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Occupational health and safety hazards: a literature review and an empirical study of a hospital’s employee… Naruse, Alice Michiyo 1981

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OCCUPATIONAL HEALTH AND SAFETY HAZARDS: A LITERATURE REVIEW AND AN EMPIRICAL STUDY OF A HOSPITAL'S EMPLOYEE INJURY EXPERIENCE FROM 1970 TO 1976 by ALICE MICHIYO NARUSE B.A.SC, The Univers ity of B r i t i s h Columbia, 1942 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE THE FACULTY OF (Department of Health in GRADUATE STUDIES Care and Epidemiology) We accept th i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1981 (c) A l i ce Michiyo Naruse, 1981 In presenting th i s thesis in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the L ibrary sha l l make i t f ree l y avai lable for reference and study. I further agree that permission for extensive copying of th i s thesis for scholar ly purposes may be granted by the Head of my Department or by his representat ives. It i s understood that copying or pub l icat ion of th i s thesis fo r f i nanc i a l gain shal l not be allowed without my written permission. Department of H e a l t h Care and E p i d e m i o l o g y The Univers i ty of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date April 23, 1981 ABSTRACT Occupational health and safety concerns, though not new, have only recently emerged as v i t a l factors in the economic and social l i f e of Canadians at work. It appears that steps need to be taken by the health care system which has h itherto been motivated to care mainly fo r the s i ck , to channel more of i t s energy, resources and manpower towards the prevention of i l l n e s s and accidents. To th i s end, th i s study was designed to investigate employee accidents in a health care f a c i l i t y in an attempt to determine causation by u t i l i z i n g an epidemiologic model of host, agent and environment. It was hoped that these findings would lead to a model for planning better prevention programs. The study was divided into two parts. The f i r s t part reviews the ear ly h istory of occupational health, the internat ional scene and the Canadian experience. Some general concepts derived from the f i e l d of accident research proved useful in analyzing hospital employee i n j u r i e s . It was found that there was l i t t l e d i r e c t evidence of these concepts used in the health care f i e l d . The second part deals with the invest igat ion of accident trends of hospital employees in a medium-size publ ic general hospital in B r i t i s h Columbia. An epidemiologic study of 561 i n ju r i e s that occurred over a seven-year period was undertaken to obtain comparative i i data as well as to determine some of the underlying causes of accidents. Examination of the var iat ions in the frequency of accidents by departments, age groups, length of employment, time of day and year, locat ion of accidents, type of accidents, nature of injury and parts of the body involved provided some ins ights on the employee and environmental determinants of accidents. Despite the high technology equipment and hazardous substances found i n modern hosp i ta l s , very few accidents were recorded in areas where these were used. The great majority of i n ju r i e s sustained are s t i l l the usual s t ra in s , cuts, bruises and burns, caused by over-exert ion, sharp instruments, f a l l s , and heat and steam. A recommendation a r i s ing out of th i s study would be to i n i t i a t e comprehensive occupational health and safety services in a l l hosp i ta l s , to include three basic components; a hazard control program, an in fect ion control program and an employee health serv ice. This program should include a f u l l range of a c t i v i t i e s re la t ing to health promotion, health protect ion, prevention and counsel l ing serv ice, to more t r u l y r e f l e c t the objectives of the World Health Organization 's d e f i n i t i o n of occupational health: The promotion and maintenance of the highest degree of phys ica l , mental and soc ia l wel l-being of workers in a l l occupations; the prevention among workers of departures from health caused by t he i r working condit ions; the protection of workers in the i r employment from r i sks resu l t ing from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological equipment and to summarize, the adaptation of work to man and each man to his job. i v TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENTS v LIST OF TABLES i x LIST OF FIGURES AND ILLUSTRATIONS xi ACKNOWLEDGEMENTS x i i DEDICATION x iv PROLOGUE xv INTRODUCTION 1 Part I LITERATURE REVIEW 9 Chapter 1. AN OVERVIEW OF OCCUPATIONAL HEALTH 9 1.1 Early History 9 1.2 Effects of the Industr ial Revolution 10 1.3 Twentieth Century Concerns 15 1.3.1 Safety Hazards vs. Health Hazards 20 1.3.2 Major Costs in Occupational Health 24 1.3.3 Research and Prevention 39 1.3.4 Summary and Future Implications 42 Chapter 2. THE INTERNATIONAL SCENE IN OCCUPATIONAL HEALTH 47 2.1 Some Global Problems 47 2.2 World Organizations 53 2.3 Occupational Health in Selected Indust r ia l i zed Nations 57 2.4 The Developing Countries 76 v Page Chapter 3. THE CANADIAN EXPERIENCE IN OCCUPATIONAL HEALTH 79 3.1 Occupational Health Status 80 3.1.1 Events 81 3.1.2 Laws 87 3.1.3 Programs 91 3.2 Issues, Conf l i c t s and Related Problems 96 3.2.1 Issues 96 3.2.2 Conf l i c t s 115 3.2.3 Related Problems 133 3.3 Design of Po l icy 148 Chapter 4. ACCIDENT RESEARCH 150 4.1 Introduction 150 4.2 Some Obstacles to Accident Research 152 4.2.1 Myths 153 4.2.2 Social Value of Safety 154 4.2.3 Costs 154 4.2.4 Inert ia to Change 155 4.2.5 Psychological Factors 156 4.2.6 Inherent Violence Factor 157 4.3 Present Status of Accident Research 158 4.4 Main Theories in Accident Research 159 4.5 Problems in Accident Research 162 4.5.1 Def in i t ion 162 4.5.2 Concept of Cause 164 4.5.3 Methods of Study 167 4.5.4 C l a s s i f i c a t i on Systems 170 4.6 Some Findings in Industrial Accident Research 172 4.7 Safety Research in Industry 177 vi Page 4.7.1 Problems in Evaluation 177 4.7.2 Preventive Measures Used in Industry 179 4.7.3 Human Factors in Accident Prevention 185 4.7.4 Accident Investigation 186 Chapter 5. EPIDEMIOLOGY: A CONCEPTUAL FRAMEWORK FOR THE STUDY OF ACCIDENTS 189 5.1 Introduction 189 5.2 Def in i t ion of Epidemiology 190 5.3 Basic Tenets 192 5.4 Understanding Disease Causation 193 5.5 Some Applications of an Epidemiologic Model 195 Part II THE STUDY 203 Chapter 6. OCCUPATIONAL HEALTH AND SAFETY HAZARDS IN A HOSPITAL MILIEU 203 6.1 Introduction 203 6.2 Typical Hazards 203 6.2.1 Infection 209 6.2.2 Spec i f i c Hazards 210 6.3 Special Risks to Women 214 6.4 Labour Impact 215 Chapter 7. THE STUDY AREA 217 7.1 T r a i l , B r i t i s h Columbia 217 7.2 T r a i l Regional Hospital 219 7.2.1 Occupational Health Services 222 7.2.2 Safety Committee 223 7.2.3 Infection Control Program 224 7.2.4 Union Representation 225 7.2.5 Board of Trustees 225 v i i Page Chapter 8. RATIONALE AND OBJECTIVES OF THE STUDY 229 8.1 Occupational Health Concerns in Hospitals 229 8.2 Rationale 231 8.3 General Objectives 232 8.4 Spec i f i c Objectives 232 Chapter 9. DESIGN AND METHODOLOGY 234 9.1 T r i - p a r t i t e Approach 234 9.2 Def in i t ions 236 9.3 Abbreviations 238 9.4 Sources of Information for the Study 238 9.5 Population 240 9.6 Assumptions 240 9.7 Limitations 241 9.8 Ethical Considerations 242 9.9 Method of Computing Injury Rates 243 Chapter 10. RESULTS AND DISCUSSION 250 Chapter 11. CONCLUSIONS AND RECOMMENDATIONS 283 LIST OF REFERENCES 291 BIBLIOGRAPHY 303 APPENDIX A 305 vi i i LIST OF TABLES Page 1. Total Hospital Employee Injuries Reported to the Workers' Compensation Board for the years 1970-1976. 3 2. Comparison of Overall Injury Incidence Rate and Disabling Injury Frequency Rate, 1975. 85 3. Annual S t a t i s t i c s for the T ra i l Regional Hospital 1976. 5. T ra i l Regional Hospita l . Annual Employee Injury Rates, per 1,000 for Departments for the Years 1970-1976. 226 T ra i l Regional Hospita l . Number of Pay Cheques Issued to Departments per 75 Man Hour Work Period (Equivalent person). A Single Two Week Pay Period in August, 1976, 1977, 1978 (corrected for overtime), 246 248 6. T ra i l Regional Hospital. Annual Employee Injury Rates, per 1 ,000 for Services for the Years 1970-1976. 255 7. T ra i l Regional Hospita l . Frequency D i s t r ibut ion of Number of Employee Injuries According to Departments, 1970-1976 by Time of Day. (Day S h i f t , Evening S h i f t , Night S h i f t ) . 259 8. T ra i l Regional Hospita l . Frequency D i s t r ibut ion of Number of Employee Injuries According to Departments 1970-1976 by Time of year. (Spring, Summer, Fa l l and Winter). 261 9. T ra i l Regional Hospita l . Injuries Sustained by Employees According to Services, 1970-1976. External Causes of Injury(by Number, Percent, Rank). 263 10. T ra i l Regional Hospita l . Injuries Sustained by Employees According to Services, 1970-1976. Nature of Injur ies (by Number, Percent, Rank). 264 11. T ra i l Regional Hospita l . Injuries Sustained by Employees According to Services, 1970-1976. Parts of Body Involved (by Number, Percent, Rank). 265 12. T ra i l Regional Hospital. Comparison of Employee Injury Rates per 1,000 Before and After In s t i tut ion of Safety Committee in 1971. 274 i x Page 13. Number of F i r s t Payment Time Loss Cases and Number of F i r s t Payment Medical Aid only Cases for Selected Hospitals 1970-1976 inc lus ive. 278 14. Medium - s ize Publ ic General Hospitals in B r i t i s h Columbia with Safety Programs. (Bed Capacity 200-299). 279 x LIST OF FIGURES 1. Man-days l o s t : Str ikes vs. Injur ies. 1968-1974. 2. Modified Epidemiologic Model in an Accident S i tuat ion . 3. Epidemiologic Model used in a Hazard Control Program, 4. Regional Hospital D i s t r i c t s of B r i t i s h Columbia. 5. T ra i l Regional Hospital - photograph. 6. T ra i l Regional Hosp i ta l - organizational chart. 7. T ra i l Regional Hospita l . Frequency D i s t r ibut ion of Number of Employee Injuries According to Departments, for the Period 1970-1976. 8. Tra i l Regional Hosp i ta l . Average Total Employee Injury Ratesper 1,000 According to Departments, for the Period 1970-1976. 9. T ra i l Regional Hospita l . Annual Employee Injury Rates per 1,000 According to Services, for the Years 1970-1976. 10. T ra i l Regional Hospita l . Frequency D i s t r ibut ion of Number of Employee Injuries According to locat ion of Occurrence, for the Period 1970-1976. 11. T ra i l Regional Hospita l . Frequency D i s t r ibut ion of Number of Employee Injuries According to Age Category, for the Period 1970-1976. 12. T ra i l Regional Hospital. Frequency D i s t r ibut ion of Number of Employee Injuries According to Length of Employment for the Period 1970-1976. 13. Occupational Health Services for Hospital Employees. xi ACKNOWLEDGEMENT F i r s t and foremost, I wish to thank Dr. C.J.G. Mackenzie for his invaluable help. His chairmanship, characterized by strength, decisiveness, good humour and uncanny a b i l i t y to apply theory to the real world, provided the impetus and the encouragement to complete th i s task. I would also l i k e to thank the rest of my thesis committee; Dr. M. Vernier for his epidemiologic expertise and help in the p r e l i -minary stages and Dr. Nancy Kle iber, who was temporarily on the committee, for her wise counsell ing in program evaluat ion. I am g ra te fu l , too, to Dr. D. Bates who not only acted in the capacity of external examiner, but provided me with much information on occu-pational health from his personal f i l e s . To Dr. M. Schulzer for his guidance in the s t a t i s t i c a l aspects of the thesis and Dr. L. Kornder who acted as consultant in occupational health, I wish to extend thanks. To facu l ty members involved in the program, I wish to express my appreciat ion. Mr. Paul Nerland, mentor, provided me with moral support at a c ruc ia l time in the course. Dr. Morton Warner was a tower of strength throughout, and Dr. Anne Crichton gave generously of her time and talents during the f i n a l phase of thesis submission. I acknowledge the Tra i l Regional Hospital Administration for providing information which was central to the study. Special thanks are extended to Winnifred Dobbs and Bernice Saunders for t he i r amazing memory banks, Ron Parisotto for his accounting knowledge, C la i re MacKinnon xi i for Safety Committee records, and to a l l those kind people who responded to a questionnaire. The Workers' Compensation Board of B.C. was very generous with the i r time. The Accident Prevention Department w i l l be remembered for the i r kindness and courtesy in supplying me with deta i led information--espec ia l ly Marie Froese, whose time and e f f o r t on my behalf were much appreciated. To Gail Helgeson, executive secretary of Health and Safety, loca l 480 and member of Senior Joint Committee on Health and Safety at Cominco, and to Rob Muth from The Employers' Council of B.C. I wish to express my thanks for requested information. I wish, a l so , to thank Muriel King, Grace Green and Shir ley Kenyon for material used in the thes i s . To Ronnie S i z to , special c red i t must be given. His time and attention to the computer program were beyond the c a l l of duty. I wish to thank Marjorie McLean and Deanna Cul l en for typing i n i t i a l drafts at my convenience, and Celine Gunawardene for her meticulous care in the f i n a l preparation. To my many f r iends , both within and without the program, I owe a debt of grat itude. Their kindness and support were i n sp i r a t i ona l . F i n a l l y , the la s t shal l be the f i r s t . I wish to thank my fami ly—Grant, Mark, Ross and Kim, and above a l l , Henry without whose love, patience and understanding, th i s thesis could not have been completed. x i i i Dedication In Memory of Hideo and Tatsu Eguchi xiv Prologue Health i s that precious heritage Of p r ie s t and layman, fool and sage, I t ' s worth a hundred times i t s cost But no-one learns that ' t i l i t ' s l o s t , George Shepherd xv INTRODUCTION Hospitals have been slow to recognize the health and safety hazards that confront the i r employees. This i s under-standable, as hosp i ta l s ' prime concern has been the welfare of the i r pat ients. Nonetheless, i t behooves hospitals now to d i rec t equal consideration to the health of the i r s t a f f . The myth that proximity to treatment f a c i l i t i e s and health professionals magically keeps hospital workers free from i n ju r i e s and disease prevailed un t i l f a i r l y recent ly, as occupational health and safety measures escaped p r i o r i t y consideration in most hosp ita l s . T rad i t i ona l l y , hospitals have not been involved in a comprehensive health care program for employees. Some have provided immunizations, f i r s t aid and infirmary care. Others have given pre-employment and annual medical examinations including routine laboratory tests and chest x-rays. These prototypes, however, are far from universal (Bonham, H. and Naruse, A.M. Br ief to B.C. Health Min i s t ry , May 1979). In the past,a few larger hospitals have supplied some recreational f a c i l i t i e s such as tennis courts for s ta f f use. With increasing cap i ta l costs and budget re s t r i c t i on s hospitals today have l i t t l e room to manoeuvre in a l l oca t ing funds for "non e s sent i a l s . " Most hospitals have safety committees as i t i s required by law 1 1 ( Industr ial Health and Safety Regulations, Workers' Compensation Board of B.C. 1978: Sec. 404), but often they pay l i p service to safety programs or give them fa i n t recognit ion. Many hospitals s t i l l re ly on " c r i s i s management" and "cor r idor consul-tat ions " in coping with day by day s ta f f contingencies. These methods, though expedient, are poor substitutes for a comprehensive employee health service. Such a service would embrace not only disease prevention and environmental health and safety protection but health promotion by education and provis ion of a c t i v i t i e s and f a c i l i t i e s fo r the physical and mental well-being of a l l hospital employees. In the long run, hospitals would l i k e l y benefit as they discover that an occupational health program would enable workers to perform with optimum e f f i c i ency and permit them to maximize the care of the patients they serve. A. STATEMENT OF THE PROBLEM There i s evidence that many hospitals have a r i s i n g incidence of occupational i n j u r i e s . Table 1 presents to ta l hospital employee i n j u r i e s , reported to the Workers' Compensation Board of B.C. for the years, 1970-1976. I f hospital i n ju r i e s are to be control led and reduced, hospitals must exercise increased v ig i lance and adopt preventive methods of control where none ex i s t , or where ex i s t ing controls are inadequately administered. Preventive methods must also 3 Table 1 Total Hospital Employee Injur ies Reported to the Workers' Compensation Board for the years 1970 - 1976 Including Back stra ins (Excluding "Medical Aid Only" cases) Paid for the F i r s t Time Year Total Injuries Total Backs 1970 744 256 1971 873 288 1972 1,264 397 1973 1,537 489 1974 1,905 595 1975 2,286 731 1976 2,254 812 Source: S t a t i s t i c a l Records Section, Finance Department, Workers' Compensation Board of B.C. include the employee's re spons ib i l i t y for his or her own protection. It i s believed that most i n ju r i e s are la rge ly preventable by the appl icat ion of good sound common sense and t ra in ing . The cost of protection i s small compared to the high cost of f a i l u r e to protect. Costs are a major factor in occupational i n ju r i e s and disease, and w i l l be enlarged upon in the more deta i led discussion in th i s d i s se r tat ion. B. PURPOSE OF THE STUDY This study proposes to examine the epidemiologic aspect of reported employee accidents in a medium-size publ ic general ho sp i ta l , to evaluate an employee safety program, and to lay the foundation for an e f fec t i ve hazard control program as part of an occupational health and safety service for hospital employees. C. APPROACH TO THE LITERATURE There i s a paucity of information regarding employee accidents in hosp ita l s . It i s somewhat surpr i s ing , but a review of the l i t e r a t u r e revealed an absence of any real research work done in th i s pa r t i cu la r f i e l d . What would account for the dearth of information in th i s area? One obvious explanation i s hospital accident studies 5 usually focus on patients rather than employees. Then too, accidents of hospital workers are l i k e l y viewed as minor, and as such, would not permit the attention accorded the more dramatic or fa ta l accidents occurring elsewhere. Perhaps the major reason which i nh i b i t s vigorous research invest igat ions of hospital employee accidents i s the lack of funds and sponsors. Whatever the reasons, there appears to be a near vacuum in research of occupational i n ju r i e s in a hospital mi l ieu (Curr ie, J .H . , Sept. 1979, K e l l , R.L., Sept. 1979). Notwithstanding, some background information from which th i s study i s developed was es sent ia l . As a consequence, the l i t e r a t u r e search was conducted along three wel l -def ined areas: 1. This study of employee accidents in the work place w i l l be viewed within the to ta l context of occupational health and safety with prevention as the pervasive theme. Therefore, a glance into the past for events of h i s t o r i c a l s i gn i f i cance seemed to be appropriate. The high level concern for the worker safety in the western world today owes i t s o r i g i n to the e f fo r t s of some early pioneers in the f i e l d , even before the Industr ial Revolution. As w e l l , in the 20th Century, ident i f y ing the major issues d i r e c t l y related to the ever burgeoning sphere of occupational health and safety seemed relevant. The internat ional scene w i l l be b r i e f l y examined, where information was ava i l ab le , according to l e g i s l a t i o n , 6 administration and technical measures in various countr ies. This w i l l permit Canadians to relate with various developments in occupational health and safety services in other parts of the world. Canada i s rapidly becoming a major i ndu s t r i a l i zed country with a l l i t s attendant benefits and i l l s . The nation i s perceiving that, indeed, some of i t s larger concerns may be cent ra l l y connected to the work environment. This i s expressed by Dr. Nicholas Ashford (1976:3) of the Massachusetts Ins t i tute of Technology who says: ...the growing debate over health care and preventive medicine cannot proceed far without encountering probable occupational causation of a surpr is ing proportion of disease. Problems of i ndus t r i a l product iv i ty , work a l ienat ion and management - labour disputes re late increas ingly to occupational health and safety. In add i t ion , the monetary costs of job injury and disease are beginning to be more f u l l y rea l i zed and deserve c loser attent ion during a period of i n f l a t i o n and materials and energy shortages. 2. Some general knowledge of accident research was necessary to serve as a baseline and a point of departure for the study. Despite the lack of hospital employee studies, considerable accident research has been done in other settings by various professionals in the b i o l o g i c a l , socia l and physical sciences (McFarland, Ross A. 1964. Hale and Hale, 1972:9). Moreover, many theories and methods of study have been developed by 7 these d i f f e ren t ind iv iduals and d i s c i p l i ne s . But with the whole f i e l d of accident research in a state of f lux i t seemed prudent to consolidate some of th i s knowledge. At th i s point, a comprehensive approach to the study appeared to be possible and desirable. Therefore, looking mainly at the vast array of work already done in t r a f f i c accidents and indust r ia l i n ju r ie s i t was thought that the basic tenets which evolved from these studies could be applied in researching hospital employee accidents. Immediately however, the complexity of accident research became apparent. On the one hand, i t appears, in these circumstances, the common denominator i s the human component which should make comparisons simple. On the other hand, factors such as environmental inf luences, motivational responses and spec i f i c s k i l l s required, need to be considered which make comparisions d i f f i c u l t . Yet, i t i s possible to del ineate s i m i l a r i t i e s in human behaviour under l i k e condit ions. Hence, some lessons learned from one s i tuat ion may j u s t i f i a b l y be transposed to another s i tua t ion . And there being s u f f i c i e n t pa ra l l e l s between hospitals and industry, a hospital s i tuat ion may be equated to an indust r ia l sett ing in studying occupational i n j u r i e s . Therefore, th i s study of hospital employee i n ju r i e s w i l l r e f l e c t , in the main, accident research done on the indust r ia l scene. 8 An exhaustive search of the f i e l d would be very d i f f i c u l t and unnecessary for the present study. Hence, some general f indings w i l l be discussed and a few selected studies w i l l be c i t ed . 3 . The l i t e r a t u r e was also reviewed for information that would lead to an e f fec t i ve methodology for studying hospital employee accidents. Epidemiology was used as a conceptual framework in that i t u t i l i z e s the three components of host, agent and environment; studies the demographic character i s t i c s of events; attempts to determine causation; and i s committed to prevention. A l l three areas are elaborated upon in Part I, L i terature Review. The L i terature Review w i l l be as comprehensive as poss ible, not only because i t w i l l serve as a background for the study on hospital employee in ju r ie s but because i t w i l l attempt to consolidate much of the information avai lable today on occupational health and safety hazards, into one manual. 9 PART I LITERATURE REVIEW CHAPTER 1 AN OVERVIEW OF OCCUPATIONAL HEALTH 1.1. Early History The concept of occupational health and safety on the job i s not new. As far back as the f i r s t century A.D., P l iny the Elder (23-70 A.D.), a Roman scholar and author of "H i s to r i a Natura l i s " recorded a descr ipt ion of a protective mask used by workers subjected to lead fumes (Felton et al 1964:8). By 1472, U l r ich El lenburg, a German Physician in Augsburg, was wr i t ing on the poisonous ef fects of mercury and lead, warning metal workers to avoid becoming contaminated. In the 16th Century, Paracelsus (1493-1541) son of a Swiss doctor, himself a physician and alchemist, wr i t ing from his own experience ca l l ed attent ion to the real dangers involved in exposure to tox ic materials in mines and smelters (Felton et al 1964:19). In the same era, a German mineralogist, Georg Bauer (1494-1553) known as Agr i co la , who l a t e r became a physician in a mining town, compiled a major t reat i se on mining. His "De Re Meta l l i c a " was published in 1556 and was considered a c l a s s i c in metallurgy. In the twelfth section of th i s book, i t described the diseases and accidents prevalent among miners and the means of preventing them. 10 The t rans lat ion of th i s important work was done by Herbert and Lou Henry Hoover in 1912 (Felton et al 1964:17). The ideas planted by these early pioneers had uncertain and sporadic growth periods. Nevertheless, the threads of continuation managed to survive. Ernest Mastromatteo (1976:9), Director Occupational Safety and Health Branch, International Labour Organization, addressing the Canadian Public Health Association in 1976, reported that ear ly attempts at actual research into occupational disease and measures to protect workers were i n i t i a t e d by some c l i n i c a l s pec i a l i s t s as early as 1700. He sa id , moreover, that occupational cancer had been discovered for over 200 years. Mastromatteo also stated that Bernardino Ramazzini, an I ta l i an physician (1633-1714), wrote a deta i led "Discourse of Diseases of Workers" about th i s time. "De Morbis Ar t i f i cum D ia t r iba " described the occupational diseases then known, such as the poisonous ef fects of lead and other metals encountered in mines (Felton et a l . 1964:20). 1.2 Effects of the Industr ial Revolution The essence of the Industr ial Revolution in Europe was the suddenness of change from a s t a t i c agrarian society to a manufacturing society result ing in an unprecedented burst of economic growth. In turn, th i s a c t i v i t y rap id ly gave r i s e to the factory system and converted the majority of the population 11 from country dwellers to urban workers. Adapting to a t o t a l l y new way of l i f e created great problems for the working masses during and a f te r th i s t r an s i t i on . Historians disagree as to the exact period of the Industrial Revolution. Most w i l l concede 1750 i s a convenient s tar t ing point because the f i r s t great burst of i n du s t r i a l i z a t i o n occurred in Great B r i t a i n during the second ha l f of the eighteenth century (Grant, 1973:1-3). However, some steam driven inventions were in use a number of years before th i s date. Donald Hunter (1975:60-61) who wrote on the Industrial Revolution in the "Diseases of Occupations", places th i s period as 1760 - 1830. He claimed the complex series of events changed the face of England not only in the i n d u s t r i a l , but also in the soc ia l and i n t e l l e c t u a l spheres. The problems created by industry were due part ly to the introduction of machinery in production processes, as in the cotton and wool trades. Workers were exposed to previously unknown hazards. One of the more unpleasant aspects of the factory system was the use of ch i l d labour (Grant, 1973:49). About th i s time, an English surgeon, S i r Percival Pott in 1775 described occupational cancer of the scrotum in chimney sweeps resu l t ing from exposure to coal tars (Page and O 'Br ien, 1973:25). 12 Some time l a t e r , many notable English gentlemen with "a conscience" persuaded the government to protect the working c la s s . In 1802 S i r Robert Peel succeeded in securing the enactment of a law for the protection of the health and morals of apprentices (Kober and Hayhurst, 1924). Other advocates of socia l reform; Charles Lamb, 1823; Charles Dickens, 1837; Charles Kingsley, 1863; and Lord Shaftesbury, 1875; stood out in sharp contrast to the apathetic p o l i t i c i a n s of the day (Hunter, 1975:142-145). Among these soc ia l reformers, Lord Shaftesbury was perhaps the most s t r i k i n g . He brought about many reforms in the mines and m i l l s and was known as the " father " of Factory Acts for protection of women and chi ldren in B r i t a i n . Though there were a series of factory acts from 1802 - 1878, the f i r s t serious attempt at control of working conditions was the Factory Act of 1833 (McKeown and Lowe, 1974:234). A further step towards improving the l o t of the labourers was taken by Charles Thackrash, (1795-1833) a physician from Leeds. He devoted his l i f e to the study and prevention of occupational hazards which accompanied indust r ia l i sm. His t reat i se on occupational medicine was the f i r s t book of i t s kind to be published in England (Felton et a l , 1964:28). In th i s era a l so, S i r Edwin Chadwick campaigned for publ ic health and hygiene. In 1842, his celebrated "Report on the Sanitary Conditions of the Labouring Population of Great B r i t a i n " was published (Hunter, 1975:94). 13 V i ta l s t a t i s t i c s began with Will iam Farr. His e f fo r t s led to the f i r s t publ icat ion of the Registrar General 's occupational morta l i ty supplement in 1851. Subsequently i t has been issued at ten year i n te rva l s . Thus: For the l a s t hundred years in England and Wales i t has therefore been possible to tabulate the deaths of men according to the occupations which are recorded on the death c e r t i f i c a t e s . Bringing these number of deaths, by age and c e r t i f i e d cause, into re la t ion with the numbers of men fol lowing d i f fe rent occupations, as recorded in the decennial census, gives, in terms of morta l i ty , some ind icat ion and measure of special occupational hazards. In the Supplement to the t h i r t y - f i f t h Annual Report, Farr pointed out that the morta l i ty of needle manufacturers at 35 to 45 was excessively high and that earthenware manufacture was one of the unhealthiest trades in England (Hunter, 1975:95). S t i l l another leader worthy of mention was Robert Owen (1771-1858). He was a Welsh s o c i a l i s t and pioneered the . cooperative movement in industry (Felton, 1973:28). However: ...despite the Owenites and other reformers, organized labour made l i t t l e p o l i t i c a l headway un t i l the second half of the nineteenth century. Trade unions although they ex i s ted, were i l l e g a l in most places . . . . The economy, indeed the whole soc iety, was geared to the pursuit of p r o f i t , and the employers had a l l the ammunition (Grant N., 1973:53). As in England, pa ra l l e l developments and conditions were occurring in most of the western world. A l b e i t , conditions varied between one country and the next, the general course of events was surpr i s ing ly s im i l a r . Each country had i t s share of problems and produced i t s own experts on occupational health concerns. 14 Over the centuries, lead poisoning has been a plague on the working c lass. In France, in the mid nineteenth century, Tanquerel des Planches, an authority on plumbism described the sever ity of lead poisoning among unprotected workers, and t r i ed to refute the common opinion that men who succumbed to lead poisoning were drunkards (Hamilton, A. 1943:6). Later in America in the early 20th Century, Dr. A l i ce Hamilton observed conditions at f i r s t hand and accepted soc ia l action on medicine's re spons ib i l i t y . She further substantiated the nature of lead poisoning and inst igated genuine reforms for the protection of lead workers (Felton et a l , 1964:32). As plumbism became less threatening, other hazards to health appeared. Cancer-causing substances are now one of the major occupational concerns. In Germany, a physician, Dr. Rehn in 1895 recorded exposure to chemical agents in a dye factory as causing cancer of the bladder (Mastromatteo, 1976:9). More recent ly, in Canada, Dr. C. Mackenzie (1975:45-46) of the Health Care and Epidemiology Department of the University of B r i t i s h Columbia, with reference to cancer causing chemicals, traced the early h istory of some carginogenic substances as being occupational in o r i g in . He stated: ...Those cancers where a cause was known or strongly suspected a l l had an environmental o r i g i n , such as an i l i ne dyes in factory workers, soot and coal of chimney sweeps, arsenic compounds in smelter workers 15 The Industr ia l Revolution gathered momentum and by the end of the nineteenth century other countries were appearing on the i ndus t r i a l scene, notably Russia and Japan. Great B r i t a i n by this time, had begun to s l i p from i t s dominant pos it ion as the world 's leading manufacturing nation. The new indus t r i a l giants were the United States and the German Empire (Grant, 1973:76-80). Though the scenario sh i f t s the Industr ial Revolution, in a sense, has not ended yet as changes are s t i l l taking place. 1.3 Twentieth Century Concerns The pace of technological change did not f a l t e r af ter the creation of an indust r ia l society in the western world, rather i t accelerated. By the turn of the century, new indust r ies , new machinery, new equipment, new sources of power and new forms of communications were appearing. This rapidly expanding technology, to a great extent, i s responsible for the current state of a f f a i r s in environmental and occupational health and safety problems: 1. The technology creates new problems. 2. There i s l i t t l e coordinated e f f o r t to pass on the knowledge about health and safety hazards attending the new technology (Ashford, 1976: 127). After the i n i t i a l surge of a c t i v i t y regarding worker 16 protection during the eighteenth and nineteenth centuries, there seemed to be remarkably l i t t l e progress made since in., hazard prevention and contro l . Many examples can be c i ted to substantiate this statement: Two hundred years a f te r chimney-sweeps were found with scrota l cancer because of exposure to coal combustion by-products, steel workers in Hamilton and Sault St.Marie, Ontario, are inhal ing the same class of substances that produced the chimneysweeps scrotal cancer... .Seventy-five years a f te r asbestos was known to cause fa ta l f i b ro s i s of the lung, asbestos workers in the Yukon, B r i t i s h Columbia, Ontario, Newfoundland and Quebec have been found to be working i n high levels of asbestos dust (Tataryn, L. 19,79:11-12). Most s c ien t i s t s w i l l agree that the concerns of the work environment have suffered a time lag from the beginning of the twentieth century to the contemporary era because of the complexities created by the technological explosion. In some areas s c ien t i s t s have been able to el iminate or reduce many of the occupational hazards that involve r i sk to workers. However, as former hazards become less important, newer ones seem to be created. Modern technology has been spawning health hazards at an alarming rate and these continue to mult iply (Page and O'Brien, 1973:9). Thus, i n the 20th Century, the dramatic in teract ion of man and i ndu s t r i a l i zed society seem to be acting out i t s major role in the work place. 17 During the present century most of the toxic occupational hazards of the past, mercury, lead, arsenic and phosphorus have been f a i r l y well eliminated or contro l led. However, standardized mortal i ty rat ios indicate there remain substantial r i sks associated with the place of employment. Some of them are att r ibutable to low income, nut r i t i on or other factors , but the rest r e f l e c t the effects of the work environment. One of the obvious adverse features i s the e f f ec t of i ndus t r i a l pol lutants. Another i s the high r i sk of work related i n ju r ie s (McKeown and Lowe, 1974: 239). In an interview in Vancouver, recent ly, A l f red Knudson, president of the American Society of Human Genetics and a researcher at the Phi ladelphia Cancer Research Centre sa id: The world has moved from an "age of infect ions to an age of chemicals" with l i fe - th reaten ing infect ious diseases decl in ing but dangers from chemicals increasing (The Province, Vancouver, October 6, 1978:14). He included a l l chemicals - herbic ides, pest ic ides, the chemicals that are ingested and those which surrounded people at work and at home. The danger that some of the many new organic compounds introduced into industry w i l l prove to be toxic i s a constant ., concern. Centuries l a t e r , the implications of Percival Po t t ' s demonstration that exposure to soot could lead to cancer have become apparent to the general publ ic : 18 . . . I t has been estimated by Dr. John Higginson of the International Agency for Research in Cancer that chemical agents in the environment are responsible for 90 per cent of cancers which occur in people (Mastromatteo, 1976:12). Lloyd Tataryn (1979:2) strengthens th is statement in his report on Canadian i ndus t r i a l problems, "Dying for a L i v i n g " , when he says: Research s c ien t i s t s now agree that the vast majority of cancers are environmental in o r i g i n . He quotes from a United States government report : There i s abundant evidence that the great majority of malignant neoplasms - probably 90 per centof the to ta l - are induced, maintained or promoted by spec i f i c environmental factors Carcinogens must therefore be regarded as one of the most s i gn i f i can t potential consequences of environmental contamination (U.S. Department of Health, Education and Welfare. March, 1970). This high percentage includes those exposed to occupational hazards, and the i r fami l ie s . There are also reports of residents near chemical plants and nuclear plants being at increased r i sk for cancer. The recent near-disaster at Three Mile Island in Pennsylvania, and the evacuation of the near-by residents, remains the most dramatic i l l u s t r a t i o n of the nuclear power industry ' s problems in the United States. Cancer r i sk evidence also extends to metal producing plants, smelters and steel m i l l s . 19 Chlorine gas, another tox ic chemical used extensively in m i l l s to bleach pulp causes permanent damage to workers' lungs and respiratory t r ac t s . This deadly gas was responsible for the largest and c o s t l i e s t - evacuation in Canada's h istory when about 220,000 Mississauga residents were forced out of the i r homes (The Province, Vancouver, November 30, 1979:A4). Going beyond the work environment, on a much broader scale with national and internat ional impl icat ions, "ac id r a i n " i s today's great concern. Federal Environment Min i s ter , John Fraser has said acid r a i n , which contains sulphuric and n i t r i c ac id from pol lutants poured into the a i r from indus t r i a l chimneys and vehicle exhausts, i s the most serious environmental problem facing Canada. Undoubtedly the pub l i c i t y regarding various environmental pol lutants has raised the awareness of workers and the general publ ic to the grave r i sks created in the work place: By now we are a l l well aware that our rapidly developing technological society poses potential threats to human health - although the scope and extent of the hazards are often only vaguely formulated (Somers, E. Nov./Dec. 1979:388). To keep ahead of the enormous changes technology has wrought, man must cont inual ly adapt. This creates a need for constant v ig i lance and continued preventive measure in order to survive, and maintain optimum health. This also requires 20 an understanding of change as an integral part of existence, recognition of the rap id i ty with which a need for change presents i t s e l f in today's society, and an acknowledgement of the complexity of the interact ions that change i n i t i a t e s (To f f l e r , 1970). 1.3.1 Safety Hazards Versus Health Hazards Occupational health hazards and occupational safety hazards are often distinguished by health and safety profess ionals, workers' compensation boards and employer a c t i v i t i e s as being related but d i f fe rent . Though i t seems f u t i l e to separate these two interconnected aspects of occupational health, there i s some merit in the pract ice. As Ashford (1976:68) points out, there are operational ly s i gn i f i c an t d i s t inct ions r e f l e c t i n g : 1. the time frame in which the harm occurs or i s recognized, 2. the cause of the harm, 3. the kind of professionals dealing with the problems, and 4. the extent to which the harm can:;be quant i f ied monetarily and incorporated into the operating costs of the f i rm or business Safety Hazards Safety hazards are generally recognized to ar ise in work environments which cause immediate or sometimes v io lent injury and i s associated with equipment or the physical surroundings. The concern in safety i s more l i k e l y to be the explosive nature of chemicals rather than the i r toxicology or 21 the long term effects of absorption. In the case of noise po l l u t i on , hearing loss i s the major concern rather than the resultant stress related diseases. Thus, in safety, the focus seems to be on the time the worker i s on the job. Spec i f i c safety hazards presently ex i s t ing are: f i r e s and explosions, e l e c t r i c a l hazards, machinery and equipment, operations requir ing eye protect ion, operations requir ing l i f t i n g and moving, transportation hazards, noise, heat stress, poor l i g h t i n g , bacter ia l contamination and v ibrat ions. The harm caused by these safety hazards are: f a l l s , cuts, bruises, sprains, burns, broken bones, loss of limbs, i n f ec t i on , damage to eyes and hearing, d i s a b i l i t y and death. The mult iple ef fects of hazards are becoming widely known. Noise can reduce visual acuity and can increase the l i ke l i hood of accidents. Sometimes hazards combine in a synerg i s t ic way. For example, carbon monoxide i s more tox ic when the temperature i s ra i sed. (Ashford, 1976:71). In recent times, safety on the job has had more recognition and wider acceptance by the employer than before, mainly because accidents are reportable to the workers' compensation system. Thus, i n ju r ie s become a concern for the f i rm, i t s insurance ca r r i e r s , and to i t s safety professionals (Ashford, 1976:68). 22 Health Hazards Occupational health concerns i t s e l f with the preservation of the workers' health at work and extends th i s concern beyond the work place to the home and community, and to the consequent ef fects of job-re lated health hazards. In 1950 the World Health Organization (1963:4) defined the objectives of occupational health as: The promotion and maintenance of the highest degree of phys ica l , mental and soc ia l wel l -being of workers in a l l occupations; the prevention among workers of departures from health caused by t he i r working condit ions; the protection of workers in t he i r employment from r isks resu l t ing from factors adverse to health; the placing and maintenance of the worker in an<;6ccupational environment adapted to his physiological and psychological condi t i on . Another de f i n i t i on of occupational health states: Occupational health consists of those occupational or work-related factors potent ia l l y a f fect ing worker (and secondarily community) health, the resu l t ing effects on to ta l health status, and the programs for the _ . promotion of health and work adjustment (Chisholm, 1977a: 190). Unlike safety hazards, occupational health hazards are often d i f f i c u l t to recognize, s low-acting, cumulative, i r r e v e r s i b l e , complicated by non-occupational factors and can manifest themselves in sickness when the employee i s no longer working. The "chance" of dying from cancer because of occupational exposure and having a v io lent accident on the job may be equal. Some spec i f i c health hazards with long term ef fects may be l i s t e d as: noise; harmful dusts that can cause asbestosis s i l i c o s i s , beryl l ium disease, and byss inos is; some tox ic gases, metals and chemicals; carcinogens of various types heat s t ress , v ib ra t ion , radiat ion and ergonomic factors. As in safety hazards, occupational health hazards may also combine in such a way that the i r ef fects are not merely addit ive but synerg i s t i c . Dr. E. Mastromatteo (1977:30) in his paper e n t i t l e d , " Industr ia l Medicine in the World", to the Canadian Medical Association in June, 1977 warned that: ...occupational exposures are often mult ip le. There i s evidence that the effects of combined., exposures are important, eg: Dust and sulphur dioxide; benzpyrene and dust: etc. and account of th is should be taken in the design of health s tud ies. . . This area dealing with the combination e f fect of health hazards has hardly been explored, yet the real world rare ly presents i so lated hazards. At the present time, there i s a disproportionate emphasis on accident prevention with the divers ion of attent ion away from disablement and death caused by occupational diseases 24 (Ison, 1977:10). Put another way, safety on the job has long been recognized as a proper concern of management, but job-related disease has only recently become a socia l issue. Nicholas Ashford (1976:83) concludes: The f a i l u r e of the injury reporting system and the workers' compensation system to recognize occupational disease has contributed to the f a i l u re of society to rea l i ze the severity of occupational health hazards. However, Dr. Robert Murray, (1974:20) Medical advisor, Trades Union congress of the United Kingdom has maintained a pos i t ive a t t i tude: ...I do believe that in various sets of circumstances i t i s possible to engineer out the hazards, that by applying the techniques of occupational hygiene to the control of dust and fumes and gas and noise and heat, and a l l the other problems that are presented by industry, you can minimize the hazard. 1.3.2 Major Costs in Occupational Health. The magnitude of occupational health problems and the attendant soc ia l costs of hazardous working conditions are not f u l l y rea l i zed by the average c i t i z e n , average employer or average union member. As w e l l , the various levels of government seem to be unaware of the gravity of the s i tuat ion . Canadian figures show, in 1974, there were over one m i l l i on i n j u r i e s involv ing loss of work time at a cost of over 25 hal f a b i l l i o n dol lars to employers in compensation assessments. A further estimate of $2 b i l l i o n was l o s t due to occupational in jur ies in terms of l o s t production, material damage and retra in ing (Begin, M. 1978:272). Many factors compound and cloud the issue of cost. For one thing,job related disease and injury are not always immediately i d en t i f i a b l e as occupationally connected, within the framework of our ex i s t ing health scheme. For another, work place accidents and i l lnesses are not always recognized as such. Furthermore, many go under-reported and unrecorded. It i s small wonder that the v a l i d i t y of current s t a t i s t i c s i s questioned. Another disturbing factor that has d i s torted or suppressed occupational disease s t a t i s t i c s has been the pervasiveness of the " industr ia l -medica l complex" referred to by many health professionals and workers. This s i tuat ion can best be described as - the employees' perception that company doctors are pro-management over work-related diseases, even though doctors stress the i r job i s to be impartial (Financial Times, 28 February, 1978:17). Though th i s medical reputation, to a great extent, i s unwarranted and unjust, s t i l l , there are many instances wherein there i s ample j u s t i f i c a t i o n for such. Paul Brodeur(1973) in his book, 26 "Expendable Americans" speaks of the industr ia l -medical complex, which he f e l t hindered the recognition and control of occupational diseases. Lloyd Tataryn's (1979) account of the p o l i t i c s of indust r ia l death in his "Dying for a L i v i n g " , i s replete with examples of co l lus ion between doctors and industry to suppress information of hazardous conditions in the workplace. In f ac t , he goes further and includes some sc i en t i s t s hired by industry: In almost any occupational and environmental health controversy, medical doctors and s c i en t i s t s have t e s t i f i e d that the working and l i v i n g conditions under attack were in fact harmless. But the medical and s c i e n t i f i c surveys used to ra t iona l i ze the contaminated conditions have usually been shown to be fau l ty and industry-sponsored (Tataryn, 1979:164). The industr ia l -medical complex has led to some serious consequences. Not only has i t caused untold human su f fe r ing , costs and death to workers in certa in occupations, but i t has concealed pertinent information which might have e f f e c t i v e l y pursuaded management and governments to enforce s t r i c t e r regulatory and control functions at the workplace. In an address recent ly, to a s c i e n t i f i c conference, Dr. Franklin Hicks, (Vancouver Sun, 11 June, 1980:B5) ch ief a rch i tect of the federal ly-created Canadian Centre for Occupational Health and Safety in Hamilton, Ontario, sa id: . . .a vigorous occupational health and safety program would almost prove more p ro f i tab le for industry because of the extremely high cost of work i njur ies. Costs of occupational injury and disease are generally assessed in terms of l o s t wages, medical expenses, insurance c l a i production delays, l o s t time of co-workers and equipment damage. But at best, these f igures are grossly underestimated. According to Ashford (1976:84-85) the present costs are ref lected i n : (1) The numbers of job-re lated i n j u r i e s , diseases, d i s a b i l i t i e s and deaths; (2) l o s t work days; (3) the population exposed to potential hazards; (4) workers' compensation costs; (5) workers' perception of the magnitude of occupational health and safety problems may in fact be much larger than currently avai lable s t a t i s t i c s i nd i ca te . . . . He also recognized there are a host of costs not " i n te rna l i z ed " in any accounting system. The human dimension of pain, suffer ing degradation, family d i s locat ion are incalculable but are equally as s i gn i f i can t as the economic dimensions. The costs of occupational i n ju r ie s and disease w i l l be dealt with according to Ashford's categories: (1) The numbers involved in occupational disease and injury are enormous. As stated previously, each year more than a m i l l i o n indiv iduals are affected by work place f a t a l i t i e s , accidents and diseases. Provincial workers' compensation boards have records showing: 28 On a typ ica l day in Canada, every eight hours, more than 4000 workers are injured on the job (Rabinovitch, 1979:21). In the United States, an average of one in ten workers experienced a job-re lated injury or i l l ne s s during 1972. P r e l i -minary Bureau of S t a t i s t i c s estimates indicate that a tota l of 5.6 m i l l i o n recorded job-re lated in ju r ie s and i l lnesses were sustained by Americans during that year - exclusive of the publ ic sector, mining and ra i l roads , agr icu l ture and se l f employed (Occupational Safety and Health Reporter, 1974: 1062)'. A recent disease spec i f i c study done by the Department of Health, Education and Welfare in the United States estimated that 20-38 percent of a l l cancer deaths are due to on-the-job exposure to carcinogens (Rabinovitch, 1979:21). More fr ightening s t i l l , the rate of indus t r ia l i n ju r ie s has been steadi ly climbing in recent years (Ashford, 1976:84, Begin, M. 1978:271). An American survey done in 1971 indicated a continuing increase in the rate of work i n ju r ie s in manufacturing to a level of 15 per m i l l i on man hours worked - the highest rate of indus t r ia l accidents in twenty years (Ashford, 1976:85). Despite these astonishing f igures , there is concern that the magnitude and seriousness of occupational disease are considerably understated. Therefore i t would seem wise to go beyond any government records to ascertain the facts . 29 A true picture of the cris-is in health and safety in Canadian work places as stated by Rabinovitch (1979:21-22) considers: (a) Accidents and diseases not reported to local compensation boards ( f a i l u re to report i s a s i gn i f i can t problem a r i s i ng from ignorance of some workers, and pressures from employers anxious to maintain a "clean company record" ) ; (b) Individual claims rejected by compensation boards on questionable grounds; (c) General wear and tear on the human body (such as recurrent problems of the spine and back) not yet f u l l y accepted as a work place hazard; (d) Incidents which are under-reported, through assignment of injured workers to " l i g h t duty tasks " , use of holiday time for recuperation and non-inclusion in s t a t i s t i c s of the i n i t i a l day lo s t when the incident occurs. Further reasons for under-reporting of workers' ailments in Canada has been enunciated by Terance Ison (1977:4-6), law professor at Queen's Univers ity and former chairman of . The Workers' Compensation Board of B r i t i s h Columbia. He says (a) It i s f a i r l y common to f ind that a complete occupational history has not been taken by an attending physic ian, even i n cases in which i t might estab l i sh an indust r ia l base for the disease. (b) There i s no systematic and national program for monitoring new chemicals used in production. Not only are they largely untested for the i r health ef fects but i t i s common to f ind chemical compounds being introduced that are not even i d e n t i f i e d . . . A patient may be unable to t e l l his doctor exactly what i t i s he works with or has worked wi th , even when the questions are asked. 3U (c) Some indust r ia l diseases which resu l t in permanent d i s a b i l i t y or death can be caused by exposure for periods of less than f i v e years, sometimes less than one year. But with some of these diseases, and cancer i s a good example, the disablement may not resu l t un t i l twenty years or more a f ter termination of the exposure to the "cancer causing substance". Even when a worker changes, his job a f te r a period of exposure, some diseases continue to develop. Not only does th i s time lag postpone the community knowledge of the o r i g in s , but i t may also reduce the prospects of the cause being cor rect ly determined when the disease becomes noticeable and d i sab l ing. (d) There has not been a systematic and national program of research into incidence and causes of i ndus t r i a l diseases. In many s i tua t ions , the research has not been done, or has not been done to a s u f f i c i en t extent to provide an answer in a pa r t i cu la r case. (e) An aggravating factor i s that occupational medicine has not yet become a recognized specia l ty in Canada and there are not s u f f i c i en t t ra in ing programs for doctors w i l l i n g to spec ia l i ze in th i s area. Obviously mult iple factors must be taken into account when a r r i v ing at a r e a l i s t i c assessment of costs due to occupational i n ju r ie s and disease. (2) When one considers the level of worker health, th i s i s perhaps better indicated by the tota l l o s t work days. It i s possible that a considerable proportion of absenteeism due to sickness presently att r ibuted to non-occupational causes i s in fact job- re lated. In the United States 25 m i l l i on work days, excluding f a t a l i t i e s were l o s t during 1972 (Ashford 1976:85). In Canada, the f igure is arr ived at somewhat d i f f e r en t l y . S t a t i s t i c s show 70 m i l l i o n work days l o s t in 1976 (Rabinovitch, 1979:22). The Canadian f igure includes both temporary and 31 permanent d i s a b i l i t i e s , the time l o s t due to compensated f a t a l i t i e s and an estimate of time los t due to non-compensated cancer f a t a l i t i e s and to other causes of under-reported incidents -but does not include a further range of indus t r ia l diseases which w i l l some day be shown to have spec i f i c connections with working condit ions, namely stress related diseases, 'mental disorders, alcoholism and various cardio-vascular i l l ne s se s . One cannot help but feel the level of worker health or i l l health must be a s i gn i f i can t factor in product iv i ty of a f i rm and the G.N.P. Work place i n ju r ie s and diseases are l i k e l y the largest s ingle source of l o s t production in the economy. In Canada, the 70 m i l l i on los t days i s at least s ix times greater than the annual loss of time due to lock-outs and s t r ikes (Rabinovitch 1979:22). P rov i n c i a l l y , the figures are much the same, for example, in 1973 in Alberta there were 165,552 days lo s t to s t r ikes and lock-outs, while man days lo s t for temporary i n ju r ie s were 707,465 (Stopps, J . 1976:67). In the United States, the recorded time l o s t as a re su l t of occupational i l l ne s s and injury i s roughly ten times the man days l o s t to s t r ikes (Ashford, 1976:85). Data from Great B r i t a i n suggests s im i la r f igures. It was reported in 1967 there were eight times as many work days lo s t due to occupational i n ju r ie s as reported to the Workers' Compensation Board as compared to work days lost.due to s t r ikes (Ashford, 1976:85). 32 There i s every ind icat ion that work safety and worker sa t i s fac t ion need to be made a p r i o r i t y issue - as a socia l r i ght and a re spons ib i l i t y under a national health care scheme - involving the best e f fo r t s of both labour and management. As for governments, i t i s important that they recognize cleaning up the work place may be an investment they cannot afford to ignore. (3) Exposure to potential hazards varies according to occupations. For example, loggers, miners, construction and transportation workers and other "blue c o l l a r " personnel generally are more at r i sk to occupational in jury and disease than other workers. Figures for 1972 in The United States, show the accident rate for the fol lowing manufacturing industr ies to be: timber, 25.1; metal products, 22.8; food 19.3; t e x t i l e s , 11.6; chemicals, 9.9; and the book trade, 7.5 (Hellen, 1974:38). The figures indicate percent of workforce in each trade per year. Numberous workers are af fected, s t i l l today, by the major health hazards such as asbestos, cotton dust, s i l i c a , lead and carbon monoxide. The Occupational Safety and Health Administration in the U.S.A. chose to concentrate i t s ear ly health enforcement e f fo r t s on these f i ve hazards for three reas'ons: (1) They were considered serious health hazards; (2) They are substances which can be measured and monitored; and (3) Large numbers of workers are exposed to them (Ashford, 1976:86). 33 Uranium and coke production also create grave r i sks in industry (Page, J . and O 'Br ien, M. 1973:25-26). Workers exposed to these hazards suffer disproport ionately higher injury and disease. Ashford (1976:86) quotes: . . .of the 6000 men who have been uranium miners, an estimate 600-1100 w i l l die during the next 20 years as a re su l t of rad iat ion exposure, p r i n c i pa l l y from lung cancer. Coke-oven workers as a group are two and a half times as l i k e l y to die from lung cancer as steel workers who do not work in coke plants, and are seven and a half times as l i k e l y to die from kidney cancer More recently v iny l ch lor ide monomer has been c i t e d , in the United States, Canada and elsewhere in the world as hazardous in certa in production f a c i l i t i e s with observed connections to certa in types of cancer (Cra l ley, L. and Atk ins, P. 1975:46. Science Council of Canada, Report No. 28, 1977:22). Augmenting th i s l i s t of chemicals, as many as 12,000 toxic substances are in widespread use throughout industry. Approximately 3000 new chemicals are synthesized annually with one in s ix entering the indus t r i a l market (Ashford, 1976:88). Chemical agents come in the form of so l i d s , l i q u i d s , gases, or combinations. They can be inhaled, ingested or absorbed through the sk in. To be inhaled, the chemicals may be in the form of gas, vapour, smoke, dust, mist or fume. 34 Some of the workers' concern surrounding chemical agents can be understood: Of the estimated half m i l l i o n substances found in the occupational environment, only 450 have become subject to T.L.Vi.'s and many of these maximum exposure l i m i t s are sadly out of date (Page and O'Brien 1973:45). Threshold l i m i t values (TLV's) are permissable l im i t s of exposure to environmental agents on the job and refer to time weighted average concentrations which apply to an eight hour work day, for ty hour week. The TLV's widely used in North America have been established by the American-Conference of Government Industr ial Hygienists (Mastromatteo, 1977:22). The most important means by which injur ious substances enter the body i s the respiratory system. Much of the respiratory disease that plagues workers i s known to be job- re lated. In Canada, Grzybowski and Yeung's research (197 8) has corroborated the f indings of several previous studies deta i l i ng serious long abnormalities due to grain dust. Grain handlers, then, are in the high r i sk category for respiratory occupational diseases. Occupational disease, is not necessari ly confined to the indust r ia l worker. Dentists are exposed to x-rays, mercury and anaesthetics which correlate s i g n i f i c an t l y with nervous disorders, leukemia and lymphatic malignancies. Likewise, - i t has been observed that administrators and executives are more prone to coronary diseases than s c i en t i s t s and engineers (Ashford, 1976:86). 35 Some studies of l a t e , however, have indicated that coronary heart disease i s no longer l imited to executive types. It i s becoming much more common among semi-sk i l led workers. The question that must be asked i s , are there d i f fe rent types of stress responsible or are there other causes -of coronary thrombosis that need to; be addressed (Pomerleau, 0. et al , New England Journal of Medicine, 1975:3). How has the new technology affected various occupations? Indeed, increasing technology has wrought many changes. On the one hand, the introduction of high speed steels and dry d r i l l i n g has increased the range of occupational hazards in many industr ies . On the other hand, some heat stress and physical stress that workers, less than a hundred years ago were subjected to , are v i r t u a l l y unknown today. Physical agents such as u l t r a - v i o l e t rad ia t ion , e lectron ic equipment including video terminals and micro-wave appliances are now in common use. None of these have been time-tested for long term health hazards for workers handling them. Yet there has been great improvements made in noise, v ibrat ion and heat control and radiat ion safety. As w e l l , automated machinery in the lumbering industr ies has markedly reduced the r i s k of physical in jury. However, loggers are s t i l l in the highest r i sk category for occupational i n j u r i e s . Dusts have changed but perhaps not reduced. As the old hazards become less 36 formidable, new ones appear on the scene. It i s obvious technology can have both benef ic ia l and negative e f fec t s . Do the benefits outweight the r i sks in a l l occupations? (4) Workers' compensation costs also vary with d i f fe rent occupations. T rad i t i ona l l y , the pulpwood industry and long-shore-men's work have been considered extremely hazardous. Whatever the level of r i sk in certa in categories, the overal l medical, legal and administrative costs are substantial without addressing the d i rec t costs of insurance premiums. The present method of administering workers' compensation i s less than perfect, sometimes resu l t ing in increased pain and suffer ing for the v ic t im. There have been cases of workers wrongly advised to delay seeking medical aid in order to improve the i r chances of obtaining a bigger settlement (Ashford, 1976:88). In the United States, The National Commission on State Workmen's Compensation Laws has proposed reforms to correct such inadequacies and other loop-holes in the system. It i s estimated that compliance with a l l of i t s recommendations w i l l resu l t in cost increases ranging up to 65% in some States. ...These figures moreover, are l i k e l y to be a substantial understatement, pa r t i cu l a r l y i f occupational disease becomes more widely compensable as a resu l t of the commission's recommendation (Ashford, 1976:89). 37 In Canada, the B r i t i s h Columbia Federation of Labour in May, 1978 sent a b r i e f to the Health Ministry confronting the Workers' Compensation Board and the medical profession for the i r "biased" approach in s e t t l i n g back injury claims which const itute 65% of a l l appeals to the Boards of Review. The Federation stated that claimants have insurmountable hurdles placed in front of them as each new back injury i s reported. Furthermore, there i s no wr itten po l icy ava i lab le . The rejected claims are so abundant that the economics of the s i tuat ion must be questioned: This cost factor includes the extra time spent by an adjudicator, medical costs of both the claimant and the Workers' Compensation Board Medical Department, time spent by the Boards of Review and union representatives as well as o f f i c i a l s of the Department of Labour (The B.C. Federation of Labour, 1978:13). A legit imate case could be made of the Federation's stand. It may be a reasonable solut ion to assess upwards Workers' Compensation premiums in those occupations which report a high proportion of back i n ju r i e s . Acceptance of claim need not be automatic, but the injured worker may obtain a more favourable hearing. Continued reject ion appears to be f u t i l e and cost ly . (5) From the workers' point of view,, there has been a noticeable s h i f t from wage demands to fr inge benefits in recent years on the North American continent. The magnitude of the occupational health and safety problems faced by employees is f i n a l l y being rea l i zed . 38 Quinn reports in The Monthly Labor Review (November 1973:35), that health and safety hazards were more frequently c i ted than any other labour standards problem area (Ashford, 1976:89). A typ ica l membership survey of working conditions conducted in the United States in the early 19701s by the Research Staff of A l l i e d Industr ial Workers' International Union gave s imi la r resu l t s . In rat ing the importance of a var iety of possible "job improvements, the respondents rated "better health and safety pract ices " (79%), and "better contingency protect ion" (71%) as "very important", which prompted the research team to state: "In the face of considerable controversy over the issue of job safety and health as a major federal concern, i t i s interest ing to note that the results of the present study indicate that union members do have a real concern about th i s issue (Donoian, H.A. and Brotslaw, I. 1973:37). (6) The true extent and the social cost of occupational safety and health problems are impossible to compute. As stated previously, current ly avai lable o f f i c i a l s t a t i s t i c s can only hint at the magnitude of work place i n j u r i e s , which i s chron ica l ly d i storted due to f r a i l t i e s in the system. Moreover, there has been a pervasive bias towards safety in recent years, as previously suggested. Yet the potent ia l l y far more important socia l problems of occupational i l l ne s s and disease are generally ignored due mainly to d i f f i c u l t i e s in obtaining accurate records (Ashford, 1976:92-93). For these reasons, the presently 39 avai lable s t a t i s t i c s greatly underestimate the seriousness of the country 's occupational health problem and socia l costs of hazardous working condit ions. 1.3.3 Research and Prevention The primary role of research in occupational health i s in expanding the understanding of the causes of occupational disease and injury in order to improve the methods of prevention -both mental and physical causes. Much of the research knowledge w i l l be dependent upon the studies of other d i s c ip l i ne s such as, environmental sciences, medicine, public health, and the soc ia l sciences. The problems of the general and work place environment are int imately connected and need to be pooled together. Environmental health research has generally enjoyed governmental support and has been taught at schools of public health or environmental medicine. To a lesser degree, safety research i s performed in a few univers i ty schools for safety and departments for indus t r ia l engineering but mainly in pr ivate organizations, such as the National Safety Counci l , the National F i re Protection Associat ion, or the insurance companies (Ashford, 1976:98). And yet , i r o n i c a l l y , the focus in industry and governments has been on safety measures to prevent in ju r ie s with 40 workers obliged to take re spons ib i l i t y for themselves, rather than safeguards to prevent occupational and environmental diseases with employers taking more re spons ib i l i t y (Ison, T. 1977:10). In Canada, the Workers' Compensation Board of B r i t i s h Columbia has done some very commendable work in research. It has supported a number of health and safety studies which are extremely relevant to occupational health. One of the studies was detecting breathing problems, a l l e rg ie s and other possible ef fects of the working environment on the health of pulp and paper workers. Dr. Grzybowski who spearheaded the project stated: "The Board recognizes that to get meaningful prevention, you've got to have meaningful research" (W.C.B. News Sept/Oct. 1978:1). In another move to promote occupational health research, the Workers' Compensation Board entered a j o i n t funding project with the B r i t i s h Columbia Lung Association to conduct surveys where workers are exposed to conditions which may damage the lungs (Workers' Compensation Board News, Sept/Oct. 1978:2). More recent ly, in June, 1979 i t co-sponsored the f i r s t advanced course in safety held at the Univers ity of B r i t i s h Columbia with the B.C. Safety Counci l. The Workers' Compensation Board also has excel lent laboratory f a c i l i t i e s where injur ious substances are monitored in workers and contaminants are measured in work places. 41 The present Board's focus appears to be sh i f t i ng from stra ight compensation and rehab i l i t a t i on to education and prevention, as well as research. The media have been used extensively in the past few years to educate the public in the dangers of the work place. Televis ion commercials have been pa r t i cu l a r l y e f fec t i ve in accident prevention. However, the Board's advert is ing has been c r i t i c i z e d because i t tends to place the onus and blame on the employee without a counter-balancing share of r e spons ib i l i t y put on the employer. Morever, safety hazards are graphical ly i l l u s t r a t e d but other factors such as indust r ia l pol lutants have not had equal coverage. Research into the causes of accidents, which can have far reaching implications for both occupational and general safety i s acknowledged. But for the most part, in Canada as well as the United States, th i s research has concerned i t s e l f with motor vehicle safety, transportation safety and accident prevention in the home. Concern for product safety and equipment safety are s t i l l comparatively new f i e l d s (Ashford 1976:100). The behavioural s c i en t i s t s and health care researchers have been studying the ef fects of stress as co-factors i n heart disease and other degenerative diseases. Research to c l a r i f y the ro le of stress has major impl icat ions for prevention in occupational health. 42 Ashford (1976:102-107) refers to three useful studies that have contributed to the del ineat ion of research needs in environmental health sciences, namely, "Chemicals and Health", (1973) "Man's Health and the Environment - Some Research Needs" (1970) and "Man, Materials and Environment" (1973). Probably the most useful of the reports i s , "Man's Health and Environment -Some Research Needs." It itemizes many research needs regarding indust r ia l exposure, and postulates: There are innumerable instances in which technology is ava i lable for the prevention or e l iminat ion of environmental hazards, but i t i s not employed for personal, social or economic reasons. It appears now that man has been unable to keep pace with the accelerat ion of technology. And i t can also be said that occupational and environmental injury and disease may be the resu l t of his i n a b i l i t y or unwillingness to adapt s o c i a l l y or b i o l o g i c a l l y . However, Ashford (1976:107) asserts: Solving occupational health and safety problems w i l l necessitate both the development of new technology and some abandonment of the o ld . The form that the solutions take w i l l depend c r i t i c a l l y on how we view causation, and hence prevention, in spec i f i c cases. 1.3.4 Summary and Future Implications It i s obvious by now that attempts to separate general health and occupational health, or mental health from physical health w i l l be counter productive. Un i latera l approaches to solving one aspect of a set of problems can only lead to r id icu lous outcomes, for example as happened in the United States: 1) removing DDT from the general environment has led to the use of a subst itute pest ic ide that i s much more dangerous to the farm workers who handle i t ; 2) the Environmental Protection Agency (EPA) a i r qua l i ty standards for the general environment do not seem to bear any re lat ionsh ip to the Occupational Safety and Health Administration's(OSHA) standards for the work place. For example, the EPA's standards for sulphur dioxide and part iculates are much more str ingent than those of the OSHA, although exposure i s e spec ia l l y high in the work place (Ashford 1976:126). The rat ionale has been: ...That community standards are usually for 24 hours per day or for longer periods and they apply to the to ta l population in the community including in fants , e lder l y people and the i l l . Work exposure standards on the other hand, generally apply to f i t t e r persons between the ages of 18 and 65 years of age and for 8 hours a day (Mastromatteo, 1977:23). What i s not taken into account i s the inter re lat ionsh ip between the exposure to environmental agents at the workplace and in the community .Only when th i s factor is taken into consideration can r e a l i s t i c exposure standards be set. Some coordination of e f f o r t appears necessary and past due. The p ro l i f e r a t i on of chemicals into the general and occupational environment i f not checked, could spel l d i saster . Appropriate safeguards are often not avai lable or disregarded due 44 to ignorance of the dangers involved. The patent system encourages monopol ist iccompetit ion and i s part ly responsible for th i s p r o l i f e r a t i on . The issue of control i s c ruc ia l to solving the problem. Therefore, socia l control of technology must be attempted through l e g i s l a t i v e processes, backed by government, the s c i e n t i f i c community, industry, labour and an informed publ ic . Ef forts to improve occupational health and safety however, are not l i k e l y to be successful in the absence of the worker's i n te re s t , r e spons ib i l i t y and control of some aspects of his work environment. Workers need to be educated and trained to exercise appropriate precautions in order to prevent occupational disease and in jury. At the same time, every possible means could be explored by management to take re spons ib i l i t y for reducing indus t r i a l contamination, improving plant and equipment design, making changes in products or materials handled by employees, and of fer ing occupational serv ices, to guard the health of t he i r workers. Preventive measures then, include a l l e f fo r t s by management and labour to reduce to a minimum the ravages of the work place. There are general control measures which could help in reducing the hazards created by industry, as advocated by Paul Falowski, Environmental representative of the United Steel Workers of America: 45 Subst itut ion Very often a non-poisonous material can be substituted for a poisonous one without a f fect ing the product. Handling Methods If i t i s necessary to handle dangerous mater ia ls , i t should be done in such a manner to reduce exposure to workers. In p ract i ce , th i s involves the use to enclosed systems of processing, preferably under reduced pressure. Other methods include wet handling instead of dry, brush painting instead of spraying and vacuum cleaning instead of sweeping. Vent i l a t ion If poss ible, loca l exhausts should be used at a l l points where tox ic substances may escape into the workroom. Examples of local exhaust are the spray booth, hoods, exhausted chromium plat ing tanks and grinding wheels. When a loca l exhaust i s not poss ib le, general vent i l a t i on i s required with subsequent increased cost of heating in cold weather. Recirculat ion of a i r containing free s i l i c a or tox ic materials should not be permitted. Segregation Processes using dangerous materials should always be segregated so that a minimum number of workers are exposed. Personal Protective Equipment Respirators, special c lo th ing , gloves, goggles and protective cream may be required. Care should be taken to obtain the r ight equipment for the hazard in question. Personal Hygiene Good personal c leanl iness should be pract iced. Workers should wash ca re fu l l y at the end of each work s h i f t and before eating. Under certa in condit ions, showers at the end of the work day are necessary. A regular program to provide clean work clothes i s essential when tox ic materials that can be absorbed through the skin are handled. A double locker system, one for steet clothes and one for work clothes i s often des i rable. (Falkowski, no date:16). 46 Conclusion The l i t e r a t u r e has revealed huge discrepancies in the health care del ivery system as i t affects working people. A co-ordinated po l icy is d e f i n i t e l y required for safeguarding man's to ta l health, both in and out of the work place. Serious consideration needsto be given to education and research, the market mechanism and regulatory a c t i v i t i e s . In the f i n a l ana lys i s , How we approach the present and future problems in occupational health and safety w i l l be a r e f l ec t i on of our sense of equity and j u s t i ce as i t appears to the indiv idual in our society (Ashford 1976:130). 47 CHAPTER 2 THE INTERNATIONAL SCENE IN OCCUPATIONAL HEALTH Occupational health and safety pose great problems in the world today. Accidents and disease take a heavy t o l l among workers in many countries. More than 100,000 fa ta l occupational accidents occur in the world annually (World Health, 1974:3). In add i t ion, occupational accidents and diseases are responsible for heavy economic losses to nations great and small. S t i l l other problems such as soul-destroying monotony and stresses of modern production methods in the highly i ndus t r i a l i zed soc iet ies are matters of grave concern. No less serious are the social and cu l tura l problems brought about by rapid i ndu s t r i a l i z a t i on and urbanization in the developing countries - reminiscent of the effects of the indust r ia l revolution in the i ndu s t r i a l l y developed countries more than two centuries ago. 2.1 Some Global Problems In the highly i ndus t r i a l i zed countr ies, about one worker in ten i s reported to have a workplace accident each year. To c i t e a few examples; in 1971 in West Germany, nearly 2.6 m i l l i o n work i n ju r ie s or occupational diseases were reported among 27 m i l l i o n workers. In the same year in France, nearly 1.1 m i l l i o n occupational i n ju r ie s were recorded among 13 m i l l i o n workers. 48 S im i l a r l y , in the United States in 1972, as mentioned in .a previous text , more than 5.6 m i l l i on cases, excluding farms, railways and mines were recorded among 58 m i l l i on employees. Though there has been a reduction in the tota l numbers of fa ta l accidents in some of these countries, despite the increasing numbers of workers, the tendency i s not universal (Hel len, E., 1974:36). These figures give only a rough idea of the immensity of the problem, as s t a t i s t i c s published in d i f fe rent countries are not d i r e c t l y comparable. A major d i f f i c u l t y is that the minimum period of d i s a b i l i t y which is s t ipu lated for recording workplace in ju r ie s varies from one country to another (Hellen, 1974:36). However, the national f igures that do ex i s t reveal an extremely serious s i t ua t i on . Taking a look at.: the th i rd world countries, World Health (1974:3) reported that of a to ta l of 7,770,000 workers in B raz i l in 1972, there were 1,470,000 who sustained i n ju r i e s or were victims of occupational disease. And more s p e c i f i c a l l y in some of these developing nations, up to 23 percent of miners and workers in quarries suffered from f i b r o t i c pneumoconiosis, and in others a 60 percent prevalence of byssinosis and other respiratory conditions was found to be f a i r l y common. 49 Perhaps the most neglected workers are those in small industr ies a l l over the world, who Dr. El Batawi (1974:5), Chief, Occupational Health, ,at the World Health Organization, refers to as the "forgotten masses". These are workers in f lax-processing plants along the Ni le Delta, or in the dusty quarries in Malaysia and Singapore, and in the dim-grain-mi 1 l i ng plants in Burma. Their hours are long and arduous, and workers often include the young and the o ld . The de f i n i t i on for small industr ies d i f fe r s from country to country, however: i t has been agreed by the sub-committee, on this subject, of the Permanent Commission and International Association on Occupational Health, that a l l work establishments employing fewer than 50 workers - f a l l into th i s category. This decision was made mainly for s t a t i s t i c a l purposes and to f a c i l i t a t e surveys and f i e l d studies as well as the planning of occupational health care programmes (El Batawi, 1974:7). Thus defined, small industr ies contribute considerably to indus t r i a l production and employ a large part of the tota l work force in both the emerging countries and the developed countries. In India the population engaged in cottage and small industr ies i s estimated at 8.4 m i l l i on compared to 2.2 m i l l i on in large-scale production. In Indonesia 94 percent are engaged in small plants among 3 m i l l i on people working in the manufacturing 50 industry. In Argentina 78 percent of a l l i ndus t r i a l s i tes employ between 10 and 50 workers. Elsewhere, in the technological ly advanced nations, the proportion of i ndus t r i a l operations with fewer than 50 persons i s : France 90 percent, Sweden 70 percent, Switzerland 73 percent and the United States 48 percent (El Batawi, 1974:7). In contrast with the large scale indust r ies , which now recognize the need to maintain a healthy productive workforce, these small enterpr ises, espec ia l ly in the developing countries rarely have access to health f a c i l i t i e s . The indiv idual establishments are e i ther too small to organize a service or are often too poor to afford i t . Yet the hazards of these small plants can be serious. Besides the health problems, the small industr ies are often caught in a legal dilemma over which government departments are responsible for them. Workers exposed to occupational hazards are supposed to be protected by law in most countr ies, but there have been many fa i l u re s in the appl icat ion of legal provisions for them. ...even in some of the highly i ndus t r i a l i zed countries, the l eg i s l a t i on may be administered by d i f fe rent governmental bodies concerned with health, labour, industry, soc ia l secur i ty , and pensions (El Batawi, 1974:6). With theoret i ca l l y adequate l e g i s l a t i o n , small industr ies s t i l l su f fer the most. Their numbers alone, and the i r 51 wide d i s t r ibu t ion make i t impossible for health and labour inspectors to cover them s a t i s f a c t o r i l y . Apart from a chronic manpower shortage of health personnel, the problem of introducing control measures becomes a f rus t rat ing experience. The conditions and layout of the work often defy any recognized environmental control methods. Moreover, many small-scale employers are techn ica l ly unable to appreciate the need for occupational health and safety measures or to i n s t a l l them - and the employees are ever fear fu l of los ing t he i r jobs. Added to these economic and administrative d i f f i c u l t i e s , the small industr ies in the developing countr ies, often encounter innumerable soc ia l problems of l im i ted education and low income. Furthermore, since labour unions in the th i rd world countries gain the i r strength from large concentrations of factory workers, they are of l i t t l e help-to the small plant workers. At the same time, the small scale operators do not merit recognition by the larger establishments. Therefore, neither from the workers' nor the employers' perspective have voices been raised to protest unsatisfactory working conditions (El Batawi, 1974:7). Since the p l i ght of the small industr ies has global appl icat ions, who then should speak for them? In 1971, a meeting of World Health Organization consultants took the i n i t i a t i v e and reviewed the health problems 52 of small industr ies in France, Sweden, the United Kingdom and the Soviet Union. They agreed that a study of a systematic approach to these problems was required in i ndus t r i a l i zed and developing countries a l i k e . Since then, WHO has assisted f i e l d studies on the environment and health conditions in small '. industr ies in a number of countries a l l over the world. The results of these studies were to be used in 1975 to prepare guidelines to ass i s t governments and health author i t ies in organizing adequate health services for those hitherto neglected small industr ies (El Batawi 1974:8). The only pract ica l approach would appear to: be the grouping of small firms in a shared occupational health serv ice, with accompanying strategies of t ra in ing and education for those involved: ... even with th i s arrangement, small plant health services would not l i k e l y be viable without some form of government support (Mastromatteo, 1977:25). Having touched upon a few of the immense problems pertaining to occupational health and safety on the internat ional scene, i t may be relevant, at th i s point, to study the objectives of the internat ional organizations concerned with these global issues. The question also a r i ses , how are the nations of the world facing the problems encountered by the i r working populations? 53 2.2 World Organizations The International Labour Organization (ILO) and the World Health Organization (WHO) have been the two most active internat ional organizations in occupational health and safety. International Labour Organizations Established by the Treaty of Ve r sa i l l e s , the International Labour Organization has been involved in worker health and safety since 1919 (Mastromatteo, 1977:17). In the years fol lowing i t s incept ion, th i s Body adopted 54 Conventions and 52 Recommendations d i r e c t l y related to occupational health and safety. One o f ' the more important of the Conventions requires a government to i n s t i t u t e a state factory inspection system. Among the Recommendations, there are spec i f i c ones pertaining to the establishment of occupational health services and control of workplace hazards (Ashford, 1976:515). In 1959, an occupational health service was defined in Recommendation 112 of the f o r t y - t h i r d session of the Geneva Conference of the International Labour Organization, as: A service established in or near a place of employment for the purpose of; (a) protecting the workers against any health hazard which may ar i se out of the i r work or conditions in which i t i s carr ied out; 54 (b) contr ibut ing towards the workers' physical and mental adjustment, in par t i cu la r by the adaptation of the work to the workers and the i r assignment to jobs for which they are su i ted; and (c) contr ibuting to the establishment and maintenance of the highest possible degree of physical and mental well-being of the workers (Gauvin, 1968:322). More recent ly, the International Labour Organization has adopted Conventions on occupational cancer, a i r po l l u t i on , and noise and v ibrat ion at work (Mastromatteo, 1977:17). The hope i s that extensive adoption of these Conventions and Recommendations in the i ndus t r i a l i zed world would inst igate uniform safety standards and work pract ices. Among i t s other a c t i v i t i e s , the International Labour Organization i s known for f a c i l i t a t i n g the exchange of information and operating technical assistance programs in countries who seek i t s help (Ashford, 1976:516). The World Health Organization The World Health Organization has strongly promoted occupational health since 1948. Its objectives are s imi la r to the International Labour Organization 's. It believes that occupational health encompasses not only the prevention of injury and occupational disease, but takes into account the workers' phys ica l , mental and socia l well-being o f f and on the job. Like •55 the International Labour Organization, the World Health Organization offers d i rec t sc ient i f i c -med ica l assistance to member countries. However, ph i losophica l ly the two organizations have d i f fe rent approaches. Unlike the International Labour Organization, the World Health Organization i s committed to the un i f i ca t ion of occupational and general health care. Hence, i t advocates a central health authority in governments, whereas the International Labour Organization would separate occupational health and general health in the i r respective departments of labour and public health (Ashford, 1976:516). In another area, the World Health Organization has been responsible for development of c r i t e r i a documents on many important indus t r i a l substances (Mastromatteo, 1977:18). Despite the i r d i f fe rent approaches, there i s no doubt that both the International Labour Organization and the World Health Organization have contributed much to the exchange of information and sc ient i f i c -med ica l expert ise, and have greatly influenced the sett ing of international standards in occupational health and safety. There are other world bodies which have been involved in concerns of the environment. The European Economic Community, so f a r , has focussed on developing uniform standards for the general environ-ment but with less emphasis on the work environment. The Organization for Economic Cooperation and Development i s also beginning to rea l i ze the importance of environmental and qua l i t y - o f - 1 i f e issues. The United Nations Conference on the Environment, l i k e the others, 56 concentrate on the general environment rather than on the occupational environment (Ashford, 1976:516). However, the importance of a l l these internat ional bodies should not be underestimated. Global issues such as nuclear f a l l - o u t and acid ra in require internat ional cooperation, and the presence of these organizations augurs well for the future. Yet another group of internat ional organizations on health matters, deal with the special dangers of rad ia t ion. This group comprises; The International Gommission on Radiological Protect ion, (TCRP) The WHO International Reference Centre on Environmental Radiation, United Nations S c i e n t i f i c Committee on the Effects of Atomic Radiation, The International Labour Organization and the International Radiation Protection Associat ion, a l l of which attest to the need for radiat ion protection and standards (Will iams, R., 1977:13-14). Among these internat ional agencies, the International Commission on Radiological Protect ion, formed in the 1920's, commands great esteem: Its various radiat ion protection recommendations form the basis for the regulat ions, norms, standards, codes and laws issued by other i n t e r -national organizations as well as by national governments (Will iams, R., 1977:14). Because radiobiology experts from a l l over the world part ic ipate in i t s committees, th i s prestigious Body's recommendations have become very close to internat ional consensus standards. 2.3 Occupational Health in Selected Industr ia l ized Nations Among the i ndus t r i a l i zed nations today, there are many governments demonstrating the i r concern with hazards that a f fect t he i r populations, by passing laws and implementing programs both in the occupational and general environments. Though they share s imi la r concerns about combatting the harmful ef fects of indus t r ia l pol lutants Their governments d i f f e r in s ty le and approach, r e f l e c t i ng the s o c i o - p o l i t i c a l values indigenous to the i r soc iet ies (Bates, D.V., 1977:7). In a background study for the Science Council of Canada, examining how the three governments of the United Kingdom, the United States and Sweden regulated and control led exposure to s ix human health hazards, (mercury, oxides of nitrogen, v inyl ch lo r ide, asbestos, lead and radiat ion) Roger Williams (1977:10) had th i s to say: It has not been possible to treat the countries concerned in an exactly s im i la r comparative, fashion - t he i r differences are simply too great to permit t h i s . Nor has i t been possible to deal equally with each of the s ix hazards, both because the countries themselves have not dealt equally with them, but because the information to hand tends to be d i f fe rent in kind and unequal in amount. In the fol lowing pages a b r i e f descr ipt ion of occupational health services within the major world powers i s presented, not for the purpose of comparison, but with a view to understanding how occupational health problems are perceived and dealt with in these countries. As w e l l , some aspects or approaches of certa in countries may have appl icat ion to the Canadian scene. To th i s end, the l e ga l , 58 administrative and technical aspects of occupational programs are considered in capsule form for the fol lowing nations; France, Germany, Great B r i t a i n , Japan, the Soviet Union, the United States and the Scandanavian countries. France The Occupational Health Services was leg i s la ted in France in 1946. This program applies to a l l employers in France and includes workers on the farm, in the mines, factor ies and commercial establishments. Companies are required by law to provide one hour per month of physician time for each 10 factory workers or 20 o f f i ce workers. The employers pay the f u l l cost of th i s service. Small firms requir ing less than 32 hours per month may obtain prorated occupational physician services from inter-company groups. These inter-company groups have government and union representatives on the i r boards (Mastromatteo, 1977:7-8). A l l workers have compulsory pre-employment and periodic examinations. The interva l s for periodic examinations are determined by the occupational physicians who assess the degree of r i sk encountered by the i nd i v idua l . The purpose for these examinations, when the law was f i r s t enacted, was to protect the general health of workers, when p r i o r i t y was placed on reconstruction a f te r World War I I, and the need for a healthy labour force. 59 Occupational physicians i n France must have a postgraduate diploma in Occupational Medicine, however, the i r duties include only preventive medicine. They cannot provide primary care, hence: This has tended to impede the development of comprehensive occupational health services (Mastromatteo, 1977:7). Augmenting the Occupational Health Services ' program are the medical labour inspectors in the Ministry of Labour who ass i s t in development and enforcement of health standards. Yet another ministry involved i s the Social Security Agency which has a medical s t a f f who deal with claims adjustment and r ehab i l i t a t i on . This agency has i t s own inspectorate and can levy special assessments for employers contravening safety and health requirements. Furthermore, Social Security funds support a National Research Inst i tute in Occupational Safety and Health (Mastromatteo, 1977:8). Germany The Federal Republic of Germany passed l e g i s l a t i o n in recent years requir ing firms to employ medical and safety experts. Occupational Medical Services are administered through the Department of Labour and Social Order. To supply these services with the necessary physicians, engineers and other health s pec i a l i s t s , a major manpower t ra in ing program i s under way. At the plant l e v e l , j o i n t occupational safety and health committees have been operative for many years. Of added in te res t , insurance companies in Germany, besides the governmental agencies, are involved in sett ing standards and conducting inspections for the i r members (Mastromatteo, 1977:13). Great B r i t a i n State involvement in occupational health and safety in the United Kingdom dates from the early 1800's. Though there have been former Public Health Acts during the Industr ial Revolution, dealing mainly with san i ta t ion , the most recent ones af fect ing workers and the general publ ic were passed in 1974. These are the Health and Safety at Work Act and the Control of Po l lut ion Act (Halsbury, 1975: 1083). The Health and Safety at Work Act i s based to a great extent on the work of the Committee on Safety and Health at Work, chaired by Lord Robens and reported in 1972 (Robens Report). Part I of the Act provides fo r : ...one comprehensive and integrated system of law dealing with the health, safety and work a c t i v i t i e s of work people and the health and safety of the public as affected by work a c t i v i t i e s ; and to estab l i sh a Health and Safety Commission and Executive to be generally responsible for administering "the relevant statutory. "provis ions" (Halsbury, 1975:1083). The Health and Safety Commission comprises an independent chairman, three union members, three employer nominees, two loca l authority nominees and one member from the non-governmental safety organizations. Though i t i s independent of government, i t i s 61 responsible to Parliament through the relevant Minister (Employment, Public Health). Its mandate includes; general administration of the Act, promotion of research, proposing of new regulat ions, and provision of an advisory and information service (Will iams, 1977:25). The commission's operating arm i s the Executive which consists of three persons appointed by the commission, with one person designated as d i rector (Halsbury, 1975:1094). The Executive combines the former inspectorates of Factor ies, Mines and Quarries, Nuclear I n s ta l l a t i on s , A l ka l i and Clean A i r , and Explosives. It also includes the Safety in Mines Research Establishment and the Employment Medical Advisory Service. The Executive has some 1400 inspectors who operate from 18 regional o f f i ces (Will iams, 1977:26). Reporting for the Science Council of Canada, Roger Wil l iams, (1977:26) wr i tes: The scope of the new Act i s uniquely comprehensive. It protects some f i ve m i l l i o n employees not covered by previous l e g i s l a t i o n , and i n e f f e c t , v i r t u a l l y a l l workplaces and a l l people at work are now included. Further, the general publ ic is to be protected and informed about hazardous a c t i v i t y which might a f fect them: It has therefore in e f f e c t , been accepted in B r i t a i n , that there should be no' sharp d i s t i n c t i on between the work place and the general environment so far as the regulation of hazards is concerned (Will iams, 1977:26). However, the mechanics of working th i s out between the local authority and the government authority are as yet unclear. 62 Part II of the Act under the t i t l e Employment, re-enacts certa in provisions of the Employment Medical Advisory Service Act of 1972 (Halsbury, 1975:1083). The Employment Medical Advisory Service, referred to above, provides advice on health aspects related to the workplace to governments, unions and employers. In add i t ion, i t i s responsible for carrying out periodic examinations of workers exposed to health hazards and ass i s t s in worker r ehab i l i t a t i on (Mastromatteo, 1977:6). At the workplace, the Health and Safety at Work Act provides for the establishment of j o i n t occupational safety and health committees. Physicians in the United Kingdom are employed by most of the larger firms to provide occupational health services (Mastromatteo, 1977:6). An interest ing feature of the B r i t i s h Act i s that i t i s an enabling one. It gives the minister and commission broad powers, subject to formal processes of consultat ion, to establ i sh and, as appropriate, to amend the Act ' s deta i led provis ions: ...The intention is to promote a system which can respond quickly and e f f ec t i ve l y to future technical and medical developments in the determination and control of hazards (Will iams, R., 1977:26). For th i s purpose, Regulations and Codes of pract ice are used: Regulations are subsidiary l e g i s l a t i on made under delegated powers and are, therefore, enforceable through the Courts v ia the criminal law...Codes of Practice are not l ega l l y binding in the same way as regulations (Will iams, 1977:27). The Robens Committee had;.'recommended that Codes were to be preferred to Regulations wherever poss ib le, hence: 6 3 There has been some c r i t i c i s m to the Robens Report in i t s approach to se l f - regu la t i on , se l f - in spect ion and the use of industry-wide codes of pract ice to replace deta i led governmental regulations (Mastromatteo, 1977:5). Nicholas Ashford, (1976:514) somewhat scept ica l of the f e a s i b i l i t y of se l f - regu lat ion at the federal l e v e l , ( i . e . warnings instead of f i r s t -instance sanctions, f l e x i b l e non-statutory work practices rather than r i g i d standards, the d iscret ionary power of inspectors) concedes: Both the National Ins t i tute of Safety and Health and The Occupational Safety and Health Administration spokesmen have praised the Robens Report and supported adopting of i t s recommendations in the United States -espec ia l l y the recommendation that " s e l f - r egu l a t i on " be the operating norm. A plan for health and safety committees in hospitals i s on the drawing board to be incorporated into The National Health Service. But because of the huge operating costs involved, i t has not as yet been implemented (Crichton, A. 1977). Japan The re spons ib i l i t y of occupational health protection in Japan is vested in the Industr ial Safety and Health Department in the Ministry of Labour. Also administered by the same Ministry i s the National Inst i tute of Occupational Health. Japanese f i rms, depending on the number of employees, are obliged to hire safety and health supervisors and indust r ia l physicians. As w e l l , they must establ i sh occupational safety and health committees. 64 A recent interest ing development in Japan i s the proposal to establ i sh a College of Occupational Medicine subsidized by the government (Mastromatteo, 1977:16). Soviet Union In Russia, there are Central Inst i tutes for Occupational Health administered by the Health Ministry and by the Trade Unions. These i n s t i t u te s develop health standards, and d i s t r i c t hygiene stations provide advice and consultation on occupational health (Mastromatteo, 1977:14). Dr. Nikolai Izmerov (1974:22), D i rector, Inst i tute of Work Hygiene and Occupational Diseases, Academy of Medical Sciences of the USSR, wr i t ing in World Health, said the f i r s t i n s t i t u t e for research in occupational diseases was set up in 1923 in Moscow to develop preventive act ion and promote health ier working and l i v i n g condit ions. It i s now part of the USSR Academy of Medical Sciences and i s responsible for research on work hygiene and occupational diseases. A set of "P r inc ip le s governing the Labour Legis lat ion of the USSR and the Union Republics" was adopted in January, 1971. Of pa r t i cu l a r importance in th i s new l e g i s l a t i on for the health protection of workers, i s the r ight to healthy and safe working conditions (Izmerov, 1974:25). Health care for workers i s provided by physicians employed by the State Health Services. They are usually located e i ther within 65 enterprises, depending on the i r s ize or in community centres. Inspection of enterprises i s done by the trade unions (Mastromatteo, 1977:14). Recent events in Russia show great str ides in worker safety and health. According to Izmerov (1974:22), in the chemical industry, mechanization and automation have been used to protect workers from harmful compounds. Highly e f fec t i ve vent i l a t ion systems are i n s t a l l ed in a l l f a c to r i e s , a l l apparati are hermetically sealed, and operations designed to run continuously have replaced those requir ing periodic stoppages. New chemicals are prohibited by law without pr io r authorizat ion from the s tate, the less toxic substances are used wherever possible. Following the attent ion given to working conditions in chemical p lants, serious cases of poisoning among workers have p r a c t i c a l l y disappeared from the USSR, and the incidence rates of chronic occupational poisoning have s tead i ly decreased. Carcinogenic substances are prohib ited, without exception (Izmerov, 1974:22). A l b e i t , in the Soviet Union, standards for airborne gases, vapours, dusts, f ibres and physical agents are set at a much lower leve l than those of the west, Mastromatteo (1977:14) postulates: In part, th i s i s due to differences in interpret ing harmful response in animals. and stated: Despite the published exposure standards, however, the level of airborne contaminants appeared much higher in the Soviet plants which I v i s i t e d . 66 United States of America The Occupational Safety and Health Act (OSHAct) in the United States was passed by congressional action in 1970 (United States Code, 1971:1852). This Act was the f i r s t comprehensive attempt by the federal government to assure safe and healthful working conditions for working men and women and to integrate former Acts re la t ing to occupational health. The safety and health standards promulgated under several previous laws for example, the Walsh-Healy Act of 1936, were deemed to be occupational safety and health standards issued under th i s Act, as well as under such other Acts (United States Code, 1971:1855). Pr ior to 1970, the federal government's involvement in i ndus t r i a l health and safety regulations of non-government employees was l imited to certa in industr ies such as maritime, construction and mining and certa in businesses with federal contracts. The primary regulation of industry was at the state level (Ashford, 1976:142): But the general pattern of neglect on the part of the states eventually led to federal action and the passage of the Occupational Safety and Health Act of 1970 (Ashford, 1976:51). Three main Agencies have been set up within the federal government to administer and enforce the Occupational Safety and Health Act. According to Ashford, (1976:144-145) these are; 1. The Occupational Health and Safety Administration (OSHA) i s located within the Department of Labour, and i s required to set standards and to conduct inspections of workplaces. It has the power to issue c i ta t ions against employers and to assess penalt ies for v i o l a t i on s . 2. The Occupational Safety and Health Review Commission i s an independent quasi-judicial review board which rules upon a l l challenged enforcement actions. I t consists of three members appointed to 6-year terms by the President. 3. The National Ins t i tute for Occupational Safety and Health (NIOSH) in the Department of Health, Education and Welfare (HEW) i s pr imar i ly a research body. It i s responsible for developing and recommending occupational safety and health standards. This Agency i s s p e c i f i c a l l y required to publish a l i s t of a l l known toxic substances and the concentrations at which these substances exh ib i t tox ic e f fec t s . In addit ion to these three Agencies, there i s a National Advisory Committee on Occupational Safety and Health (NACOSH) which consists of " representat ives" of management, labour, occupational safety and health, professionals and the publ ic . This agency i s required to advise, consult with and make recommendations to the Ministers of Labour and Health, Education and Welfare (Ashford, 1976:145). The Occupational Safety and Health Act was promoted by good intent ion - to reduce the annual rates of accidents and diseases of occupations (Will iams, 1977:65). Further: The OSHAct was a major l e g i s l a t i v e i n i t i a t i v e bringing v i r t u a l l y a l l employees in the U.S. under federal coverage, the vast majority of them for the f i r s t time (Will iams, 1977:65). 68 Be that as i t may, among other c r i t i c i s m s , two areas of weakness became apparent in the implementation of the Act. One was a case of "too much too f a s t , " the other, "too l i t t l e too slow." To i l l u s t r a t e , the "specia l duty" clause of the Occupational Safety and Health Act allows for adoption of ex i s t ing national consensus standards, (any occupational safety and health standard which has been so designated by the Secretary - United States Code, 1971:1854) within two years of the Act ' s coming into force. Some 170 ex i s t ing standards never intended to have the force of law were promulgated with in the two year period. It does not seem to have been much considered when the OSHAct was passed that neither the federal nor the consensus standards had received the scrutiny necessary i f they were to become lega l l y binding, and on the tota l workforce (Wil l iams, 1977:66). There were severe c r i t i c i sms that too many unsatisfactory s imp l i f i ca t i on s had been made when voluntary guidelines suddenly became s t a t u t o r y " - . standards. It now appears that the government rushed through l e g i s l a t i on in a complex technical f i e l d where i t had very l i t t l e previous experience. The second weakness in carrying out the Occupational Safety and Health Act seems to be a bureaucratic malaise which prevents or delays objectives being achieved. For example, the "general duty" clause pertaining to hazards states: This has been defined by the federal courts,and to succeed under i t OSHA must show the hazard in question could in p r inc ip le be el iminated, and that pract ica l means for e l iminat ing i t are at hand (Will iams, 1977:66). 69 Moreover, the Act provides for standards which must contain pa r t i cu la r sampling techniques, ana ly t i ca l methods, medical te s t s , work pract ices, monitoring and record keeping, and hazard warning arrangements as well as basic environmental l i m i t s . However, the standards taken over by the Occupational Safety and Health Administration were e s sent ia l l y environmental guides, and nothing more (Will iams, 1977:66). There seems to be a general i n e r t i a that has engulfed the implementation process of the Occupational Safety and Health Act. The root of the problem appears to be in the Occupational Safety and Health Administration: Since so few health standards have been adopted by OSHA and the enforcement of the general duty obl igat ion to provide a safe and healthful work-place i s not l i k e l y to be pursued, workers remain e s sent i a l l y unprotected from health hazards (Ashford, 1976:294). There i s also doubt that the Occupational Safety and Health Administration w i l l monitor the state programs e f f e c t i v e l y in the occupational health area because of i t s poor re lat ionsh ip with the National Inst i tute for Occupational Safety and Health. In an overview of " Industr ia l Medicine in the World", Mastromatteo (1977:15) mentions in the United States, the National Inst i tute of Occupational Safety and Health has submitted over 50 c r i t e r i a documents but r e l a t i v e l y few have been promulgated as standards by the Occupational Safety and Health Administration. Ashford (1976:295) had th i s to say: 70 OSHA has not taken any i n i t i a t i v e to act on NIOSH's p r i o r i t y l i s t of 113 tox ic substances or on the 1000 to 2000 tox ic substances and agents NI0SH deems s i gn i f i can t enough to require federal standards... and since OSHA has v i r t u a l l y no health expertise in-house, the problems of occupational health remains la rge ly ignored. Furthermore, the Occupational Safety and Health Administration has not undertaken a s i gn i f i can t program of information dissemination to workers or to the general publ ic . However, the Occupational Safety and Health Administration is to be reorganized and i t s previous po l i c i e s evaluated. Perhaps a new commitment and new p r i o r i t i e s may emerge (Ashford, 1976:299). The Scandanavian Countries Mention must be made of the developments in some of the Scandanavian countries. They are highly i ndus t r i a l i zed nations and have been for many years in the forefront of health del ivery systems. Sweden In Sweden, occupational health and safety issues are combined i n the National Board of Occupational Safety and Health which i s responsible to the Min ister of Labour. Swedish occupational safety l e g i s l a t i on dates back from an 1889 Act with the f i r s t labour inspectors being appointed in 1890. The Workers Protection Act of 1949 and the sett ing up of the National Board of Occupational Safety and Health in the same year became a 71 benchmark in Swedish soc ia l l e g i s l a t i on (Will iams, 1977:107). In 1970, a Work Environment Commission was appointed, and more recently Sweden has introduced l eg i s l a t i on requir ing the prescreening of chemicals used in industry (Mastromatteo, 1977:9). Recent l e g i s l a t i on also c a l l s for compulsory labour management cooperation. Worker safety delegates in each plant are empowered to assess safety and health r i s k s . The appointment of worker safety delegates has necessitated major t ra in ing programs to be set up (Mastromatteo, 1977:9). Central min i s t r ies are very small in Sweden. Consequently, they confine themselves to pol icy matters. Legis lat ion i s t y p i c a l l y developed by spec ia l l y appointed commissions. These commissions usually comprise 5-10 members selected from government and opposition pa r t ie s , labour and management, interested organizations and relevant professions. The Swedish system has some disadvantages and some advantages. On the one hand, i t i s time-consuming and cumbersome., For example,after several years in closed session the commissions present t he i r reports to parliament. On the other hand, the process i s thought worthwile to promote democratic government, with a uniquely thorough and mature consensual approach (Will iams, 1977:108). However one assesses the Swedish system, one must concede by internat ional standards, the Swedes are among the health iest peoples, in the world. 72 A quotation used by Roger Williams in the background study for the Science Council of Canada in comparing the occupational and general environment regulations in the United Kingdom, United States and Sweden, says: " I f countries were c l a s s i f i e d according to: (1) t he i r wi l l ingness to spend money on the environment; (2) the i r economic wea l th . . . . ; (3) anti po l lu t ion laws; and (4) the needed public support to help government agencies carry out the i r work; then Scandanavia would ce r ta in l y be in class A with Sweden at the top". (Wil l iams, October, 1977:107). There are some or ig ina l funding schemes in occupational health care that merit attent ion. A Swedish Work Environment Fund, raised by an indust r ia l payrol l assessment of a l l employers in Sweden, including government enterpr ises, provides monies for research to prevent occupational i n ju r i e s and diseases. In another area, Swedish Health Insurance Funds are used to subsidize up to 50 percent of the medical and nursing costs for occupational health services in small plants. This has provided a powerful incentive for employers of small firms to establ i sh occupational health c l i n i c s (Mastromatteo, 1977:9). A recent interest ing event with powerful impl icat ions for occupational and environmental considerations was Sweden's democratic vote on March 23, 1980 for more nuclear power generation. A tota l of 58 percent were in favour of bringing s ix more reactors into operation. However, two-thirds of them added that a l l twelve reactors 73 should be phased out in 25 years and other energy sources made ava i lab le. Though 39 percent of the voters indicated a wi l l ingness to accept a lower standard of l i v i n g , the majority vote indicated that national need can enhance the respectab i l i t y of th i s controvers ial energy source (Province, the Vancouver E d i t o r i a l , 25 March, 1980:B1). Finland The approach to occupational health services in Finland generally fol lows the Nordic pattern. The National Board of Health and the National Board of Labour Protection co-operate and report to the Minister of Social A f f a i r s and Health. According to Mastromatteo (1977:10), every place of work with more than 20 employees must have an occupational safety and health committee. Under Finnish law, the employer provides pre-employment health examinations and periodic screening for workers exposed to hazards. Depending on the s ize of the f i rm, the employer may select the type of medical service that suits him, whether i t i s independent occupational health serv ices, j o i n t occupational services with other enterpr i ses, pr ivate physician pract ice or community health centres. In Finland, as in Sweden, employers may be p a r t i a l l y reimbursed (up to 60 percent) for occupational expenditures from the Sickness Insurance Fund (Mastromatteo, 1977:11). 74 In studying the major character i s t i c s of the occupational health services in the European countr ies, Nicholas Ashford (1976:509) compares the American scene with the European approach. His summarized observations may have some s ign i f icance to Canadians as they contemplate the i r own occupational health e f f o r t s . Dr. Ashford found in many European health services that; 1. Leadership in the various agencies responsible for occupational health and safety has the necessary health and safety expert ise. 2. The counterpart of the National Inst i tute of Occupational Safety and Health (U.S.) i s at a higher organizational level within government - or i s an independent organization. 3. Where a national organization ex i s t s , i t s capab i l i t y makes research relevant to c r i t i c a l occupational health and safety problems. 4. The government consults with the employers, and f i r s t - i n s t ance c i ta t i on s are infrequent. Warnings and improvement notices are the major enforcement mechanisms. 5. Standards are generally regarded as guidel ines, and the inspector has d iscret ionary power. 6. The inspectors are more specia l ized and are better trained than the i r American counterparts. 7. Physicians are very often part of the inspectorate system. 8. There are legal requirements for occupational health services in the workplace, or in case of small f i rms, for par t i c ipat ion in a j o i n t medical serv ice. 75 9. Occupational disease has been recognized for many more years in Europe than in the United States. Therefore, i t has figured extensively in compensation and control purposes. 10. Safety and health have an equal emphasis. 11. Since occupational disease is compensable, employers respond well to economic incentives that remove health hazards on the job. 12. A major portion of the workforce i s organized. 13. Either works' councils or j o i n t health and safety committees, even for small f i rms, are generally mandated by law. 14. Employers and employees generally accept health and safety to be a j o i n t r e spons ib i l i t y . 15. Employers and employees are usually equally represented in the agencies and organizations responsible for occupational health and safety. 16. Co l lec t i ve bargaining i s often done at the federation rather than at the plant l e v e l . 17. There i s a great national commitment to provide a safe and healthy workplace and a great sense of f a i r play. 18. Preventive medicine plays a prominent ro le in job health and safety. 19. Industr ial hygiene i s incorporated within the duties of the plant physician or safety engineer as part of the i r expert ise. I t i s not developed as a spec ia l ty as i s the case in the United States. 20. Ergonomic factors that are conducive to both the mental and physical well-being of the workers receive considerable at tent ion. 76 21. The transfer of ideas on workplace safety occurs read i ly across national boundaries. 22. Great importance i s given to internat ional cooperation and the need to agree on standards and work pract ices. 2.4 The Developing Countries The concept of occupational health and safety i s s t i l l f a i r l y new in the emerging nations of the world. The major obstacles of lack of knowledge and t ra in ing in modern health matters, cu l tura l differences arid often poor economy are l i k e l y to impede progress in t h i s f i e l d . But preventing occupational i n j u r i e s and disease i s ju s t as v i t a l in the developing countries as i t i s in the highly i ndus t r i a l i zed countries. Within the global v i l l a ge the nations have a re spons ib i l i t y to work together for the betterment of the world 's population. Having over two hundred years lead time, the developed countries must show the way. Workers in the small industr ies in these developing nations have almost insurmountable problems. These problems were discussed in a preceding section on the " International Scene." The world ' s economy i s s t i l l largely a g r i c u l t u r a l , and agr icu l ture s t i l l dominates the developing regions. Three quarters of the working population in the world are engaged in ag r i cu l tu re , though th i s proportion varies in advanced and developing countr ies. A substantial part of the rural population in Asia and 77 and A f r i ca 1 ives and works under the conditions of a developing society (Macuh, P., 1974:10). Though occupational health problems in agr icu l ture are not the same everywhere, nations that have been oppressed and exploited for centuries have not attained the leve l of ag r i cu l tu ra l development enjoyed by t he i r more af f luent counterparts in the rest of the world. These more pr imit ive soc iet ies are s t i l l plagued by infect ious diseases such as zoonosis and tuberculosis as well as pa ra s i t i c diseases, and: ...although somewhat on the dec l ine, are s t i l l a real hazard for rural populations engaged in ag r i cu l tu re , espec ia l ly in the developing countries (Macuh, 1974:13). Proper protective and preventive measures are required, along with adequate ins t ruct ions . Dr. Mastromatteo (1977:16) suggests: Technical co-operation assistance to developing countries should f i r s t emphasize the development of basic information and basic i n f r a structure rather than the i n s t a l l a t i o n of sophist icated ana lyt ic equipment. Since ag r i cu l tu ra l production i s cont inual ly increasing to meet world demand, i t i s important to do everything possible to protect the health of the people who produce food. There i s much that needs to be done in the developing countries. There i s much that can be done for them by the developed nations. Continued exp lo i ta t ion i s unjust. Merely sharing technology i s i n s u f f i c i e n t . A real concern for the d ign i ty , welfare and health of the th i rd world countries must be demonstrated by the "have" nations. This f i n a l 78 point i s c ruc ia l to the success of any soc ia l or economic program directed towards the protection of the emerging countries. In th i s way a l l nations can benefit with in the "global v i l l a g e " . Conclusion A p r o f i l e of occupational health in various countries has revealed that the workers' health i s indeed a global concern, not only in the i ndus t r i a l i zed nations but in other parts of the world. The many world organizations r e f l e c t th i s global r e spons ib i l i t y and ind iv iduals are beginning to rea l i ze that "no man i s an i s l and " . 79 CHAPTER 3 THE CANADIAN EXPERIENCE IN OCCUPATIONAL HEALTH There is a new awareness of occupational health and safety in Canada today. David Chisholm (1977b: 1), Long Range Planning Branch, Department of National Health and Welfare, says in a discussion paper on Occupational Health and Safety: After languishing in the shadows of public health and health care advancements during the past several decades, and the more recent concerns for the general environmental qua l i ty and i t s impact on health, the f i e l d of occupational health and safety has cDme a l i ve in the mid-1970 1s. This long overdue pub l i c , government, labour, management, profess ional , and s c i e n t i f i c in teres t has been accelerated by the increased recognition of the contr ibut ion of the workplace to physical and mental health problems. Nevertheless, c red i t must be given where governments have taken protective action on such hazards as asbestos, lead, mercury, oxides of nitrogen, rad iat ion and v iny l ch lor ide. For example, in the case of lead: Government actions within Canada have taken a var iety of forms: drinking water standards, maximum permissible levels of lead in commercially-ava i lable foods, consumer protection prohibit ions on, for example, paint and toys, occupational guidelines on threshold l i m i t values, emissions and ambient a i r qua l i ty standards, and establishment of expert committees and task forces. The major mining, smelting and manufacturing industr ies have i n s t a l l ed control technology to reduce emissions both within and outside t he i r operations and have made ava i lab le protect ive equipment to be used by the i r workforce. Organized labour and public safety groups have publ ic ized the hazardous conditions to which people are subjected through c o l l e c t i v e bargaining demands and prosecution of po l l u te r s , and have thereby prec ip i tated government action at both the prov inc ia l and federal levels (Science Council of Canada No.28, October, 1977:17-18). Economics, employer apathy, lack of knowledge of hazards, inconsistent government controls a l l have played the i r part in delaying worker protect ion. Compounding the s i t ua t i on , the acceleration of technology has contributed greatly to the confusion and delay. For one th ing, there are technological advances today that enable f i ne r and more accurate measurements of pa r t i c le s and trace metals in the ambient environment than was possible previously Hence, guidelines followed in the past may no longer be relevant today. Since the experts do not always agree, they tend to avoid de f i n i t i v e stands which deter rapid pronouncements in changing s i tuat ions (Stopps, J . , 1976:65-66). This perhaps accounts for the statement: ...acceptance of occupational health has not kept pace with the increase in knowledge of potential or real health hazards, of our enhanced s k i l l s and methods for diagnosis of occupational diseases, nor of methods for control of the working environment....(Watkinson, E.A., 1976:7). 3.1 Occupational Health Status Simultaneously looking back at some accomplishments in the f i e l d of occupational health and safety, and ant ic ipat ing future action in th i s d i r e c t i on , Health and Welfare, Canada has th i s to say 81 During the past century improvements in working conditions and the qual i ty of working l i f e in Canada have been considerable, r e f l ec t i ng concerns and e f fo r t s by governments, profess ionals, management and labour. Leg i s lat ive and regulatory act ion, although complex and uneven, at times have been substant ia l , as have been the e f fo r t s and achievements in safety protection and education, occupational health serv ices, and workers' compensation. Nevertheless, the rapid development of new physical hazards to which increasing numbers of workers are potent ia l l y exposed has reemphasized, and accelerated interest i n , these concerns about worker health. Even more apparent are the adverse effects of psycho-social factors ubiquitous to. . many occupations yet intimately l inked to community l i f e and personal l i f e s t y l e character i s t ic s (Occupational Health in Canada - Current Status, 1977:48). The Canadian status in occupational health and safety w i l l be reviewed b r i e f l y under the headings; events, laws and programs. 3.1.1 Events The working document, "A New Perspective on the Health of Canadians" (Lalonde, 1974) served as a great impetus for promoting the preventive aspects of health care in Canada. The Health F ie ld Concept (Human Biology, Environment, L i f e s t y le and Health Care Organization) which i s introduced in the publ icat ion i s comprehensive enough to involve occupational health and safety under any one of the d iv i s i ons , but pa r t i cu l a r l y under Environment. This category comprises: . . . a l l those matters related to health which are external to the human body and over which the ind iv idual has l i t t l e or no control. . . (Lalonde, 1974:32). 82 To further stimulate those interested in the area of occupational health and safety, they perhaps may take ser iously the statement: . . . F i n a l l y , the Health F ie ld Concept provides a new perspective on health, a perspective which frees creative minds for recognition and exploration of h i therto neglected f i e ld s (Lalonde, 1974:33). Cl ive Dennis (1976:64), Executive Director, The P ra i r i e Inst i tute of Environmental Health, refer r ing to the document, said i t : . . . i s t ru ly an outstanding exposition of health needs and no occupational health s pec i a l i s t should f a i l to digest th i s document and apply i t s concept ; to occupational health. Each characte r i s t i c of the Health F i e ld Concept i s int imately related to health and safety in the workplace... One c r i t i c of the Lalonde Report (McEwan, D., 1979), feels a f te r f i ve years since i t s publ icat ion there has been no pos i t ive action or follow through by the federal government in atta in ing i t s objectives - that i t s health promotional a c t i v i t i e s are of doubtful value. At present, there appears to be no federal plan for further implementation of the document. Given the d iv i s ion of powers vested in the Canadian cons t i tu t ion , the provinces w i l l most l i k e l y be l e f t with the strategies of implementation. Did the Lalonde Report merely ident i f y needs and provide the vision? Or was i t the f i r s t step in an overal l grand design for a prevention program in health care for Canada? 83 The rebi r th of in teres t in occupational health and safety was further sparked when: Occupational health was i d e n t i f i e d as a p r i o r i t y issue by the Federal and Prov inc ia l Deputy Ministers of Health i n June, 1975 (Chisholm, 1976:1). possibly f ue l l ed by some accident s t a t i s t i c s furnished by Labour Canada for 1975 (Figure T, Table 2). As momentum continued to gather, the Canadian Publ ic Health Association took an important step forward in occupational health in Canada. It organized the f i r s t National Conference on Occupational Health in 1976 in Toronto. Representatives from industry, labour, government, law, various health d i s c ip l i nes and the general publ ic attended. The conference placed the seal of approval on occupational health services and programs as an integral part of health services and health care (Canadian Journal of Public Health, Sept/Oct. 1976). Another step forward took place in 1978 in Ottawa, with the establishment of the Canadian Centre for Occupational Health and Safety. This centre was set up i n i t i a l l y to promote occupational health and safety on the job-, in an e f f o r t to reduce loss of work time (CPHA Newsletter, October,1978:4). To insure an unbiased approach to occupational issues, the centre was established as an independent self-governing body which reports to Parliament but i s part of no government department or agency. I t i s guided by three main p r i nc i p l e s : Figure 1 Man-Days Lost: Strikes vs. Injuries Man-days lost due to strikes ^ ^ ^ ^ and lockouts *"™"^™" compared to injuries (excluding fatalities). Canadian figures in millions of man-days. 12 10 • 8 6 4 2 I I I I I I I 1968 1970 1972 1974 Occupational Safety and Health Directorate Canada Labour, Ottawa Table 2 COMPARISON OF OVERALL INJURY INCIDENCE RATE AND DISABLING INJURY FREQUENCY RATE - for industries under Federal jurisdiction By Province Injury Incidence per 100 Employees Disabling Injury Frequency Rate By Industry Division Injury Incidence Per 100 Employees Disabling Injury Frequency Rate Nova Scotia 31.57 72.17 1. Air Transport 14.26 18.62 Newfoundland 5.42 13.47 2. Banking 0.64 0.80 New Brunswick 27.90 19.97 3. Bridges and Tunnels 13.81 20.00 Prince Edward Island 2.27 1.88 4. Broadcasting 4.79 6.15 Quebec 15.16 14.93 5. Communications 5.15 4.78 Ontario 10.49 17.94 6. Crown Corporations 20.90 36.50 Manitoba 19.09 24.25 7. Feed. Flour and Seed 19.59 31.92 Saskatchewan 12.36 17.57 8. Grain Elevators 23.73 27.74 Alberta 20.10 23.41 9. Longshoring 45.25 43.24 Northwest Territories 21.30 30.81 10. Mining 74.08 165.29 British Columbia 12.65 16.27 11.Pipelines 8.13 8.78 Yukon Territory 24.07 60.58 12.Postal Contractors 9.72 10.94 Canada Total 14.43 19.57 13. Railways 14. Road Transport 30.12 23.10 17.39 55.54 15.Water Transport 16.30 25.40 Canada Total 14.43 19.57 Disabling Injury Frequency Rate » Number of disabling work injuries x 1,000,000 man-hours worked Source: Occupational Safety and Health Directorate, Labour Canada, 1975 86 (a) The desire to work openly and provide information f ree ly . (b) To support research in order to provide facts without value judgments. (c) To maintain i t s independence so that i t may speak out strongly on v i t a l issues (Canadian Nurses Associat ion, October 1978:3). The council of governors has an equal number of representatives from labour and industry. Each province and t e r r i t o r y receives representation and the federal government has four members - a tota l of 39. The purpose of the centre i s to serve as l i a i s o n , nat ional ly and i n t e r -nat iona l l y , with a l l agencies, groups and indiv iduals concerned with hazards in the workplace .- i t s main concern is to promote safety at work (Law, C.E., Financial Post, March 10, 1979:12). During i t s formative year, the Canadian Centre for Occupational Health and Safety maintained a low p r o f i l e . However, i t appears to be gearing into action according to a few news releases. The Council i s preparing to host the Tr iennial World Congress for the Prevention of Accidents and I l lness at Work in 1983 (Law, C.E., March 10, 1979: 12). In May, 1980, David Cohen a spokesman for the Centre, announced a computerized occupational health hazard information service w i l l be set up at an i n i t i a l cost of $1.5 m i l l i o n . The idea of the service i s to put information on rad iat ion, chemical hazards, safety regulations and spec i f i c background on r i sks in the workplace, d i r e c t l y into the hands of the Canadian workers so that they can make 87 informed decisions on what affects them (Vancouver Sun,: May 30, 1980:A3). The Canadian Centre for Occupational Health and Safety has great potential to act as a cata lyst in the maturation process of occupational health in Canada. Furthermore, this national Body could f a c i l i t a t e a smooth implementation of occupational health and safety l e g i s l a t i on at a l l levels of government in Canada. Further evidence of heightened interest in occupational health and safety has; been; The Science Council of Canada's research and studies on exposure to hazards, 1977, and the f i r s t conference of the Council on Protective Equipment for Canadian Workers (COPE) in 1978. Events such as these and others a l l at test to a growing concern in Canada of the health factors and health effects that are int imately involved with the well being of a l l working Canadians and the general publ ic . As the decade of the 80's begins, the future looks br ight. 3.1.2 Laws The subject of laws i s indeed a very extensive and complicated one. Apart from acknowledging the difference between laws regarded as indiv idual j u s t i ce in common law, and l e g i s l a t i on of groups by statute law or other methods of regulat ion, this section w i l l deal exc lus ive ly with statute law as i t affects workers' health. 88 Concerning the health of Canadian workers, the current swing to prevention requires support at a l l l e ve l s , systematical ly including l e g i s l a t i o n , resource a l locat ion and planning. Reinforcing th i s statement, Sutt ie B. (1976:8) says: However more v i s i b l e the rewards of treatment over those of prevention may be, we dare not with impunity ignore the need for a greatly increased e f f o r t in the prevention of occupational and environmental health hazards. Leg is lat ion concerning prevention of hazards and worker protection is highly varied in Canada. To understand the process, i t i s necessary to go back into h istory. In the B r i t i s h North America Act (1867) there i s no term of reference to health r e spon s i b i l i -t ies in the Powers of Parliament other than (a) "Quarantine and the Establishment and Maintenance of Marine Hospitals" and (b) " Indians, and Lands reserved for the Indians" (B r i t i sh North America Acts, Consolidated, 1967:25). This has enabled each prov inc ia l l eg i s l a tu re to make exclusive laws in re lat ion to certain classes of subjects such as "Hosp i ta l s " , "Local Works" and other "Matters of a merely local or pr ivate Nature in the Province" (B.N.A. Acts, Consolidated, 1967:27-28). This explains why occupational health and safety leg i s lat ion may be covered,by d i f fe rent departments in various min i s t r ies and why man-made hazards a f fect ing working people and the general population are subject to a wide var iety of l e g i s l a t i v e controls at the federal and prov inc ia l l eve l s . 89 In a background study for the Science Council of Canada, Robert Franson et al (1977:27) c l a s s i f i e d the relevant leg i s lat ion., into ten categories: 1. General po l lu t ion control statutes; 2. Industr ia l safety, workers' compensation and occupational health l e g i s l a t i o n ; 3. Special statutes dealing with pa r t i cu la r contaminants; 4. Motor vehicle statutes; 5. Publ ic Health statutes; 6. Food and Drug statutes; 7. General Contaminants statutes; 8. Statutes regulating development and use of pa r t i cu la r resources; 9. Statutes regulating spec i f i c indust r ies ; 10. Consumer safety statutes. Within these ten categories, there i s much dupl icat ion and overlapping between categories, between provinces and in re lat ion to the federal statutes. However, under the category, Industr ial Safety, Workers' Compensation and Occupational Health Statutes, most provinces have protection laws for workers in one ministry or another. A l l provinces as well as the federal government have enacted indust r ia l safety l e g i s l a t i on (Franson et al 1977:29-30). 90 According to Health and Welfare Canada's pub l i cat ion, "Occupational Health in Canada - Current Status" (June, 1977), there are s i x prov inc ia l governments thatconsol idate most occupational health and safety a c t i v i t i e s in the Department of Labour. These are A lberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia and Ontario. Three provinces, namely, B r i t i s h Columbia, Newfoundland and Prince Edward Island delegate most occupational health and safety a c t i v i t y to the Workers' Compensation Board. Quebec as yet has no s ingle focal point for overal l occupational health and safety. However, i t appears that the Province of Quebec i s leaning towards the Health Min i s t ry , by organizing occupational medicine programs in community health centres (Chisholm, 1977a:190). Recent important developments have been the Saskatchewan Occupational Health Act of 1972, the Alberta Occupational Health and Safety Act of 1976 and the Manitoba Workplace Safety and Health Act of 1977 (Occupational Health in Canada - Current Status, 1977). Newfoundland and the federal government adopted s im i l a r l e g i s l a t i on short ly a f t e r , and Ontario and Quebec are introducing l e g i s l a t i on in the near future (Rabinovitch, 1979:22). It i s in terest ing to note the provision and administration of the Federal Publ ic Service Health Program enta i l s the cooperation of several departments. The Treasury Board develops and provides standards governing the health, safety and physical working conditions of employees. The Department of National Health and Welfare, supported 91 by the i r resources throughout Canada and abroad, i s responsible for the provis ion of appropriate technical advice and for the supervis ion, organization and operation of the Program. The Department of Labour, in addition to i t s safety inspection serv ices, acts in an advisory and technical capacity (Occupational Health and Safety, 1974:16). Excluding the Te r r i t o r i e s , which rely on Ordinances (Occupational Health in Canada - Current Status, 1977:65), the tota l Canadian occupational health scene emerges with a complex assortment of l e g i s l a t i o n , regulations and enforcement procedures under a var iety of administrations..in eleven d i f fe rent j u r i s d i c t i on s . Further discussion on laws w i l l be presented in succeeding pages, under "Issues." 3.1.3 Programs Comprehensive occupational health and safety programs in Canada which include safety, indust r ia l s hygiene and employee health serv ices, are usually found in large establishments (over 500 employees). Examples of these are the u t i l i t i e s (Bel l Canada), petroleum industr ies (Imperial O i l ) , chemical processors (Dow Chemical), e lectronics (General E l e c t r i c ) , motor vehicle manufacturers (General Motors), major a i r and transport companies (Canadian P a c i f i c ) , large steel processors (Ste lco), m i l i t a r y serv ices, major mining companies(Inco), some central o f f i ces of insurance companies (Metropolitan L i f e ) , and governments (Federal, 92 Provinces of Ontario, B r i t i s h Columbia and A lberta, and the City of Vancouver).(Occupational Health in Canada - Current Status, 1977:46). Employee health services in Canadian firms follow no par t i cu la r pattern. Po l i c ie s are as varied as the services they o f fe r . Most large enterprises have some features of an internal employee health service and provide on-s ite f a c i l i t i e s with a company physic ian, f u l l or part-t ime. Medium and small firms tend to contract out for physician serv ice, ch ie f l y for medical examinations. I t i s believed that most medium and small enterprises provide no health service at a l l . A tota l of 1,500 nurses and an unknown number of physicians are pract i s ing within employee health services (Occupational Health in Canada - Current Status, 1977:46). Patterned a f te r functioning models in Europe, some Canadian employee health services have been established to cater to a geographic co l l ec t i on of small and medium s ize businesses. Generally these services are funded by employers and operated pr ivate ly (Occupational Health in Canada - Current Status, 1977:46). However, the Red Deer Health Unit in Alberta offers a public service to a group of t h i r t y -nine d i f fe rent types of industry, ranging from one employee to 175 employees. The service provides for : 1. pre-placement health assessments on prospective employees; 2. baseline health assessments on current employees; 93 3. per iodic audiometric te s t ing ; 4. immunizations for special hazards; 5. re fer ra l s to local physicians and community serv ices, as necessary; 6. follow-ups as indicated and/or requested by attending physic ian; 7. CO2 monitoring for one industry; 8. health education f i lms and lectures (McKenzie, S., 1977:59-60). I t i s surpr i s ing that there are so few successful endeavours of this kind in Canada (Occupational Health in Canada - Current Status, 1977:47). What i s there to stop other health units fol lowing i t s lead? Is i t lack of funds? There are other diverse types of employee health services set up in response to various needs of se lect groups. F ie ld f i r s t - a i d nursing stations operate in remote or underserviced locations in special geographic areas. For years, executive health programs have operated within corporation with the emphasis on per iodic health examinations, counsel l ing, immunizations and provis ion of exercise f a c i l i t i e s . More recently, employee f i tness and health promotion programs have developed, and treatment of programs for alcohol - related problems, are being successful ly implemented through places of work (Occupational Health in Canada - Current Status, 1977:47). Obviously those fragmented approaches r e f l e c t a desire to meet spec i f i c needs of workers, but appear to be guided by no overal l objective for a comprehensive 94 employee health program - as embodied in the concept of the 4 P ' s, promotion, prevention, protection and placement ( refer to d e f i n i t i o n , of Occupational Health, page 22). Notwithstanding, Health and Welfare, Canada's report on Occupational Health in Canada - Current Status (1977:47), notes that workplace programs and a c t i v i t i e s have increased emphasis on internal r e spons ib i l i t y , ind icat ing trends in the development of: 1. employer-employee occupational health and safety committees; 2. i ndus t r i a l safety surve i l lance; 3. general health promotion ( including alcohol and f i t ne s s ) ; and 4. employee health services (several modes of operation), and integrat ion of these with other community health services. One can only speculate why employee health services have not f lour i shed. The fac t remains, other seemingly p r i o r i t y issues generally took precedence over occupational health in the past, and health care of employees i s a somewhat more recent concern. In the meantime, the workforce and the public have become cognizant of workplace and environmental hazards. There appears to be, now, a huge receptive workforce that can benefit from a f u l l range of occupational health Services: 95 Although underut i l ized to date, the occupational sett ing in Canada provides an opportunity for general health promotion as well as the promotion of health for work-related problems (Occupational health in Canada - Current Status, 1977:47). This, however, may be eas ier said than done, mainly because of ideological commitments of the present government in Ottawa (Marchak, 1975; Navarro, 1976), and the fact that there i s no overal l soc ia l po l icy in occupational health where objectives are i den t i f i ed and in which resources are directed to t he i r pursuit. In comparing soc ia l po l icy of d i f fe rent ideologies, Joyce Warham (1974:38) expounded, in her paper, on the democratic s o c i a l i s t doctorine as opposed to the l i b e r a l philosophy. She says: In democratic soc ia l i sm, socia l services have a pos i t ive role and a permanent place, within an overal l commitment, to equal i ty of condition as between socia l classes and income groups. She continues: In l i b e r a l philosophy on the other hand, they tend to be seen as properly ephemeral, and as desirably diminishing in scope and importance as the increasing affluence of a society i s assumed to reduce the numbers of those who are necessari ly dependent upon them. Vincente Navarro (1976:447) of the John Hopkins University School of Hygiene expresses his views on the re lat ionship of capita l i sm to occupational diseases. He says: The et iology of those diseases i s very much the resu l t of.control of the labour process by capita l and not by labour, with profit-making taking p r i o r i t y over job safety and worker s a t i s f ac t i on . 96 He adds: ...One of today's most act ive state po l i c i e s at the central governmental level in most Western c a p i t a l i s t i c countries i s to encourage and stimulate those health programs, such as health education, that are aimed at bringing about changes in the indiv idual but not in the economic or p o l i t i c a l environment. Governments do change, however, and new ideologies take over. And the astute planner would consider both personal and environmental factors in any comprehensive occupational health program. 3.2. Issues, Conf l i c t s and Related Problems 3.2.1 Issues Some of the issues in occupational health and safety have already been discussed on previous pages under "Twentieth Century Concerns". However, to bring them more in l i ne with a Canadian content, i t may be worth focussing on those perceived to be p r i o r i t i e s in Canada. The various Canadian author i t ies on occupational health and safety (Bates 1977, Chisholm 1977, Dennis 1976, Ison 1977, Mastromatteo 1977, Rabinovitch 1979, Somers 1976, Stopps 1976, Watkinson 1976, etcetera) have lent the i r perspective to the major issues, c o n f l i c t areas and related problems, in a r t i c l e s , papers and speeches. The.recurrent themes hammered out by them in dealing with the issues appear to center around, (1) the need for integrated programs and coordinated pol icy at the prov inc ia l and federal l e ve l s , and (2) the need for a national data base and research/information centre. In order to make headway on these issues, while seeking so lut ions, i t i s essential to understand the con f l i c t s that can impede progress and the related concomitant problems and co ro l l a r i e s that compound the issues. Since these three top ic s , issues, con f l i c t s and related problems impinge on one another, i t seemed appropriate to consider them together. The vastness and complexity of the whole subject of occupational health and safety ensures that progress w i l l be slow despite the well meaning e f fo r t s of dedicated people. (1) The need for integrated programs and a coordinated pol icy  at the prov inc ia l and federal l eve l s . The majority of the provinces in Canada has consolidated a l l occupational health and safety a c t i v i t i e s in the Labour M in i s t ry , as mentioned under "Laws". For the next step, integrat ion of programs might be considered in the areas of (a) safety and health in the workplace, (b) Taws pertaining to hazardous substances and (c) occu-pational environment versus general environment. (a) In dealing with safety and health in the workplace, standards for occupational hazards in the workplace environment are establ ished almost exc lus ive ly under one category of l e g i s l a t i o n , the i ndus t r i a l safety, workers' compensation and occupational health statutes. Some relevant provisions are also contained in some Public Health Acts and certa in of the special statutes regulating pa r t i cu la r 98 contaminants (Franson et a l , 1977:46). However, Somers (1976:49) contends: There are nearly 200 l e g i s l a t i v e acts and over 400 sets of regulations and codes applying to occupational health and safety. Most of these acts, regulations and codes are safety or ientated. What seems to be neglected i s the occupational health aspect of the workplace environment. Occupational hazards such as continual exposure to l i g h t , noise, v ib ra t ion , heat, computer terminals, long term ef fects of chemicals, causes of chronic back-pain etcetera, deserve greater attent ion. No less important are the mental, psycho-social and stress factors that af fect people at work. Integrated comprehensive occupational health and safety programs would consider a l l factors and should be i n s t i tu ted at the provincia l level under whichever ministry has j u r i s d i c t i o n . If th i s were to become a r e a l i t y in a l l provinces, Dr. Somers' (1976:49) remark: Canada i s the only i ndus t r i a l i zed country in the Western World without a national program of occupational health and safety. may not have to be taken too ser ious ly. In f a c t , some would argue that a federal plan might eas i l y become a redundancy. After a l l , most of the Canadian provinces are each larger than many of the European countries by land mass and some by population. If the workforce i s adequately protected in a province-wide comprehensive occupational health program, and assuming the 99' provinces consider types of industry, and diseases indigenous to t he i r pa r t i cu la r regions, i s there much l e f t for a federal role? One of the more frequent arguments for a nation-wide set of rules i s that i t prevents indust r ia l d r i f t to the less regulated areas. Of paramount importance in an integrated program, must needs be that both union and non-union employees are included. Dr. Mastromatteo (1976:14) states that a high p r i o r i t y i s to avoid fragmentation and dupl icat ion in occupational health and safety programs, as present programs in Canada afford many examples of fragmentation. He says: ... I t would seem best to consider a comprehensive occupational safety and health law which would indicate i n general terms what i s to be achieved and the r e spon s i b i l i t i e s of employers, workers and governments.... He states further that the l e g i s l a t i v e and administrative measures should provide the basis fo r protection of the workers and surrounding residents. The law should be f l e x i b l e enough to cope with the rapid ly developing technology in the f i e l d . The d e t a i l s , he f ee l s , should be l e f t to codes and guides. He does not th ink, however, that a centra l ized approach as has been adopted in the United Kingdom and Sweden i s necessari ly best: ....but the system which is used should permit maximum use of the resources ava i lab le. Taking a d i f fe rent view of any endeavours re la t ing to the subject, Dr. Boyd Sutt ie (1976:8) says: 100 ...The construction of an improved de f i n i t i on of and response to occupational and environmental health issues and hazards i s c l ea r l y of national dimension and cannot be e f f e c t i ve l y addressed by i n i t i a t i v e s of one province or of a group of provinces, unless federal involvement, support and coordinating e f fo r t s are strongly and v i s i b l y committed Whatever the j u r i s d i c t i o n may be, to be e f f e c t i v e , preventive measures in occupational health and safety demand a consideration of the worker's to ta l environment both within and outside his or her immediate cont ro l . David Chisholm (1977c: 1-2) in the preamble to his paper, "Occupational Health in Canada, Future D i rect ions, " places responsi-b i l i t y on workers, management and government, and advocates cooperation, and coordination of occupational health and safety programs. His views are: ...Health and safety a c t i v i t y and po l i c i e s re la t ing to workers should be an integral part of the tota l health concept in which: - ind iv idua l s accept re spons ib i l i t y fo r matters re la t ing to t he i r mental and physical health over which they can exert personal cont ro l ; - industry, business and governments ensure a high level of protection against health hazards in the workplace; and -workers who suffer i l l health because of the i r work are cared for and rehab i l i ta ted within the framework of social secur ity systems. And further: Given the d i v i s i on of powers under the Canadian Const i tut ion, the federa l , p rov i nc i a l , t e r r i t o r i a l and municipal/regional governments should work together and develop integrated and coordinated po l i c i e s and programs. These should be backed up when necessary by statutory requirements to ensure that a l l who are ga in fu l l y employed are protected by adequate health and safety measures. 101 Clear ly i t would appear that the provinces with the i r vested powers can and should make ava i lab le integrated comprehensive occupational health and safety programs for a l l t he i r employed population. The federal government, on the other hand, must deal with matters which by the i r nature require a s ingle national po l icy as well as with matters which require an internat ional voice. (b) In dealing with laws pertaining to hazardous substances, Franson et al (1977:47) have th i s to say: There appears to be a good deal of overlap among statutes that deal with contaminants in one form or another. For example, the mercury content of a par t i cu la r p lant ' s e f f luent could be regulated under the po l lut ion control l e g i s l a t i on of a province, under the federal Fisheries Act, or in appropriate circum-stances, under the Canada Water Act. The same problem might be dealt with by cont ro l l i ng manufacturing processes under the Environmental Contaminants Act. Overlapping j u r i s d i c t i o n i s not necessari ly bad. It i s preferable to gaps in j u r i s d i c t i o n s . And statutes a l l served the spec i f i c purpose at the time they were needed. Franson et al (1977:48) state: . . . i t may be one way of assuring that a l l interests are consulted before action is taken. In add i t ion, i t would be very d i f f i c u l t to draft statutes dealing with d i f fe rent subjects that neither overlap nor leave important areas out a l together. . . . In order to eliminate possible gaps, supplemental l e g i s l a t i on i s occasional ly required. For instance, Environment Canada o f f i c i a l s maintain: 102 . . . that the Environmental Contaminants Act i s designed for a supplemental ro le . It i s intended to cover problems that cannot be dealt with e f f e c t i ve l y under other environmental l e g i s l a t i on (Franson et a l , 1977:48). It would seem wise i f i t s purpose were c l ea r l y stated, however, i f only to counter public h o s t i l i t y at i t s apparent inact ion, as indicated by Rabinovitch's (1979:23) remark: ...the ex i s t ing federal Environmental Contaminants Act i s well-known for i t s weakness and i t s lack of enforcement. Because of the numerous acts in the l e g i s l a t i v e framework with the i r various regulations and guidel ines, i t i s d i f f i c u l t for the public not to be confused. Without an indepth study i t i s impossible for the ordinary c i t i z e n to comprehend the structure. Therefore, i t would be only reasonable to expect regulators to have c lear po l i c i e s and to integrate and streamline ex i s t ing l e g i s l a t i on with a system of cross- indexing, including both provincia l and federal statutes. Before proceeding fur ther , i t may be helpful to explain the difference between regulations and guidel ines, as used in Canadian legal terminology: A regulation may be defined as a rule made by a competent authority re la t ing to actions of those under i t s cont ro l . Regulations are s p e c i f i c a l l y authorized by statute, are l ega l l y enforceable in the ordinary courts, must usually be passed by Order in Counci l , and must be published in the o f f i c i a l gazette of j u r i s d i c t i o n . A guideline i s an informal statement issued by a regulatory agency sett ing forth the standards of conduct that i t expects those under .: i t s control to exercise. It i s not enforceable in the ordinary courts (Franson et a l , 1977:34). 103 It i s interest ing to note in the Science Council of Canada's background study, "Canadian Law and The Control of Exposure to Hazards," Franson et al (1977:48) indicated that regulators seem to have a c lear preference for issuing guidelines rather than regulations which create many d i f f i c u l t i e s . Not only are guidelines ' unenforceable but are hard to locate for researchers and the general publ ic . Their claim to fame i s that they can be more quickly changed than regulations: ...but perhaps the loss in enforcement and pub l i c i t y are too high a price to pay for greater f1exibi1ity(Franson et a l , 1977:48). At the same time, i f standards entrenched in regulations are more e f f e c t i v e , several problems become evident. F i r s t , empowering statutes and regulations do not necessari ly require regulatory author i t ies to establ i sh standards for any pa r t i cu la r contaminant. This power i s nearly always given in d iscret ionary terms which makes i t un l i ke ly that courts w i l l order reluctant regulators to promulgate standards. Secondly, even i f an agency does establ i sh contaminant standards, i t i s rare ly under enforceable duty to revise or review ex i s t ing standards in the l i g h t of new knowledge. B r i t i s h Columbia has the only Po l lu t ion Control Act with a pol icy of per iodic review (Franson et a l , 1977:49). A l be i t , the i ron-c lad nature of the various l e g i s l a t i v e components lead to f rus t rat ions . However, attempting to make changes may often create more problems than they would solve. Nevertheless, there are areas where improvements can be i n s t i t u t ed . The Science 104 Council Report No. 28 (October, 1977:23) invest igat ing hazards, found among other items: 1) ... a lack of uniformity between the provinces in respect of standards. As w e l l , many standards appear to have been selected in an ad hoc and a rb i t ra ry fashion. 2) ...a lack of c lear de f i n i t i on of r e spon s i b i l i t i e s between d i f fe rent departments within provinces. 3) . . .a lack of c lear de f i n i t i on of r e spon s i b i l i t i e s between federal and prov inc ia l governments, and possibly the most s i gn i f i can t f inding was: 4) The Canadian regulatory process i s characterized by a lack of openness in information gathering, i n information access and a v a i l a b i l i t y , and in decision-making and determining accountabi l i ty . To continue in th i s unsatisfactory manner can only be regarded as a gargantuan d isserv ice to the Canadian workforce - and to the Canadian companies who might operate in more than one province having to cope with the vagaries of d i f fe rent l e g i s l a t i o n . Chisholm (1977c:9) notes in his "Occupational Health in Canada, Future D i rect ions " : Currently the regulatory methods and f a c i l i t a t i v e resources used within each j u r i s d i c t i o n are highly var iab le , with only l imited i n t e r j u r i s d i c t i o na l cooperation, coordination, and sharing of resources regarding occupational health and safety. Therefore, i t would appear there i s a de f in i te challenge for administrators of occupational health and safety l e g i s l a t i on to adopt at least more uniform standards among j u r i s d i c t i on s (Chisholm 1977a:191). 105 The perennial argument of "enforceable standards" as opposed to "guidel ines" i s debated hotly by t he i r proponents from labour, industry, government and health administrators on the North American continent. In Canada, government regulatory agencies have largely adhered to the philosophy of se l f - regu la t ion for industry, claiming that th i s fosters co-operation between government regulators and businesses subject to regulation. Instead of r i g i d statutory controls del ineating exposure l eve l s , "guidel ines" have been establ ished. In the United States, on the other.hand, extensive publ ic hearings are held by the Occupational Safety and Health Administration, which establishes legal standards (not guidelines) for occupational exposure to hazardous substances. The adopted standards are lega l l y enforced and have lead to increasing l i t i g a t i o n (Tataryn, L., 1979: 162-163). Tne Science Council of Canada (1977:45) assessing the two countr ies ' approaches, concluded: We have been impressed by the testimony of the indiv iduals most affected by the major occupational hazards we have studied, to the e f fec t that there is no reason why they should have any confidence in a system of "guidel ines" or of "non-enforceable standards." I t seems c lear that for some major hazards, for example, asbestos, lead, vinyl ch lor ide, and rad iat ion, the level of exposure measured as precise ly as possible with modern technology, must be control led by enforceable regulations. 106 (c) In dealing with occupational health and environmental health, the Canadian Publ ic Health Associat ion, in a pol icy statement issued these words: Man's health and environment are inseparable... Therefore environmental health standards, which can be understood by the publ ic , should be adopted on the s c i e n t i f i c evidence, professional judgment and publ ic health knowledge of the protection of human hea l th . . . Health supervision at places of work should be l inked with environmental agencies... (Watkinson, 1976:7). The statement goes further. I t says that human enterprises a f fect the environment, by the waste products of the i r processes, by the ef fects of the f i n a l products themselves and by the effects of the disposal of the products. Moreover, the information about the workplace environment which i s gathered to protect the worker's health should be extended to protect the general publ ic . In a s im i l a r vein, Dr. Somers (1976:50) presents the concept that occupational health i s part of the greater t o t a l i t y of environmental health. He notes: ...because of the intense exposure suffered occupationally, knowledge of environmental effects i s best developed from occupational data. Many other occupational health author i t ies (Chisholm, 1977; Dennis, 1976; Stopps, 1976; Karr, 1976;) view occupational health as an integra l and inseparable part of environmental health which broadly includes interact ions of the human environment and 107 health, injury and disease. For th i s reason, there i s a great need for c loser cooperation and integration of departments in dealing with the health of Canadians. As Wil l iam Karr (1976:72), Secretary, Canadian Council on Occupational Medicine, puts i t : I f the problem of occupational health in general and environmental hazards in par t i cu la r are to be solved, we must work together, and take guidance from cohesive, coordinated, central sources, headed by properly trained people (2) The need for a national data base and research/information centre. With the acceleration of technological changes in industry and the increasing complexities of the work and l i v i n g environments, the Canadian workforce requires an instrument for quick exchange of information and documentation on a national and in te rnat iona l ' l e v e l . As i t i s : ...no focal point exists: in Canada for information co l l ec t i on or exchange. Data on health hazards, e f fec t s , and health states of workers are not adequately monitored nat iona l l y , and thus remain fragmented and incomplete. National standards for safety ofvlthe workplace do not e x i s t , which leads to prov inc ia l var iat ions and i nequa l i t i e s . . . (Chisholm, 1977a:189). The two main areas for discussion in this section w i l l be; (a) monitoring occupational disease and injury and (b) control of hazardous substances. 108 (a) Occupational disease and injury are costing the Canadian government b i l l i o n s of dol lars and incalculable cost in human suffer ing to Canadian workers. Yet, Ison (1977:1), notes in his paper, "The Dimension of Industr ial Disease": There does not ex i s t any administrative structure for ascertaining and recording the to ta l incidence of indust r ia l disease (however defined). HOw far disablement from indus t r i a l disease has been brought under control i s , therefore, not determinable... Somers (1976:49) also says: Our present s t a t i s t i c a l reporting systems and workers' compensation are unable adequately to present the e f fec t of occupational diseases.... Without a uniform data base on which the extent of occupational disease and injury can be assessed and or from which the effectiveness of ex i s t i ng , or new programs can be measured, occupational health and safety w i l l be unable to move forward. Unless there are figures to prove that a national problem ex i s t s , neither industry nor government w i l l give preventive action the same p r i o r i t y as would be assigned to i t i f the dimension of the problem were f u l l y known. Then too, lack of usable s t a t i s t i c a l data impedes the process of r isk assessment for both communities and ind iv idua l s . It prevents them from making informed decisions on what are acceptable r i s k s : 109 Uncertainty about the dimensions of i ndus t r i a l disease can be an impediment to the rat ional making of indiv idual choices as well as community decisions (Ison, 1977:35). Chisholm (1977c:l) adds: S c i e n t i f i c and technical knowledge should be gathered, disseminated and discussed, not only to monitor the trends of problems and successes, but to provide a sound basis for future act ion. It i s c lear , then, that a national data base i s essent ia l to determine the extent of occupational disease and injury which answers a l l the questions of "what", "who", "where", "how much" and "why". This in turn f a c i l i t a t e s decisions on p r i o r i t y and fund a l l oca t i on . F i n a l l y , i t i s fundamental to program evaluation and program planning. Mastromatteo (1976:15) suggests further that: A good system of reporting and recording occupational diseases and l i nk i ng ex i s t i ng health records to exposure to environmental agents on the job i s needed. In th is connection, Dr. V. Cecil ione (1976:60), in a keynote address to the Canadian Publ ic Health Association at the f i r s t National Conference on Occupational Health, said that the medical profession should play a more active part in community health and provide more assistance to the i r patients who work in industry. He mentioned the p o s s i b i l i t y of occupational cancer and other diseases a r i s ing from the use or exposure to .chemical compounds 110 or materials in the workplace - hence, the necessity for keeping complete records. These records should be made avai lable to a l l employees and the i r family physicians, not only during t he i r working years but a f te r the i r retirement as w e l l : only in th i s way can many occupational diseases and cancer be studied more thoroughly and prevented in the future (Cec i l ione, 1976:60). The Radiation Protection Bureau i s carrying out a commendable service to Canadian workers dealing with radioactive substances by monitoring the i r exposure to rad iat ion: Occupational Radiation Hazards Div is ion provides spec ia l i zed dosimetry services to over 70,000 workers throughout Canada on a regular basis. This information i s used by Provincia l and Federal agencies in implementing regulatory contro l . Each worker's exposure history i s maintained in a national records system which i s used to obtain s t a t i s t i c a l information on health r i sks (Environmental Health Directorate, 1978:7). (b) The increasing number of chemicals in widespread use on the Canadian scene today i s a major concern to the general pub l i c , the workers and health professionals (Ison, 1977; Mastromatteo, 1976; Somers, 1976): Although some 10,000 new chemicals are launched on the market each year, only a few can be f u l l y investigated with our present time-consuming methods...New standards are needed for the thousands of known or potent ia l l y dangerous substances already in use in industry t oday . . . (Cec i l i on i , 1976:59-60). I l l However, to put th is into perspective, other author it ies claim that most of these chemicals are new formulations of those already on the market. S t i l l , a s izable number are new compounds. In 1973 v inyl ch lor ide, which hadbeen in indus t r i a l use for over 30 years was found to produce a rare tumour of the l i v e r . This episode has served to arouse national and internat ional concern over the hidden health hazards of the workplace (Mastromatteo, 1976:9). However, the control of the vinyl chloride hazard i l l u s t r a t e s the importance of a quick exchange of information at the national l e v e l : In respect of vinyl ch lor ide, information exchange between industry and academic s c ien t i s t s worked we.ll, possibly because industry commissioned s i gn i f i can t s c i e n t i f i c research (Science Council of Canada. Report No. 28. 1977:22). Several recent Canadian government reports and pol icy papers on health and safety, notably in Saskatchewan, A lberta, Ontario, Manitoba and Quebec have included in the i r recommendations, among other items: ...the expansion of research and test ing f a c i l i t i e s throughout the country in order to detect tox ic substances in the atmosphere and to pre-test chemicals before they are introduced into i ndus t r i a l usage... (Rabinovitch, 1979:22). I t i s in terest ing to note at th is point that Sweden has national l e g i s l a t i on which pre-screens chemicals before they are 112 permitted for use in industry. Furthermore, Sweden also passed a new law in 1974, which places the onus on each importer or d i s t r i bu to r for every new product introduced, to ensure that i t can be used without hazard to workers or to the environment ( C e c i l i o n i , 1976:59). Proposals for reg i s t rat ion and pre-screening of chemicals are being act ive ly studied in the United States, by the European Economic Community, and in other countries (Mastromatteo, 1976:14). The l i s t of hazardous substances, including physical agents, materials and chemicals that threaten the worker in industry i s long and growing longer each year. Thus, there i s a need to set up a system of p r i o r i t i e s for evaluating the health and environmental ef fects of chemicals fo r which there i s no information. Dr. Mastromatteo (1976:14) fee l s : P r i o r i t y should be given to those chemicals which bear a s t ructura l s i m i l a r i t y to those chemicals with known hazards. P r i o r i t y should also be given to those chemicals which are in widespread use and to which many workers are exposed. Of a l l the poisonous effects of hazardous substances in the occupational and general environments, carcinogenesis seems to be of most universal concern. The truth of the matter i s the vast majority of i ndus t r i a l and commercial substances 113 are not carcinogenic. Lloyd Tataryn (1979:55).in his well documented book, "Dying for a L i v i n g " , wr i tes : There i s l i t t l e doubt that many widely used i ndus t r i a l and commercial substances are carcinogenic. It i s ce r ta in l y true that many industry wastes can cause cancer and other diseases. But is i t also true that most indus t r i a l processes, products and by-products are r e l a t i v e l y harmless. An a r t i c l e in Occupational Health Nursing (Rubenstein and B e l l i n , 1976:17) referr ing to the chronic ef fects of chemicals, mentions: An advance has been made in evaluation of carcinogenesis: with only a few exceptions most carcinogens are bacter ia l mutagens. This i s the basis for a r e l a t i v e l y inexpensive pre-screening test for carc inogen ic i ty . . . . Lloyd Tataryn (1979:155) adds: ...Indeed epidemiological surveys and animal experiments have already uncovered many of the materials which give b i r th to the dread disease. Therefore i t would appear that the use of bacter ia l cultures (Ames Test) alone or in combination with other measures may o f fe r some hope as a prescreening method f o r carcinogenic and mutagenic substances (Mastromatteo, 1976:14). However, i t would be prudent to avoid placing excessive rel iance on th i s procedure because in many cases, chemicals that are bacter ia l mutagens have not been associated with cancer. 114 Preventive and control measures should be practiced on those materials found to be carcinogenic. Even though cancer-causing substances may be i d e n t i f i a b l e , i t i s not always easy to proh ib i t the i r i ndus t r i a l use without wide-spread economic and technical d i f f i c u l t i e s - for example, asbestos and vinyl ch lor ide. The task, then, confronting governments, and publ ic health o f f i c i a l s i s to enforce the s t r i c t e s t measures possible to prevent human exposure to them or to adequately protect workers who come in contact with them. Moreover: The discovery of a lternat ives to occupational carcinogens i s greatly to be encouraged and should permit the abandonment of the manufacture and use of these substances without economic hardship (Clayson, David, 1976:241). This a l ternat ive method of cont ro l , the l icencing and regulation. of the manufacture and use of occupational carcinogens i s supported by the International Labour Organization (I.L.O. June 24, 1974: NO.147). ...Nevertheless, in replacing these compounds, adequate experimental invest igations must be carr ied out to ensure that one hazard i s not replaced by another (Clayson, D., 1976:242). In Sweden the occupational carcinogens are divided into three categories: 1. Those which are banned without spec i f i c authorization (outr ight) . 2. Those which are permitted for use but subject to spec i f i c use prescr ipt ions. lib 3. Those which are permitted for use with an assigned T.L.V. (Mastromatteo, 1976:13). Competent Canadian author i t ies must develop s im i l a r approaches to categorization and control of occupational carcinogens and vigorously pursue prevention as a national cancer po l i cy . Recognizing that grave problems do ex i s t in the lack of and dissemination of information, the federal government, in 1978, established the Canadian Centre for Occupational Health and Safety. The serious gap in worker protection w i l l hopefully be el iminated. The Honourable Monique Begin, in a keynote address to the Second International Congress of the World Education of Publ ic Health Associations at Hal i fax in May, 1978 had th i s to say: An immediate a c t i v i t y of the Centre w i l l be the development of a national information system on the whole spectrum of occupational health and safety. The Centre w i l l then begin by providing Canada and Canadians with a coordinated and integrated source that up to now has been lacking in th is f i e l d . The Centre w i l l attempt through information to promoite healthy l i f e s t y l e s for a l l workers and to prompt the i nd i v i dua l ' s own re spons ib i l i t y in th is area (Begin, M., August, 1978:272). 3.2.2 Conf l icts In dealing with the major issues in occupational health and safety, consideration must be given to the various con f l i c t s that can occur. I t i s interest ing to note the apparently s im i l a r 116 s i tuat ion faced in the United States. Speaking of the d i f f i c u l t i e s encountered when the law is used as the predominant mechanism for the soc ia l control of science and technology, Ashford (1976:4-8) postulates: . . .the law, and espec ia l ly the Occupational Safety and Health Act, cannot be successful ly implemented i f we continue to ignore the fundamental con f l i c t s and tensions which ex i s t between various groups of people and between various i n s t i t u t i on s in our society. He i den t i f i e s at least four broad categories of con f l i c t s that characterize health and safety in the workplace, namely;-(1) management-labour, (2) inadequate knowledge, (3) perceptual differences and (4) i n s t i t u t i o na l divergence. I t would be^ prudent to examine these c o n f l i c t areass i f progress i s to be made in integrat ing programs and coordinating pol icy in Canada. (1) The f i r s t type of c o n f l i c t i s the clashing of d i f fe rent s e l f interests that i s cha rac te r i s t i c of management-labour re lat ions . In unionized s i tuat ions , the t rad i t i ona l adversarial climate creates overt c o n f l i c t . This basic c o n f l i c t of s e l f interests stems from management's desire to keep costs down and to maintain control of the workplace versus the workers' desire to gain the largest package of wages and benef i t s , job secur ity and control (Ashford, 1976:5). In connection with management-labour issues, developments in occupational health and safety in Canada c losely 117 pa ra l l e l events occurring south of the border. Nicholas Ashford (1976:30) speaking of the United States, says: H i s t o r i c a l l y , organized labour has not emphasized health and safety in co l l ec t i ve bargaining for several reasons. Worker concern with i n f l a t i o n and economic problems has often pre-empted health and safety considerations Most importantly, the fear that jobs would be l o s t i f s t r i c t safety arid health standards were introduced, or i f a worker f i l e d a complaint with the state author i t ies , has often deterred workers or unions from ra i s ing th i s issue except in extremely serious s i tuat ions. Further, i t was not unt i l 1966 that the National Labour Relations Board established the p r inc ip le that health and safety issues are mandatory subjects for bargaining... A f ter a h istory of hard won rights for workers on the North American continent, i t appears co l l ec t i ve bargaining w i l l continue to be the most e f fec t i ve way of a r r i v ing at settlements between labour and management. Among other important issues on the labour scene in Canada today, the r ight to work in a safe environment w i l l increasingly focus on occupational health and safety measures. The negotiating process in th is connection has great potent ia l . I t enables d i f fe rent local and industry-wide needs to be met, pa r t i cu l a r l y where hazards are extensive. As w e l l , i t moves the re spons ib i l i t y for occupational health and safety out of the sole hands of management and thus encourages the par t i c ipat ion of workers in the process of cont ro l l i ng technology 118 in the workplace (Ashford, 1976:31). However, during a climate of change, con f l i c t s w i l l ar ise as the adversarial approach dies hard. On the one hand, there w i l l be some reluctance on the part of labour to completely t rus t management. In the past, workers have f e l t they were exploited for p r o f i t . And the " industr ia l -medica l complex", referred to in another sect ion, i s s t i l l pervasive. The Science Council of Canada (1977:47-48)notes: ...Many people believe that the reason for th i s i s that physicians are wholly employed by company management and that independent medical advice i s therefore not avai lable within the work-place. The result of which, induces workers in major industr ies to seek medical opinion outside the p lant, and often as not, outside Canada, in order to confirm the i r suspicions of occupational diseases (Tataryn, 1979). The record of medical performance in Canada, in t ru th , has been less than dist inguished. Dr. David Bates, addressing the Canadian Medical Association convention in June of 1977, referr ing s p e c i f i c a l l y to the hazards Canadians have experienced as a resu l t of exposure to asbestos, rad ia t ion, lead and mercury, sa id: ...There has been a "major def ic iency" in the role played by the medical profession in the f i e l d of occupational health. 119 The be l i e f by some i s that much of th i s s i tuat ion can be l a i d at the door of the exp lo i ta t i ve c a p i t a l i s t system. Navarro (1976:446) says that state intervention rep l i ca tes , the ideology of medicine which complements rather than c o n f l i c t s , with the ideology of cap i ta l i sm. In his view, the state sees the " f a u l t " of disease as l y ing with the indiv idual and absolves the economic and p o l i t i c a l environment from respons ib i l i t y for disease. Occupational health nurses, as sa lar ied medical personnel are also suspect, as evidenced by a su i t launched against Pac i f i c Press Limited in March 1977, in Vancouver over v i s i t s by nurses to s ick employees: The Guild threatened e a r l i e r th is week to lay criminal charges i f P a c i f i c Press, which publishes the Province and the Sun, did not stop sending nurses out to v i s i t i l l employees, a practice the Guild claimed amounted to harrassment... (The Province, Vancouver, 18 March, 1977:10). The negative att itudes by labour, b u i l t up over the years, have contributed to the poor re lat ionship that now exists between labour and management. On the other hand, management personnel who have long been responsible for making decisions in a l l aspects of the work-place w i l l feel threatened that occupational health and safety needs are no longer i t s prerogative. The process of re l inquish ing part of th is status may even be pa in fu l . G i v e Dennis, former 120 head of the health and safety program in Saskatchewan i s c r i t i c a l of the way professionals have been relegated to the s ide l ines . He feels that one important side e f fec t of an occupational health program oriented towards the promotion of worker power i s : . . . tha t professionals employed in the workplace... promoting health and safety are automatically c ruc i f i ed as stooges of management for the purpose of exp lo i t ing the workers, be they physician, nurse, safety d i r ec to r , f i r s t - a i d worker, occupational hygienist, safety engineer, or r ehab i l i t a t i on counsellor (Dennis, 1976:62). I t i s c lear that an atmosphere of mutual t rust and consideration must be encouraged. As long as the bases for con f l i c t s are recognized they should be acknowledged and dealt with. The pos i t ive potential for c o n f l i c t in strengthening decisions and improving re lat ions may be a concept worth studying. The major occupational health and safety laws enacted in Canada by prov inc ia l governments since 1975 have l a i d the emphasis on prevention, without diminishing the t rad i t i ona l commitment to compensating victims of i ndus t r i a l accidents and disease. With.this added stress on the need for better prevention, management and labour now argue about the nature of safe and healthful work conditions: These new con f l i c t s thus center around issues that , i f resolved, are more l i k e l y to improve workers' health and safety (and product iv i ty in the long run) than the resolution of con f l i c t s over who w i l l pay for the harm (Ashford, 1976:5). 121 The Saskatchewan Occupational Health Act of 1972 ( substant ia l ly revised in 1977) has been of prime importance in terms of o r i g i n a l i t y and innovation (Rabinovitch, 1979:22). Bob Sass, d i rector of the Saskatchewan government's Health and Safety Service, Labour Department, acknowledges that the law and the way i t i s administered c l ea r l y favours workers. The keystone of the Saskatchewan program comprises the employer-employee safety committees which are established in a l l companies with 10 or more workers regardless of union or non-union shops. These committees have access to a l l information gathered by government inspectors and have the power to invest igate conditions in a given plant or o f f i c e . Another key in the Act i s the worker's r ight to refuse unsafe or unhealthy work. The Act i s one of the most far-reaching health and safety l eg i s l a t i ons in the country, and other provinces, namely, Newfoundland and Ontario have patterned the i r occupational health laws a f te r i t (Financial Times, 15 October, 1979:14). The 1975 Alberta Industr ial Health and Safety Commission views occupational safety and health concerns as being the j o i n t re spons ib i l i t y of labour, management and government. It i s attempting to el iminate the "adversary" method of handling these concerns with the development of t r i - p a r t i t e involvement whenever and wherever, possible (Stopps, _.J.:, 1976:66). The implementation of these Canadian Acts i s slowly serving to ra ise the consciousness of both management and labour. 122 Moreover, i t i s requir ing a high degree of worker-employer co-operation to i den t i f y , control and reduce hazards to the health and safety of workers. In add i t ion, the terms of reference in these Acts which accept the workers assuming more re spons ib i l i t y fo r decisions made about his or her own protection i s pointing to the need for long range pol icy planning whereby the welfare of the worker has equal p r i o r i t y with that exercised by management. With the assumption that co l l e c t i ve bargaining w i l l continue to be the foundation of the Canadian indust r ia l re lat ions system, i t can be expected that occupational health and safety concerns w i l l be constantly redefined as workers become more act ive on environmental issues. F i n a l l y , in as much as c o l l e c t i v e bargaining provides the mechanism for change in att i tude and behaviour, i nd i rec t benefits may accrue to unorganized workers and small f i rms: National po l icy must u l t imately address the i r problems and provide them with information, educational serv ices, legal a i d , and technical assistance that they both badly need (Ashford, 1976:31). (2) The second type of c o n f l i c t i s that which is caused by lack of knowledge. ( i ) In the case of cancer - causing substances in the workplace, for example, there i s continuing debate over "safe l eve l s " or "zero thresholds" regarding exposure. Although some carcinogens are now i d e n t i f i a b l e , i s there a permissible safe l e v e l , would be 123 the s i gn i f i can t question. It should be noted, at th i s point, that carcinogens stop damaging c e l l s when exposure i s ended. The problem remains that the already damaged c e l l s give trouble. Carcinogens in large doses can k i l l human c e l l s much l i k e poisons, but in smaller doses they cause c e l l s to mutate. It i s rea l ized now that cancerous growths can appear years a f ter a person has been exposed to an i n i t i a l sub-poisonous contact by a cancer-causing agent. But what i s that minimum amount? And to what degree are indiv iduals susceptible? The zero threshold advocates f i n d , under scrut iny, that i t i s not pract ica l as only 20 percent of the population gets cancer. Moreover, establ i sh ing a threshold - a lower l i m i t of exposure that i s not dangerous - i s nigh on impossible. To quote Dr. Ronald Glasser (1976:113-14): ...over f i f t y years of continuing experimentation has proven that the amount of carcinogen necessary to produce cancer can be minute and s t i l l be deadly... that i t i s s c i e n t i f i c a l l y possible that a molecule of a carcinogen getting into a c e l l could damage any DNA molecule (the part of every c e l l which determines what we are) enough to change i t , to cause the c e l l to lose control and become malignant... Complicating the threshold approach, i s that thresholds are usually established as though the substance in question is the only cancer - causing agent a person ever encounters. The U.S. Department of Health, Education and Welfare publ icat ion on "Chemical Carcinogenesis" speaks to th i s point: 124 We have current ly no established s c i e n t i f i c method to determine threshold levels for chemical carcinogens... in the indus t r i a l environment, workers may be exposed to mult ip le carcinogenic agents which may compete for the same target s i t e . It states further: Mult ip le exposures can occur on the job, in the d i e t , and in the ambient and home environments. Under these circumstances, some people may have already received doses from mult iple exposures in excess of any presumed threshold for any s ingle carcinogenic chemical. Consequently, any incremental increased exposure to chemical carcinogens could then resu l t in an increased r i s k of cancer (Bridbord et a l , 1977:181). Because of the r i sks involved in dealing with carcinogens, which may not be en t i r e l y eliminated in an i ndus t r i a l soc iety, i t has been suggested that the concept of "safe" levels be replaced by that of " s o c i a l l y acceptable level of r i s k " . This, however, raises the question, acceptable to whom (Tataryn, 1979: 179)? Obviously, there are many unanswered questions. Nevertheless, in the meantime, some action i s imperative: As the debate over threshold levels ind icate, the regulation of i ndus t r i a l health hazards remains e s sent i a l l y a s o c i a l , economic and p o l i t i c a l question, rather than a s c i e n t i f i c one. At issue i s the price tag to be placed on a human l i f e (Tataryn, 1979:181) The United States federal health agencies have adopted the approach that there is no threshold to carcinogenic exposures (Tataryn 1979:178). The Canadian occupational and environmental regulatory agencies have as yet developed no consistent pol icy on thresholds to chemical carcinogens. 125 The reason for the d i f fe rent stances i s , in part , p o l i t i c a l . The Canadian governmental system allows for more discussion among agencies, while i t s U.S. counterpart does not. The outcomes, therefore, are e i the r ; the r i s k of some dangerous pract ices , or perhaps unwarranted heavy state expenditures. Which i s the worse of the two ev i l s ? ( i i ) Another example of lack of knowledge or i n s u f f i c i en t research that causes c on f l i c t s i s the subject of nuclear safety. In Canada, the Science Council reporting on " Po l i c i e s and Poisons" (1977:21), warns of the hazards of low-level rad ia t ion : -Radiation exposure at low levels may produce lung tumours h i s t o l o g i c a l l y ident ica l to those that are not a consequence of rad iat ion exposure. -The present radiat ion doses from diagnostic medical x-rays const itute a major source of population exposure and one that i s poorly contro l led. Some sc ien t i s t s d isc la im that there i s any r i s k from low-level rad iat ion. They point to studies of s izeable populations with control groups, which revealed no s i gn i f i c an t d i f ference. Many s c i en t i s t s say that today we s t i l l do not know what level of rad iat ion i s dangerous and many bel ieve we w i l l never know. The ef fects of longterm exposure to low levels of radiat ion are far more d i f f i c u l t to document than exposure to high levels (studies on survivors of Hiroshima and Nagasaki bombings). Since human experiments with low level radiat ion are uneth ica l , re l iance must needs be placed on animal experiments and other avai lable data of human exposure. There are further problems, such 126 as the absence of symptomology at low level exposure, and a long developmental period for cancer: Added to t h i s , researchers must have precise information on the amount of radiat ion received by the population studied, in order to determine a re lat ionsh ip between radiat ion and disease. Here again, how much rad iat ion i s s o c i a l l y acceptable? The fact remains, the best ava i lable knowledge on radiat ion protection should be used. At the same time, the benefits of the nuclear age must also be recognized. Nuclear radiat ion can detect po l l u t i on , cure cancer and diagnose i l l n e s s with prec i s ion. The Science Council of Canada (Po l i c ie s and Poisons, 1977:21) states: -The r i sk of injury from ion iz ing radiat ion was recognized short ly a f ter i t s discovery in 1895. A continued growing awareness of radiat ion hazard and i t s association with cancers, leukemia and genetic changes resulted in the creation of the International Committee on Radiological Protection (ICRP).... - Since the 1940's the ICRP has issued guidelines on the "maximum permissible" radiat ion exposure to the body... Most countries have adopted standards at least as str ingent as those proposed by the ICRP.... Conf l i c t i ng viewpoints continue to be aired in the nat ion ' s d a i l i e s and per iodica ls as the forces of health bat t le with the forces of economics. In the f i e l d of radiat ion research, progress has been substant ia l . However, there is obviously much more to learn. 127 ( i i i ) S t i l l another example of inadequate knowledge causing con f l i c t s can be seen in the area of possible work-related conditions such as heart disease. This i s the leading cause of death in the United States and Canada. Executives and workers a l i ke are affected. It has been general knowledge in recent years, that the incidence of heart disease has r isen in blue c o l l a r workers, in tandem with the i r wages increasing and physical work dec l in ing. Nonetheless, there has been very l i t t l e research on th i s condition l i nk ing i t to the work environment. A report by the U.S. Health, Education and Welfare Department, e n t i t l e d , "Work in America"(1973:79) says: research findings suggest that d i e t , exercise, medical care, and genetic inheritance, may account for only 25% of the r i sk factors in heart disease... Although research on th i s problem has not led to conclusive answers, i t appears that the work r o l e , work conditions and other soc ia l factors may contribute heavily to th i s "unexplained" 75% of r i s k factors . E f fort s to have heart disease recognized as a work-related compensable disease would obviously f a i l , because they would c o n f l i c t with po l i c i e s which are more safety oriented than disease oriented. However, i f there were more data demonstrating to what extent heart disease i s caused d i r e c t l y by the work environment, the outcomes may be d i f fe rent (Ashford, 1976:42). Pomerleau et al (1975:3), in The New England Journal of Medicine, regarding causes of the major diseases in Canada, state: 128 An analysis of the p r inc ip le causes of morbidity and morta l i t y , revealed that environmental factors and l i f e s t y l e contributed so greatly as to const i tute the key to e f fec t i ve cont ro l . As programs in occupational health and safety become more integrated and comprehensive, the question of coronary-artery disease w i l l need to be addressed. (3) The th i rd type of c o n f l i c t occurs when there are differences in perception which cause real problems in pol icy development. For instance, the proverbial argument over whether to permit use of a certa in substance un t i l proven harmful, or proh ib i t use un t i l proven safe, can pose great d i f f i c u l t i e s . What i s ju s t and f a i r ? E ither course involves costs and r i sk s to someone. In another instance, the question of policy-making with regard to the general environment as compared to the work environment i s complicated by the differences in the degree and s e l e c t i v i t y of the r i s k posed. A case in point, certa in chemical pest ic ides used in d i luted form may present low r i sks to the general population and confer important benef i ts , but they can create severe r i sks to workers handling the mater ia l . There would be strong assertions that these s i tuat ions are not equitable (Ashford, 1976:6-7): whether i t i s f a i r for the l i ve s of selected employees to be sac r i f i ced for the betterment of society and whether employees can r a t i ona l l y assume the r i sk of hazardous employment are questions that need to be addressed (Ashford, 1976:43). 129 A f i n a l instance where honest men can d i f f e r i s in how much control a government should exercise in protecting i t s c i t i z en s . Here the question of "guidel ines" versus " regu lat ions " , i l l u s t r a t e s the point. Some occupational and safety experts, l i k e Dr. V ictor Rabinovitch, d i rector of health and safety at the Canadian Labour Congress Centre for Labour Education and Studies, fee ls strongly that government must enforce the rules of behaviour at the workplace (Davies, Financial Times, 15 October, 1979:14). In agreement with s t r i c t government enforcement, Ken Valentine, safety d i rector for the Canadian d i s t r i c t of the United Steel workers of America says: Unless occupational safety and health codes and l e g i s l a t i on are policed and enforced, they w i l l have l i t t l e e f fect on workplace safety and health (Davies, G., F inancial Times, 15 October, 1979:14). However, other experts are inc l ined to disagree. James McLellan, d i r ec to r , occupational health and safety, Federal Department of Labour, doesn't believe health and safety regulations should be enforced. Likewise, Jim McNair, d i rector of occupational health and safety, indus t r ia l branch, province of Ontario, does not see his main function as a policeman (Davies, G., Financial Times, 15 October, 1979:14). Dr. G.J. Stopps (1976:66) associate professor, Div is ion of Community Medicine, Univers ity of Toronto, with an extensive background of environmental ef fects on workers, quotes the Alberta Industr ial Health and Safety Commission as saying: 130 We feel there are real l im i t s to which improved occupational safety and health conditions can be brought about through the regulatory e f fo r t s of government. If the system i s to be e f fec t i ve i t has to be largely se l f - regu la t ing . It would appear that a successful se l f - regu lat ing system must need to depend upon two factors. The f i r s t , from management's point of view; l e g i s l a t i o n in the f i e l d of occupational health and safety must be c lea r , reasonable and enforceable (Stopps, G.J . , 1976:66). The second, from the worker's point of view; to e f fect att i tude and behaviour change, information, explanation, p a r t i c i -pation and necessary role models must be offered. Added to these two factors i t i s essential that both employer and employee are beholden to assume personal re spons ib i l i t y and accountabi l i ty . From a l l accounts, i t seems the recently enacted prov inc ia l occupational health and safety acts in Canada are promoting fundamental changes in the workplace atmosphere, in an attempt to reduce in ju r ie s and i l l n e s s in the working population. Acknowledging how these changes take place, i s c ruc ia l to the i r implementation . Chin and Benne (1976:23) out l ine three approaches that are commonly used: (1) Empirical - rat ional s t rateg ies , in which rat ional s e l f in terest i s the operative element. Change i s promoted when some group or person can demonstrate to others that the proposed action w i l l re su l t in gain for those affected by the change. (2) Normative - re-educative s t rateg ies , where in order for change to take place, people have to change the i r old values and adopt new ones. (3) Power-coercive s t rateg ies , which use economic and p o l i t i c a l power in order to achieve goals that are viewed as desirable by the change agents. In the past, governments, administrators and the health care system have leaned heavily on the empir ica l - rat iona l and power-coercive strategies. A judic ious use of the three strategies w i l l l i k e l y continue to be used. However, i f employees are to assume some re spons ib i l i t y for t he i r own safety, change w i l l need to take place within the framework of the normative - re-educative strategy, emphasizing the inherent d ign i ty and in te l l i gence of the i nd i v idua l : The use of the.normative - re-educative framework for change requires a philosophical stance which recognizes the consumer (worker) as an indiv idual with a store of untapped personal resources at his disposal (Green, G., 1978:16). Therefore, i t would seem in a democratic country, other a l ternat ives to too much government control are feas ib le . Perhaps in the f i n a l ana lys i s , workers would f ind a government that enforces workplace conduct according to the s t r i c t l e t t e r of the law, jus t as unpalatable as an a l l powerful management doing the same. (4) The fourth type of c o n f l i c t deals with the lack of coordination among i n s t i t u t i on s and agencies within the whole spectrum of occupational health and safety. For example, the type of c o n f l i c t that arises when publ ic and plant environmentalists work in i s o l a t i o n , has been discussed in the previous sect ion, under "differences in perception". Cleaning up the factory may resu l t in po l lu t ing the general environment, and conversely, containing the po l lu t ion may mean increased po l lut ion within the 132 plant (Ashford, 1976:7). Jo int problem - solving or improved communication between agencies, i f not amalgamation, could, perhaps, avoid the inev i tab le c o n f l i c t s . Within the medical profession, i t s e l f , often d i f fe rent languages are spoken: In f a c t , many professionals concerned with medical care del ivery systems w i l l define preventive medicine as merely early detection of disease, rather than an el iminat ion of those hazards that can u lt imately cause disease (Ashford, 1976:7-8). The d i s t i n c t i on i s v i t a l l y important, espec ia l ly with diseases such as cancer whose progress i s d i f f i c u l t to reverse (Ashford, 1976:8). Preventive medicine needs to be more f u l l y understood and pursued. The Canadian Medical Association rea l i zes that occupational health services are designed and implemented to maintain or improve the tota l health of employees, so that each indiv idual can function as a se l f - respect ing , productive person throughout his working career. Further, in i t s booklet, "Guiding Pr inc ip les for the Provision of Occupational Health Serv ices " , i t states: ...As one aspect of the overal l preventive or publ ic health program in the community, i t i s important that occupational health professionals consider each worker not ju s t in respect to his working environment but, also in re la t i on to his home and community (Canadian Medical Associat ion, no da te : l ) . The ethics of occupational medicine decree that i t does not encroach on the f i e l d of private medicine. The work of the occupational health physician supplements that of the family 1 3 3 physician who i s u l t imately responsible for the employee's treatment. As w e l l , occupational medicine must be practiced in accordance with ex i s t ing l o c a l , prov inc ia l and federal l e g i s l a t i o n , such as the Workers' Compensation and Public Health Acts (Canadian Medical Associat ion, no date: 2). Thus i t seems that in an atmosphere of cooperation and co l laborat ion, with each segment respecting the others ' s pec i a l t i e s , c on f l i c t s can be reduced to a minimum between the treatment establishment and the preventive f i e l d . 3.2.3. Related Problems Most of the problems related to occupational health and safety issues have already been mentioned. However, there are a few that need to be addressed more f u l l y , namely; economic considerations, manpower impl ications and the Workmen's (Workers') Compensation in Canada. (1) Economic Considerations It has been observed that occupational disease and injury are considered part of the tota l human and socia l costs of production: ...As such, the level of workplace - related injury and disease i s influenced by the economic forces that come to bear on firms and the i r employees (Ashford, 1976:18). On the one hand, .companies need to produce an adequate rate of return i n order to remain economically v i ab le , hence are under great pressure to keep costs down in order to be competitive in 134 the market place. On the other hand, the many ways of reducing costs may increase workplace hazards for the employees. Rabinovitch (1979:23) says: Employers have a legal duty to provide safe and healthy workplaces. In p ract i ce , the immediate pressures of production targets and cost reduction e f for t s during an economic squeeze generally take precedence over health and safety protect ion. If employers were required to include health and safety in t he i r tota l costs of production, i t might motivate them to make improvements in the workplace. This approach advocated by some, suggests that publ ic po l icy should be geared toward intervention in the market system to make i t function in such a.way that a l l prices r e f l e c t true soc ia l costs and a l l " e x t e r n a l i t i e s " are " i n t e rna l i z ed " (Ashford, 1976:18). It i s often the case, however, safe conditions are more expensive to achieve for smaller firms than for larger ones. Typ ica l l y , the larger companies have the advantages of at t ract ing better management, longer time span for evaluating investment in good safety equipment and practices and better access to information and expert ise. As i t happens, many of the most p ro f i tab le firms are also the safest (Ashford, 1976:20). In an a r t i c l e in the Financial Times, e n t i t l e d , "Safety F i r s t at Dupont," Graham Davies, (1979:4), wr i tes: Dupont of Canada has one of the best indus t r ia l safety records in North America. Last year, only two of i t s workers of 5,400 suffered lost-t ime in ju r ie s at the chemical company's 22 plants, warehouses and o f f i ce s - the same as in 1977. 135 He quotes management as saying: We are charged with giving safety a p r i o r i t y at least equal that of production, qua l i ty of products, cash flow and cost Davies in prais ing Du Pont, also notes: Du Pont i s one of the few companies that have shown that indiv idual-corporat ions can reduce workplace accidents to a minimum without government regulation and in ter ference. . . . By the same token, i t i s possible for the smaller or marginal operations to provide safe workplaces and s t i l l stay in business. They can of f set the economies of scale and high priced managers by other methods to promote health and safety in the work environment. Safe operations are usually well managed operations. And good management promotes safe conditions by ranking job safety as top p r i o r i t y along with other v i t a l company a c t i v i t i e s . Good management also fosters a close employer-employee re la t ionsh ip , with each indiv idual responsible for safety of equipment and procedure. As Ashford (1976:20) puts i t : . . . i n many cases, the workplace can be made safer and health ier by education and management -labour co-operation, with l i t t l e cap i ta l expenditure for new equipment or expensive substitute mater ia l . In such cases, the s ize or marginal nature of the f i rm need not be a reason for ignoring workplace hazards. Wi l l companies make job safety a top p r i o r i t y , or w i l l they leave provincia l governments no choice but to increase i t s involvement with the accompanying costs and decreased freedom of action (Davies, G., 1979:4)? 136 (2) Manpower Implications The manpower problem with a l l i t s ramif icat ions i s far too extensive as a subject to do i t j u s t i ce in an overview of occupational health and safety in Canada. An indepth study i s essential in understanding the to ta l manpower needs for developing a coordinated national po l i cy . Roll Cal l 75 (1975:18), a Univers ity of B r i t i s h Columbia pub l i cat ion, stated that the Federal/Provincial Health Manpower Committee had established f i e l d s which require attention and study in 1975. Of the f i ve most urgent concerns in Canada, i t l i s t e d occupational health as th i rd p r i o r i t y a f ter dental health and mental health. Roll Cal l suggested further research into the f i e l d s and r e a l i t i e s of occupational manpower, in order to r a t i ona l i ze the production and the d i s t r i bu t i on of health workers which can be translated into po l icy for future programs. To h ighl ight some of the main concerns, th i s topic w i l l be examined under three headings; current shortage, types of manpower required and t ra in ing f a c i l i t i e s . (a) Current shortage With the focus now on prevention in health care and concern about the health hazards in the workplace and general environment, demand for trained personnel to work in the occupational health and safety f i e l d s has increased. Dr. G.J. Stopps (1976:67) says: 137 . . .with the passing of the Occupational Safety and Health Act in the United Stated in 1970 a huge demand has been created for occupational health professionals in that country. Canada i s having to. compete against th i s demand with t o t a l l y inadequate resources. Other Canadian author i t i e s , such as Dr. Mastromatteo (1976:15) rea l i ze the need for qua l i f i ed personnel: Education and t ra in ing of the professional s p e c i a l i s t s , technicians, and others needed in the occupational safety and health f i e l d w i l l be required to provide the s k i l l s and resources needed. Undergraduate and post graduate t ra in ing of physicians in occupational health should be stressed. The integrat ion of occupational and environmental health topics throughout other undergraduate teaching programs is also needed. The chronic shortage of qua l i f i ed personnel has become apparent in the l a s t decade as interest mounted in occupational health and safety concerns. Possible reasons for th i s dearth of occupational health workers are given by David Chisholm (1977b:2): 1. Lack of c l a r i t y about the f i e l d i t s e l f and bonafide ro le of professionals and technicians in i t ; and 2. "Market mechanism" re-supply and demand. He further postulates that the supply portion of the equation has received i n s u f f i c i e n t attention and support, largely due to a weak demand for well trained personnel. The manpower dilemma can best be i l l u s t r a t e d by a simple f igure i . e . Nee'cLAvailabi l ity. If there i s a need which cannot be met by ava i lab le manpower, the need tends to be 138 by-passed. If there i s manpower but no need, a need i s often created. At the present time, there i s a need but not much demand. Besides the aforementioned reasons, a th i rd may be added, the d i s i n c l i n a t i o n of professionals to enter the f i e l d because; not only are roles not c l ea r l y defined but there i s lack of recognition and support from the i r peers, espec ia l ly in medicine and nursing;and the antagonism from labour as seen in the "medica l - industr ia l complex." In order to develop a manpower planning po l i cy , i t i s necessary to analyze the needed expertise in each area to project the numbers required.This- i s a d i f f i c u l t task, however. As pointed out by Dr. Chisholm (1977b:2): (a) no c l a s s i f i c a t i o n scheme ex i s ts as to what are professional and technical d i s c ip l i ne s involved in th i s f i e l d (primary and secondary). (b) No national survey or inventory exists for a l l d i s c i p l i n e s , nor for any s ingle d i s c i p l i n e . (c) No estimations of future requirements have been undertaken for a l l d i s c i p l i n e s , although very rough estimates have been projected for a few. Unt i l the serious shortage of manpower i s recognized in the market-place and by governments, there w i l l be i n s u f f i c i e n t resources for t ra in ing the people required to do what needs to be done. (b) Types of manpower required The types of manpower required can be viewed from the aspect of role prescr ipt ions , bas i ca l l y to supply the three broad 139, fronts of governments, management and labour. Nicholas Ashford (1976:22-25), in his study for the Ford Foundation, " C r i s i s in the Workplace", found at least four categories of health workers should be considered: 1. Enforcement personnel which includes health and safety inspectors. 2. Qual i f ied researchers including chemists, physicians, environmental phys io log i s t s , epidemiologists, t ox i co l og i s t s , indus t r ia l hygienists, and engineers are required to i dent i f y potential occupational health and sa fe ty hazards, to assess t he i r ef fects and to determine the requirements for assuring a safe and healthful working environment. 3. Personnel who provide health and environmental services are needed to aid in developing and implementing techniques, methods and programs for the prevention and treatment of occupational disease and in jury. This group includes: occupational physicians, indust r ia l nurses, safety profess ionals, indus t r ia l hygienists, and technicians, as well as executives and managers in business, labour unions, and governments. 4. Personnel are needed to teach the s k i l l s necessary for performing the tasks within each of the above mentioned groups. One of the least studied categories of health manpower in Canada i s the health administrator. While progressive changes 140 have evolved from the host i le administrative climate of the "dua l -1 ine-of-author i ty " era (Smith, H., 1955), the upgrading of health administrators has lagged far behind the modern concept of health care. As Hastings, J.E.F. (1976:1) states: At th i s time, however, there i s considerable evidence emerging in the form of government statements, actions and commissioned reports, that changes.are taking place in the health care f i e l d now and during the next decade, that w i l l both a f fect the health administrator and be affected by his/her performance in the ; profession. In general, these changes f a l l into three broad categories: (1) the structure of the health care f i e l d ; (2) the philosophy of health care prov is ion; and (3) changes due to increased technology. Changes such as these suggest that health administrators w i l l increasingly be concerned with a range of new problems and issues rather d i f fe rent from those of the present and recent past. Irrespective of the spec i f i c nature, extent and d i rect ion of such changes, the role and knowledge and s k i l l requirements of health administrators (and in a l l p robab i l i t y the i r numbers and deployments as wel l ) w i l l be influenced. Many health administrators are doing an admirable job in spite of f i s c a l constraints and cutbacks in services offered the publ ic . But many others need to upgrade the i r basic managerial s k i l l s and be more informed about prevention in health care - espec ia l l y in re la t ion to occupational health and safety. An interest ing study was done in B r i t i s h Columbia (Mackenzie, S., 1977:2) in which she noted the changing character of occupational health manpower personnel. She states: Environmental hazards have three ef fects on man; b i o l o g i c a l , psychological and phys ica l . In the past, the worker, management, health providers 141 and l e g i s l a t i on have focused on the physical ef fects of environmental hazards, then safety personnel emerged, compensation acts expanded and safety committees became established in industry. Now the emerging emphasis of occupational strategies in the 1970's i s on the b io log ica l ef fects of environmental hazards. This has resulted in changes of manpower categories of occupational health workers. These changes are: 1. The emerging new categories; e,g: audiometrician. 2. Developmental changes of established categories; eg: nurses and physicians. 3. Increased emphasis of categories;e.g. i ndus t r i a l hygienist, psychologist. More recent ly, a study on occupational v i s ion care (Schmidt, B., 1978:66) emphasized the fact that eye safety i s an important component of health and safety programming, and encouraged optometrists as primary providers of v i s ion care to take more i n i t i a t i v e to become involved in occupational health a c t i v i t i e s both in government and industry. As occupational health and safety programs become more integrated and comprehensive, the psycho-social environment of the working population should be considered. Close cooperation with other spec i a l i s t s such as soc ia l workers, soc io log i s t s , behavioural s c i e n t i s t s , physical f i tness experts, may be necessary, as the "team" concept develops. 142 (c) Training f a c i l i t i e s There are very few post-graduate t ra in ing programs for occupational health and safety manpower in Canada at the col lege l e v e l . Consequently, there i s a continuing rel iance on courses e i ther in the United States or the United Kingdom. In a Discussion Paper on "Professional and Technical Personnel Resources for Occupational Health and Safety in Canada," David Chisholm (1977b:4) states that the Univers ity of Toronto, and Humber, Algonquin and Grant MacEwan Colleges do have t ra in ing programs for these d i s c i p l i ne s . He said several more are being proposed, developed or expanded at the fol lowing un i ve r s i t i e s ; McMaster, Toronto, B r i t i s h Columbia, Laval, Montreal, and McG i l l , and several community col leges. However he says: (a) There i s l i t t l e co l laborat ion among these i n s t i t u t i on s . (b) Curr icu lar guidelines are being developed independently and hence are highly variable even within the same d i s c i p l i ne s . (c) D i sc ip l ines created have no common standards, t i t l e s , e tc . between provinces as well as within provinces. (d) No agency i s maintaining an on-going inventory of t ra in ing i n s t i t u t i o n s , programs, cert i f icates/diplomas/ degrees of fered, c u r r i c u l a , future plans (Chisholm,D., 1977b:4). During the 1970's there have been a number of attempts by the Medical Associat ion, the Nursing Associat ion, the Canadian Public 143 Health Associat ion, Science Council of Canada, other organizations and interested indiv iduals to stimulate interest in t ra in ing in the general d i s c i p l i ne of occupational health (Chisholm, D., 1977b: 5-6). (3) Workmen's (Workers') Compensation in Canada A comprehensive coverage of "Workers' Compensation in Canada" i s not possible within the scope of th i s paper, but the author would be remiss i f some reference i s not made to the pr inc ip les underlying the system, and to the l e g i s l a t i v e j u r i s d i c t i o n s . The Canadian workers' compensation system i s based on two main p r i nc ip le s : c o l l e c t i v e l i a b i l i t y on the part of employers and compulsory insurance in a state fund, known as the Accident Fund. I t i s , in e f f ec t , a mutual insurance scheme in which the employers in a class of industry are j o i n t l y or c o l l e c t i v e l y l i a b l e for the cost of a l l accidents occurring in that c lass . In each province, coverage i s compulsory for a l l employment within the scope of the law. Neither the employee nor the government makes any contr ibut ion to the Accident Fund. The costs of compen-sation are regarded by employers as a d i rect cost of production and passed on to the consumer. The workers' compensation system i s an example of an attempt to " i n t e r na l i z e " cost - but a f te r the harm has been done. A s i gn i f i can t feature of the Canadian workers' compensation system i s that each law i s administered by a v i r t u a l l y autonomous 144 board, with f u l l and f i n a l authority to determine a l l matters a r i s ing in the administration of the Act. However, in B r i t i s h Columbia a worker whose claim has been rejected by the claims department of the Board, may appeal the decis ion to a Board of Review. Accident prevention i s an integral part of the Workers' Compensation system of a l l Canadian provinces, though the responsibi-l i t i e s may be assumed by the Board, or in some instances, employers' associat ions. Regulations governing safety committees vary from province to province. In the provinces where the Board has d i rec t re spons ib i l i t y for accident prevention, (A lberta, B r i t i s h Columbia, Newfoundland, Prince Edward Island and Saskatchewan) i t has wide statutory powers. I t i s empowered to make and enforce regulat ions, to require the i n s t a l l a t i o n of necessary safety devices, to carry out an extensive educational program and to take other measures to protect the work force against injury in the course of i t s employment (Workers' Compensation in Canada, 1969). There are some problems in the system that are gradually being worked out. The safety aspect i s exce l lent , but as yet the system does not adequately deal with occupational problems such as chronic conditions and environmental hazards. Ashford (1976:19) comments: Workers' compensation, in paying for treatment, r e h a b i l i t a t i o n , or harm, i s probably not nearly as cos t -e f fect i ve as prevention. However, since prevention costs must be faced immediately, whereas treatment and compensation costs may be deferred -145 or even avoided en t i r e l y - the higher do l l a r costs of delayed action may be discounted to a r e l a t i v e l y lower present value than prevention costs. Further problems are surfacing as unions become more vocal in t he i r demands for the workers' health and safety. For example, the B.C. Workers' Compensation Board commissioners came under attack, recently at the International Wood Workers of America Convention in Vancouver, B.C., as reported by Peter Comparelli (Vancouver Sun, 12 September, 1979: A l l ) . They were accused of meddling with decisions made by Workers' Compensation Board boards of review. Apparently other unions have previously made s imi la r publ ic statements condemning Workers' Compensation Board Commissioners for overturning successful union appeals granted by boards of review. Among the resolutions passed at th i s convention c r i t i c i z i n g WCB p o l i c i e s , the fol lowing are ind icat ive of labour ' s growing concern for t he i r own health and welfare, such as: 1. An increase in WCB assessments against employers to counteract a " f i e r c e cutback in coverage for injured workers." 2. That the board increase i t s inspections of unsafe working conditions and impose harsher penalties against employers for i ndus t r i a l health and safety in f ract ions . 3. A change in WCB regulations to enable t ra in ing of safety committees. 4. Ful l access to a l l WCB f i l e s by claimants or the union. 5. That a WCB representative look at a job with an injured employee instead of reject ing his or her claim on the basis of management's descr ipt ion. 146 6. Changes to WCB l e g i s l a t i on to guarantee that time loss benefits continue unt i l the injured worker is f u l l y retrained or back working at the same or better wages. One important resolut ion concerning health rather than safety was also passed. This was for s pec i f i c regulations covering dust control and a i r qua l i ty for cedar and ^plywood m i l l s . On. the other hand, Workers' Compensation Board has had occasion to implicate both management and union members in i ndus t r i a l f a t a l i t i e s . A case in point, as reported by Keith McQuiggan in the T ra i l Times (29 November, 1978:3) was negligence of both Cominco and Local 480 leading to the deaths of three young men. I t appears then, that the Workers' Compensation system together with labour ought to cooperate in good f a i t h , moving away from the "adversar ia l " atmosphere to a t ru l y " c l i n i c a l " approach. This would necessitate employers putting workers' health before products, and workers assuming more respons ib i l i t y for the i r own health and for the health of the i r fel low workers. Workers' Compensation Board of B.C. The B r i t i s h Columbia Workers' Compensation Act was formulated in 1916 and came into e f fect on January 1, 1917. Under th is act , the Board i s the sole judge of a l l questions of law and fact which ar ise out of the Act (Berry,J.P. lec ture , no date: 1-9). 147 The Board bas i ca l l y has 3 functions, to provide: (a) a program of compensation for d i s a b i l i t y , (b) a program for income maintenance and the protection of economic loss due to d i s a b i l i t y , (c) r ehab i l i t a t i on programs aimed at restoring the disabled to optimum levels of functioning. The B.C. Workers' Compensation Board i s one of the largest on the continent and has 1 ,000 patients (W.C.B. Interviews, Nov:;T976):It has d iv i s ions concerned with accident prevention; indus t r ia l hygiene, safety research and t r a i n i ng ; medical care to employees; r ehab i l i t a t i on c l i n i c s ; claims and claims processing; organizations to inspect and advise on methods of improving working conditions. Writing in the Labour Gazette, Ralph M. Wirls (September 1977:407), former ed i tor of the Oregon Workers' Compensation Board Magazine said that B.C.'s Workers' Compensation Board has been accepted for most of the province's i ndus t r i a l h istory as the proper authority over the physical well-being of i t s workers, and: B r i t i s h Columbia's occupational safety and health program contains many advances U.S. and other Canadian agencies would do well to study... 148 3.3 DESIGN OF POLICY The Canadian experience c lear l y demonstrates that occupational health and safety problems are not only diverse but inordinately complex. Therefore, i t i s un l ike ly that solutions w i l l evolve from s imp l i s t i c strategies based on.single approaches. The foregoing pages dealt at length with the many issues, con f l i c t s and problems of occupational health and safety. It appears that l e g i s l a t i on and enforcement w i l l not s u f f i ce : neither w i l l research alone, to generate knowledge and determine standards. On the other hand, se l f - regu lat ion has i t s c r i t i c s , and would probably create more problems than i t would solve. Ashford (1976:34) suggests four sets of polncy instruments: 1. The law. 2. Market incentives. ' 3. The generation, dissemination and u t i l i z a t i o n of knowledge. 4. The development of personnel in the various professions, in the labour unions, in management, and in government with the requis i te knowledge of the issues. In summation; even while these instruments are aggressively developed and pursued, they also w i l l not be s u f f i c i en t without the active involvement of both employers and employees. Workers must assume a greater role in monitoring the qua l i ty of the i r own work environment as well as checking on management's r e spon s i b i l i t i e s . This does not mean, however, that employers can rel inquish any of t he i r 149 re spons ib i l i t y , as there are circumstances which are beyond the control of the workers. The issues that a r i se , whether they be safety or health hazards, worker dissatisfaction or production delays, supervision and t ra in ing methods or ergonomic factors , they can a l l be addressed in the da i ly interact ion of informed and concerned employees and employers. The placing of a higher p r i o r i t y on job environment issues in the co l l e c t i ve bargaining process would go a long way towards resolving problems. The focus of occupational health must be prevention, and the goal should be optimum phys ica l , mental and soc ia l well-being of the worker. The goal i s the essence of po l icy. 150 CHAPTER 4 ACCIDENT RESEARCH 4.1. INTRODUCTION Following in the wake of the s c i e n t i f i c and technological revolution - a continuation of the i ndus t r i a l revolution - many new ., hazards were created and are s t i l l being created. The existence of these are of grave concern to indiv iduals and communities,at work, in homes, in transportation and recreat ion. Moreover, the real tragedy appears to be the needlessness of a great many of the hazards which lead to the accidents that plague the publ ic . Gabor (1970:9), in his book " Innovations", expresses th i s sentiment succ inct ly : The most important and urgent problems of technology today are noJonger the sat i s fact ions of primary needs or archetypal wishes, but the reparation of the e v i l s and damages wrought by the technology or yesterday. For more than ha l f of the i r l i v e s , the people of the United States and many other Western countries are more l i k e l y to die from accidents than from any other cause (Haddon et a l , 1964:2). Accidents, as a cause of death, on a global scale are now out-ranked only by cancer and cardiovascular disease (Candau, 1961). Thus: It seems e s sen t i a l , therefore, that as much attention be directed towards the prevention of accidental death and in jury as i s devoted to the control of infect ions and degenerative diseases (McFarland 1964). 151 Nevertheless, i t i s wise to view accidents as a cause of death with some sort of perspective. It i s suggested that accident morta l i ty , at least in the Western countries, has " r i s en " by v i r tue of remaining unchanged while dramatic reductions have occurred in the incidence of fa ta l diseases of mankind. With improved san i ta t ion , pasteurization of milk and other environmental controls , a n t i b i o t i c s , vaccines, advances in surgery, and a general r i se in standards of l i v i n g and medical care, morta l i ty from other causes have markedly declined (Haddon et a l , 1964:2; Hale and Hale, 1972:18). ;However: - - . Accident f a t a l i t i e s taken as a whole have shown no such decrease. Changes in culture and technology change the incidence of s pec i f i c kinds of accidents ( ra i l road f a t a l i t i e s decrease and motor vehicle f a t a l i t i e s increase), but the substant ia l ly unchanging over -a l l tota l s tend to lend c r e d i b i l i t y to the widespread popular be l i e f that, accidents, l i k e the poor, we shal l always have with us (Hadden et a l , 1964:2). Dr. Mastromatteo (1976:11) warns: There is need, however, for a fresh approach in accident prevention because occupational accideifts in general have leve l led of f and the trend seems to show increasing accidents in some indus t r i a l sectors. Due to the fact that accidents occur in a l l walks of l i f e , i t has become a subject of interest to a number of d i s c ip l i ne s including psychology, sociology, ergonomics, engineering, design, s t a t i s t i c s , medicine, i ndus t r i a l hygiene, safety, etcetera. As a consequence, many d i f fe rent aspects of accidents have been studied and various methods of study have been employed. A search of the 152 l i t e r a tu re confirms the m u l t i p l i c i t y of possible .approaches to the subject (Haddon et a l , 1964: Hale and Hale, 1972). The awesome task facing the researcher has been aptly described: Accident research i s highly heterogeneous in content and emphasis. It ranges from intensive studies of the role of s pec i f i c variables to broad scale invest igat ions of accident incidence. There are many types of accidents, and many factors , often i n t e r - r e l a t ed , that may be s i gn i f i c an t . This complexity i s soon apparent to those approaching the subject for the f i r s t time, and i t remains a source of concern to establ ished investigators (Haddon et a l , 1964:14). Bearing in mind the complexity of the f i e l d and the m u l t i p l i c i t y of methodology, a researcher also needs to guard against overemphasizing the importance of some variables!; to quote: Each one natura l ly tends to look at accidents from his own point of view and to concentrate on those variables and those methods of study which are f ami l i a r to him (Hale and Hale, 1972:9). Notwithstanding the p i t f a l l s and problems encountered in accident research, i t i s possible to extract some general concepts which have been proven useful in the recent past, and to apply them towards a balanced approach to the study of accident prevention. 4.2. SOME OBSTACLES TO ACCIDENT RESEARCH In viewing some areas for an explanation of the d i f f i c u l t i e s encountered in accident research, a few factors can be 153 i so lated that may have contributed to th i s s i tua t ion . I t seems the way in which accidents are perceived by contemporary society has had a great bearing on the lack of sophist icat ion in th i s f i e l d . 4.2.1. Myths Well establ ished myths on the causes of accidents and prevention methods are s t i l l propagated in .many quarters. Various publ ications and a r t i c l e s on safety blame human carelessness as the . major cause of safety problems. To counter t h i s , Rabinovitch (1979:22) states: In f ac t , many reputable studies have demonstrated conclusively that "carelessness" i s a minimal factor . Other.myths, in occupational sett ings, tend to present the picture, of worker ignorance and "bad worker att i tudes " as requir ing counter-measures in the form of s t r i c t management controls and s imp l i s t i c educational programs. Such myths ignore the physical and soc ia l elements in work s i tuat ions , and act ive ly deter the development of pos i t ive programs and the search for accident causation (Rabinovitch 1979:22). Another impediment to accident knowledge i s what appears to be a universa l ly held concept embodied in the oft-quoted phrases, "Act of God", " l u c k " , "chance", implying that which i s beyond human contro l . In the words of Haddon et al (1964:2): As a re f l ec t i on of t h i s , accidents remain the only major source of morbidity and mortal i ty which many continue to view in ext ra - rat iona l terms. 154 This c u l t u r a l l y acceptable explanation continues to be applied to such "natura l " disasters as floods and earthquakes, and often-times as not, goes unchallenged. But i f the assumption i s that most accidents are not causal ly unique then the ent i re accident f i e l d must come under more concerted scrut iny. 4.2.2 Social Value of Safety Safety per se has never graced the top rung of socia l values. Safety measures often involve the r e s t r i c t i o n or prohib i t ion of behaviour that the indiv idual enjoys or that the culture esteems. Hence, personal freedom becomes threatened and g r a t i f i c a t i o n from r i sk - tak ing i s thwarted: The American cu l ture, i f not Western culture as a whole, has always prized and rewarded the taking of r i s k s . The r i sk - taker - the explorer, the voyager, the medical researcher, the entrepreneur, the p r i ze - f i gh te r and b u l l -f i gh te r , the sports car racer, the test p i l o t -has always been endowed by society with heroic q u a l i t i e s , even when his r i sk - tak ing i s unsuccessful and he i s maimed or k i l l e d (Haddon et a l , 1964:7). 4.2.3 Costs Safety measures involve understandable threats to spec i f i c industr ies or to the publ ic as a whole. Safety features that are found to be e f fec t i ve can be cost ly to the manufacturer and to the consumer. The slogan " i t i s better to be safe than sorry" i s not always heeded. It i s only f a i r to say, however, that many industr ies and firms have improved the safety of the i r products 155 and operations without organized publ ic pressure or legal sanctions. As mentioned in the preceding chapter, the Du Pont company i l l u s t r a t e d what can happen by showing that indiv idual corporations can reduce work place accidents to a minimum without government regulation and interference. On the other hand, the history of safety l e g i s l a t i on has demonstrated that often action takes place only because of high level pressure from an outraged publ ic . By and large, in the absence of such disasters as the T i t a n i c ' s s ink ing, or the mult ip le re f r i gerator deaths of small ch i ld ren , society has been insens i t ive to assuming the costs of e f fec t i ve counter-measures to prevent accidents. 4.2.4 Inert ia to Change Inert ia to change i s an addit ional problem which i s detrimental to vigorous research study and implementation of i t s re su l t s : Even such organizations as those responsible for the provisions of medical care, insurance, vehicle repair and d i s a b i l i t y benefits have character i s t i c s which are but slowly susceptible to change (Haddon et a l , 1964:8). Although there i s nothing to suggest that par t i cu la r interests are threatened nor accident research in general i s opposed, Haddon et al (1964:8), continue: It does mean, however, that the appl icat ion of any new f inding may be hampered by the i n e r t i a so often associated, in any se t t ing , with change in functioning. 156 C i t ing an instance, a substantial change in at t i tude towards the cu l pab i l i t y of indiv iduals involved in accidents might require enormous revis ions of l e g i s l a t i v e statutes with corresponding expenditures at various l e ve l s , of time, money and e f f o r t . The bureaucratic delays, to say the l ea s t , would be most disheartening knowing that accident research does not seem to qua l i f y for high p r i o r i t y status. Conf l i c t i ng views held on the adequacy of ex i s t ing accident prevention programs also obstruct progress and delay change. Some persons may be reassured that they are protected regardless of the e f f i cacy of a given program. Others may question certa in procedures and feel i n s u f f i c i e n t knowledge i s being communicated. These d i f fe rent be l ie f s tend to delay an objective evaluation of any accident reduction measures. 4.2.5 Psychological Factors Some psychological obstacles to accident research also need to be considered. Human behaviour seems to be greatly influenced by the "remoteness" factor with respect to accidents. To i l l u s t r a t e with three examples; f i r s t , Haddon et al (1964:9) noted: Public response to a socia l problem often seems to require a stimulus that i s immediate, close at hand, and dramatic. Hence, the public may demand immediate f l i g h t safety l e g i s l a t i on af ter a hundred passengers die in an a i r l i n e crash. But i t accepts the same s t a t i s t i c s in t r a f f i c or occupational f a c i l i t i e s 157 with apparent indifference simply because the cumulative resu l t may be spread widely over time and space. Secondly, there i s the commonly held be l i e f that accidents, l i k e cancer or the aging process only happen to the "other person" (Lalonde, M. 1974:8). Unless there i s the a b i l i t y to i dent i f y with accident v ict ims, there seems to be no great urgency for people to establ i sh preventive measures. Th i rd ly , the d i f f i c u l t y in connecting cause and ef fect also makes immediate preventive action less l i k e l y . For instance, the long term e f f e c t ' of ion iz ing radiat ion may be noted years a f ter exposure. Thus: If s c i e n t i f i c investigators often have d i f f i c u l t y in establ i sh ing the ro le of pathogenic agents and quantifying the i r e f f ec t s , i t i s not surpr is ing that socia l concern and action may be d i f f i c u l t to stimulate (Haddon et a l , 1964:10). 4.2.6 Inherent Violence Factor One other aspect of the pub l i c ' s apparent tolerance to accidents, i s the pre-occupation of society in the various forms of violence related to human s a c r i f i c e . To c i t e a few examples from ancient h istory to the present day are siuch experiences as public executions, bu l l f i g h t i n g , contact sports, sad i s t i c motion p ictures: It i s possible that accident research and prevention w i l l not obtain the publ ic support and approbation accorded to medical research un t i l those aspects of accidents and the ro le of violence in human behaviour are under-stood... (Haddon et a l , 1964:10). 158 4.3 PRESENT STATUS OF ACCIDENT RESEARCH The aforementioned obstacles to the establishment of accident research as an independent d i s c i p l i n e may account to some extent forvthe status of the f i e l d of accident research today. Whereas research on diseases have enjoyed government and public support over the years, accident research in sharp contrast has not had th i s attent ion: Except in a scatter ing of laboratory and f i e l d programs in the United States and other countries devoted ch i e f l y to the development and evaluation of "hardware" - seat be l t s , indust r ia l safety equipment, and a i r c r a f t , for example - there are few well trained groups of invest igators working in recognized and adequately supported research centres and un i ve r s i t i e s . . . (Haddon et a l , 1964:4). Thus, despite the enormous amount of l i t e r a tu re on accidents there has been a scarc i ty of organized qua l i ty accident research (Hale and Hale 1972:80'; Haddon et a l , 1964:280). What accident research has been done has been conducted largely by interested indiv idual professionals e i ther in the course.of the i r work, or to test a theory or a technique: ...But an adequate accident-research program, l i k e broad research programs in areas of more t r ad i t i ona l medical concern may require, depending on i t s focus, professionals trained in many d i s c i p l i n e s . . . (Haddon et a l , 1964:4). Nevertheless, science i s growing at an exponential rate. New concepts in medicine, psychology, sociology and s t a t i s t i c s , together with the expertise in these f i e l d s , are providing the 159 needed impetus for a more comprehensive study of accidents. And with the widespread interest in occupational health and safety today, accident prevention i s becoming high p r i o r i t y with more governments in Canada. Added to t h i s , the publ ic is gradually becoming aware that "modern" accidents appear to be increasing in developed countr ies, as well as in developing countries current ly undergoing westernization (Haddon et a l , 1964:11 ). This concern i s being ref lected in organizations such as the Workers' Compensation Boards using the media for safety education, and labour/management teams including safety clauses in the i r c o l l e c t i ve agreements. Thus the climate in the clos ing years of the twentieth century appears to be favourably disposed to a new emphasis on and a new d i rect ion for accident research and safety programs. 4.4 MAIN THEORIES IN ACCIDENT RESEARCH Most serious students of accident research, over the years, have postulated various theories. Some of these theories have since f a l l en into disrepute, while others have been b u i l t on previous ones or modified. S t i l l others have taken on en t i r e l y new approaches to the subject. Hale and Hale (1972:14-17), divides them into two groups, non s i tuat iona l and s i tuat iona l theories. F i r s t , the ones that concentrate on the person to the exclusion of the s i t ua t i on , are l i s t e d as; pure chance, biased 160 l i a b i l i t y , unequal i n i t i a l l i a b i l i t y - more commonly known as the accident prone theory, adjustment/stress theory, goals/freedom/ alertness theory, and unconscious motivation. Perhaps the most i n f l uen t i a l of these in accident research has been the accident prone theory. Ba s i ca l l y , th i s theory states that some people are more l i a b l e to accidents than others due to innate personal cha rac te r i s t i c s : The basic hypothesis requires that a l l people in the same sample considered are exposed to the same r i s k , so that the differences in l i a b i l i t y are en t i r e l y due to personal ity cha rac te r i s t i c s . A log ica l deducation from th i s hypothesis i s that i t should be possible to ident i f y the character i s t i c s responsible for a high level of l i a b i l i t y (Hale and Hale, 1972:15). Ea r l i e r works on accident proneness dealt mainly with sensorimotor var iables, but from the 1940's onwards the studies changed the i r emphasis to personal ity variables (Hale and Hale, 1972:15). Today, accident proneness i s taken as s u s cep t i b i l i t y to accidents due to human factors. It i s considered that a l l persons are subject to th i s s u s cep t i b i l i t y at d i f fe rent times and in d i f fe rent circumstances, save that the degree varies with indiv iduals (Encyclopedia of Occupational Health and Safety, 1971:18). The second group of theories mentioned by Hale and Hale (1972), concerns the accident l i a b i l i t y of s i tuat ions . Faverge 161 i s reported as analyzing the s i tuat ions leading to u n r e l i a b i l i t y and accidents, stress ing pa r t i cu l a r l y the concepts of breakdown and degradation of the normal work routine. Winsemius, another researcher, produced a detai led theory of task structures, considering an accident to be a disturbance in the task a c t i v i t y which may or may not resu l t in in jury. The Domino theory, due to Heinr ich, encompasses both personal and s i tuat iona l factors. It describes the sequence of events leading up to an injury in f i ve stages: (a) ancestry and social environment, leading to (b) f au l t of a person, const i tut ing the proximate reason for (c) an unsafe act and/or mechanical hazard, which results in (d) the accident, defined as being struck by, f a l l i n g , being burnt by, etcetera, which leads to (e) the in jury. It i s th i s theory that gave r i se to the consideration of accidents by unsafe acts and unsafe condit ions, which i s used widely in industry today (Hale and Hale, 1972:16). The epidemiologic theories owe much to the influence of ideas formalized in the study of epidemics in the publ ic health f i e l d . This approach has introduced three terms into the language of accident research f i r s t postulated by Gordon (1948); the host (victim) to whom the accident happens, the agent according to Haddon et al should refer to the "abnormal exchange of energy" which causes the injury (defined as mechanical, chemical, e l e c t r i c a l , thermal, ion iz ing etcetera) , and the environment refers to the 162 circumstances surrounding the accident, subdivided into phys i ca l , b io log ica l and socio-economic. The accident i s regarded as being caused by the conjunction of factors from a l l three areas (Hale and Hale, 1972:17). 4.5 PROBLEMS IN ACCIDENT RESEARCH The study of accidents presents many basic problems which need to be reviewed. Some of the more obvious ones w i l l be examined. 4.5.1 Def in i t ion In order to study a subject s c i e n t i f i c a l l y , i t must f i r s t be defined. Therein l i e s the f i r s t problem. The Encyclopedia of Occupational Health and Safety (1971:10) says: An accident may be defined as an unexpected, unplanned occurrence which may involve i n j u r y . . . . Webster's New World Dictionary uses terms such as: 1. an unexpected happening 2. an unfortunate occurrence; mishap 3. chance Yet any hint of causelessness i s d iametr ica l ly opposed to the s p i r i t of s c i e n t i f i c enquiry. Thus, researchers have had to provide t he i r own de f in i t i ons t a i l o red to su i t the research questions under invest igat ion. A few examples are put for th by Hale and Hale (1972:11): 163 "In a chain of events, each of which is planned or cont ro l l ed , there occurs an unplanned event, being the resu l t of some non-adjustive act on the part of the indiv idual (variously caused), may or may not resu l t in in jury . This i s an accident" (Arbous and Kerich). "An accident.with or without i n ju ry , i s in the main a morbid phenomenon resu l t ing from the integrat ion of a dynamic var iable conste l lat ion of forces and occurs as a sudden, unplanned and uncontrolled event" (Schulzinger). Suchman discusses the problem of de f i n i t i on at length and concludes that " I t i s doubtful that any s ingle de f i n i t i on w i l l cover a l l types of events of interest to the student of accidents." He goes on to produce a l i s t of indicators of the accidental nature.of an event. The more indicators that are present, the more l i k e l y the event is to be ca l led an accident: low degree of expectedness, low degree of avo idab i l i t y and low degree of intent ion. Haddon et al (1964:3) say: Accidents are almost invar iab ly defined - in tabulat ions, in control programs, and in research - as the occurrence of unexpected physical or chemical damage to l i v i n g or non- l iv ing structures. The Encyclopedia Americana, Canadian ed i t ion (1963:70) states: ...The word sometimes carr ies implications of the absence of human f au l t or negligence; and in th i s sense an accident i s an occurrence which could not have been prevented by the exercise of ordinary care In many cases, however, the term has been interpreted by the courts as meaning simply an event occurring without one's foresight or expectation, and thus including happenings which involve negligence. Hale and Hale (1972:11-14) and Haddon et al (1964:140), who have compiled useful reviews on accident research l i t e r a t u r e , found that in the majority of research papers, the words accident and injury are almost synonymous. They also came to the same conclusion, that the choice of de f i n i t i on and behaviour to be studied should be 164 dec ided l y the use to which the research findings are to be put. P rac t i ca l considerations of data co l l ec t i on have ensured that most researchers have used i n ju r i e s as the i r subject of study (Hale and Hale, 1972:12). To lessen the confusion, i t would seem reasonable to expect researchers studying actual i n j u r i e s , to refer to them as such, and not "acc idents " . What seems to be required is the d i f fe rentat ion between a conceptual de f i n i t i on and an operational de f i n i t i on of accidents, so as to permit comparative and cumulative research (Suchman, E., in Haddon et a l , 1964:281). 4.5.2 Concept of Cause Unlike diseases in human beings, accidents are commonly regarded as somewhat d i f fe rent when establ i sh ing causation. Since there are many unknown factors in the cause of accidents, researchers have been su itably vague and have hedged about in pin-point ing d i rect cause. Crucial to understanding of accident causation i s f i r s t , an understanding of what i s usually meant by the term "accident" and secondly a comparision between accident causation and that of other sources of morbidity and mortal i ty for which accidents are often believed to d i f f e r (Haddon et a l , J 9 6 4 : 2 ) . In the absence of s pec i f i c causes such as bacter ia , viruses or other signs of pathology which are responsible for disease, 165 researchers from the various d i s c ip l i nes focus on other factors , according to the i r pa r t i cu la r f i e l d of investigaton. Haddon et a l , (1964:17) observed that the terms "cause" and "causation" are often used in descr ipt ive papers, emphasizing the qua l i ta t i ve and quant i tat i de f i n i t i on in s t a t i s t i c a l terms of parameters, and the i r relat ionships associated with high rates of occurrence. I t i s largely accepted by most researchers, now, that in an accident s i t ua t i on , there i s a causal chain of events and the occurrence of " t r i gge r " events that touch o f f the accident (Suchman, E.A.,in .Haddon et a l , 1964:281). Therefore, emphasis i s placed on the i d e n t i f i c a t i o n of the major stages or steps in the accident sequence. Terms such as "predisposing" re la t ing to human factors , and "contr ibut ing " in the environment factors are often used. This mu l t i f ac to r i a l nature of accident causation i s evidenced by the comment of the Encyclopedia of Occupational Health and Safety (1971:11): Accident causation is a complex subject but in essence most in jur ies are caused by a combination of physical circumstances and human acts in varying proport ions.... John E. Gordon ( in Haddon et a l , 1964:21-22), whose study was done i n 1948, defined agents concerned with i n ju r ie s and accidents as of phys ica l , chemical and b io log ica l in nature. He maintained that the causative factors in accidents have been seen to reside in the agent, in the host and in the environment. The mechanism of 166 the accident production, he stated, is the process by which the three components in teract to produce a re su l t , the accident - but i t i s not the cause. Various kinds of mechanism, however, serve to advantage irii c l a s s i f y i ng accidents by type, with pa r t i cu la r events ascribed to cu t t i ng , to c o l l i s i o n or to crushing, yet the agent in a l l three instances may be a glass panelled door. Conversely, he argues, a f a l l may be related to such d i s s im i l a r agents as a fau l ty ladder or a p layfu l pup. Haddon et al (1964:27) commenting on Gordon's analysis say: ...although i t i s a landmark in the s h i f t of medical attent ion to accidents, i t f a i l s to ident i f y the agents required by the host-agent-environment model... They f e l t that describing parts of the environment, for example, a glass panelled door as the agent, was not s p e c i f i c , since such in ju r ie s as lacerations can be produced by other means. They speak of the "abnormal energy exchanges" which are necessary and are the spec i f i c causes of accidents (Haddon et a l , 1964:140). Haddon et al contend that the abnormal energy exchange i s the common factor in accidents, without which unexpected in ju r ie s to l i v i n g or inanimate structures cannot occur. When this question i s considered, i t appears a l l such types of damage f a l l causally into a r e l a t i v e l y small number of groups. I t follows then, each type of damage i s the resu l t of a s pec i f i c type of energy exchange and i t can usually be produced in..no other way. They c i t e for example, the crushing, tearing and breaking of s t ructure, whether a 167 fender or a leg, can only be produced by the transfer to that structure of a s u f f i c i e n t quantity of mechanical energy. Thus, they suggest the several forms of energy, thermal, e l e c t r i c a l , mechanical and ion iz ing meet a l l the c r i t e r i a of agents in the host-agent-environment model. The fundamental problem in accident prevention, then, i s seen to be the prevention of these abnormal energy exchanges (Haddon et a l , 1964:28). Once the essent ia l role of abnormal energy exchange i s recognized i n accident causation, two important points can be made. F i r s t , i t makes c lear the nature of the basic events that motivate and define the f i e l d . Secondly, i t demonstrates the close para l le l i sm between th i s area .and.others - s p e c i f i c a l l y infect ions and other insu l t s to the body which have long been the concern of preventive medicine (Haddon et a l , 1964:29). 4.5.3 Methods of Study A subject as heterogenous as accident research c a l l s fo r a m u l t i p l i c i t y of methodologies. Indeed, investigators from the various d i s c ip l i ne s have had a wide f i e l d in choosing research questions and methods of study. Most of these works can be grouped into two major subdivis ions; those papers which look at one group of people or events and those which compare two groups of people or events. Within these two d i v i s i ons , there are studies which use past accident history as a c r i t e r i on for choosing a group or groups, 168 and there are those which choose the group on other grounds and look at d i s t r i bu t i on of accidents within them (Hale and Hale, 1972:18). A number of problems become apparent when these studies are reviewed. One of the p i t f a l l s in case studies of accident victims and accident s i tuat ions , has been the common error of assuming a causal re lat ionship between certa in character i s t i c s and accidents without studying the extent of such character i s t i c s in the general population. Hale and Hale (1972:18) point to Se l l i n g ' s study which found some visual impairment in a l l those over 65 years in 35 accident prone dr ivers. But he did not examine how many others in th is age group also had some visual imperfections. With the case study method, there i s also danger of general izing the results too widely beyond what i s supported by the evidence leading to un jus t i f i ed conclusions. This problem arises when a sample population is too small or represents a spec ia l i zed segment of society (Hale and Hale, 1972: 19) or i f based on data known by informed researchers to be fau l ty (Haddon et a l , 1964:36). Nonetheless, i t can be said the case studies have much of value in them provided they look at a l l aspects of the accident, both-personal and s i t u a t i ona l , and provided that the deta i led information which they produce i s object ive ly analyzed. Comparing two groups on the basis of t he i r past accident h i s to ry , fo r example, accident prone people with the non-accident prone, gives r i se to a number of problems. Even when investigators 169 accept the theory of accident proneness, they f ind the term "accident prone" can be applied only, to a very small proportion of any population. Added to th i s d i f f i c u l t y , they f ind operational def in i t ions of accident prone and non-accident prone need to be s t ipu lated. Davis and Coi ly used drivers with more than three accidents per 100,000 miles of d r i v ing , as t he i r accident prone group and those with less than three accidents per 100,000 miles as t he i r safe group. Marcus et al used the same c r i t e r i on for the i r accident prone group, and those with one accident or less as t he i r accident free group. Others have used four accidents or more as opposed to no accidents during 100,000 miles of dr iv ing (Hale and Hale, 1972:28). It appears the variat ions of def in i t ions are mult i far ious making corroborative studies impossible, unless the same c r i t e r i a are used. Other p i t f a l l s , mentioned in the i r "Review of Industr ia l Accident Research L i te rature " (Hale and Hale, 1972:30-31), are: (1) not acknowledging the differences in r i s k in the i r populations. For example, a l l people with the same job t i t l e are not necessari ly exposed to ident i ca l r i sks . (2) Fai lure to recognize that accidents are not a homogeneous-entity. What l i t t l e work has been done on comparing factors associated with various kinds of accidents has indicated important differences. (3) A besetting s in of accident research, i s the interpretat ion of corre lat ion as causal when the evidence does not support t h i s . A greater c l a r i f i c a t i o n of the factors central to causation must be considered in any accident 170 research. (4) There i s a tendency to in terpret results of research according to personal or professional bias ignoring other equally plaus ible explanations. (5) Reliance on records as a source of accident data often precludes the r e a l i t i e s of the i ndus t r i a l s i tua t ions , such as s k i l l s required fo r s pec i f i c jobs, the m u l t i p l i c i t y of machines and various task components of a job. Researchers are often unaware of the i n t r i c a c i e s of the i ndus t r i a l s i tuat ion and generally do not acknowledge them. 4.5.4 C l a s s i f i c a t i on Systems There are many ways of c l a s s i f y i ng accidents. These can be according to cause, degree of severity of i n ju ry , time loss and no time loss , nature of the i n ju r y , parts of the body involved and ..... according to place of accident(at work, in publ ic places, at home and in motor veh ic les ) , etcetera. The c l a s s i f i c a t i o n according to cause appears to be the least straightforward and creates much confusion. The various methods of c l a s s i f y i ng accidents according to causes take the form of simple c l a s s i f i c a t i o n systems and mult iple c l a s s i f i c a t i o n systems, and as often as not, "cause" and "type" are used interchangeably. Sometimes the l i s t s refer to the motion that prec ip i tates the act ion , fo r example, f a l l i n g or struck by, as the cause..Other times, the external agent such as machinery, i s considered the cause (Encyclopaedia of Occupational Health and Safety, 1971:10,20). 171 Many countries keep accident s t a t i s t i c s of work, travel and home accidents, but the basis for compilation varies between countries and between a c t i v i t i e s so that va l id internat ional comparisons are d i f f i c u l t (Encyclopaedia of Occupational Health and Safety, 1971:10). The t rad i t i ona l means of c l a s s i f y i ng accidents by cause has been the External Cause section of the International S t a t i s t i c a l C l a s s i f i c a t i on of Diseases, Injuries and Causes of Death (ISC). This system has been used over the years by the v i t a l records section of many health departments to code cause of death on death c e r t i f i c a t e s . However, the International S t a t i s t i c a l C l a s s i f i ca t i on does not describe non-fatal accidents with s u f f i c i e n t deta i l to permit p ract i ca l appl icat ion for planning prevention programs (Haddon et al 1964:141). The problem with this type of c l a s s i f i c a t i o n i s that i t has def in i te l im i t s when applying i t to an accident study, because accidents do not ex i s t within c lea r l y defined categories. Furthermore, the conditions prevalent in a pa r t i cu la r study population may make a r i g i d c l a s s i f i c a t i o n system i r re l evan t , for example, sk i ing accidents or computer personnel accidents. I t follows then, that each researcher must develop his own c l a s s i f i c a t i o n system according to the data co l lected. 172 4.6. SOME FINDINGS IN INDUSTRIAL ACCIDENT RESEARCH It may be said that the incidence and type of accident varies with the occupation: the frequency rate in the heavy indust r ies , such as sh ipbui ld ing, i s higher than in the l i g h t trades such as the c lothing industry, f a l l s from a height are more prevalent in the bu i ld ing industry than in most other occupations; trades with a high ra t i o of machinery to men w i l l have a higher proportion of machinery accidents than trades where there are many non-mechanical operations. Therefore, i t would appear that each industry has i t s own charac te r i s t i c type of accident, but the general overa l l pattern of indus t r ia l accidents remains the same. As an example of th is pattern, the main causes of indus t r ia l accidents in Great B r i t a i n for the year 1968 as shown in the Encyclopaedia of Occupational Health and Safety (1971:10) were as fol lows: Handling 29.5% Persons f a l l i n g 16.6% Machinery 15.0% S t r i k ing against object 9.4% Transport 8.0% Struck by f a l l i n g object 6.7% Hand tools 7.3% Others 9.3% Comparison with other years shows that percentages vary l i t t l e and there is no reason to suppose that there is any essential difference in the - re la t i ve percentages from other i ndus t r i a l i zed countries (Encyclopaedia of Occupational Health and Safety, 1971:10). 173 In other findings on i ndus t r i a l accidents, researchers in d i f fe rent d i s c ip l i nes have produced some interest ing information. In "A Review of the Industr ia l Accident Research L i terature " (Hale and Hale, 1972), a l i s t of findings from the published papers on i ndus t r i a l accidents have been compiled and commented upon. These studies have examined many independent variables from the biographical , phys ica l , psychological, personal ity, soc ia l and environmental spheres. For the purpose of the present study, however, i t was thought advisable to l i m i t the discussion to the biographical data. Sex A few researchers have attempted to discover whether men or women are more l i a b l e to accidents. In industry, men and women are rarely employed in the same work, because of t r ad i t i on and d i f f e r e n t i a l pay rates and in order to make a va l i d comparison they must a l l be working in ident ica l jobs. Consequently, few studies have been conducted in industry to test for sex. Vernon studied the difference i nd i r e c t l y in a munitions factory and found that, when a working day was increased from 10 to 12 hours, the accident rates of the women increased more than those of the men. He attr ibuted th i s to a difference in f a t i g u a b i l i t y adding that the energy expenditure outside working hours might be playing a part (Hale and Hale, 1972:32). I t appears that much research i s required to c l a r i f y 174 differences in accident rates between the sexes, espec ia l l y since men and women in industry seldom do the same work. Age This factor i s one of the more frequent variables considered in accident research: Overall f indings seem to be in agreement. During the teens and ear ly twenties the number of accidents i s high: i t then drops charply, l e v e l l i n g out in the mid-twenties. A f ter th i s there i s a s l i g h t decl ine unt i l the middle or late fo r t ie s when the numbers ., s t a r t to r i se again t i l l the end of the working l i f e (Hale and Hale, 1972:11 ). The younger workers are usually more inexperienced and thus the ef fects of age and experience are eas i l y confused. A few studies matched groups for experience but s t i l l found younger people had more accidents. Yet other studies found the same in one department but in another the older workers had more accidents. A number of researchers have suggested younger workers have accidents for reasons other than dnexperience, namely; inat tent ion, lack of d i s c i p l i n e , impulsiveness, recklessness, misjudgement, overestimation of capacity and pride. I t i s possible that these are correct in certain circumstances, but appears to be mainly based on the researchers' subjective impressions. Wh i t f ie ld suggested that perception and cognition were a f au l t in accidents involv ing youthful workers (Hale and Hale, 1972:34). Possible reasons for accidents in older workers were found to be poor motor coordination, less mental a g i l i t y , sensory 175 def i c ienc ie s , slowness in adapting to new s i tuat ions . A l l these explanations could be correct in certa in circumstances, but there i s no evidence to c l a r i f y how important each is in any given s i tuat ion (Hale and Hale, 1972:34). Whatever the reasons are for the strong re lat ionship between age and accidents, i t seems a wise move to concentrate on the two ends of the d i s t r i bu t i on scale in any attempt to reduce the number of accidents in i ndus t r i a l sett ings. Experience Researchers have examined the effects of experience since the e a r l i e s t accident studies. How much a worker learns and remembers about hazards in the workplace w i l l obviously a f fect his a b i l i t y to avoid unnecessary work accidents. And as the person gains experience so his perception of his surroundings change. Hale and Hale (1972:35) l i s t s f i ve kinds of experience which could be pertinent to accidents: 1. Experience of industry in general. This provides knowledge of general i ndus t r i a l hazards. 2. Experience in the f i rm. This gives knowledge of s pec i f i c danger points in the factory, e.g. the places where the fork trucks can be encountered. 3. Experience in a sect ion. This affords s pec i f i c information about loca l hazards, e.g. uneven f l oo r ing . 4. Experience on a type of work, e.g. press work. 5. Experience on spec i f i c tasks which fami l i a r i zes people with the hazards of indiv idual machines and components. 176 Many authors have f a i l e d to make these v i t a l d i s t inc t ions and this has caused great confusion in interpret ing the l i t e r a t u r e on accidents (Hale and Hale, 1972:36). In new rec ru i t s , the general f inding has been that experience i s the c r i t i c a l factor in accident causation. There seems to be strong evidence that length of service has an e f fec t on accident rate over the f i r s t one to two years of employment in a company - but th i s experience e f f ec t does not account for a l l of the peak of accidents in young workers (Hale and Hale? 1972:37). As inexperience appears to be an important contr ibution . to accident causation i t would be expected that t ra in ing should make a considerable difference to accident rates. However, in studies of the effectiveness of formal job t ra in ing and spec i f i c safety t ra in ing programs, the conclusions were: 1. Some t ra in ing programs had no e f fec t on accidents because the mater ia l ' inc ludedI in them was not relevant to the normal work s i tua t i on . 2. Inadequate t ra in ing methods and instructors were responsible for other t ra in ing f a i l u re s . 3. Some t ra in ing programs were successful enough to indicate that most job t ra in ing had not rea l i zed i t s f u l l potential i n accident prevention (Hale and Hale, 1972:37). The published evidence suggests that the potential o f . safety t ra in ing has not been f u l l y exploited :(Hale and Hale, 1972:37). Perhaps th i s i s an area that vigorous research must d i rec t i t s e l f . 177 4.7. SAFETY RESEARCH IN INDUSTRY Accident research in industry has mainly focused on examining human factors and s i tuat iona l variables in an attempt to determine causation. Industry, then, having gained some ins ight into the causes of accidents proceeded to implement preventive strategies in order to reduce the accident rates. But good evaluation studies of safety measures have been scarce, as l i t t l e e f f o r t has been made to val idate the preventive measures in the work s i tuat ion (Hale and Hale, 1972:68): The advantages of va l idat ion are not widely enough rea l i zed , but advances in the e f f i c i ency of the measures cannot be expected without a s o l i d base of proven evidence (Hale and Hale, 1972:78). Perhaps ver i fy ing the effectiveness of safety procedures has had l i t t l e success because of the lack of expertise on the part of most invest igators. As w e l l , the conduct of evaluative studies i s of f a i r l y recent o r i g i n . However, today's emphasis on accounta-b i l i t y and re spons ib i l i t y puts the onus on management to prove the e f f i c iency and effectiveness of preventive techniques. Therefore, program evaluation regarding safety at work may be more act ive ly pursued in the future. 4.7.1 Problems in Evaluation I t was found in most published attempts to val idate safety measures that they take the form of comparing accident rates before and a f te r a safety program has been i n s t a l l e d . At 178 the outset, there would be two problems. F i r s t , the question has to be asked, what c r i t e r i a w i l l be used as a measurement of success? Secondly, what other factors in the s i tuat ion w i l l have to be dist inguished from the e f f ec t of the safety measure? The recorded accident rate i s not s u f f i c i e n t as a c r i t e r i on of success because there i s danger of rel iance on the reporting of accidents rather than the actual occurrence of accidents. Thus, even though the reported accidents show a reduction, the program may not have prevented accidents at a l l (Hale and Hale, 1972:69). On the contrary, i f reported in jur ies show an increase -for various reasons - i t does not hold that the program i s i ne f fec t i ve or that there have been any more accidents. Because of the fa lse picture that recorded accident rates can give, some researchers have used other c r i t e r i a such as "dangerous behaviour" improvement and "changed a t t i tude " to safety as c r i t e r i a of the success of safety t ra in ing . In the former human cha rac te r i s t i c , there i s a problem in extrapolating dangerous behaviour to accidents. In the l a t t e r , there i s a program of determining what i n i t i a l att i tudes people have had. Beisdes, changes in att i tude do not necessari ly e f f ec t changes in behaviour. Both character i s t i c s are d i f f i c u l t to measure. The most sat i s factory procedure would seem to be the use of as many c r i t e r i a as possible in evaluating the success of a safety program (Hale and Hale, 1972:69). 179 Evaluation projects must also discount the e f fec t of other factors in operation that may change the accident rate, and hence, as many potent ia l l y "contaminating" variables as possible w i l l have ' to be monitored, so that changes in accident rates can be attr ibuted to the safety measures and not to changes in other circumstances (Hale and Hale; 69). 4.7.2 Preventive Measures Used in Industry There are four basic methods of preventing accidents. The effectiveness of these w i l l be discussed below: 1. Se lect ion, to insure that any people who are pa r t i cu l a r l y l i a b l e to have accidents are prevented from exposing themselves to s i tuat ions which are hazardous to them. 2. Training,to establ i sh necessary s k i l l s and knowledge to avoid accidents. 3. Changing of at t i tudes , aimed at establ i sh ing more desirable behaviour, pa r t i cu l a r l y in the use of safety c loth ing, or aimed at making people more aware of the seriousness of accidents and the importance of r i s k s . 4. Ergonomic design changes, to produce safer machinery and tools and working environments more conducive safe and accurate performance (Hale and Hale, 1972:70). (1) There is a place for se lect ion in accident prevention, but i t s scope i s l im i ted . I t appears to be useful in two f a i r l y obvious circumstances; (a) a very small percentage of people are t o t a l l y unsuited for certa in types of work due to serious physical defects or because of certa in conditions such as epilepsy or psych iat r ic disturbances, and (b) in certain professions where an 180 exceptionally high degree of s k i l l i s required and costs of accidents are high (Hale and Hale, 1972:70). (2) In job t r a i n i ng , there was no conclusive evidence in the papers reviewed that e f f e c t i ve l y cut down accidents. Rotta et al found that young workers who had been through a t ra in ing program, in f ac t , had a higher rate of accidents than untrained workers for the f i r s t two years of the i r employment, but in the subsequent f i ve years they had les s . The authors f e l t perhaps the trainees had acquired an exaggerated fee l ing of being safe in the beginning, but l a te r t he i r better basic grounding rendered them safer than the untrained workers. I t was found, too, that " o f f the job" t ra in ing did. not make a worker safe, because of the difference in environment of the t ra in ing school and the plant. However, there i s broad agreement in the accident l i t e r a t u r e that the accident rate declines as experience on the job increases. This i s the resu l t of a f am i l i a r i z a t i on process whereby a person trains himself to recognize hazards on the job (Hale and Hale, 1972:70). (3) Att itudes towards accident causation and preventive devices are important considerations when pract ica l steps are being taken to prevent accidents. The research reviewed has indicated that att itudes play an important part, in conjunction with knowledge, in any decis ion involv ing behaviour. Hale and Hale (1972:59) notes: The central att itudes are those towards the r i sk involved and towards the goal of the act ion. The former can be regarded as d i rect ing the choice, the l a t t e r as providing the motivation. These central 181 att itudes are affected by a host of other at t i tudes ; to supervis ion, to management, to other members of the work group and to the general soc ia l norms Many preventive measures aim to change att i tudes and to inculcate safety consciousness. To achieve th i s end, the measures must advocate a change in the re la t i ve values placed upon safety ( refer to normative-re-educative strategy of change, page 131 . Propaganda attempts to change people's att i tude to r i sk and safety competitions try to motivate people to be safe. Hale and Hale (1972:59) says: At the moment most of these campaigns have to be based on hunch, guesswork, and the piecing together of scraps of information about att itudes and motivation from other f i e l d s of research. Accident prevention is t ru l y a complex f i e l d which requires the pooled knowledge of many d i s c i p l i ne s . One of the more popular forms of propaganda that t r i e s to change att itudes and behaviour i s the use of safety posters. General conclusions set out by Undeutch advocate: (a) posters should in s t ruct rather than threaten; (b) they should deal with s pec i f i c behaviour; (c) they should be pos i t ive rather than negative in manner; (d) they should be placed in areas where t he i r message i s relevant; (e) they should not be l e f t for long periods to become part of the furniture (Hale and Hale, 1972:75). 182 Incentive schemes are another method of attempts to a l t e r att itudes and behaviours. There has been a s ingular lack of well documented va l idat ion of th is type of safety measure to warrant widespread use. However, competitions and bonuses continue to be used to develop safety consciousness in workers. It appears to be an example of a technique which has face v a l i d i t y without substantial objective evidence of i t s usefulness (Hale and Hale, 1972:75). Oftentimes, i t merely accomplishes a change in reporting behaviour rather than the level of accidents. In contrast to incentive programs, the use of harsh d i s c i p l i na r y measures are sometimes used against accident sustainers. Some studies have been done on the armed forces showing a drop in accidents fol lowing remedial treatment of a number of accident v ict ims. On the whole, in industry the most such action might accomplish i s a reduction in the reporting of accidents (Hale and Hale, 1972:75). Hale and Hale (1972:76) s tate, from the studies reviewed, the evidence shows s a t i s f a c t o r i l y that att i tude i s not the only thing which governs behaviour, but i t i s an important ingredient which deserves further research. (4) Ergonomics i s a r e l a t i v e l y new science. In the words of Professor Martti J . Karvonen, Director, Inst i tute of Occupational Health, He l s i nk i , Finland (1974:30): 183 Ergonomics i s an applied science that combines biomedical and engineering expert ise. I t helps design methods of work, tools and the environment to f i t man's s t ructure, functions and a b i l i t i e s . Its purpose i s to reduce unnecessary e f f o r t , fat igue, wear and tear. Ergonomics does not try to modify man, i t modifies work. It aims pr imar i ly at protecting the worker and not increased production. Ergonomic improvement may change a d i f f i c u l t job to an easy one and an easier job may increase production. This method of accident prevention has probably been the most widely used in industry. Hale and Hale (1972:76) places guarding of machinery and other design changes, safety rules and protective c lothing under this heading. Many proponents of ergonomics have been advocating better machine and tool design in the prevention of accidents but much of the published l i t e r a tu re consists of exhortations to change, rather than concrete proposals for changes or evaluations of the e f fec t of changes (Hale and Hale, 1972:76). Safety clothing and safety glasses are frequently provided for workers in an attempt to prevent i n ju r i e s . But safety o f f i c e r s and accident researchers often note a reluctance to wearing them. Various reasons are given; discomfort, cosmetic e f f e c t , supervisors not being examples nor act i ve ly encouraging use, management laying down rules without p r io r explanation or consultation with workers and socia l pressure. The conclusion seems to be the provision of safety gear alone Wi l l not ensure that i t i s worn. Besides the four basic methods used in accident prevention i s the regular safety walk by management personnel observing for 184 safety defects. Rees has shown th i s to be an e f fec t i ve stimulant to greater safety, but he provided no published analysis of the reasons for i t s success (Hale and Hale, 1972i:,77). These safety tours appear to be benef ic ia l part ly because of the i r propaganda e f fec t demons-t rat ing concern of the f i rm, and part ly because supervisors are kept alerted to any v i s i b l e safety i n f rac t ions . One other concept of accident prevention that grew out of the work of Heinrich i s damage control (Hale and Hale, 1972:77). This strategy emphasizes reporting of damage (to e i ther people or machinery) as opposed to concentrating on just those accidents that produce in jury . It i s f e l t much can be learned of the interplay of converging forces that produce accidents i r respect ive of resu l t ing in jury . A l b e i t , the various causes or factors inherent in a given s i tuat ion may be evaluated d i f f e ren t l y by d i f fe rent people depending on the i r background and a c t i v i t i e s . Two Canadians, Fletcher and Douglas (1970) have wr i t ten a book on ' th i s concept of tota l loss contro l . A study on safety research was done by Simonds and Shafai-Sahri (1977:120-27) whereby eleven matched pairs of companies were examined to determine what factors contributed to the difference in injury frequency rates. Factors found to be related to lower frequency rates were: (1) top management involvement in safety; (2) better injury record keeping systems; (3) use of accident cost analys is ; (4) smaller spans of control at foreman l e v e l ; (5) recreational programs for employees; (6) higher average age of employees; (7) higher percentage of married workers; (8) longer average length of employment with the company; (9) roomy and clean shop environment; and (10) more and better safety devices on machinery. Factors not related with injury frequency were: (1) e f fo r t s to promote safety through workers' fami l ies and (2) qua l i ty and quantity of safety rules. The findings of th i s research work have interest ing organizational implications for safety management. 4.7.3 Human Factors in Accident Prevention It may be argued that analysis of accidents in terms of the human factors involved may have an important drawback. Nonetheless, i t can provide valuable^information for l a te r safety act ion. I f conclusions are drawn that workers are responsible for the accidents that occur, there may be a tendency on the part of employers to overlook investment in safety equipment or guarding of machinery. On the other hand, as stated in the Encyclopaedia of Occupational Health and Safety (1971:16): 186 ...the study of the human factors involved in the accidents w i l l bring to l i g h t faults in the man-machinery system, unfavourable influences of environmental factors such as l i g h t i n g , heating, vent i l a t ion etcetera, undesirable att itudes held by the work group, and shortcomings in the organization of the work process. These can then be r e c t i f i e d by the i n s t a l l a t i o n or improvement of safety devices, by ra i s ing the standard of the physical environment, by improving select ion procedures, by t ra in ing in safe working pract ices , by e l iminat ing negative att itudes through greater attention to employer-employee relat ionships and, f i n a l l y , by r a t i ona l i z i ng production systems. 4.7ii4 Accident Investigation The aim of invest igat ing an accident i s to obtain the f u l l e s t information regarding i t s cause or causes. Not only i s an invest igat ion fundamental for preventing s im i l a r accidents, but i t may. reveal new or unnoticed dangers that can lead to the devising of well planned safety measures. Obviously, a l l accidents which result in injury should be invest igated, but i t i s equally important to invest igate accidents which do not result in injury - the "near misses", espec ia l l y i f they are of a serious nature. In many countr ies, certain dangerous occurrences must, by law, be no t i f i ed to the competent author i t ies in the same way as occupational accidents. Examples of dangerous occurrences are; collapse of a crane, explosion or f i r e , e l e c t r i c a l short c i r c u i t and structural collapse (Encyclopaedia of Occupational Health and Safety, 1971:14). The person in charge of the invest igat ion must bear in mind the importance of an object ive assessment of a l l the conditions 187 leading to the accident. The aim is to uncover the fac t s , not to attach blame. The invest igat ion should be carr ied out as soon as possible a f te r the incident has taken place. The facts to be co l lected can be divided into two main groups; the f i r s t group should involve everything about the time, person and place, and the second group of facts concerns the occurrence and the conditions under which i t occurred (Encyclopaedia of Occupational Health and Safety, 1971:7). I t is probably wise to have a check l i s t regarding deta i l s of environmental conditions and whether the worker had been adequately trained and supervised, so that a judgment can be based correct ly on any divergence from legal requirements or current pract ice. The complementary re lat ionship of safe work conditions and the corresponding safe conduct of the worker should be constantly borne in mind by the accident invest igator , since i t w i l l provide a valuable guide when determining the action that should be taken on the basis of the invest igat ion: Whenever possible an attempt should be made to improve the degree of measured " technica l safety" simply because technological measures are. more r e l i ab l e than measures which depend on the human factor (Encyclopaedia of Occupational Health and Safety, 1971:17). 188 Conclusion It has been abundantly c lear that in order to do any study on accidents, many factors w i l l have to be considered. The be l ie f s and att i tudes that people hold in connection with accidents are varied and sometimes d i f f i c u l t to change - which i s a consideration in planning prevention programs. Other d i f f i c u l t i e s become apparent when one t r i e s to pin down a de f i n i t i on for accidents, or contemplate cause. C l a s s i f i c a t i on systems have posed problems for many researchers, and methods of study are as yet ..... unsophisticated. Nevertheless, the research done on the i ndus t r i a l . worker w i l l be very useful when applied to hospital workers. The prevention measures used in industry are applicable to a hospital sett ing. Safety research done on the i ndus t r i a l scene regarding the major factors that reduce accident rates could have great s ign i f icance for hospita ls . Furthermore, accident invest igat ion should be fundamental to an accident prevention program and be included in any well planned hazard control program in a hosp i ta l . CHAPTER 5 EPIDEMIOLOGY: A CONCEPTUAL FRAMEWORK FOR THE  STUDY OF ACCIDENTS 5.1 INTRODUCTION In search of a conceptual framework for the study of accidents, wherein the ent i re subject of accidents could be approached systematical ly, epidemiology was found to s u i t th i s purpose most s a t i s f a c t o r i l y . It can be equally adaptable to accidents in which environmental factors predominate as well as those in which human factors are of primary importance. Moreover, careful search of the l i t e r a tu re revealed many pa ra l l e l s between disease and accidents, both in causal sequences and preventive techniques (Haddon et a l , 1964:3). The dominant impressions of accidents, in general, which tended to occlude ins ight into these basic s i m i l a r i t i e s have been; (1) the fee l ing that accidents are somehow beyond human control and (2) the sudden unexpected and often v io lent occurrence of damage which is d iametr ica l ly opposed to the longer, less spectacular time interva l for disease to develop. Suchman (in Hale and Hale, 1972:73) argues: ...thus i f accidents are regarded as a sign of the wrath of God, or as b l ind t r i ck s of fa te, then those who suf fer them w i l l be convinced that no actions of t he i r own can prevent t he i r occurrence. 190 Therefore, accident prevention needs the acceptance of accidents as dysfunctional. I t follows that the existence of hazards must be condemned. Haddon et al (1964:12) note: . . . i t i s the unexpectedness rather than the production and prevention of that damage per se that has been emphasized by much of accident research. They further s tate: This approach i s not j u s t i f i e d by the present knowledge and i s in sharp contrast to the approach to the causation and prevention of other forms of damage, such as those produced by infect ious organisms, where l i t t l e i f any attention i s paid to the unexpectedness of the insu l t s involved, and only t he i r physical and b io log ica l nature i s emphasized - with notable success. A conceptual framework embraces a l l aspects of a topic and allows for analys i s , argument, evaluation, communication and decis ion. Thus, th i s epidemiologic framework is proposed to provide such a structure for the present study of hospital employee accidents. 5.2. DEFINITION OF EPIDEMIOLOGY Two main areas of invest igat ion are indicated in a de f i n i t i on of epidemiology, as expressed by Brian MacMahon (1967:3): Epidemiology is the study of the d i s t r i bu t i on of disease in human populations and the factors that determine that d i s t r i bu t i on . Its predominant, though not exclus ive, purpose i s the understanding-of disease et io logy and the i den t i f i c a t i on of preventive measures. The f i r s t area describes the d i s t r ibu t ion of health status in terms of age, sex, race, geography, education, socio-economic 191 and marital status - more or less an extension of the d i s c i p l i ne of demography to health and disease. The second area examines the patterns of d i s t r i bu t i on of a disease or condition in terms of causal factors (MacMahon and Pugh, 1970:11). Both components supply basic facts that can be put to many uses. MacMahon and Pugh (1970:12) state: Knowledge of the d i s t r ibu t ion of disease may be u t i l i z e d to elucidate causal mechanisms, explain local disease occurrences, describe the natural h istory of a disease, or provide guidance in the administration of health services. The most s i gn i f i can t purpose this knowledge imparts i s that i t can form a basis for prevention of unhealthy states in human populations. The c l a s s i c example of the epidemiologic process i s exemplified by the work of John Snow in 1854during a cholera epidemic in London. He observed the epidemic was confined largely to people who purchased the i r water supply from one of two competing water companies that served the area. Dr. Snow knew he could modify the incidence of cholera by changing the water supply -years before the causative agent, the cholera bac i l l u s was discovered (Enter l ine, P., 1979:45-6). The aim of epidemiology has always been the improvement of the health of populations. In the past, the emphasis was on the conquest of communicable diseases, and the concern was with improving basic environmental factors such as san i ta t ion , housing and work conditions. In the developed nations, th is i s now giving 192 way to an in teres t in the major chronic diseases, in man-made environmental hazards, and in the planning and del ivery of health services in hospital and in the.;community (Holland and Gi lderdale, 1977:12). 5.3. BASIC TENETS The history of epidemiologic methodology i s largely due to the development of four ideas: (1) human disease i s related to man's environment, (2) the counting of natural phenomena may be i n s t r uc t i ve ; (3) "natural experiments" can be u t i l i z e d to invest igate disease et io logy; and (4) under certain condit ions, experiments on man can also be u t i l i z e d for this purpose. (MacMahon and Pugh, 1970:5). The special contribution of epidemiology in seeking the determinants of disease, i s i t s use of the knowledge of frequency and d i s t r i bu t i on of disease in populations. As w e l l , in studying disease occurrences, i t uses groups of persons as i t s primary units of concern, not separate ind iv idua l s . In general, epidemiologists involve themselves with explanations of disease patterns and trends in communities or nations. Hence, epidemiology has long been the forte of publ ic health personnel. 193 5.4 UNDERSTANDING DISEASE CAUSATION (Application to accident causation) In the study of any disease, one finds more than one factor has contributed to i t s occurrence. Friedman (1974:3) gives tuberculosis as an example. He says tuberculosis i s not merely caused by the tubercle b a c i l l u s , because not everyone exposed to the tubercle bac i l l u s develops the disease. Other factors have been i den t i f i ed which c lea r l y contribute to the occurrence of th is disease, such as, poverty, over-crowding, malnutrit ion and alcoholism. Conversely, amelioration of these factors can do much to prevent tuberculos is. Epidemiologists have been credited with organizing the complex mu l t i f a c to r i a l process that leads to disease in various ways: One useful way to view the causation of some diseases, pa r t i cu l a r l y certa in infect ious diseases, i s in t r i p a r t i t e terms of the agent, the environment and the host (Friedman, 1974:3). This host-agent-environment in ter re la t ionsh ip i s not a l inear progression of steps, but rather an interact ive process, whereby disease production depends on c r i t i c a l factors of a l l three components. Thus considerations of host s u s cep t i b i l i t y are important; virulence and volume of the agent can t i p the balance between health and disease, and environmental factors include poverty, crowding, seasonal and c l imat i c conditions. Given this view, preventive strategies advocated are; reduce the s u s cep t i b i l i t y of the host, make the agent less hazardous and modify the environment to lessen p o s s i b i l i t y of a 194 host-agent i n te rac t ion . Another epidemiologic view of disease et io logy i s a "web of causation": This concept of disease causation considers a l l the predisposing factors of any type and the i r complex re lat ions with each other and with the disease (Friedman, 1974:3). In the case of a myocardial i n f a r c t i o n , the many inter re lated factors lead to a complex causal web, which when disentangled can present possible courses of action to prevent the condit ion. These actions among other considerations include dietary modif icat ion, treatment of hypertension and changing publ ic att i tude toward smoking and exercise (Friedman, 1974:5). The search for a primary cause of disease i s not always relevant to disease prevention. In terms of disease prevention i t may be more pract ica l to attack a causal web at a point that seems r e l a t i v e l y remote from the disease. For example, draining swamps to control the mosquito population may be a pract ica l and e f fec t i ve approach to prevent malaria rather than merely t ry ing to destroy the malaria parasite (Friedman, 1974:5). As MacMahon and Pugh .(1970:25) put i t : Fortunately i t i s not necessary to understand causal mechanisms in t he i r ent i rety to e f fec t preventive measures. Knowledge of even one small component may allow s i gn i f i c an t degrees of prevention. 195 5.5 SOME APPLICATIONS OF AN EPIDEMIOLOGIC MODEL I t has been noted that accidents as a health, problem of populations conform to the same b io log ic laws as do disease processes and regular ly evidence comparable behaviour (Haddon et a l , 1964:3). And epidemiology as a conceptual framework f o r accidents offers l im i t l e s s opportunities for study since i t s extension from the o r i g ina l r e s t r i c t i o n to communicable diseases. However, the d i f f i c u l t y with the use of an epidemiologic model has been in defining the agent in a non-infectious condit ion. In recent years, notwithstanding, there have been some notable attempts to modify and adapt the model to describe non-communicable states. A health promotion model based on the epidemiological components of host, agent and environment was described by Richard Lauzon (1977:311-317). The host was perceived in terms of the i nd i v i dua l ' s r i sk status re l a t i ve to l i f e s t y l e agents commonly accepted as disease or injury precursors, for example, a lcoho l , automation, automobiles, tobacco etcetera. The micro-environmental s i tuat ions provided the sett ing in which agent and host interacted. In the study of accidents, the use of the epidemiologic approach was pioneered by John E. Gordon in 1948 (Haddon et a l , 1964:15). Since then, his s c i e n t i f i c paper has influenced many authors of accident research. 196 Suchman (1967) successful ly applied a modified version of the epidemiologic model in an accident prevention program. The purpose of the exercise was to analyze the acceptance or reject ion of a protective glove for sugar-cane workers. In his a r t i c l e , Suchman translated each of the epidemiologic components of host, agent and environment into social -psychological factors relevant for health-related behavioural change. In the present study of employee accidents in a ho sp i ta l , the appl icat ion of an epidemiologic model considers the host as the employee at r i s k , the environment comprising the phys ica l , b io log ic and socio-economic spheres (Gordon in Haddon et a l , 1964:22-25), and the agent as the abnormal exchange of energy which can be mechanical, chemical, e l e c t r i c a l , thermal, ion iz ing etcetera (Hale and Hale, 1972: 17, Haddon et a l , 1964:28). The accident i s regarded as being causedibythe conjunction of factors from a l l three areas with unsafe actions and unsafe conditions creating hazards that result in i n ju ry , damage or disease (Heinr ich ' s domino theory in Hale and Hale, 1972;16). Host factors that contribute to unsafe actions may be stated as physical d i s a b i l i t y , genetic factors , psychological problems, job d i s s a t i s f a c t i on , age, inexperience, work s t ress , a lcohol , drugs, fat igue and others. Lalonde.(1974:31-32) separates the host factors in to ; human biology and l i f e s t y l e . Under the Human Biology element he includes the genetic inheritance of the i nd i v i dua l , the processes of maturation and aging, and the many 197 complex internal systems of the body. The l i f e s t y l e category consists of the aggregation of decisions by indiv iduals which a f fect t he i r health and over which they more or less have contro l . Environmental factors that influence unsafe conditions may be phys ica l ; equipment, c l imate, ven t i l a t i on , l i g h t i n g , noise, or b i o l o g i c a l ; bacter ia , animals, persons, or socio-economic; occupation, l i v i n g quarters, income etcetera. The environmental category includes a l l those matters related to health which are external to the human body and over which the ind iv idual has l i t t l e or no control (Lalonde, 1974:32). This l a s t aspect of environmental factors has generally been ignored in the study of accident causation. Gordon (in Haddon et a l , 1964:25) maintains: The part exerted by the socio-economic environment i s probably the most neglected of any epidemiologic inf luence, and accidents are not d i f fe rent in this respect from any other causes of damage Given the state of health where there i s an establ ished and sat i s factory equi l ibr ium or adjustment between man and his environment, a s i gn i f i c an t disturbance of that equi l ibr ium is the basis fo r disease or in jury: ...The disturbance may occur e i ther through pr inc ipa l action of the agent, because of a charac te r i s t i c of the host, or as a function of environment, but most often through some combination of the three. These are the fundamental factors in causation (Gordon in Haddon et a l , 1964:20). 198 Figure 2 represents a potent ia l accident s i t ua t i on . It depicts; (1) the mu l t i f ac to r i a l nature of causation, (2) the interact ion of host, agent and environment and (3) the act ivat ion of the agent. Unlike the infect ious disease model where the three en t i t i e s of host, agent and environment are d i s t i n c t and separate but in teract to cause disease under certain circumstances, the agent in an accident s i tuat ion is.viewed as the energy derived from part of the environment as i t interacts with the host factors. With accident causation conceptualized in Figure 2, any remedial action must be suited to the whole of the cause as i t l i e s in the host, agent and environment. Preventive strategies are then employed to make the host more res i s tent , to decrease the agent's a b i l i t y to act ivate and to block harmful environmental inf luences. Figure 3 represents an intervention scheme whereby these three strategies are incorporated in a hazard control program to reduce accidents. Ba s i ca l l y , intervention programs are geared to counter unsafe actions of the host and unsafe conditions in the environment. The preventive measures in the case of the former are; se lec t i on , t r a i n i ng , supervision and changing att itudes by propaganda and incentive schemes. In the case of the l a t t e r ; the preventive measures can take the form of guarding of equipment, improved machinery design, protective clothing and safety glasses, good 199 Figure 2 Modified Epidemiologic Model in an Accident S i tuat ion. Unsafe Actions Abnormal Energy Exchange Unsafe Conditions Figure 3 Epidemiologic Model used in a Hazard Control Program. Unsafe Actions Abnormal Energy Exchange Unsafe Conditions Causes: Injury Damage Disease Methods to make Host more resistant. Decrease Agent's ability to activate. Methods to block harmful environ-mental influences Reduction of: Injury Damage Disease 200 housekeeping and environmental controls. Though environmental factors are of great importance in making the workplace safe, i t appears that the human factors require much more consideration: ...probably more causes of accidents l i e within what we choose to c a l l host factors , within people themselves, than in any other of the three parts of the t r i a d which explain disease and injury. The host patterns of persons who suf fer from accidents are of the same general order of those long recognized in many disease processes (Gordon in Haddon. et a l , 1964:21). I t would be unwise, however, to in terpret th i s in such a manner that employers can blame the worker or abdicate t he i r r e spon s i b i l i t i e s for safety of operation in the work environment. Rather, i t should be noted that unsafe conditions creating hazards may be the reason for some unsafe actions on the part of workers. For example, production pressure, lax safety ru les, poor ' t ra in ing and supervis ion, unguarded machinery etcetera can have a d i rec t bearing on the human factors leading,to unsafe acts. The emphasis, here, must be on the interact ive process of host, agent and envi ronment. The epidemiologic model shows c lear l y the mu l t i f ac to r i a l nature of accident causation, the conjuction of forces that resu l t in injury or damage and how i t can be used in a hazard control program to reduce the number of i n j u r i e s . Therefore, in applying this model in an intervention program, i t i s possible not only to decide upon preventive strategies to be employed but to evaluate the i r effect iveness. 201 This model w i l l be re-introduced l a t e r in the study to evaluate an employee safety program and to lay the foundation for an e f fect i ve hazard control program as part of an occupational health and safety service for hospital employees. In summary, i t was necessary to review some basic concepts of epidemiology in order to understand the conceptual framework:, as applied to the study of accidents. The host-environment-agent t r i ad can be used e f f e c t i v e l y , since i t has been noted that accidents as health problems conform to the same b io log ic laws as do disease processes. Cone! us ion Part I has been an attempt at a comprehensive examination of occupational health and safety hazards. The reason/for the extensive l i t e r a tu re review has been two-fold. F i r s t , i t provides a background for the study, which fo l lows, on hospital employee i n ju r i e s . I t i den t i f i e s various problems in the p o l i t i c a l , economic, soc ia l and technical f i e ld s that have been obstacles to development of prevention programs and can pose d i f f i c u l t i e s when sett ing up occupational health services in the publ ic sector. Secondly, Part I i s meant to stand alone as a descr ipt ive account of the whole gamut of occupational health - the h i s t o r i c a l background, the internat ional developments and the major issues confronting the Canadian labour force today. It has been an 202 approach to systematical ly consol idating and coordinating the various fragments of knowledge derived from many d i f fe rent sources. I t i s hoped that i t can serve as a point of reference for future use. PART II THE STUDY 203 CHAPTER 6 OCCUPATIONAL HEALTH AND SAFETY HAZARDS  IN A HOSPITAL MILIEU 6.1. Introduction Hospitals, an industry concerned with health care,have been s ingu lar ly unaware of the occupational health and safety hazards that a f fect the i r employees. I t can be said a hospital that does not apply v ig i lance to safety measures for the protection of i t s employees i s , in f ac t , working against the very pr inc ip les for i t s existence. Taking a h i s t o r i c a l perspective of industry in general, i t was not unt i l the Industr ial Revolution was well advanced that workers gained some recognition for the i r own protect ion. Pr io r to that, the Courts were inc l ined to take the att i tude that (1) the employee assumed r i sk by w i l l i n g l y accepting employment in the hazardous m i l l s and coal mines and (2) the employee's injury could resu l t only from his own carelessness. Through the years, th is att i tude has gradually been reversed and the trend today i s toward ! employer re spons ib i l i t y and d i s a b i l i t y compensation for i ndus t r i a l workers (Safety Guide for Health Care In s t i tu t ions , 1972:4). Perhaps the reason why hospitals lagged behind other 204 industr ies in worker protection has been the i r pecul iar status with respect to char itable i n s t i t u t i on s : Under the doctrine of charitable immunity (or ig inated in English courts in 1846), eleemosynary i n s t i t u t i on s such as churches and hospitals could not be held responsible for employee negligence leading to the injury of others (Safety Guide for Health Care In s t i tu t ions , 1972:5). In contemporary soc iety, th i s t r ad i t i on has been superseded by the legal opinion that hospitals are bas i ca l l y business corporations and, as such, are subject to re s t r i c t i ons and penalties imposed on other f i rms. ' Hospitals, then, can learn from industry since industry, in comparison, has had a longer h istory of safety survei l lance programs. Some benefits from these programs have been reduced insurance costs, increased e f f i c i ency and greater product iv i ty , a more s a t i s f i e d labour force and a minimal loss of time. Like industry, hospitals with a dedicated management can reduce the number of accidents by cont ro l l i ng unsafe practices and el iminat ing unsafe working condit ions, thereby promoting optimum e f f i c i ency and maximizing patient care outcomes. However, unl ike most industr ies where r i g i d controls are establ ished for employees and outsiders to safeguard them from potential hazardous areas, the hospital has extra burdens. Not only i s i t a 24-hour operation, seven days of a week, but i t involves the care and safety of patients and must contend with a heavy 205 t r a f f i c of v i s i t o r s , salesmen and del ivery personnel. Moreover, hospitals have the added r i sk of in fect ion and contamination, besides patient induced i n j u r i e s , for example, moving and caring for phys ica l ly dependent and sometimes:, unpredictable and disturbed indiv iduals involve r i sk . In add i t ion, with advances in medical research and technological innovations of the past two decades, the very nature of the therapeutic and diagnostic equipment i s a hazard to the employee. It i s somewhat surpr i s ing, in view of the above, that hospitals have not been more concerned with personnel safety than have other establishments. In most countries, hospital f a c i l i t i e s in occupational health and safety are very much behind the times. In England, J.A. Lunn (1975) says: I t i s true of most hospitals there i s no ready means of assessing injury rates and no methods are establ ished for doing so. Likewise, th is p r o c l i v i t y to minimize the health of hospital s t a f f i s evidenced elsewhere, as in Wales: There i s l i t t l e published information here upon accidents in hosp ita l s . This i s part ly because, unlike industry, there i s no system of safety organization within the National Health Service ( K e l l , R.L., Personal Correspondence, 18 September, 1979). In the United States, the need for hospital safety programs has long been recognized. In 1954, the American Hospital Administration and National Safety Council j o i n t l y published a "Hospital Safety Manual for Use by .Hospital Administrators and 206 Department Heads" (Safety Guide for Health Care In s t i tu t ions , 1972, "forward"). During the intervening years, however, advanced technology, new equipment, new f a c i l i t i e s , new knowledge regarding such things as hepat i t i s r i sks through breaks in the sk in , ion iz ing rad ia t ion, etcetera, have presented new hazards. In 1976 Dr. John F inklea, Director of the National Inst i tute of Occupational Safety and Health, U.S.A., in a keynote address to the Canadian Publ ic Health Association at the F i r s t National Conference on Occupational Health (1976:44), asked: Do your hospitals have act ive programs addressing the hazards encountered by t he i r own workers? One of our greatest f a i l i n g s has been that we have ignored workplace hazards in our hosp ita l s . The f au l t seems to be universal. Canadians are not exempt.. Though the establishment of a safety committee has been a requirement by the Canadian Council of Hospital Accreditat ion (1977), there have been very few provinc ia l statutes to make them mandatory unt i l f a i r l y recent ly, with the enactment of new provinc ia l occupational health and safety acts ( refer to Chapter 3). In B r i t i s h Columbia, there i s as yet , no prov inc ia l po l icy covering occupational health. The publ icat ion of Richard Foulkes 1 "Health Security for B r i t i s h Columbians" (1973) formulated what was c losest to an occupational health pol icy for hospital workers: 207 Recommendation 144 -A. The d i rector of the present occupational health d i v i s ion be given the re spons ib i l i t y for the establishment of programme standards,-, e t c . , to promote occupational health programmes within the province: occupational health pro-grammes be planned immediately for a l l employees of government, crown corporations and a l l other i n s t i t u t i on s financed by government including a l l publ ic ho sp i ta l s . . . . The Workers' Compensation Act came into e f fect in 1916, and is the major.piece of l e g i s l a t i on re la t ing to occupational health and safety (Occupational Health in Canada - Current Status, 1977). The Workers' Compensation Board of B r i t i s h Columbia has the power, under the Industr ia l Health and Safety Regulations (1978) to enforce these regulations in those industr ies covered by the Act in which the Board holds inspectional j u r i s d i c t i o n s , but these regulations do not have the f u l l force of law. Nevertheless, most indust r ies , including hosp i ta l s , are required to i n s t i t u t e safety programs as s t ipu la ted : (a) a workforce of twenty or more workers, in an industry c l a s s i f i e d as "A" or "B" hazard by the Board's F i r s t Aid Regulation, or (b) a workforce of f i f t y or more workers in an industry c l a s s i f i e d as "C" hazard by the Board's F i r s t Aid Regulation ( Industr ia l Health and Safety Regulations, W.C.B. B.C. 1978:4.04). 6.2 TYPICAL HAZARDS It i s true that hospitals are not prone to have employee 208 f a t a l i t i e s and major accidents that f igure prominently in heavy industry and manufacturing f irms. For the most part, they f a l l into the category of having the subt ler type of accidents and minor in jur ies which go unnoticed un t i l a disease develops, a chronic condition surfaces, or mutagenic and teratogenic ef fects reveal themselves. Yet in many respects, hospitals l i k e large hotels are s e l f contained communities having t he i r own repaira 'nd maintenance workshops, the i r own laundry and sewing rooms, the i r own food service and storage areas, a l l of which place the workers at r i sk to innumerable hazards. In these various hospital departments, occupational health and safety hazards are the same as in the trades elsewhere: safety of ladders and work platforms must be observed, dangerous parts of machinery must be guarded, e l e c t r i c a l equipment must be e f f i c i e n t l y grounded and protected, transportation..hazards must be considered. According to a Canadian survey on "Accidents in Hospitals " (Le Bourdais, 1977) done on acute, extended care and psych iat r ic hospitals of a l l s i zes , the most common: types of accident events were, backstrains, punctures and f a l l s . Most accidents by personnel group were, nursing, kitchen s t a f f and housekeeping. The reasons for the accidents appeared to be careless hurry,judgment error and ignoring safety procedures. 209 6.2.1 Infection The greatest r i sk in hospitals i s in fect ions. In addition to i t s medical s t a f f and paramedical personnel, today's hospital labour force includes a wide cross section of support s t a f f . A l l these persons need to be protected. Unt i l recently, l i t t l e acknowledgement was made of the v i t a l role played by these employees who contribute a wide var iety of s k i l l s and serv ices, profess ional , techn ica l , engineering, a n c i l l i a r y , administrative and c l e r i c a l . A l l hospital s t a f f are potent ia l l y subject to problems and hazards in varying degrees according to the i r occupation, but those with patient contact are exposed to certain added r i sk s . These risks.-have generally lessened with the decline in incidence of serious infect ious diseases, but are s t i l l present where there i s a large immigrant or i t i nerant population, or pockets of poor housing and soc ia l condit ions, and a related higher incidence of pulmonary tuberculosis. S taf f persons in a hemodialysis or kidney transplant units are at special r i sk from serum hepat i t i s . In intensive care or burn un i t s , many patients have received various drugs so that s t a f f may be exposed to drug res i s tant strains of organisms. Laboratory s t a f f handle infected specimens, and in research laborator ies where animals are used there is always the danger of bites and scratches and also of zoonoses (Hamilton, M., 1979:20). Laundry workers and pathology technicians often have to handle infect ious l inens and contaminated a r t i c l e s . Housekeeping s t a f f are required to clean and d i s i n fec t i s o l a t i on rooms af ter a patient i s discharged or deceased. Infection i s a real concern for people working in hospitals and ought not to be minimized. 6.2.2 Spec i f i c Hazards Some hazards which are unique to hospitals are found in operating theatres. These are oxygen, nitrous oxide, cyclopropane and v o l a t i l e l iqu ids such as halothane and ether. Explosions sometimes occur. Furthermore, many operating rooms have inadequate vent i l a t ion systems. This can lead to heavy po l lut ion by waste anaesthetic gases breathed out by the pat ient, which i s now suspected of being harmful to the health of theatre . s t a f f and of congenital abnormalities in the i r chi ldren (Hamilton, M., 1979:21): Possible e t i o l og i ca l factors for the increase in spontaneous abortion among operating room personnel include exposure to low concentrations of anaesthetic gases and x-rays, exposure to v iruses, exposure to cleaning solutions used in operating rooms, fatigue from working long hours, and strenuous physical demands. Exposure to anaesthetic gases i s considered the most l i k e l y factor (Corbett, T.H. 1972:866-890). Laboratory technicians are exposed to da i l y hazards. Risks vary according to the type of laboratory, for example, haematology, microbiology, histopathology, biochemistry, nuclear 211 medicine, animal unit etcetera. Besides d i rect and i nd i rec t patient contact, these technicians work in areas surrounded by r i sk s . These can be c i t ed as; chemical burns, lacerations from broken glass apparatus, dermatitis from handling chemicals, eye in ju r ie s from chemical splashes, explosions from chemicals, burns from bunsen burners, dangers from ingesting pipette contents where this technique i s s t i l l used. Technicians in the Department of nuclear medicine and medical physics are at pa r t i cu la r r i sk from exposure to ion iz ing radiat ion since th i s work involves the preparation, handling and disposal of radioactive material and sources. Cyanide i s used in small quantit ies in some culture media in laboratory work (Jones, V.E., 1978:26). A number of other tox ic chemicals are used in normal laboratory work. Benzene, toluene, formaldehyde, mercuric chloride are among the substances commonly handled which may be skin i r r i tants . . Benzene and toluene have also been associated with bone marrow damage, reproductive problems, l i v e r damage and red blood c e l l damage (George, A., 1978:15). There i s evidence to suggest that acute t o x i c i t y to xylene i s even greater than the acute t o x i c i t y of toluene or benzene (Bush, C.L. and Nelson, G. an A r t i c l e used in T ra i l Regional Hospital Laboratory, 1979). Especia l ly important to the histology and cytology technologists i s the requirement to have a hood or some type of exhaust system over the area where sta in ing i s performed in order to avoid chronic 212 poisoning brought on by da i l y contact with the vapours of xylene. Ionization hazards in the nuclear medicine laboratory i s counteracted by three devices; (1) laboratory monitor, (2) patient dose isotope ca l i b ra to r and (3) f i lm badge that comes from The Atomic Energy Radiation Protection Bureau in Ottawa. This device contains copper and lead which f i I t e r s d i rec t and ind i rect gamma or x-rays and records how much a technician receives. A safe level i s 40 mil l i rems each month .(Searle, R., June 1976). A Radiology Department s t a f f also uses these badges for the same purpose, as rad io log i s t s and nursing s t a f f can be exposed to excessive rad iat ion. Over-exposure to radiat ion i s reported to cause leukemia and reproductive d i f f i c u l t i e s , skin and mouth u lcers , kidney dysfunction, malfunction in the small in test ine and nausea (George, A., 1978:15). Chemical hazards in hospitals are not l im i ted to laborator ies. Ethylene Oxide used in Central S t e r i l e Supply areas can cause possible reproductive changes in workers who breathe in the fumes (Rendell-Baker L., and Fredericks, R.J., 24 January, 1979). Many new chemicals coming on the market each year pose the i r own brand of hazards, a f fect ing pharmacy s t a f f who mix various so lut ions, and housekeeping s t a f f who use them in cleaning. In other areas today's hospitals have many advantages of the technological explosion. Up-to-date e lect ron ic equipment is used extensively in intensive care units and premature nurseries: 213 The use of e l e c t r i c i t y in the care of patients in hospitals introduces the hazards of burn, f i r e , e l e c t r i c shock and power f a i l u r e . The more intimate the appl icat ion of e l e c t r i c i t y , the more subtle the hazard, and the more c r i t i c a l the protective measures required to assure safety (Walter, C.W., 1969:142). I t i s obvious that everyone using e l e c t r i c i t y in the care of the patient, must be highly trained or continuously instructed and supervised. An area that i s usually considered part of the "hazard of the trade," but receives minimal recognition is patient i n f l i c t e d in ju r ie s - nonetheless important for s t a f f who w i l l i n g l y expose themselves to th i s pa r t i cu la r type of r i s k . These vary in degree from minor i n ju r i e s to severe wrenches, strains and sometimes even death. While these conditions may arise in any of the c l i n i c a l areas in hosp i ta l , they usually occur when patients are disturbed or uncooperative. In psych iat r ic wings of hosp i ta l s , the injury to an employee generally occurs when a patient i s "act ing out": "ACTING OUT" i s a po l i te way to say f i gh t i n g , but the term also includes such actions as patients i n ju r ing themselves, attacking other pat ients, destroying or damaging property, sett ing f i r e s , i n ju r ing employees, and other unacceptable behaviour, usually involv ing force (Pederson, T., 1970:121). In such a potent ia l l y harmful s i t ua t i on , i t i s extremely important that the employee control his temper and fee l ings , in order to properly evaluate and bring the incident under control without injury to himself or to the pat ient, or to others. Perhaps the 214 most e f fec t i ve way to prevent accidents of this nature is through the employee's knowledge of the pat ient, which includes what behaviour may be expected of him or her. But the danger i s ever present and the s t a f f must be thoroughly trained to understand and to handle ; combative behaviour. With respect to how much abuse hospital employees must take from patients under the i r care, the question was tested in court recently. A patient was successful ly charged with assault of a nurse on a psych iatr ic unit of Vancouver hosp i ta l , and was placed on probation for one year. In th i s pa r t i cu la r case, i t was found that the legal action had benef ic ia l ef fects on the c l i n i c a l outcome of the patient who was thus confronted with acceptance of re spons ib i l i t y for her own behaviour (Schwartz, C.J. and Greenfield, G.P. 1978). 6.3. SPECIAL RISKS TO WOMEN Approximately 60% of hospital employees are female (George, A., 1978:15). These include nurses, doctors, laboratory technicians, cleaning and laundry s t a f f , d i e t i c i an s , aids and physiotherapists, plus c l e r i c a l s t a f f . There i s no evidence to suggest that women are more susceptible than men to e i ther infect ions or i n ju r i e s encountered in hosp ita l s : The only exception for women workers is one related to pregnancy. There i s no doubt that there are special r i sks in pregnant and nursing women exposed to ion i z ing rad ia t ion, to tox i c chemicals, and to strenuous physical exertion (Mastromatteo, 1976:13). 215 There i s need, however, to consider more care fu l l y such things as machines and l i f t i n g equipment used in hospitals to s u i t an average woman's height, weight and frame. 6.4. LABOUR IMPACT • Hospitals are i n the main a "people se rv i ce " . Labour now accounts for 69-83% of an acute care hosp i ta l ' s tota l budget. The numbers of health care workers have now increased to the point where there are almost three employees per patient bed (MacDonald, H.D., 1976). Hospitals have a great deal of catching up to do as fa r as occupational health and safety are concerned. It would be prudent of them to i n i t i a t e action in th i s d i rect ion rather than have labour demand the i r r ights . From labour ' s point of view, enlightened s e l f interest might open up new vistas in occupational health and safety that would in the long run, serve both management's and labour 's interests and promote a better climate and increased production. Health i s a fundamental human need, as the const i tut ion of WHO recognized more than t h i r t y years ago. It.:should be pursued for i t s e l f and not only as a bargaining item. The well-being of people, in general can only be achieved by way of an approach to health that i s oriented to the needs of working people who make up the bulk of the population. An occupational health and safety 216 program in a hospital ought to be considered ah essent ial service and high p r i o r i t y . I t i s indeed a sad commentary on today's values that the focus appears to be on the conservation of the world 's " na tu ra l " resources rather than on our human resources. And in many modern hosp i ta l s , machines take precedence over personnel. Conclusion I t has been observed that hospital hazards are in some respects s imi la r to those found in industry. Many are attr ibutable to "hotel - type" functions carr ied out in hospitals. Special hazards are charac te r i s t i c to spec ia l ized areas. . Infection and patient care r i s k s , not normally problems in industry, are added hazards pecul iar to health care i n s t i t u t i on s . 217 CHAPTER 7 THE STUDY AREA 7.1 T r a i l , B r i t i s h Columbia T r a i l , B r i t i s h Columbia known as the " S i l v e r C i ty " i s located in the south-eastern part of the province in the Kootenay Boundary Regional Hospital D i s t r i c t (Figure 4). It was established in 1895 fol lowing the discovery of gold in Rossland, i n i t i a l l y serving as a landing point on the Columbia River to service the mines along the pack t r a i l up T ra i l Creek. T ra i l i s the only survivor of the early smelter towns at the turn of the century in the Kootenays, i t s future assured by the unlocking of the lead and z inc ores from the nearby Su l l i van Mines in Kimberley. Cominco Limited in T r a i l , reputed to be the world 's largest non-ferrous smelter and the economic mainstay of the region, has been deeply involved i n the community l i f e of the town i t spawned - - its., generosity exemplified in many beaut i f i cat ion programs, recreational and education f a c i l i t i e s donated to the c i t y . The City of T ra i l was incorporated on June 14, 1901 and today has a population of 12,000 and services an area of 25,000. The mult i -ethnic composition of the c i t y and surrounding d i s t r i c t s , predominantly I t a l i a n , Anglo-Saxon and Russian Doukhobor re f lec t s a cosmopolitan atmosphere. The annual International Folk Fest ival i s a well attended a t t rac t i on . The climate i s modified continental 218 Figure 4 Regional Hospital D i s t r i c t s of B r i t i s h Columbia Regional Hospital Districts of British Columbia 1 EAST KOOTENAY 2 CENTRAL KOOTENAY 2o KOOTENAY BOUNDARY 3 OKANAGAN-SIMILKAMEEN 4 COLUMBIA-SHUSWAP. 5 NORTH OKANAGAN 6 CENTRAL OKANAGAN 7 THOMPSON-NICOLA 8 CARIBOO 9 SQUAMISH- IILLOOET 10 FRASER-CHEAM 11 CENTRAL FRASER VALLEY 12 DEWDNEY-AIOUETTE 13 GREATER VANCOUVER 14 SUNSHINE COAST 15 POWELL RIVER 16 MOUNT WADDINGTON 16a OCEAN FALLS changed to "CENTRAL COAST" 17 SKEENA-QUEEN CHARLOTTE 18 KITIMAT-STIKINE 19 BULKLEY-NECHAKO 20 FRASER -FORT GEORGE 21 PEACE RIVER -LIARD 22 STIKINE 23 CAPITAL 24 COWICHAN VALLEY 25 NANAIMO 26 ALBERNI-CLAYOQUOT 27 COMOX-STRATHCONA Source: Div is ion of Health Services Research and Development Univers ity of B.C. 219 with low humidity, above average sunshine, some rain and heavy snow at the higher leve l s . The average temperature ranges from -15°C to 35°C. Tra i l is on the southern Trans-Provincial Highway No.3, has twice da i ly a i r service from Castlegar A i rport to Vancouver and Calgary, and d i rect Greyhound bus service once a day with a shutt le service connecting the greyhound bus service with T ra i l twice a day. Vancouver and Calgary are equidistant from T r a i l - approximately 450 miles. T ra i l i s also the medical centre of the B r i t i s h Columbia southern i n t e r i o r . I t has two private medical c l i n i c s , the West Kootenay Health Unit, and the Regional D i s t r i c t ' s 237 bed ho sp i ta l , besides a good representation of the province's health professionals (T ra i l D i s t r i c t Chamber of Commerce, 1978). 7.2 , T ra i l Regional Hospital The T r a i l Regional Hospital stands as a monument to the early pioneers of the c i t y and in pa r t i cu la r to Dr. Douglas Corsan, the f i r s t physician to set up practice in the area in 1896. The f i r s t hospital was part of his home and o f f i c e . In 1906 a bui ld ing was erected, the present Park Hotel, which served as T r a i l ' s only hospital for twenty years. With the expanding f a c i l i t i e s of the smelter matched by the increase in the s ize of the town, the need for increased hospital f a c i l i t i e s also grew. In 1926 a 50 bed hospital was b u i l t by Cominco at the corner of Cedar Avenue and V i c t o r i a Streets. A hospital society was formed under the chairmanship of 220 Mr. S.G. Blaylock, general manager of the consolidated Mining and Smelting Company. Mayor Herbert Clark became the f i r s t president of the hosp i ta l . When a new wing was added to the hospital in 1932, the bed capacity was increased to 129. The present hospital complex, then ca l led the Trail-Tadanac Hospita l , was b u i l t in 1954, on the east side of the Columbia River with a bed capacity of 150 and at a cost of $2,250,000 (Figure 5). It housed separate f a c i l i t i e s for the departments of pathology, radiology and physiotherapy, and provided a centra l ized laundry and dietary service. With the Regional D i s t r i c t Hospital Act (1967), the Trai 1-Tadanac Hospital assumed the role of the regional re fer ra l centre and in 1969 o f f i c i a l l y became the T ra i l Regional Hospita l . The catchment area comprises the East and West Kootenay regions and includes Grand Forks and Greenwood. Two new wings were added in January 1970; a 50-bed extended care un i t , and a regional pathology laboratory, below which there i s a 24-bed psych iat r ic un i t . Many new services were incorporated in the years fo l lowing. A renal d i a l y s i s unit which began in a modest way i n 1968 was gradually being improved. It was one of the f i r s t to be set up outside the lower Mainland. In 1971 an electrodiagnost ic service was started. Both nuclear medicine and a social service department were added in 1973. By th i s time, an intensive care unit was also started on a 4-bed ward on the surgical f l oo r . A pulmonary department to work with the r ehab i l i t a t i on services was begun in 1974. This year also marked the Figure 5 TRAIL REGIONAL HOSPITAL 221 Source: T ra i l Regional Hospital Annual Reports 222 o f f i c i a l opening of the Nuclear Medicine Laboratory on the main f l o o r , and the establishment of a coronary pulmonary rehab i l i t a t i on unit on the second f l o o r . The newest section of the hospital b u i l t over the pathology department was completed in February 1975. It comprises the new 7-bed intensive care unit and a separate 3-bed renal care unit . It i s in these two units that advances in medical technology over the past few decades are most apparent. These additions have brought the capacity of the hospital to 237 beds and 22 cots. According to the Master Plan (1973), the dietary department was re-organized and renovated in June 1976. Phases II and III of the Master Plan are now in progress. A complete renovation of the operating room theatres, post-anaesthetic room f a c i l i t i e s and central supply room are planned. The emergency department w i l l be enlarged and out-patient f a c i l i t i e s w i l l include 3 day care surgical beds. A l l e lectro-diagnost ic and radio-isotope services w i l l be centra l ized on the main f l oo r . When completed the red i s t r ibut ion of beds w i l l be as fo l lows: 46 medical, 87 su rg i ca l , 15 ped iat r ic and 13 ob s t e t r i c a l , 50 extended care, 24 psychiatr ic (Tra i l Regional Hosp i ta l , Master Plan, 1978). 7.2.1 Occupational Health Services Prevention in health care of hospital employees has been practiced at the T ra i l Regional Hospital since the l a t t e r part of 1972. At that time an occupational health service on a part time 223 basis was inst igated by the local medical health o f f i c e r , Dr. N.Schmitt. Then in Ju ly , 1974, the hospital administrator Ross Cavey, influenced by R.. Foulkes' recommendation in "Health Security for B r i t i s h Columbians" (1973), offered a f u l l time occupational health service to the employees. In June, 1975 the duties of in fect ion control o f f i c e r were added to the occupational health department. Notwithstanding, a comprehensive program of promotion of health, prevention, protection and counsell ing was carr ied out. However, with budgetary constraints in 1979, th i s service was cut back to three days a week. It appears that preventive services for employees in hospitals are s t i l l low p r i o r i t y . This status i s almost certain to continue as long as governments at a l l levels view occupational health as a " f r inge benef i t ' rather than an essential service (G. Shoblom, January 1979). 7.2.2 Safety Committee The Trail-Tadanac Hospital Safety Committee was organized on November 16, 1967. From i t s inception un t i l 1969 i t appeared ac t i ve l y involved with i t s stated functions. From 1969 to 1971 there seems to have been a period of i n a c t i v i t y . The absence of records of th i s e a r l i e r time make i t d i f f i c u l t to reconstruct the sett ing into which the present safety committee emerged. On May 26, 1971, urged by the Workers' Compensation Board, the safety committee was reactivated and re-named 224 The T ra i l Regional Hospital Safety Committee (Tra i l Regional Hospital Safety Committee minutes 1971). 7.2.3 Infection Control Program In accordance with national standards recognized and established by the Canadian Council of Hospital Accred i tat ion, the T ra i l Regional Hospital has had an in fect ion control program for many years. The purpose of the program i s : - to maintain a bac te r i a l l y control led hospital environment; - to f a c i l i t a t e patient and s t a f f wel l -being; - to insure an uninhibited progress in the pat ient ' s condit ion. The in fect ion control program i s the re spons ib i l i t y of the Infection Control Committee which comprises; the medical health o f f i c e r , the hospital administrator, a pathologist, a surgeon, a medical doctor, a representative from nursing, the housekeeper, the in fect ion control o f f i c e r and the d i e t i c i a n . The in fect ion control o f f i c e r i s d i r e c t l y responsible to the medical health o f f i c e r and the hospital administrator with duties pertaining to the survei l lance of pat ients, personnel and environment (Tra i l Regional Hospital Orientation Pamphlet for Employees, no date). 225 7.2.4 Union Representation There are four bargaining associations represented in the T r a i l Regional Hospita l . These are: 1. Health Sciences Associat ion. 2. Hospital Employees Union. 3. International Union of Operating Engineers. 4. Registered Nurses' Association of B r i t i s h Columbia. I t i s a condit ion of employment that employees j o i n the union or associat ion whose c e r t i f i c a t i o n they come under, and remain members of those organizations throughout t h e i r employment (Tra i l Regional Hospital Orientation Pamphlet for Employees - no date). 7.2.5 Board of Trustees The governing body, or Board of Trustees, of the T ra i l Regional Hospital comprises 12 loca l community appointees represen-t ing T ra i l and the surrounding areas. The City of T ra i l i s represented by 6 members. The v i l l age s of Warf ie ld, Montrose and Fru i tva le have one member each. There i s one member who represents the Kootenay Boundary Regional Hospital D i s t r i c t and one member who represents the Women's Aux i l i a ry to the T ra i l Regional Hospita l . There i s also a prov inc ia l government's representative to complete the tota l of twelve (Tra i l Times, 6 January, 1975:4). The T ra i l Regional Hospital has been an accredited hospital for over twenty years, having met the standards of service l a i d down by the Canadian Council on Hospital Accrediat ion. It has 226 maintained th i s status during the period of the study 1970 - 1976 (Tra i l Regional Hospital Administration and Annual Reports, 1970 - 1976). These standards are revised pe r i od i ca l l y and the hospital i s surveyed every 3 years to insure that i t s t i l l warrants accreditat ion status. Table 3 shows the annual s t a t i s t i c s for the T ra i l Regional Hosp i ta l , 1976 (Tra i l Regional Hospital Administrat ion, 1976). TABLE 3. Annual S t a t i s t i c s for the T ra i l Regional Hospita l , 1976 TABLE 1 Beds - Acute Care 175 - Newborn 22 - Extended Care 62 Admissions - Adults and chi ldren 5,923 - Newborn 298 - Extended Care 35 Births 298 Patient Days - Adult and chi ldren 49,154 - Newborn 1,852 - Extended Care 22,815 Average Days Stay - Acute Unit 8.3 Occupancy Rate 11% Personnel (Ful l Time Equivalent) 404 Surgical Procedures 2,987 Electrocardiograph Exams 2,763 Electroencephalograph Exams 506 Emergency Treatments - out 5,153 - in 342 Physiotherapy Treatments 20,632 Occupational Therapy 1,771 Radiological Exams 10,470 Nuclear Medicine Units 383,230 Laboratory Units 2,532,857 Gross Expenses $7,571 ,256 Salaries Expenses $5,839,815 Social Service V i s i t s 1,814 Aux i l i a ry Members 166 Volunteer Hours 9,146 Source: T ra i l Regional Hospital Administration 227 Figure 6 shows the T ra i l Regional Hospital Organizational Chart. Conclusion The T ra i l Regional Hospita l , in 1976, had 237 beds. It i s located in the Kootenay Boundary Regional Hospital D i s t r i c t but serves the East and Central Kootenays as w e l l . It i s one of eleven public general hospitals in B r i t i s h Columbia with a bed capacity of 200-299 (Canadian Hospital Directory, 1977:23). With an annual payrol l in excess of 500 persons, i t was deemed possible that an examination of employee in ju r ie s at the T ra i l Regional Hospital might serve some use-fu l purpose. Figure 6 TRAIL REGIONAL HOSPITAL ORGANIZATIONAL CHART SPECIAL COMMITTEES STANDARD COMMITTEES LABORATORY MEDICAL RECORDS TRAIL REGIONAL HOSPITAL SOCIETY BOARD OF TRUSTEES JOINT CONFERENCE COMMITTEE ADMINISTRATOR PURCHASING and STORES NURSING EDUCATION MEDICAL ADVISORY COMMITTEE DIRECTOR OF NURSING 1 ASSISTANT ADMINISTRATOR RADIOLOGY PHARMACY NUCLEAR MEDICINE BUSINESS OFFICE PLANT and WOMEN'S AUXILIARY MAINTENANCE NURSING SERVICE REHABILITATION MEDICINE DIETARY RESPIRATORY SERVICES a VOLUNTEERS PERSONNEL HOUSEKEEPING LINEN and LAUNDRY PULMONARY LABORATORY SOCIAL SERVICE INFECTION CONTROL and OCCUPATIONAL HEALTH SWITCHBOARD and ADMITTING Source: T ra i l Regional Hospital Administration ro CO 229 CHAPTER 8 RATIONALE AND OBJECTIVES OF THE STUDY 8.1 Occupational Health Concerns in Hospitals The growth of the hospital industry started in 1948 when national health grants for hospital construction were avai lable -fol lowing submission of a prov inc ia l plan. By the mid 1950's, the provinces needed support to meet operating costs. In 1957 and 1966 further cost-shared programs helped to t r a i n health professionals and to run acute care hospita ls . In 1957 The Hospital Insurance and Diagnostic Services Act was set up with f a i r l y r i g i d c r i t e r i a , but these were abandoned in 1966 when the Medical Care Act was introduced and passed. The National Health Insurance Plan in 1967 made medical coverage avai lable to a l l and great changes took place as the supply created the demand. Thus overcrowding with i n tens i f i ed u t i l i z a t i o n of serv ices, shortage of nursing s t a f f , many innovations and new therapeutic procedures made the hospital environment a potent ia l l y hazardous place in which to work. In B r i t i s h Columbia, hospital insurance was introduced in 1951 and the B r i t i s h Columbia Medical Plan has operated since 1965. The Federal Government stopped the cost-sharing construction grant in 1970. Consequently, fewer smaller hospitals are being b u i l t . However, there is a trend in the lower mainland of B r i t i s h Columbia to concentrate on larger t e r t i a r y care f a c i l i t i e s and to consolidate 230 special therapy equipment in these hospitals. This seems to be a move in the r ight d i rect ion as i t eliminates cost ly dupl icat ion. At the same time, occupational health concerns for workers in these i n s t i tu t i on s have not kept up with the demands expected of them in th i s changing mi l i eu . Hospitals as an industry employ many workers of various categories. They const itute the fourth largest business in the United States according to Perrow (1960). In Canada, the picture pa ra l l e l s that of the United States. B r i t i s h Columbia has hal f of the health care personnel employed in the public hospital system -a to ta l of 20,300 employees. Private hospitals employ 1,900 persons (Foulkes, 1973). With the introduction of the Long Term Care Program in 1978, other f a c i l i t i e s such as personal care homes, long term care and intermediate care i n s t i t u t i on s were b u i l t , increasing the number of people working in health care f a c i l i t i e s . There are indicat ions that i n ju r i e s due to accidents are occurring with increasing frequency in the work environment of B r i t i s h Columbia hospita ls . The Workers' Compensation Board reports that over a seven year period from 1970 to 1976, hospital employees' paid to ta l i n ju r ie s rose from 744 to 2,254.out of which back i n ju r i e s were 256 in 1970 to 810 in 1976 (W.C.B. Finance Department 1970 - 1976). Considering that safety programs are mandatory in a l l establishments employing more than 50 persons ( Industr ia l Health and 231 Safety Regulations, W.C.B. 1978, Section 4.04), regarding hosp i ta l s , the questions a r i se : to whom do these figures apply? what kinds of accidents are they? why are they occurring? and what can be done about the s i tuat ion? Other questions as to cause may be pondered. Are there more employees at r i s k than there were previsouly or are there more hazards in the hospitals? Are there too few people to care for the number of pat ients, or are there too many " ch ie f s " and not enough " ind ians " . The extent of the problem can only be c l a r i f i e d by professional involvement and adequate research. While the accidents which occur to hospital employees, for the most part, may not have the drama or the urgency of some indus t r i a l accidents, nonetheless they are of great concern as they account for many l o s t days of production and much human suffer ing and discontent. 8.2 Rationale This study bases i t s j u s t i f i c a t i o n on the needs; (a) for an e f fec t i ve safety program in hospitals in order to reduce the number of i n ju r i e s sustained by employees and (b) to promote a comprehensive occupational health and safety program as being of s i gn i f i can t benefit to the i n s t i t u t i on s . 232 8.3 General Objectives This study w i l l attempt to throw l i gh t on accident trends in a medium-size publ ic general hospital in a seven year study of i n ju r ie s sustained by employees which w i l l i dent i f y the frequency and type of accident, so that measures can be taken to prevent or reduce the numbers occurring. It also proposes to measure the impact of an employee safety program and to develop guidelines for a hazard control program based on an epidemiological model. In add i t ion, i t i s hoped the findings w i l l indicate further possible studies to be conducted in a f i e l d yet barely explored. 8.4 Spec i f ic Objectives It i s possible to delineate frequencies, trends and associations from primary data, which give r i se to the fol lowing questions; 1) Who are having the accident? What Department? 2) Where are the accidents occurring? In what area? 3) When are the accidents occurring? Time of day, time of year? 4) How are the accidents happening? What are the external causes? 5) What parts of the body are involved? 6) What i s the nature of the in jur ies ? 7) Is there a re lat ionsh ip between age and number of accidents? 233 8) Is there an association between length of employment and the number of accidents? 9) What e f fect has a safety program on cont ro l l i ng the number of accidents? Conclusion With over 20,000 people employed in the public hospital system in B r i t i s h Columbia, i t seems f i t t i n g to invest igate some of the causes of i n ju r ie s sustained by hospital personnel. 234 CHAPTER 9 DESIGN AND METHODOLOGY The study is a descr ipt ive analysis of injury trends of employees in a medium-size publ ic general hospital in B r i t i s h Columbia for the seven year period from 1970 to 1976. It i s pr imar i ly descr ipt ive inasmuch as the epidemiologic character i s t i c s of i n ju r ie s sustained are described. It i s also a retrospective study as i t depends upon data already ex i s t i ng . The design of the project has three sections which are l inked together in an overal l epidemiologic framework. This t r i - p a r t i t e approach addresses; f i r s t , an epidemiologic invest igat ion; secondly, an evaluation of a safety program; and t h i r d l y , an epidemiologic model of accident causation used in a hazard control program. 9.1 T r i - p a r t i t e Approach 1. Epidemiologic Investigation In examining the d i s t r i bu t i on and determinants of the recorded i n j u r i e s , several procedures are possible. Frequency rates were selected for measuring in jury experience of the various departments of the hospital so that comparisions could be made of the d i s t r i bu t i on of i n ju r ie s by persons, time and place. An attempt at ident i f y ing causation was made by l i s t i n g external causes of i n j u r i e s , nature of the i n ju r ie s and parts of the body 235 involved. In analyzing the objective data, contingency tables were used to investigate associations between the number of accidents and the independent variables of age and length of employment. 2. Program Evaluation (a) To investigate the effectiveness of an ex i s t ing safety program, research into the early h istory of i t s predecessor was necessary. A small questionnaire was d i s t r ibuted to former members of the or ig ina l committee and the results were analyzed (Appendix A). The goals and a c t i v i t i e s were then reconstructed to determine the success of achieving object ives. It was established that the new safety committee was formed on May 26, 1971. A quasi-experimental design was then set up on a "before and a f t e r " pattern and the number of accidents before and af ter the i n s t i t u t i on of the safety program was compared. The basic comparisons were of injury rates of the departments for the two years from 1970 to 1971 to the period a f te r the program took e f f e c t , a r b i t r a r i l y using the period from 1972 to 1976. (b) A documentary analysis of the Tra i l Regional Hospital Safety Committee minutes and other records was done in an attempt to l i nk events in the external environment which could a f fect the injury rates before, during and a f te r the intervention program. 236 (c) A th i rd strategy used in the program evaluation was to compare safety committees of s imi la r s ize public general hospitals in B r i t i s h Columbia for t he i r reported numbers of i n ju r ie s in the same period of time between 1970 to 1976; the figures to be obtained from the Workers' Compensation Board of B.C. 3. Use of An Epidemiological Model for a Hazard Control Program Having explored the d i s t r i bu t i on and determinants of employee i n j u r i e s , developing guidelines for an e f fec t i ve hazard control program was made possible by using the pr inc ip les of epidemiology; (a) making the host more re s i s tent , (b) making the agent less e f fec t i ve and (c) placing a barr ier in the environment (Figure 3). 9.2 Def in it ions Medium-size public general hospital - For th i s study, "medium-size" refers to hospitals which have a bed capacity of 200 to 299 (Canadian Hospital Directory, 1977:23): "publ ic ho sp i ta l ' i s defined as: one which " i s not operated for p r o f i t , accepts a l l patients regardless of t he i r a b i l i t y to pay, and i s recognized as a publ ic hospital by the province in which i t i s located" (Canadian Hospital Directory, 1977:54). "General" refers to the beds normally set up for use, including medical and su rg i ca l , o b s t e t r i c a l , intensive care, coronary care, ipaediatr ic, u ro log i ca l , gynecological and neurological (Canadian 237 Hospital Directory, 1977:50). In B r i t i s h Columbia there are eleven hospitals that f i t into this category - nine with " l a y " boards and two with " r e l i g i ou s " sponsorship. Injuries - These are recorded accidents according to.the Workers' Compensation Board regulat ions, both "medical aid only" cases or "time loss " accidents, and must be reported within three days of the occurrence. Employees - These are employed persons of the hosp i ta l , hired on a f u l l - t i m e , permanent part-time or casual basis, excluding nursing or medical students and volunteers. Equivalent persons or f u l l - t ime equivalents - These represent the man-hours worked by one (or more) employee in a s ingle two-week period of 75 hours. It i s obtained by d iv id ing the to ta l paid hours in each pay period by 75 - being the to ta l hours an employee is paid. If computed for a month, i t i s arr ived at by d iv id ing to ta l paid hours by 163.125 hours rather than 150 hours which i s a four week period. When computed for a year, i t i s arr ived at by d iv id ing to ta l paid hours by 75 hours mul t ip l ied by 26 pay periods. Hospitals in B.C. who have the i r payrol l processed by the B r i t i s h Columbia Health Association use the same accounting system using "equivalent persons" (T.R.H. Accounting Department, 1978). For the purpose of th i s study "equivalent persons" w i l l indicate a set period of employee exposure to occupational hazards at the hospital 238 (or on the premises i f in l i ne of duty) and w i l l be used as the denominator in ca lcu lat ing injury rates for the various departments. Number of pay cheques issued - This represents the number of people receiving pay cheques in each single two-week pay period and is a better indicator of the number of persons at r i sk at any one time, than "equivalent persons". Trend - This refers to a general d i rect ion or tendency. Abbreviations E.P. Equivalent persons N.P.I. - Number of pay cheques issued V.T. Vacation time S.L. Sick leave W.C.B. - Workers' Compensation Board M.A.O. - Medical aid only T.L. Time loss T.R.H. - T ra i l Regional Hospital 9.4 Sources of Information for the Study Data Col lect ion - The Workers' Compensation Board form No'>7 i s the "Employer's Report of Injury or Industr ial Disease." The tota l number of i n ju r ie s recorded for the years 1970 to 1976 was 561, both "time loss " and "medical aid only" accidents (duplicate forms retained at 239 T.R.H.) The data were analyzed using the computer S t a t i s t i c a l Package for the Social Sciences, at the Univers ity of B.C. (Nie et a l , 1975). Other Sources of Information - The Workers' Compensation Board of B r i t i s h Columbia provided the l i s t s of i ndus t r i a l i n ju r i e s for the years 1970 to 1976 as well as the number of i n ju r ie s incurred in eleven medium-size public general hospitals of B.C. for the years 1970 to 1976, together with notations on the i r safety committees. The T ra i l Regional Hospital Administration made available.,, the Annual Reports fo r the years 1970 to 1976 and the Jo int Management minutes s ta r t ing from 1967, including the "Master Plan" for renovations. The accounting department furnished information on personnel data - equivalent persons, for the period of the study, 1970 to 1976 as well as information regarding the number of pay checks issued for a sample 75 man-hour work period in August fo r the years, 1976, 1977 and 1978. Payrol l information on social secur ity numbers was used for coding i n j u r i e s , as th i s i den t i f i ed accident repeaters as well as those persons with name changes. This information f i l l e d in some gaps on the W.C.B. form No..7 such as s tar t ing dates of employment, inaccurate b i r th dates and changes in occupation within the hosp i ta l . The T ra i l Regional Hospital Safety Committee minutes from 1970 to 1976 were helpful in the documentary analys is . As wel l , : the T ra i l Regional Hospital Orientation Pamphlet furnished addit ional information. 240 9.5 Population The population at r i s k consists of approximately 500 employees reported on the pay ro l l . Total recorded in ju r ie s were 561 for the period of seven years, 1970 to 1976. This sample i s s e l f selected and may involve a number of accident repeaters. Marital status was d i f f i c u l t to determine at any one time as frequent name changes occurred - some reported and some not. Though males are usually in the minority in hosp i ta l s , th i s was also d i f f i c u l t to determine at any one time, as r e l i e f persons could be anyone ava i l ab le , and counted in as "equivalent persons". Therefore, the sex r a t i o would perhaps be meaningless in th i s study. Length of employment also posed problems, as some employees terminate for a time then are re-employed and perhaps change the i r status from f u l l time to permanent part-time or casual r e l i e f . Employees also take maternity and educational leave. To complicate matters, a f te r 90 days leave, the employee i s r e - c l a s s i f i e d as of changed status. For the purpose of the study, the length of employment was considered the period from the s ta r t ing date of employment to the time of the accident. 9.6 Assumptions 1. That a l l employees are bas i ca l l y healthy and are able to function at optimum e f f i c i ency . In l i eu of a pre-medical examination, a health assessment i s done at the time of h i r i ng . This includes taking a medical h i s tory , eye and hearing te s t , blood pressure reading 241 and routine blood and urine tests . 2. That a l l employees at work who report i n j u r i e s , are in f ac t , injured as they f i l l out Workers' Compensation Board forms for compensable reasons. They are asked to complete these forms as accurately as possible giving deta i l s of the accident. The employer i s required to submit a report within three days. Fa i lure to do so i s an offence and may resu l t in the employer being charged with paying the cost of the claim. 3. That a l l accidents that occurred for the years 1970 to 1976 were recorded. 4. That a l l employees on vacation or s ick leave were not exposed to occupational r i sks at the hosp i ta l . 5. That a l l employees w i l l avoid occupational hazards i f possible and w i l l curb unsafe acts and report unsafe conditions to management. 9.7 Limitations 1. Use of retrospective data i s usually free from bias as at the time of recording of the in ju ry , there i s no pr io r knowledge that the information w i l l be used for a study. However, bias may be present as the sample i s a s e l f selected group of ind iv iduals who report accidents from a population of approximately 500 hospital employees. 2. In the smaller departments, injury rates seem out of proportion to the larger departments in the hosp i ta l . 3. The recorded data allows fo r l im i ted control over extraneous variables that may influence the number of accidents. Also environmental factors and predisposing factors that led up to the accident are not always recorded, making the causal mechanism d i f f i c u l t to ascerta in. 4. There may be recording errors by employees, espec ia l ly i f they are under stress. Inaccuracies and omissions of deta i l can occur when in ju r ie s are reported up to three days a f te r the event. 5. There may be the researcher 's errors in transcr ib ing the raw data and in coding. 6. There may be mechanical errors in computer input. 7. "Equivalent persons" excludes the half-hour a l l o t t ed for meals, but accidents occurring during th i s time are recorded as happening on duty. It also excludes the time before or a f te r reporting for duty, but during these periods, accidents are recorded as happening on duty, as they occur on the premises. 8. Each of the 561 observatons of recorded i n ju r i e s does not necessari ly represent the number of d i f fe rent ind iv idua l s . 9.8 Eth ica l Considerations The study used retrospective data and was non-experimental and used no names of persons or hosp i ta l s , besides the T ra i l Regional 243 Hospita l . Therefore, permission to proceed with the study was granted by the administration of the T ra i l Regional Hospita l . 9.9 Method of Computing Injury Rates Frequencies were f i r s t calculated from the demographic data supplied by the W.C.B. form No. 7. In order for a count to be descr ipt ive of a group i t must be seen in proportion to i t . In other words, i t must be divided by the to ta l number in the group. Percentage, or number per hundred, i s one of.the most common ways of expressing proportions. Number or rates per one thousand or one m i l l i o n , or any other convenient base may be used: ...one of the central concerns of epidemiology i s to f ind and enumerate appropriate denominators in order to describe and to compare groups in a meaningful and useful way (Friedman, 1974:8). The commonly used Disabling Injury Frequency Rate relates i n ju r ie s to the hours worked during the period and expresses them in terms of a mi l l ion-hour unit by use of the fol lowing formula: Disabling Injury Frequency Rate = number of d isabl ing in ju r ie s x 1,000,000 employees hours of exposure (American Standard Method of'Recording and Measuring Work Injury Experience, 1954:10). However, since the T.R.H. injury rates were meant only for internal comparisons, and also to keep the f igures smal l , the American Standards Association Method was not used. 244 In search of an appropriate denominator to compute injury rates, and f a i l i n g to obtain any records denoting "number of pay-checks issued" during the seven year period from 1970 -1976, the annual December year-to-date "equivalent persons" were used (minus V.T. and S.L.) since they were the only ava i lable o f f i c i a l records found at the hospital depicting s t a f f a l l ocat ion for each department. However, no s t a t i s t i c a l records could be found for the year 1972. To overcome th i s d i f f i c u l t y , the December year - to-date E.P.'s for 1971 and 1973 were averaged for each department and the resultant means were used as the 1972 f igures. Fortunately, the T ra i l Regional Hospital f i s c a l year and calendar year coincided during the seven years of the study, but was changed short ly a f te r . To compute the injury rate, then, for each department for each of the seven years, the tota l number of i n ju r i e s for the year was divided by the "equivalent persons" in that par t i cu la r department. Having done t h i s , the researcher was confronted with the question, does "equivalent persons" or employees hours of exposure accurately r e f l e c t the number of indiv iduals at r i s k to occupational hazards? For example, one E.P. could represent one person at work for seven and a hal f hours a day for ten days. It could also mean three persons working two and a half hours a day for ten days. The potential for more accidents may not be any greater in the l a t t e r case, but ce r ta in l y there are more people at r i s k over the same 245 period of time. Thereupon the researcher was advised to seek further information whereby some recent s t a t i s t i c s denoting both "equivalent persons" and"number of pay cheques" issued could be applied to the period of the study, 1970-1976, with a view to adjusting the injury rate in order to more accurately r e f l e c t manhour exposure as well as number of persons at r i s k . With the assurance that the payrol l at the T ra i l Regional Hospital has been f a i r l y constant over the years, a sample 75 man-hour work period with E.P.'s and N.P.I.'s was obtained(Parisotto,-R. and Saunders, B. in November 1978). Th i s " tab le " depicted the corresponding two week period in August for the years 1976, 1977, 1978. The number of pay cheques issued were considerably more than the numbers of "equivalent persons". Overtime was also noted in the departments showing fewer N.P.I.'s than number of E.P. 's. Using th i s tab le , f i r s t , a l l overtime was converted into s t ra ight time by subtracting N.P.I, from E.P. and mult ip ly ing by 2/3 (time and a half ) and adding the excess to the stra ight time. When each set of pairs was converted for the three years 1976, 1977 and 1978, a r a t i o of E.P. to N.P.I, was calculated by adding the E.P.'s for three years and div id ing by the sum of the three N.P.I.'s for the three years. Table 4 shows the August f igures for 1976, 1977, 1978 corrected for overtime, along with the r a t i o . Table 4 T ra i l Regional Hospital Number of Pay Cheques Issued to Departments Per 75 Manhour Work Period (Equivalent Persons). A Single Two-Week Period in August, 1976, 1977, 1978 (Corrected for Overtime) Departments Auq.26, 1976 Aug. 25, 1977 Aug. 24, 1978 Ratio E.P. N.P.I. E.P. r M.P.I. E.P. f M.P.I. Housekeeping 34.6 43 30.9 35 30.9 35 .853 Nursing 237.5 295 224.1 275 223.6 273 .813 Dietary 935.4 44 34.9 45 33.5 41 .798 Administration 27.0 34 30.2 32 28.9 339 .870 *Radiology 6.07 6 6.5 7 6.73 6 1.015 *Maintenance 13.73 13 13.8 14 12.4 13 .998 Laundry and Linen 11.4 13 11.3 15 9.7 13 .790 l a bo r a t o r y 25.5 26 25.0 29 26.6 25 .964 *Rehabi l i tat ion 11.6 12 9.2 10 12.3 10 1.034 *Pharmacy 2.0 2 2.07 2 2.0 2 1.012 Medical Records 5.6 7 5.3 6 4.9 8 .752 *Nuclear Medicine 4.07 4 3.0 5 4.8 6 .791 Social Service 2.2 3 2.7 3 2.7 3 .844 *E.E.G. 2.0 3 3.27 3 1.8 2 .883 *Pulmonary .1.07 1 1.0 2 2.0 2 .814 * Corrected for Overtime 247 The r a t i o was then applied to the previous injury rates which had been computed with "equivalent persons" as the denominator. The rat io divided by 26 (for an annual rate) mul t ip l ied by the old rate produced an adjusted rate which re f lect s better the numbers of employees exposed to hospital hazards. Annual injury rates per 1000 for departments, for the years 1970 - 1976, are l i s t e d in Table 5.. As long as the departmental comparisons were on a one-to-one basis, th i s new injury rate worked rather w e l l . However, i f a combination of departments were considered as services (Hospital S t a t i s t i c s and Administration of the Hospital Act, 1971:23), i t was f i r s t necessary to use the formula: N.P.I. = E.P. x 26 to convert the E.P.'s to N.P.I. 's. RATIO Then to obtain rates for serv ices, the fol lowing formula was used: Injury Rates = sum of (number of accidents for Pep'ts for each year) sum of (N.P.I. 's for Dep'ts. for each year) These injury rates per 1000 for services were used in comparing services, as well as in the "Before and A f te r " exerc ise. Cone!usion Proportions, expressed as rates, are tools frequently used in epidemiology. Therefore, the injury rates of hospital employees were examined by departments and services for the period 1970-1976. Frequency Tabulations were done to determine d i s t r i bu t i on for Table 5 Tra i l Regional Hospital Annual Employee Injury Rates per 1000 for Departments For the years 1970 - 1976 Departments 1970 1971 1.972 1973 1974 1975 1976 Average Total T. Housekeeping 14.0 22.4 27.7 18.5 13.8 19.4 7.0 17.4 Z. Nursing 5.0 4.3 6.7 6.9 7.2 ' 7.2 6.0 6.2 3. Dietary 15.1 17.3 24.6 12.3 25.3 20.8 7.2 17.7 4. Administration 4.9 0 0 1.5 5.3 3.9 4.0 2.9 5. Radiology 11.4 0 7.6 0 5.0 0 0 2.7 6. Maintenance 4.3 4.3 35.4 3.6 11.5 6.7 13.5 11.3 7. Laundry 0 3.1 13.0 0 6.7 3.4 0 3.6 8. Laboratory 0 2.0 3.7 0 13.5 2.8 2.8 3.8 9. Rehabi l i tat ion 0 0 5.7 0 0 11.5 11.1 4.7 10. Pharmacy 0 0 0 19.5 0 0 0 1.9 Note: Medical Records, Nuclear Medicine and Social Service reported no i n ju r i e s during th i s period. 249 persons, time and place; cross tabulations were also computed to establ i sh relat ionships between the number of accidents and age category and length of employment. The T ra i l Regional Hospital Safety Committee was evaluated according to; a "before and a f te r " comparison of injury rates fol lowing the intervention of a safety program; a documentary analysis of events; and a comparison to other safety committees in s im i la r s ize hospitals in B.C. Last ly , the use of an epidemiologic model in reducing the number of i n ju r i e s was explained. From the findings of the study, i t was possible to formulate prevention strategies directed towards target persons, places and time periods. 250 CHAPTER 10 RESULTS AND DISCUSSION. 1. Epidemiologic Investigation Employee i n ju r i e s recorded over the seven year period from 1970 to 1976 were examined separately by department, s i t e of accident, time of day and year, and type of accident in order to gather information which would attempt to reduce the numbers occurring. Occupation or category of personnel was not d i f fe rent ia ted within each department in th i s study owing to i t s exploratory nature, but departments were compared. Figure 7 shows which depart- _ ments are having the most i n ju r i e s . Nursing being the largest group appears to be the leader with 46.3 percent. However, when rates are calculated according to s t a f f a l l o ca t i on , the trend indicates other departments have de f i n i t e l y higher rates as i l l u s t r a t e d in Figure 8. For the tota l seven year period, i t i s evident that dietary with 17.7 per 1000, housekeeping with 17.4 per 1000 and maintenance with 11.3 per 1000 are in the lead. Nursing's average tota l in jury rate i s 6.2 per 1000. Table 5 presents the accompanying annual employee injury rates per 1000 for the years 1970 to 1976, from which the average tota l s are derived. Services were also compared. According to Hospital 251 Figure 7 T ra i l Regional Hospital. Frequency D i s t r ibut ion of number of Employee Injuries According to Departments, for the period 1970-1976. 2 5 2 Figure 8 T ra i l Regional Hospita l . Average Total Employee Injury Rates per 1,000 According to Departments, for the period 1970-1976. 17.5 r- S 15.Oh 12.5 8 1 0 0 o a- 7.5 h co L U I — < an 5.0 2.5 h \ (Medical Records, Nuclear Medicine and Social Service recorded no injuries for the period 1970-1976) 253 S t a t i s t i c s and Administration of the Hospital Act (1971:23), four groupings of ; Nursing and Special Services Department; Administrat ion; other General Services and Physical Plant are advocated. Nursing and Special Services include the departments related to patient care and enta i l a degree of professional competence and technical expert i se, such as; radiology, nuclear medicine, r ehab i l i t a t i on , laboratory, pharmacy, socia l serv ice, etcetera. In the case of the Tra i l Regional Hosp i ta l , nuclear medicine and soc ia l service were onliy added in 1973. And though they both recorded no accidents for th is period to the end of 1976, nevertheless, injury rates would have to consider the numbers of the i r personnel in the yearly calculat ions when combined in special servi ces. The Administration Department incorporates; management personnel, business o f f i c e and c l e r i c a l s t a f f , as wel l as the payrol l o f f i c e r , purchasing and stores, switchboard , admitting, and the medical records department. Medical records reported no i n ju r ie s for the seven years period from 1970 to 1976, but here again, the numbers of the i r personnel were calculated in the annual injury rates for Administration. The General Services refer to support s t a f f in the d ietary, housekeeping and laundry. : They generally operate with hotel-type functions and are necessary for the smooth running of the system. 254 Plant and Maintenance include a var iety of s k i l l e d trades, such as boiler-room engineers, e l e c t r i c i a n s , carpenters and painters, and often have the re spons ib i l i t y of secur ity guard in medium-size hospita ls . Table 6 compares the services by using the annual injury rates per 1000 for the years 1970 to 1976. The corresponding graph in Figure 9 show the three serv ices, except Administration, having a sharp r i se in injury rates in 1972. This may be att r ibuted to better reporting of accidents a f te r the inception of the safety program in mid 1971. In 1973 there i s a general drop in recorded in ju r ie s except for Administration which had an increased rate of 1.5 per 1000, having had zero accidents in the previous two years. In 1974 a l l four services recorded increased rates, but from thereon the injury trend appears to gradually lower or level o f f , except Plant and Maintenance. This department being a r e l a t i v e l y small force in numbers tends to show an e r r a t i c pattern, even when accidents are not frequent. On the other hand, there may be too few people to cover an increased work load with the expansion program that has been underway since 1974 at the hosp i ta l . I t may be argued that understaffing can be responsible for some accidents. Yet, with the addition of new services and f a c i l i t i e s s ta r t ing in 1973, the increased number of "equivalent persons" per department may have some e f fec t on the number of accidents. In 1973, 1974, 1975, and 1976, the "equivalent persons" were 326, 342.1, 363.3 and 363.2 respectively. Table 6 Tra i l Regional Hospital Annual Employee Injury Rates per 1000 For Services For the years 1970 - 1976 Services 1970 1971 1972 1973 1974 1975 1976 Average Total Nursing and Special Services 4.6 3.9 6.4 6.0 7.4 6.7 5.6 5.8 Administration 4.9 0 0 1 .5 5.3 3.9 4.0 2.9 General Services 13.9 17.2 24.1 13.0 18.2 18.0 6.1 15.9 Plant and Maintenance 4.3 4.3 35.3 3.6 11.5 6.7 13.5 11.3 Note: Services are categorized in the above manner under Departmental D i s t r ibut ion (Hospital S t a t i s t i c s and Administration of the Hospital Act, 1971:23). 256 Figure 9 T ra i l Regional Hospital. Annual Employee Injury Rates per 1,000 According to Services, for the years 1970-1976. 1970 1971 1972 1973 1974 1975 1976 257 With each addit ional "equivalent person" representing a corresponding increase in ..employees at r i s k , the injury rate could be affected one way or another. An interest ing future study could be done on the relat ionship between the number of accidents with the number of employees at r i s k . Another project could be to study how overtime might be associated with accidents. The d i s t r i bu t i on of recorded in ju r ie s according to s i t e of accident, places most of them on the c l i n i c a l areas, 59.2 percent. Figure 10 shows, however, the general service areas have 24.4.percent of the tota l i n j u r i e s , and maintenance and plant has 7.3 percent. Next come the special services areas with 4.6 percent and administration with 3.2 percent. The 1.3 percent att r ibuted to "others" include such areas as ca fe te r i a , parking l o t , and hospital grounds. From an epidemiologic point of view, i t would appear that the focus of attention in any hazard control program should be directed towards the nursing f loors and in the general service areas. When do most employee accidents happen in the hospital? A cross tabulation was done of hour.;of occurrence by departments. Table 7 presents the d i s t r i bu t i on of number of i n ju r i e s according to departments for time of day. I t i s evident that most accidents occur on the day s h i f t between 7.30 a.m to 3.30 p.m., and mostly to nursing, housekeeping and dietary personnel. For housekeeping and dietary the i n ju r ie s were spread f a i r l y evenly over the eight hours. For nursing, however, the r i s k i e s t time appeared to be Figure 10 258 T ra i l Regional Hospita l . Frequency D i s t r ibut ion of number of Employee Injuries According to locat ion of occurrence, for the period 1970-1976. 60 i -50 o\ 40 CO L U 0 z 30 L U z> 0 1 1 1 U J C£ LL- 20 10 59.2 24.4 7.3 4.6 3.2 1.3 N=561 O K * . . \ \ x % \ \ \n %\ °* <> °A, 'C «f *• V Table 7 Frequency Distr ibut ion of Number of Employee Injuries According to Departments 1970 - 1976 By Time of Day (Day Sh i f t , Evening Sh i f t , Night Sh i f t ) Department 7.30 a.m.-3.30 p.m. '3.30 p.m.- 11.30 p.m. -11.30 p.m.-7.30 p.m. Total •1, Housekeeping 86 12 7 105 2. Nursing 145 79 33 257 3. Dietary 84 27 13 124 4. Administration 5 6 3 14 5. Radiology 3 0 0 3 6. Plant and Maintenance 16 4 1 21 7. Laundry and Linen 7 0 1 8 8. Laboratory 13 0 3 16 9. Rehabi l i tat ion 7 0 0 7 10. Pharmacy 0 0 1 1 Total 366 128 62 556 N = 556 Data not avai lable 5. 260 9 a.m. to 12 noon with the heaviest reported i n j u r i e s , 27.6 percent of a l l accidents, in a 24 hour period. For time of year when most i n ju r ie s occur, a cross tabulation was done of, month of occurrence by departments. A frequency d i s t r i bu t i on i s presented in Table 8, using spr ing,. summer, f a l l and winter as convenient tr imesters. Nursing and dietary show the winter months as being the the most dangerous time of year with >73 i n ju r ie s reported out of a to ta l 172 for a l l departments for those months, whereas housekeeping does not f a i r so well in the summer months, reporting 34 i n ju r ie s out of a tota l 106 reported by the i r department for the seven year period. Two reasons can be advanced for these observations. In the winter months, more f a l l s are recorded due to wet f loors and icy parking l o t s . This i s born out by the contingency table when month of occurrence was cross tabulated with external cause of i n j u r i e s . I t showed but of 71 f a l l s of persons for the seven year per iod, 42.3 percent occurred in December, January and February. The almost ha l f of the f a l l s occurring in the winter months should indicate the appropriate preventive measures. The summer months run into vacation time and there i s usually a s t a f f shortage which could account for more accidents occurring at th i s time. Summer r e l i e f personnel could also be a factor. Machinery and . equipment, sharp instruments and heat steam rank high as the external causes of accidents during these months. Whether these Table 8 Frequency Distr ibut ion of Number of Employee Injuries According to Departments 1970 - 1976 by Time of Year (Spring, Summer, Fa l l and Winter) Department Dec.Jan.Feb Mar.Apr.May June July.Aug. Sept.Oct.Nov. Total 1. Housekeeping 28 28 34 16 106 2. Nursing 86 57 68 49 260 3. Dietary 37 33 26 29 125 4. Administration 6 0 2 6 14 5. Radiology 0 1 0 2 3 6. Plant and Maintenance 7 3 6 5 21 7. Laundry and Linen 0 2 5 1 8 8. Laboratory 7 2 2 5 16 9. Rehabi1itation 0 2 2 3 7 10. Pharmacy 1 0 0 0 1 Total 172 128 145 116 561 N - 561 262 are due to un fami l i a r i t y , carelessness on the job, poor judgment or fatigue i t i s d i f f i c u l t to say, but the evidence i s c lear that the summer months have more i n ju r ie s recorded than in the spring or f a l l . The same table shows 145 in ju r ie s in June, July and August out of a tota l 561 for a l l departments for the seven year period. In an attempt to pinpoint some causes of hospital accidents, the pr inc ip les of epidemiology were used. I f an external cause i s sought, the coding of i n ju r ie s had to centre around determining what was the agent in a pa r t i cu la r accident s i tuat ion that could be classed as mechanical, chemical, e l e c t r i c a l , thermal or b io log ica l ( refer to chapters 4 and 5). Often there i s some confusion as to the terms, " k i n d " , " t ype " , "nature" and "cause" of accidents and interpret ing the raw data posed some d i f f i c u l t i e s . However, fo r th i s study, "external cause" implies the agent, and "nature of in jury " manifests the resu l t of the accident, not the cause. Table 9,...10 and 11 present the External Causes of In jur ies , Nature of Injuries and Parts of Body Involves respectively. The causes of i n ju r i e s are summarized according to services. As shown in Table 9, over-exert ion, sharp instruments, f a l l s of persons, and machinery and equipment constituted 63.6 percent of a l l accidents for Nursing and Special Services. Heat and steam, and machinery and equipment, seem,.toobe the major hazards for General Services and Maintenance. Administration had fewer accidents but a high proportion of i n ju r ie s reported by them had to do with f a l l s of Table 9 Trail Regional Hospital Injuries Sustained by Employees According to Services 1970 - 1976 External Causes of Injuries (By Number, Percent, Rank) Cause Nursing and Special Services Administration General Services Plant and Maintenance Total No. % R No. % R No. % R No. % R No. % R 1. Over Exertion 57 20.4 1 1 7.7 4 14 6.0 7 - - - 72 13.2 2.. Sharp Instruments 47 16.8 2 - - - 34 14.6 3 2 10.5 3 83 15.2 3. Falls of Persons 37 13.2 3 4 30.8 1 29 12.4 5 1 5.3 6 71 13.0 4. Machinery and Equipment 37 13.2 3 1 7.7 4 45 19.3 2 3 15.8 2 86 15.8 5. Objects:Struck by Struck against Struck between 32 11.4 5 4 30.8 1 34 14.6 3 2 10.5 3 72 13.2 6. Patient induced 23 8.2 6 - - - 1 .4 9 - - - 24 4.4 7. Heat and Steam 22 7.9 7 1 7.7 4 55 23.6 1 9 47.4 1 87 16.0 8. Miscellaneous Insects.animals 18 6.4 8 2 15.3 3 15 6.5 6 2 10.5 3 37 6.8 9. Harmful Substance 7 2.5 9 - - - 6 2.6 8 - - - 13 2.4 TOTAL 280 100.0 - 13 100.0 - 233 100.6 - 19 100.0 - 545 100.0 N = 545 Data not available 16 Table 10 Trail Regional Hospital Injuries Sustained by Employees According to Services 1970 - 1976 Nature of Injuries (By Number, Percent, Rank) Nature of Injury Nursing and Special Services Administration General Services Plant and Maintenance Total No. % R No. % R No. % R No. % R No. % 1. Cuts, Bruises, Punctures 106 37.9 1 4 30.8 2 100 43.1 1 8 38.1 2 218 39.8 2. Pain, Strain 103 36.8 2 5 38.5 1 45 19.4 3 1 4.8 4 154 28.2 3. Swelling and Inflammation 27 9.6 3 1 7.7 4 21 9.1 4 - - - 49 8.9 4. Burns 25 8.9 4 1 7.7 4 54 23.3 2 9 42.9 1 89 16.3 5. Others: Imbedding Chipping Bites. 19 6.8 5 2 15.3 3 12 5.1 5 3 14.2 3 36 6.8 Total 280 100 - 13 100 - 232 100 - 21 100 - 546 100 N = 546 Data not available 15 Table 11 Trail Regional Hospital Injuries Sustained by Employees According to Services 1970 - 1976 Parts of Body Involved (By Number, Percent and Rank) Parts of Body Involved Nursing and Special Services Administration General Services Plant and Maintenance Total No. % R No. % R No. % R No. % R No. % 1. Upper Extremi ty 124 43.5 1 5 35.7 1 156 65.3 1 15 71.4 1 300 53.7 2. Back and Trunk 74 26.0 2 5 35.7 1 25 10.5 3 1 4.8 4 105 18.8 3. Lower Extremity 44 15.4 3 2 14.4 3 40 16.7 2 3 14.3 2 89 15.9 4. Head and Face 27 9.5 4 1 7.1 4 12 5.0 4 2 9.5 3 42 7.5 5. Multiple and Internal 16 5.6 5 1 7.1 4 6 2.5 5 0 0 5 23 4.1 Total 285 100 - 14 100 239 100 - 21 100 - 559 100 N = 559 Data not available 2 266 persons and being struck by objects. I t i s surpr i s ing to f ind Administration showing back and trunk in ju r ie s as part of the body most involved in Table 11, and pain and s t ra in ranking f i r s t in nature of i n ju r i e s in Table 10. Yet over-exertion ranks fourth under external causes in Table 9. One wonders i f some factor other than over-exertion at work causes back s t r a i n . De f i n i t e l y , there i s need for more research into the causation of back pain. In Table 11, with parts of the body involved, The Spearman's rho rank order corre lat ion between Nursing and Special Services, and Administration was s i gn i f i can t at the 1.4 percent l e v e l . Between Nursing and Special Services, and General Services i t was s i gn i f i can t at the 3.7 percent l e v e l . Between Administration and General Services i t was not s i gn i f i can t . The corre lat ion between General Services, and Plant and Maintenance, was s i gn i f i can t at the 3.7 per-cent l e v e l . The smaller the l e v e l , the more s i gn i f i cant is the corre lat ion (S iegel , S., 1956: 202-213). Age i s an important factor in employee accidents according to most.research done in industry. Hale and Hale (1972:11) say: ... during the teens and early twenties the number of accidents i s high: i t then drops sharply, l e v e l l i n g out in the mid twenties. After t h i s , there i s a s l i gh t decline un t i l the middle or late f o r t i e s when the numbers s tar t to r i se again ' t i l the end of the working l i f e 267 Figure 11 shows the frequency d i s t r i bu t i on of number of employee in ju r ie s according to age category. This graph shows only the spread of accidents according to age groups. It i s not meant for comparative purposes, as the numbers in each category were not ava i lab le. From an epidemiologic viewpoint i t has some s ign i f icance. It shows 20.4 percent of a l l the recorded accidents occurred in the under 25 age group, which i s greater than any of the other groups. This would indicate the necessity for concentrating on t ra in ing and supervision within th i s age category. On a cross tabulation between age and external cause of accidents, i t was evident that the main types of accidents occurring in th i s age category were; 22 percent caused by sharp instruments; 16.5 percent caused by machinery and equipment and 15.4 percent from over-exertion. Figure 12 shows a frequency d i s t r i bu t i on of number of employee in ju r ie s according to length of employment. The f indings of industry say that in new rec ru i t s , experience is the c r i t i c a l factor in accident causation. There seems to be strong evidence that length of service has an e f fect on accident rates over the f i r s t one to two years of employment in a company (Hale and Hale, 1972:37). Figure 12 does not compare each interva l category as to who are having the most accidents. The s ign i f icance of the spread i s of epidemiologic interest to note where most of the accidents are happening. 268 Figure 11 T ra i l Regional Hospita l . Frequency D i s t r ibut ion of Number of Employee Injuries According to Age Category.For the Period 1970-1976. 20 r 15 t o LU y i o 3 o m 5 16.6 3.8 12.9 8.6 7.5 N = 559 Data not available: 2 12.2 2.7 m n • 8.4 4.3 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 A g e in Years 269 Figure 12 T ra i l Regional Hospital. Frequency D i s t r ibut ion of Number of Employee Injuries According to Length of Employment for the Period 1970-1976. 20 r 16.3 cN CO LU £ I 0 | LU Z> O LU c* 5 13.1 13.3 7.2 7.7 6.6 7.2 N = 557 Data not available: 4 10.8 6.6 6.8 2.3 2.0 1 2-3 4-6 7-12 1-2 2-3 3-5 5-7 7-10 10-15 15-20 20+ MONTHS 1 I • YEARS " Length of Employment 270 In the period under two years, 41.8 percent of a l l the accidents are occurring. This may suggest that accident prevention measures should be directed towards employees in the i r f i r s t two years. P a r t i c u l a r l y , i t would be wise to consider the f i r s t month of or ientat ion as v i t a l l y important in view of the fact that 7.2 percent of accidents occur in the under one month period before i t drops to 6.6 percent in the 2-3 month period. The 2-7 years experience group accounts for 40.4 percent of a l l recorded accidents. This may mean there are more people working at the hospital in th i s group. On the other hand, i t may be wise to investigate what kinds of accidents they are having and why. At the extreme end of the sca le, the 17.7 percent of those with seven years of more experience may not be recording a high percentage of accidents, but there are probably fewer people working in th i s category. A cross tabulation done on length of employment and external cause of i n ju r i e s revealed that the under one month group had mainly heat and steam accidents. The under two year group's main i n ju r ie s were due to machinery and equipment, sharp instruments, and. heat and steam. The 2-7 year category indicated over-exert ion, sharp instruments, f a l l s of persons, and machinery and equipment, in that order, as the main causes of i n j u r i e s . The employees in the over seven years experience group had mostly f a l l s , heat and steam, and machinery and equipment accidents. 271 Conclusion It i s interest ing to note that the f indings from the epidemiologic invest igat ion of hospital employee in ju r ie s bore a remarkable resemblance to those which have been reported from research studies of indus t r ia l workers (refer to Chapter 4). The main causes of accidents found in the study were; over-exert ion, sharp instruments, f a l l s , machinery and equipment in Nursing and special serv ices; heat and steam and machinery in the General Services and maintenance; f a l l s and struck by objects in Administration. In both the age category and experience category, again, s imi la r f igures were produced. The under 25 age group had the greatest number of i n j u r i e s . Likewise, in the period under two years length of serv ice, was found the most accidents. I t has been the main purpose of the epidemiologic invest igat ion to gather information regarding the who, what, where and when of employee accidents. With th i s knowledge, the planning of preventive programs can be directed at areas that require the most attent ion. 272 II Evaluation of the T ra i l Regional Hospital Safety Committee  History The or ig ina l safety committee of the Tra i l Regional Hospital was organized in 1967. From a questionnaire (Appendix A) that was sent to former members, together with some old records, i t was poss i -ble to reconstruct the structure and functions of the committee. Of the s i x information gathering questionnaires sent, four were returned. One member had moved away and one had died. The or ig ina l committee consisted of; a chairman who was the hospital f i r e warden, the representatives from the nursing serv ice, housekeeping, dietary and laboratory, with management's r ight to enlarge the membership. The committee held monthly meetings and recorded minutes by an appointed secretary. The functions centred around; safe working conditions and pract i ses , a review of accident reports advising both management and labour how to cut down on the number of accidents, monthly bui ld ing inspections and ins t ruct ing hospital s t a f f on f i r e safety. It had an ambitious program of a c t i v i t i e s focussing on accident reduction. However, with a change i n administration in 1968 which was unsympathetic to i t s cause together with general apathy of s t a f f , the committee disbanded in 1969. The present safety committee sprang from the ashes of the old at the ins t igat ion of the Workers' Compensation Board of 273 B.C. in May, 1971. Most of the former pr inc ip les were retained. The purpose was simply to make the T ra i l 'Regional Hospital a safe place to work, free of f i r e s and accidents. The objectives were: 1. To implement f i r e lectures , d r i l l s and to educate s t a f f in f i ght ing f i r e s . 2. To set up safety rules for employees. 3. To set up an accident invest igat ion committee. 4. To set up a bui lding inspection committee. (a) Comparison of Rates Before and After The decision to compare injury rates of services in the hospital before and a f te r the inception of the new safety committee was with the understanding that the difference in the rates would not be the only c r i t e r i o n of success or f a i l u r e of a safety program: A design which Campbell and Stanley term non-experimental rather than quasi - experimental i s the single group "before-after " design: The status of an outcome (dependent) variable i s measured in a s ingle group before and a f te r the introduction of some treatment. Although research spec i a l i s t s have long pointed out the dangers in drawing conclusions from th is design, i t i s widely used in publ ic health programs (Deniston, O.L. and Rosenstock, I.M., 1973:154). Table 12 presents the comparison of Employee Injury Rates per 1000 before and a f te r the i n s t i t u t i on of the safey committee in 1971. Each service showed a higher rate in the 1972-1976 period than in the 1970-1971 period. However, as explained in the previous sect ion, referr ing to Figure 9, i t i s quite l i k e l y that the accidents had not increased but the recording of them had. 274 Table 12 Tra i l Regional Hospital Comparison of Employee Injury Rates per 1000 Before and A f te r In s t i tut ion of Safety Committee in 1971 Services Rates per 1000 Before Rates per 1000 Af ter 1970-1971 1972-1976 Nursing and Special Services 4.3 6.4 Administration 2.5 3.1 General Services 15.6 15.9 Plant and Maintenance 4.3 13.7 Note: Safety Committee started in May, 1971 275 The Workers' Compensation Board who ins i s ted on react ivat ion of the safety committee, no doubt, would have also informed the hospital of the penalties for not reporting employee accidents. The same f igure shows a downward trend for three of the services in 1973 and a r i se of a l l services in 1974 perhaps due to increased services and increased s t a f f , and again a s l i gh t trend downward in 1975 and 1976, except for Maintenance and Plant. It would be interest ing to examine the injury trends from 1976 onwards. Perhaps in the future, obtainable, measurable objectives might be attempted, for example:Time Toss>and Medical Aid only i n ju r i e s to be reduced by 25 percent in a given period. The f i n a l test of an e f fec t i ve safety program would be ref lected in thedecreasing numbers of T.L. and M.A.O. accidents. (b) Documentary Analysis How well the committee has ca r r i ed ' ou t i t s objectives should be the main c r i t e r i a of i t s effect iveness. Af ter a careful analysis of the safety committee minutes from 1971 to 1976, i t appears that a l l four objectives itemized have been implemented. F ire safety lectures and demonstration of f i r e f i ght ing equipment commenced on July 22, 1971 and followed by monthly programs for some time, then in termi t tent ly . Nevertheless, th i s i s an important item in the safety program and f i r e d r i l l s are done 276 regular ly. In February, 1972 Safety Rules and Regulations were drafted and completed in June 1972 and d i s t r ibuted to each depart-ment. An accident invest igat ion committee and a bui lding inspection committee make t he i r reports to the monthly meetings and suggest recommendations. These recommendations are then followed up promptly by reporting unsafe conditions to management, posting warning not ices, organizing f i lms and demonstrations on proper l i f t i n g techniques, f i r e hazards etcetera. They often e n l i s t the aid of other departments who cooperate in the areas of the i r expertise. The T ra i l Regional Hospital Safety Committee i s an act ive organization with enthusiast ic members. They keep abreast of the times by attending safety seminars, exchanging information with other safety committees and have hosted j o i n t meetings for the Kootenays. Despite the e f fo r t s of the safety committee, there are some variables over which i t has l i t t l e cont ro l , such as; administrative leadership, s t a f f at t i tude to safety, indiv idual r e spon s i b i l i t y , departmental supervision over task and personnel, and perhaps unusual weather conditions. Looking back over the records, i t was found that a great deal of construction was going on during thewho.leof 1974 with the addit ion of new f a c i l i t i e s for the nuclear medicine laboratory and a pulmonary department, as well as the completion of the intensive care and renal care units . 277 This may have been a factor in creating extra hazards that contributed to the high accident rate in 1974 for a l l services. (c) Comparing Medium-Size Hospitals of B.C. On the premise that hospitals that have safety committees, not only are upholding the law; but are cognizant of occupational health and safety hazards that can a f fect the well-being and product iv i ty of the i r employees, a l i s t was compiled of eleven s imi la r s ize hospitals in B.C. to compare how the T ra i l Regional Hospital stood in re la t i on to the others regarding reported accidents to the Workers' Compensation Board. The tota l f igures c i ted in Table 13 denote only the number of cases reported and does not indicate the sever ity or rate. The T ra i l Regional Hospital i s F. No. 14970. Table 14 presents a l i s t of medium size public general hospitals in B r i t i s h Columbia which have Safety programs. The Safety programs do not indicate structure or function or, indeed, how e f fec t i ve they are, but they do show that they are a f a i r l y recent trend. The T ra i l Regional Hospital Safety Committee can be j u s t l y proud of i t s ear ly beginnings and i t s act ive program. I l l The Use of an Epidemiologic Model in a Hazard Control Program. Concerning the Host Some answers to questions of d i s t r i bu t i on and determinants of employee in ju r ie s are shown in the results of the frequency 278 Table 13 Number of 1st Payment Time Loss Cases and Number of 1st Payment Medical Aid Only Cases for Selected Hospitals 1970 - 1976 inclusive HOSPITAL FIRM NO. TYPE 1970 1971 1972 1973 1974 1975 1976 TOTAL TOTAL CASES J . 4858 T.L. M.A.O. 8 33 3 19 6 20 12 21 19 17 16 25 26 27 90 162 252 E. 12847 T.L. M.A.O. 3 32 5 26 31 23 19 20 30 28 29 25 24 28 141 182 323 C. 14438 T.L. M.A.O. 8 14 7 17 8 20 20 17 15 25 22 32 14 26 94 151 245 F. 14970 T.L. M.A.O. 9 40 6 28 8 61 9 27 10 51 17 44 18 25 77 276 353 A. 16692 T.L. M.A.O. 3 13 4 7 13 4 11 5 10 7 8 13 17 7 66 56 122 H. 21803 T.L. M.A.O. 6 13 14 11 10 5 15 7 15 12 16 11 17 8 93 67 160 I. 27345 T.L. M.A.O. 8 7 5 7 6 10 9 10 17 7 22 10 13 4 80 55 135 B. 29102 T.L. M.A.O. 6 22 10 18 32 21 30 14 30 20 31 21 38 13 177 129 306 D. 42345 T.L. M.A.O. 6 12 8 8 5 8 16 14 18 9 12 1!) 26 18 91 88 179 K. 62427 T.L. M.A.O. 24 62 32 53 33 20 41 37 47 38 38 25 35 33 250 268 518 G. 114178 T.L. M.A.O. 6 23 11 25 25 35 29 31 34 45 32 43 31 29 168 231 399 TOTAL T.L. M.A.O. 87 271 105 219 177 227 211 203 245 259 243 268 259 218 1327 1665 2992 Please note that these counts are by year of 1st payment and are not analyzed by year of accident occurrence. Source: Workers' Compensation Board, B.C. Accident Prevention Department 279 Table 14 Medium-size Publ ic General Hospital in B r i t i s h Columbia with Safety Programs (Bed Capacity 200-299) HOSPITAL SAFETY PROGRAM DATE INITIATED A Active Safety Program. Date i n i t i a t e d not ava i lab le. B Active Safety Program. Date i n i t i a t e d not avai1 able. C No information ava i lab le. D Active Safety Program. Date i n i t i a t e d not avai l able. E Active Safety Program. Date i n i t i a t e d not ava i lab le. F Active Safety Program. Date i n i t i a t e d not ava i lab le. G Active Safety Program. Program started 1974. H Active Safety Program. Program started 1973. I Active Safety Program. Date i n i t i a t e d not ava i lab le. J ... Active Safety Program. Date i n i t i a t e d not ava i lab le. K Active Safety Program only because i t i s required by W.C.B. Regulations. Date i n i t i a t e d not avai l able. Source: Worker's Compensation Board, B.C. Accident Prevention Department 280 tabulations. The host or employee most l i k e l y to be injured in a hospital w i l l be in the nursing, d ietary or housekeeping departments. The safest occupations appear to! be medical records, nuclear medicine, socia l serv ice, pharmacy and radiology. A c lear d i s t i n c t i on in age category places the under twenty-five year group to be at most r i s k and employees with two years experience or less are more l i a b l e for i n ju r ie s on the job. Other b io log ica l and l i f e s t y l e factors of the host were not a consideration in th i s study. However, these aspects of the host are important components of the tota l person, and could be central to other research studies. Concerning the Environment The most hazardous environments were in the fol lowing order; patient care areas, general service areas, p lant, special service areas, administrative o f f i c e s , hospital grounds and ca fe te r i a . The time when injury i s most l i k e l y to happen i s on the day s h i f t , possibly in December, January or February, between 9 a.m. and 12 noon. Due to the unava i l ab i l i t y of information regarding the physical and psychological character of the environment from the records, i t was l e f t to conjecture as to why certa in areas were more hazardous than others. 281 Concerning the Agent External causes of accidents (agent) in the hospital varies for d i f f e ren t services. Nursing and Special Services, along with General Services, in the main, showed; over-exert ion; sharp instruments; f a l l s ; machinery and equipment; and heat and steam to be the worst hazards. Other causes i n f l i c t i n g injury on employees were objects; struck by, struck against, struck between; pat ients; insects ; and harmful substances. The resu l t ing i n ju r ie s were mostly; cuts, bruises and punctures; s t ra in and pain; burns; swell ing and inflammation; and others; such as b i te s , chipping and imbedding i n j u r i e s . The great majority of hospital i n ju r ie s affected the upper extremit ies, followed by back and trunk, lower extremity, head and face, and mult iple or internal i n j u r i e s . The results of the study make the appl icat ion of the epidemiologic model for a hazard control program f a i r l y s t ra ight -forward, as the roles played by the host, environment and agent are better understood. This w i l l be discussed in more deta i l in the f i n a l chapter. Conclusion The Epidemiologic study of employee in jur ies for the period 1970-1976 brought to l i g h t many previously unknown deta i l s regarding d i s t r i bu t i on and determinants of accidents at the T ra i l 282 Regional Hospita l . It was found that the typ ica l accidents happening at the hospital were very s im i la r to those occurring in industry. The specia l ized areas reported minimal numbers of i n j u r i e s , suggesting that the se lect ion process was excel lent and hazards were well under cont ro l . Very few infect ions were reported among s ta f f members, which indicate good infect ion control techniques. The obvious d i r e c t i on , then, i s to concentrate on reducing the number of i n ju r ie s that are the major problems, which seem to be the ones most often found in industry. CHAPTER II CONCLUSIONS AND RECOMMENDATIONS The study represents a systematic analysis of employee in ju r ie s sustained in a medium-size publ ic general hospital in B r i t i s h Columbia with in an overa l l epidemiologic framework. As such, the study has provided comparative data on the frequency of accidents in a hospital population at r i s k . Of more relevance, i t has provided the necessary information regarding "who, what, where, when and how" of accidents, but not "why". It has also shed some l i g h t on what should be the appropriate measures of prevention of occupational hazards in a hospital m i l i eu , which i s the cornerstone of any hazard control program. Developing Guidelines for a Hazard Control Program This study has been l imited in establ i sh ing contributory and predisposing factors that cause accidents, because of the unava i l ab i l i t y of necessary data. However, the multicausal nature of accidents, though not f u l l y observed, need not preclude any e f fo r t s i n providing a safe environment for hospital workers. Edward Tufte (1974:22) has sa id: Almost a l l e f fo r t s at data analysis seek, at some point, to generalize the results and extend the reach, of the conclusions beyond a pa r t i cu la r set of data. . . Thus, planning a hazard control program from ins ights gained from the study would need to consider the three aspects of 284 the epidemiological t r a i d , of host, environment and agent. It can be argued that each component can be d i f fe rent ia ted for a spec i f i c method of attack so as to avoid the d isequi l ibr ium that can prec ip i tate an accident. Education, engineering and enforcement -the three E's - are the three flanks that can counteract the effects of the epidemiological t r i ad in accident causation. From the data, i t was observed that nursing, dietary and housekeeping had most of the i n ju r ie s in the seven year period. Younger employees under twenty-five years and those who were new recru i t s were at increased r i s k . Education and t ra in ing should be d i rected, then, at these services and these groups of employees, ostensibly to make the "host" more res i s tant . Again from the data, the results showed the environment on the nursing f loors and general service areas to be the most hazardous for employees. Special ergonomic design and safe conditions would come under the engineering f lank. Proper l i f t i n g mechanisms, guarding of dangerous machinery and equipment and good housekeeping would be appropriate meausres here to combat the environmental dangers. In the case of external causes of i n ju ry , the th i rd f lank, enforcement, could be most e f fec t i ve in inact ivat ing the agent component. Therefore, s t r i c t supervision of procedures, safety ru le s , controls and regulations must be observed. Mechanical, chemical, i on i z i ng , thermal, e l e c t r i c a l and b io log ica l hazards are 285 the agents in question. Therefore, the development of guidelines for a hazard control program would consider these three approaches. A New Approach Why are hospital accidents increasing? Are safety committees the answer? Or should there be b u i l t - i n safety instrumentation for each job? Some industr ies are f ind ing the Job Safety Analysis procedure to be e f f ec t i ve . This process breaks down each job into basic steps, potential accidents or hazards are noted and precautions are recommended (Rustemeyer, C.R., 1979:9). Perhaps a new approach to the whole question of safety i s necessary. Att itudes need to be changed to e f fect behavioural change. The trouble with " safety" i s that i t implies a pos i t ive goal that i s attainable and des i rable, but does not indicate any concrete action towards i t . Besides, i t i s d i f f i c u l t to become safety conscious when there i s a cu l tu ra l dichotomy about the term. On the one hand, the public i s bombarded with slogans l i k e " l i v e dangerously" and on the other hand they ' re to ld " i t ' s better to be safe and sorry" . But who want to be "safe"? The publ ic also seems to have trouble with the phrase "accident prevention". I t has a negative connotation. It conjures up a v io lent s i tuat ion that i s best avoided, but does not indicate 286 any concrete action towards a goal. It may be a case of simple semantics, but "hazard control seems to be a concept that people can i dent i f y with. It denotes both health and safety hazards and indicates pos i t ive action towards a de f i n i t e goal. Human beings l i k e to cont ro l . This researcher prefers to use th i s term rather than accident prevention or safety. However, whatever term is used, the success of committees w i l l depend upon: 1. top management involvement; 2. def ining measurable object ives; 3. periodic evaluation; 4. cooperation of s t a f f ; and 5. personal re spons ib i l i t y for actions. Summary Despite the high technology equipment and hazardous substances found in modern hosp i ta l s , very few accidents were recorded in areas where these were used. The great majority of i n ju r ie s sustained are s t i l l the usual s t ra in s , cuts, bruises and burns, caused by over-exert ion, sharp instruments, f a l l s and heat and steam. From the information obtained from the data, i t was found that the types of hospital employee in ju r ie s were s im i la r 287 to indus t r ia l accidents. Except for mishaps pecul iar to operating rooms, laboratories and patient care areas, most accidents involving hospital personnel are the ones most frequently l i s t e d as occupational i n j u r i e s . For instance, i t was found in both hospitals and industry, that the great majority of causes were f a l l s amd improper handling of materials. The back i n ju r ie s from l i f t i n g patients are not too d i f f e ren t from the i n ju r ie s maintenance men sustain from heavy l i f t i n g of equipment. Cuts and burns that occur in the laundry and the d iet kitchen are repl icated in publ ic laundries and restaurants. The r i s k of t r ipp ing and f a l l i n g in corr idors of publ ic buildings and schools apply equally to hospita ls . Therefore, most of the hazards of hospital operation are commonplace and the remedies are already known. Industry has long recognized the substantial benefits that resu l t from well developed hazard control programs. Hospitals must, then, follow .industry's lead. Industry has also demonstrated that accidents are not chance occurrences or are they necessari ly inev i tab le. They are caused by unsafe practices and unsafe condit ions. Likewise, industry has shown that these unsafe conditions and unsafe actions can be control led by e f fec t i ve management. Hospitals, too, can reduce the incidence of employee in ju r ie s with better control programs. 288 However, the long term e f fec t of occupational disease and chronic conditions has not been well researched even in industry,though recently there has been noticed a great interest evolving. There i s room for much more research in this area, and as industry accepts the concept of occupational health as an important consideration for both economic and eth ica l reasons, perhaps the spin o f f w i l l bring benefits to the hospital workers. Meanwhile,there are no magical solut ions. Hospitals which are in the forefront of the health care system ought to be examples to other health care i n s t i t u t i on s . The epidemiologic study has revealed the who, what, where and when of employee i n j u r i e s . Industry has already shown the way in reducing hazards that cause workplace accidents. Other factors that a f fect the well-being and product iv i ty of working people have been discussed in Part I. Hospitals themselves must now make a concerted e f f o r t to implement programs of protection for t he i r employees, considering the i r phys ica l , mental and soc ia l health. Recommendation This study has shown that employees are exposed to many hazards in a hospital mi l ieu. Therefore, an occupational health and safety service i s recommended for a l l hospita ls . The nurse practitioner-employee rat io should be 1-500. Figure 13 OCCUPATIONAL HEALTH SERVICES FOR HOSPITAL EMPLOYEES Administration Personnel Occupational Health Services (Umbrel.la Concept)  Health Promotion Health Education: Films & Lectures Behaviour Modification Program. Exercise Program Weight Control Program. Non Smoking Program Recreation Health Protection First Aid & Emergency Investigation of sick time Hospital & Home Visits Health Assessments and Screening of New Employees T.B. Control V.D. Control Routine Tests with referrals to Doctors Rehabilitation: Injuries Back Care Alcohol & Drugs Prevention Hazard Control Program: Hazard Control Committee--Safety Hazards -Environmental Hazards -Accident Investigation Plant Maintenance: Special Areas -Operating Theatres Radiology Laboratories Nuclear Medicine Other Infection Control Program: Infection Control Committee Infection Control Officer Immunization Program: Health Office Research Program: Surveys etc. Counselling Service Mental, Social & Physical Health: Nutrition Guidance Management of Stress Job Related Personal Marital Financial etc. Retirement Preparation Record Keeping Health Records: Medical History Health Assessment Laboratory Reports X-rays Immunization Records Visits: Office Home Personal Work Habits: Absenteeism Illness etc. ro co 290 A comprehensive occupational health and safety service in hospitals would have th<ree basic components: (1) Hazard Control Program (2) Infection Control Program (3) Employee Health Service I t should be within Administraton and Personnel, and include a whole spectrum of a c t i v i t i e s re la t ing to health promotion, health protect ion, prevention, counsell ing service and record keeping. Figure 13 presents an umbrella concept of occupational , health services which incorporates many services and departments in the ho sp i ta l , with the view to keeping a l l employees on the job, and healthy and happy on the job. 291 LIST OF-REFERENCES American Standard Method of Recording and Measuring Work Injury  Experience. American Standards Associat ion, 1954. Ashford, Nicholas, C r i s i s in the Workplace: Occupational Disease and  Injury - A Report to the Ford Foundation. Cambridge, Mass.: . The M.I.T. Press, 1976, pp.3-516. Bates, D.V. Foreword in "Government Regulation of the Occupational and General Environments in the United Kingdom, The United States and Sweden" by Roger Will iams. Science Council of  Canada, Background Study, No. 40, October 1977. Bates, D.V. Paper to Canadian Medical Association Convention, June, 1977, as reported in "Dying for a L i v ing " by Lloyd Tataryn Deneau and Greenberg Publishers Ltd. 1979.p. 175. B.C. Federation of Labour. 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The absence of records of th i s e a r l i e r time makes i t d i f f i c u l t to reconstruct the sett ing into which the present Safety Committee emerged. In May 26, 1971, at the in s t i gat ion of the Workers' Compensation Board, the Safety Committee was reactivated and renamed the T ra i l Regional Hospital Safety Committee. In order to obtain a h i s t o r i c a l perspective on the current Safety Committee, information pertaining to i t s predecessor w i l l be appreciated. Please answer the fol lowing 5 questions. The information w i l l be considered con f ident i a l . I f you don 't know the answer, give your opinion. 1. Structure a. Can you reca l l the members of the o r i g ina l Standing Committee? i . How many were there? i i . Who were the o f f i cer s ? Where did they l i ve ? Chairman Secretary Others i i i . 306 2. Objectives Were regular monthly meetings held? Yes| Zl N o [ If no, state your opinion why. Were accident reports reviewed pr io r to meetings? Yes | Zl N o [ If no, state your opinion why. Were bui ld ing inspections done monthly? Yes j~~ ZINo[ If no, state your opinion why. Did ins t ruct ion in f i r e safety take place through f i lms and talks? Yes| ZlNo[-If yes, how often did these occur Did inst ruct ion in f i r e f ight ing take place in the use of f i r e extinguishers and f i r e f i ght ing equipment? Yes | ZlNoC If yes, how often did these occur? Apart from f i r e safety, was there education in other types of accident prevention? Yes | ZlN o [ Please comment. 3. Minutes a. Were minutes taken of the meetings? Yes | |No If yes, in whose keeping were they? b. Did others besides the members receive copies? YES| |No If yes, who were they? 4. Functions a. Do you reca l l any event during the period from November 1967 to 1969 that affected the functioning of the Committee? YES | |No If yes, please comment. 307 b. Do you reca l l any event during the period from 1969 to 1971 that affected the functioning of the Committee? I f yes, please comment. 5. General Information a. In your opinion what were the reasons for the discontinuance of the former Safety Committee? b. What can be learned from your experience with the f i r s t Safety Committee? In addit ion to the questionnaire, would you consider a personal interview? Yesj | N If yes, when may I see you? Yes No 

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