Overview
Economic activity, as expressed by per capita gross national product (GNP), differs substantially between developing countries and industrialized countries. According to a ranking by the World Bank, the GNP of the country heading the list is approximately fifty times that of the country at the bottom. The share of the world’s total GNP by the member countries of the Organization for Economic Co-operation and Development (OECD) is almost 20%.
OECD member countries account for almost one-half the world’s total energy consumption. Carbon dioxide emissions from the top three countries account for 50% of the earth’s total burden; these countries are responsible for major global pollution problems. However, since the two oil crises in 1973 and 1978, industrialized countries have been making efforts to save energy by replacing old processes with more efficient types. Simultaneously, heavy industries consuming much energy and involving much heavy labour and exposure to hazardous or dangerous work have been moving from these countries to less industrialized countries. Thus, the consumption of energy in developing countries will increase in the next decade and, as this occurs, problems related to environmental pollution and occupational health and safety are expected to become more serious.
In the course of industrialization, many countries experienced ageing of the population. In the major industrialized nations, those 65 years or older account for 10 to 15% of the total population. This is a significantly higher proportion than that of developing countries.
This disparity reflects the lower reproduction rate and lower mortality rates in the industrialized countries. For example, the reproduction rate in industrialized countries is less than 2%, whereas the highest rates, more than 5%, are seen in African and Middle Eastern countries and 3% or more is common in many developing countries. The increased proportion of female workers, ranging from 35 to 50% of the work force in industrialized countries (it is usually under 30% in less industrialized countries), may be related to the decreased number of children.
Greater access to higher education is associated with a higher proportion of professional workers. This is another significant disparity between industrialized and developing countries. In the latter, the proportion of professional workers has never exceeded 5%, a figure in sharp contrast to the Nordic countries, where it ranges from 20 to 30%. The other European and the North American countries fall in between, with professionals making up more than 10% of the workforce. Industrialization depends primarily on research and development, work that is associated more with excess stress or strain in contrast to the physical hazards characteristic of much of the work in developing countries.
Current Status of Occupational Health and Safety
The economic growth and the changes in the structure of major industries in many industrializing countries has been associated with reduced exposure to hazardous chemicals, both in terms of the levels of exposure and the numbers of workers exposed. Consequently, instances of acute intoxication as well as typical occupational diseases are diminishing. However, the delayed or chronic effects due to exposures many years previously (e.g., pneumoconiosis and occupational cancer) are still seen even in the most industrialized countries.
At the same time, technical innovations have introduced the use of many newly created chemicals into industrial processes. In December, 1982, to guard against the hazards presented by such new chemicals, OECD adopted an international recommendation on a Minimum Premarketing Set of Data for Safety.
Meanwhile, life in the workplace and in the community have continued to become more stressful than ever. The proportions of troubled workers with problems related to or resulting in alcohol and/or drug abuse and absenteeism have been on the rise in many industrialized countries.
Work injuries have been decreasing in many industrialized countries largely due to progress in safety measures at work and the extensive introduction of automated processes and equipment. The reduction of the absolute number of workers engaging in more dangerous work due to the change of industrial structure from heavy to light industry is also an important factor in this decrease. The number of workers killed in work accidents in Japan decreased from 3,725 in 1975 to 2,348 in 1995. However, analysis of the time trend indicates that the rate of decrease has been slowing over the past ten years. The incidence of work injuries in Japan (including fatal cases) fell from 4.77 per one million working hours in 1975 to 1.88 in 1995; a rather slower decrease was seen in the years 1989 to 1995. This bottoming out of the trend toward reductions in industrial accidents has also been seen in some other industrialized countries; for example, the frequency of work injuries in the United States has not improved for more than 40 years. In part, this reflects the replacement of classic work accidents which can be prevented by various safety measures, by the new types of accidents caused by the introduction of automated machines in these countries.
The ILO Convention No. 161 adopted in 1985 has provided an important standard for occupational health services. Even though its scope includes both developing and developed countries, its fundamental concepts are based on existing programmes and experience in industrialized countries.
The basic framework of an occupational health service system of a given country is generally described in legislation. There are two major types. One is represented by the United States and the United Kingdom, in which the legislation stipulates only the standards to be satisfied. Achievement of the goals is left to the employers, with the government providing information and technical assistance on request. Verifying compliance with the standards is a major administrative responsibility.
The second type is represented by the legislation of France, which not only prescribes the goals but also details the procedures for reaching them. It requires employers to provide specialized occupational health services to the employees, using physicians who have become certified specialists, and it requires service institutions to offer such services. It specifies the number of workers to be covered by the appointed occupational physician: in worksites without a hazardous environment more than 3,000 workers can be covered by a single physician, whereas the number is smaller for those exposed to defined hazards.
Specialists working in the occupational health setting are expanding their target fields in the industrialized countries. Physicians have become more specialized in preventive and health management than ever before. In addition, occupational health nurses, industrial hygienists, physiotherapists and psychologists are playing important roles in these countries. Industrial hygienists are popular in the United States, while environment measurement specialists are much more common in Japan. Occupational physiotherapists are rather specific to the Nordic countries. Thus, there are some differences in the kind and distribution of existing specialists by region.
Establishments with more than several thousand workers usually have their own independent occupational health service organization. Employment of specialists including those other than occupational physicians, and provision of the minimum facilities necessary to provide comprehensive occupational health services, are generally feasible only when the size of the workforce exceeds that level. Provision of occupational health services for small establishments, especially for those with only a few workers, is another matter. Even in many industrialized countries, occupational health service organizations for smaller-scale establishments have not yet been established in a systematic manner. France and some other European countries have legislation articulating minimum requirements for the facilities and services to be provided by occupational health service organizations, and each enterprise without its own service is required to contract with one such organization to provide the workers with the prescribed occupational health services.
In some industrialized countries, the content of the occupational health programme is focused mainly on preventive rather than on curative services, but this is often a matter of debate. In general, countries with a comprehensive community health service system tend to limit the area to be covered by the occupational health programme and regard treatment as a discipline of community medicine.
The question of whether periodic health check-ups should be provided for the ordinary worker is another matter of debate. Despite the view held by some that check-ups involving general health screening have not proven to be beneficial, Japan is one of a number of countries in which a requirement that such health examinations be offered to employees has been imposed on employers. Extensive follow-up, including continuing health education and promotion, is strongly recommended in such programmes, and longitudinal record keeping on an individual basis is considered indispensable for achieving its goals. Evaluation of such programmes requires long-term follow-up.
Insurance systems covering medical care and compensation for workers involved in work-related injuries or diseases are found in almost all industrialized countries. However, there is much variation among these systems with regard to management, coverage, premium payment, types of benefits, extent of the commitment to prevention, and the availability of technical support. In the United States, the system is independent in each state, and private insurance companies play a large role, whereas in France the system is managed completely by the government and incorporated extensively into the occupational health administration. Specialists working for the insurance system often play an important part in technical assistance for the prevention of occupational accidents and diseases.
Many countries provide a post-graduate educational system as well as residency training courses in occupational health. The doctorate is usually the highest academic degree in occupational health, but specialist qualification systems also exist.
The schools of public health play an important part in the education and training of occupational health experts in the United States. Twenty-two of the 24 accredited schools provided occupational health programmes in 1992: 13 provided programmes in occupational medicine and 19 had programmes in industrial hygiene. The occupational health courses offered by these schools do not necessarily lead to an academic degree, but they are closely related to the accreditation of specialists in that they are among the qualifications needed to qualify for the examinations that must be passed in order to become a diplomat of one of the boards of specialists in occupational health.
The Educational Resource Program (ERC), funded by the National Institute for Occupational Safety and Health (NIOSH), has been supporting residency programmes at these schools. The ERC has designated 15 schools as regional centres for the training of occupational health professionals.
It is often difficult to arrange education and training in occupational health for physicians and other health professionals who are already involved in primary health care services in the community. A variety of distance-learning methods have been developed in some countries—for example, a correspondence course in the United Kingdom and a telephone communication course in New Zealand, both of which have received good evaluations.
Factors Influencing Occupational Health and Safety
Prevention at the primary, secondary and tertiary levels should be a basic aim of the occupational safety and health programme. Primary prevention through industrial hygiene has been highly successful in decreasing the risk of occupational disease. However, once a level sufficiently below the permissible standard has been reached, this approach becomes less effective, especially when cost/benefit is taken into consideration.
The next step in primary prevention involves biological monitoring, focusing on differences in individual exposure. Individual susceptibility is also important at this stage. Determination of fitness to work and allocation of reasonable numbers of workers to particular operations are receiving increasing attention. Ergonomics and various mental health techniques to reduce stress at work represent other indispensable adjuncts in this stage.
The goal of preventing worksite exposures to hazards has been gradually overshadowed by that of health promotion. The final goal is to establish self-management of health. Health education to achieve this end is regarded as a major area to be covered by specialists. The Japanese government has launched a health promotion programme entitled “Total Health Promotion Plan”, in which the training of specialists and financial support for each worksite programme are major components.
In most industrialized countries, labour unions play an important part in occupational health and safety efforts from the central to peripheral levels. In many European countries union representatives are officially invited to be members of committees responsible for deciding the basic administrative directions of the programme. The mode of labour commitment in Japan and the United States is indirect, while the government ministry or department of labour wields administrative power.
Many industrialized countries have a workforce which comes from outside the country both officially and unofficially. There are various problems presented by these immigrant workers, including language, ethnic and cultural barriers, educational level, and poor health.
Professional societies in the field of occupational health play an important part in supporting training and education and providing information. Some academic societies issue specialist certification. International cooperation is also supported by these organizations.
Projections for the Future
Coverage of workers by specialized occupational health services is still not satisfactory except in some European countries. As long as provision of the service remains voluntary, there will be many uncovered workers, especially in small enterprises. In high-coverage countries like France and some Nordic countries, insurance systems play an important part in the availability of financial support and/or technical assistance. To provide services for small establishments, some level of commitment by social insurance may be necessary.
Occupational health service usually proceeds faster than community health. This is especially the case in large companies. The result is a gap in services between occupational and community settings. Workers receiving better health service throughout working life frequently experience health problems after retirement. Sometimes, the gap between large and small establishments cannot be ignored as, for example, in Japan, where many senior workers continue to work in smaller companies after mandatory retirement from large companies. The establishment of a continuity of services between these different settings is a problem that will inevitably have to be addressed in the near future.
As the industrial system becomes more complicated, control of environmental pollution becomes more difficult. An intensive anti-pollution activity in a factory may simply result in moving the pollution source to another industry or factory. It may also lead to the export of the factory with its pollution to a developing country. There is a growing need for integration between occupational health and environmental health.