Occupational and Environmental Medicine in the United States: A Proposal to Abolish Workers' Compensation and Reestablish the Public Health Model

Development and maturation of the occupational health services research field in the United States over the past 25 years: Challenges and opportunities for the future

Work is an important social determinant of health; unfortunately, work-related injuries remain prevalent, can have devastating impact on worker health, and can impose heavy economic burdens on workers and society. Occupational health services research (OHSR) underpins occupational health services policy and practice, focusing on health determinants, health services, healthcare delivery, and health systems affecting workers. The field of OHSR has undergone tremendous expansion in both definition and scope over the past 25 years. In this commentary, focusing on the US, we document the historical development and evolution of OHSR as a research field, describe current doctoral-level OHSR training, and discuss challenges and opportunities for the OHSR field. We also propose an updated definition for the OHSR field: Research and evaluation related to the determinants of worker health and well-being; to occupational injury and illness prevention and surveillance; to healthcare, health programs, and health policy affecting workers; and to the organization, access, quality, outcomes, and costs of occupational health services and related health systems. Researchers trained in OHSR are essential contributors to improvements in healthcare, health systems, and policy and programs to improve worker health and productivity, as well as equity and justice in job and employment conditions. We look forward to the continued growth of OHSR as a field and to the expansion of OHSR academic training opportunities.

Work-relatedness of low back pain in nursing personnel: a systematic review

BACKGROUND

Although non-specific low back pain (LBP) is known to be multifactorial, studies from across the globe have documented their higher prevalence in nurses. This systematic review was conducted to ascertain whether this much-documented association constitutes a causal relationship, and whether there is a discernible threshold of exposures associated with this elevated risk.

METHODS

PRISMA guidelines were followed and standard critical appraisal tools were applied. The outcome of interest was non-specific LBP or back injury; exposure was "performing nursing duties." Applicable studies, published in English during 1980-2012, were identified through database searches, screened against preset inclusion/exclusion criteria. Ergonomic assessments of nursing tasks were included along with epidemiological studies. Bradford Hill considerations for causation were utilized as a framework for discussing findings.

FINDINGS

Of 987 studies identified, 89 qualified for inclusion, comprising 21 longitudinal, 36 cross-sectional analytic, 23 descriptive biomechanical/ergonomic, and 9 review studies. Overall studies showed that nursing activities conferred increased risk for, and were associated with back disorders regardless of nursing technique, personal characteristics, and non-work-related factors. Patient handling appears to confer the highest risk, but other nursing duties are also associated with elevated risk, and confound dose-response assessments related to patient handling alone. Associations were strong, consistent, temporally possible, plausible, coherent, and analogous to other exposure-outcomes, with risk estimates ranging from 1·2 to 5·5 depending on definitions. A threshold of nursing activities below which the risk of back disorders is not elevated has not been established.

INTERPRETATION

Notwithstanding the bio-psycho-social nature of LBP, and complexities of studying this area, sufficient evidence exists of a causal relationship between nursing tasks and back disorders to warrant new policies.

Preserving workers' dignity in workers' compensation systems: an international perspective

BACKGROUND

Workers' compensation systems are among the most generous disability insurance systems in North America, although they are also known to be potentially adversarial and may have iatrogenic effects on claimants. This article examines issues to be considered to ensure fair compensation provided in a way that respects the dignity of workers.

METHODS

An overview of the literature on characteristics and effects of workers' compensation systems is followed by an analysis based on classic legal methods, including those of comparative law, complemented with interview data to examine three models of disability compensation.

RESULTS

The first part of the article identifies cross cutting issues to be considered in the examination of the equity of compensation systems and the protection of the dignity of claimants. These include three underpinnings of workers' compensation: the links between a "no-fault" system and the adversarial process, the appropriate use of medical and scientific evidence in the determination of compensability and the application of appropriate measures for promoting return to work. The second part looks at accident compensation in New Zealand, where compensation is available regardless of the cause of the accident, and disability insurance in the Netherlands, where compensation is available regardless of the cause of the disability. It then describes a composite of characteristics favorable to equity drawn from the thirteen workers' compensation systems in Canada.

CONCLUSION

Systems that succeed in reducing opportunities for adversarial interactions and that provide substantive protection could better promote the dignity of claimants.

The European influence on workers' compensation reform in the United States

Workers' compensation law in the United States is derived from European models of social insurance introduced in Germany and in England. These two concepts of workers' compensation are found today in the federal and state workers' compensation programs in the United States. All reform proposals in the United States are influenced by the European experience with workers' compensation. In 2006, a reform proposal termed the Public Health Model was made that would abolish the workers' compensation system, and in its place adopt a national disability insurance system for all injuries and illnesses. In the public health model, health and safety professionals would work primarily in public health agencies. The public health model eliminates the physician from any role other than that of privately consulting with the patient and offering advice solely to the patient. The Public Health Model is strongly influenced by the European success with physician consultation with industry and labor.

Integrating environmental health into medical education

Although environmental factors contribute to more than 25% of all global disease, and toxic agents ranked fifth in underlying causes of U.S. deaths in 2000, environmental medicine education is largely omitted in the continuum of U.S. medical education. The paucity of specialists trained in environmental medicine (i.e., occupational medicine and other preventive medicine specialties and subspecialties), coupled with the lack of adequate general medical education on how to prevent, diagnose, refer, or treat patients exposed to hazardous substances in the environment, contributes to lost opportunities for primary prevention or early intervention to mitigate or minimize environmentally related disease burden. Survey findings of graduating medical students over the past few years have identified environmental health as a medical school topic area that can be improved. This article reflects a panel presentation on the challenge of including environmental health in general medical education. It was given at the 2010 "Patients and Populations: Public Health in Medical Education" conference cosponsored by the CDC and the American Association of Medical Colleges. A variety of educational strategies, models, and educational resources are presented that illustrate how recommended competency-based environmental health content can be integrated into medical education to better prepare medical students and physicians without specialized expertise in environmental medicine to provide or facilitate environmental preventive or curative patient care.

Workers' Compensation reform requires an agenda … and a strategy

In a response to Joseph LaDou's article in this issue, Michael Lax focuses on the broader issues. If we are agreed that we need significant change in Workers' Compensation, what should the nature of those changes be? Of equal importance to knowing what we want is the development of a strategy for how to get there. Without an effective strategy, we will be consigned to discussing the issues again and again, developing attractive alternatives that live only on paper or at conferences.

Workers' Compensation in the United States: cost shifting and inequities in a dysfunctional system

Workers' Compensation is a far more significant expense to the U. S. economy than is commonly recognized. The total annual cost of the health care and disability benefits in the United States is at least $300 billion. The health care costs shifted by employers to Medicare/Medicaid and the disability costs shifted to the Social Security system far exceed the total costs of all the state Workers' Compensation programs. Most of the responsibility for compensating disabled workers now resides in the federal government, not in the state system. Federal funding of Workers' Compensation is at least four times that of state programs. State and federal Workers' Compensation programs are a costly and inefficient segment of health care that should be included in any consideration of health care reform.

Would a "one-handed" scientist lack rigor? How scientists discuss the work-relatedness of musculoskeletal disorders in formal and informal communications

BACKGROUND

When research results concerning occupational health are expressed ambiguously, compensation and prevention can be affected. This study examined the language used by scientists to discuss the relation between work and musculoskeletal disorders (MSDs).

METHODS

Language regarding work and MSDs in twenty articles from two peer-reviewed journals was compared with that in 94 messages on MSDs posted by published scientists to an internet list.

RESULTS

Almost all the articles found some link between work and MSDs. However, few articles expressed belief in such a link unambiguously in the title or abstract, and language on links was often hard for a non-health scientist to interpret. Language and methods gave excess weight to negative results. On the listserve, many scientists expressed unambiguous views on linkages between work and MSDs.

CONCLUSIONS

Scientists must express their opinions more forthrightly if they wish their results to be used to favour prevention and to foster access to workers' compensation.

Cancer and reproductive risks in the semiconductor industry

Although many reproductive toxicants and carcinogens are used in the manufacture of semiconductor chips, and worrisome findings have been reported, no broad epidemiologic study has been conducted to define possible risks in a comprehensive way. With few exceptions, the American semiconductor industry has not supported access for independent studies. Older technologies are exported to newly industrialized countries as newer technologies are installed in Japan, the United States, and Europe. Thus there is particular concern about the many workers, mostly in countries that are still industrializing, who have jobs that use chemicals, technologies, and equipment that are no longer in use in developed countries. Since most countries lack cancer registries and have inadequate reproductive and cancer reporting mechanisms, industry efforts to control exposures to carcinogens are of particular importance. Government agencies, the courts, industry, publishers, and academia, on occasion, collude to ignore or to downplay the importance of occupational diseases. Examples of how this happens in the semiconductor industry are presented.

Occupational medicine and the construction of "difficult reputations"

The creation of "difficult reputations" is a collective act of disparagement often undertaken to diminish the influence of the target individual or group for political reasons. This process can be observed in efforts to discredit the field of occupational medicine and the American College of Occupational and Environmental Medicine (ACOEM) by revising its history. Examples are given from Draper's 'The Company Doctor: Risk, Responsibility, and Corporate Professionalism' and LaDou, in which new sources of historical information do not support the allegations or impressions conveyed. This tendency is inimical to progress in occupational health in general and may be highly destructive to the field if not recognized and discouraged.