Health 450 Johnson, Dorothea; AT&T 540 Pratt, David; MaIy Imogene Bassett Hospital (Cooperstown, New York) 558 Babbitz, Matilda; American Association of Occupational Health Nurses 569 Ellis, Mary; Iowa Department of Public Health 574 Smith, Marie; American Society of Hospital Pharmacists 586 Fosco, Angelo; Laborers' International Union of North America 591 Kizer, Kenneth; California Department of Health Services 617 Berlin, Joan and Taras, Ana; American Civil Liberties Union Foundation, and Stellman, Jeanne; Columbia University 625 Goldstein, Bernard; University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School 638 Singer, Raymond; Mount Sinai School of Medicine 710 Stout, Chuck; Colorado Department of Health 783 Collins, Harvey; California Department of Health Services Occupational Safety and Health 147