@ccupational Health

in Health Service Areas:

HANDBOOK FOR PLANNING

U. S. DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE
Public Healfh Service
Cenfer for Disease Control

,f’ Nafional lns+i+u+e for Occupa‘l’ional Safei’y and Healfh

 

 

 

“

 

OCCUPATIONAL HEALTH IN HEALTH SERVICE AREAS:
Handbook for Planning

Murray L.[Cohe
Division of criteria Documentation and Standards Development

Jerry W. Newman
Division of Technical Services

Marilyn K. Hutchison, M.D;
Office of Extramural Coordination and Special Projects

U. S. Department of Health, Education, and Welfare
Public Health Service
Center for Disease Control
National Institute for Occupational Safety and Health
Cincinnati, Ohio 45226
September, 1978

 

 

 

 

 

DISCLAIMER

Mention of company names or products does not constitute endorsement by
the National Institute for Occupational Safety and Health.

The material in this publication was collected from various sources in
order to present as wide a range of information on the subject as
possible; thus, the opinions, findings, and conclusions are not
necessarily those of the National Institute for Occupational Safety and

Health.

DHEW (NIOSH) Publication No. 78-203

ii

 

 

 

Abstract l) L) L«

This handbook discusses a number of issues that are important in
developing a health systems plan (HSP) that responds to the occupational
health service needs of a community. The material is presented in terms
of: (l) The relationship of the HSA review process to the
implementation of occupational safety and health services, including the
need for review criteria. (2) The approach to planning for occupational
safety and health. (3) The scope of a comprehensive occupational safety
and health program. (4) The collection and utilization of occupational
exposure data. (5) The use of worksheets in organizing pertinent
information. The handbook is intended to serve as a starting point for
identifying the occupational safety and health program needs in a health
planning area.

111

 

CONTENTS

Abstract ....................................................... iii
Acknowledgments ................................................ v
Introduction ................................................... 1
An HSA Planning Approach to Occupational Safety and Health ..... 3
Clinical Services ............................................. 3
Environmental Monitoring and Safety Services .................. 4
Surveillance and Disease Reporting System ..................... 5
Health Education ....... . ...................................... 6
Manpower Needs ................................................ 7
The HSA Review Function ....................................... 7
Data Collection and Utilization ................................ 11
Sources of Information ........................................ 11
Developing an Industrial Profile ............................ .. 14
Problems in Developing a Meaningful Industrial Profile ........ 15
Summary and Conclusions ........................................ 17
References .............................. .. .............. ....... 18
Appendix A - Health Planning Statements ..... .................. . 20
Example 1 ... ........ . .............. . ......................... 20
Example 2 ......................... . ..... . ....... ............. 21
Example 3 .... ................ ......... ....................... 23
Example 4 ............................................. ....... 27
Example 5 .................................................... 31
Example 6 .................................................... 38
Appendix B — Clinical Aspects and Organizational Approaches .... 57
Appendix C - Selected Bibliography ............................. 73
Appendix D — Sample Industrial Profile Worksheets .............. 85
Appendix E - List of NIOSH and OSHA Resources .................. 94
NIOSH Consultants ............................................. 94
NIOSH Educational Resource Centers ............................ 96
OSHA Regional Offices ......................................... 98

iv

 

 

 

ACKNOWLEDGMENTS

The basic information used in this handbook was developed by the Harvard
School of Public Health under Contract Number 210-76—0190, for which
David H. Wegman, M.D., and Anthony Robbins, M.D., served as the
contractor's principal investigators and Marilyn K. Hutchison, M.D.,
served as NIOSH Project Officer.

The Bureau of Health Planning and Resources Development, Health
Resources Administration, DHEW, participated in the review of materials
and in the development of plans for utilization of the handbook.

 

 

 

 

ww— vnv w.

INTRODUCTION

This manual is designed to provide health systems agencies (HSA's) with
an approach to understanding and planning for the occupational safety
and health needs in their health service areas. In addition, it
provides a rationale and approach for integrating preventive,
diagnostic, therapeutic, and rehabilitative occupational safety and
health services with the non—occupational health services for workers
and their families. It contains suggestions on how to deal with
occupational safety and health problems within the context of the Health
Systems Agency's (HSA's) reaponsibilities under the law.

Occupational safety and health programs are intimately related to the
goals, purposes, and priorities of the Health Planning and Resources
Development Act (1), which stresses occupational health as follows: "In
providing health planning and resources development for its health
service area, a health systems agency shall ...assemble and analyze data
concerning ...occupational exposure factors affecting immediate and long
term health conditions."

Illness and injury caused by exposure to chemical, biological, or
physical agents and psychological risks in the workplace are major
factors in determining the health status of a community. The U.S.
Public Health Service has estimated that 3.7 million persons required
medical treatment during 1976 as a result of work related injuries (2).
The National Safety Council reports that in 1975 alone there were 12,600
deaths due to occupational injuries; an estimated 500,000 workers to
have develoPed occupational disease; and 8.7 million sustained injuries,
of which 2.2 million resulted in permanent or temporary disability (3).
A Federal interdepartmental task force estimated that as many as 100,000
excess deaths occur annually as a result of occupational disease (4).
Prevention of such illness and injury, and the coordination of the
delivery of occupational health services, can have a significant impact
through reduction of health care costs and improvement of the health of
residents in the health planning area.

The development and implementation of a comprehensive occupational
safety and health plan should address the following program elements:

1. Clinical services, including diagnostic emergency, and
rehabilitative services;

2. environmental monitoring and safety services;

3. surveillance system, including disease and injury reporting, and
recordkeeping;

4. health education;

 

 

 

5. manpower needs.

This handbook develops a health planning approach to occupational safety
and health, and presents suggestions for collection and utilization of
data for each of these program elements. Worksheets are provided to aid
area health planners in organizing pertinent information.

Strategies are developed for the prevention of adverse health effects,
for the control of occupational hazards, and for the evaluation of the
impact of occupational health and safety programs in health service
areas. The general procedures and strategies outlined in this handbook
are illustrative rather than prescriptive. The focus is on development
of planning goals and objectives, and implementation and evaluation of
effective program responses. It is anticipated that as health planners
gain experience in defining occupational safety and health problems and
control strategies on an area-wide basis, specific strategies will be
developed to meet local needs.

HSA efforts in planning and implementation of occupational safety and
health programs and services, which should be an integral part of the
health care delivery system, have the potential to produce both system
and agency benefits such as:

1. Improvement and maintenance of health status;

2. reduction of health care cost due to inappropriate utilization;

3. identification and clarification (for providers, labor, industry,
and the community) of issues and approaches to control hazardous

occupational exposures and deliver medical services; and

4. achievement of increased agency visibility, credibility, and
suppport from providers, labor, and industry.

 

AN HSA PLANNING APPROACH TO OCCUPATIONAL SAFETY AND HEALTH

Under the Act, Health Systems Agencies (HSA'S) will formulate goals,
objectives, and recommended actions (1), identify resource requirements
and establish priorities for implementation of programs that are
effective in injury and illness prevention, diagnosis, treatment, and
rehabilitation. This planning process should include consideration of
occupational safety and health services. These services are identified
as a component of each health—care—system, first-level service
categories (5) (community health promotion and protection, prevention
and detection, diagnosis and treatment, habilitation and rehabilitation,
maintenance, personal health care support, and health system enabling
services). As such, they will be subject to the agency review
procedures for project reviews, appropriateness reviews, reviews of the
use of certain federal funds, and utilization review. Occupational
safety and health service delivery, to be effective, also demands the
desirable health system characteristics of availability, accessibility,
acceptability, continuity, and quality. Therefore, the HSA should
include in its Health System Plan (HSP) a policy on the protection of
worker health and, through its Annual Implementation Plans (AIP's),
should include a plan for the implementation of appropriate health
system responses.

This chapter outlines specific occupational safety and health
considerations that could be addressed by HSP's and AIP's. Examples of
health planning statements, developed by HSA's in the first generation
of health system plans, are presented in Appendix A.

CLINICAL SERVICES

Clinical facilities and manpower are needed to provide the following
services:

1. Preplacement examinations.

2. Periodic examinations for workers exposed to certain
toxic substances or otherwise subject to increased health risks.

3. Diagnostic procedures and follow up examinations.

4. Laboratory services.

5. Worker's compensation evaluations.

6. Emergency and trauma services.

7. Short-term and long-term rehabilitation services for victims of
debilitating accidents and diseases.

8. Mental health services to deal with job related stress,

and substance abuse.

More detailed information on the range of clinical services that would
be responsive to occupational health and safety needs is presented in
Appendix B.

 

 

Various models for occupational health delivery systems have been
developed (6). Mechanisms range from contracts with local physicians to
in-plant clinics or comprehensive health maintenance organizations that
include occupational health speciality services. Sponsors include
corporations, unions, private practitioners, foundations for medical
care, independent medical organizations, and local and state
governments. Examples of delivery mechanisms are listed in Appendix B.

Occupational health and safety services to small businesses merit
special attention since most U.S. businesses employ 25 or fewer workers.
Large numbers of these workers are exposed to potentially hazardous
physical and chemical agents, and unsafe working conditions. Small
businesses rarely provide occupational safety and health services, and
employers and workers may not recognize the special health problems
created by exposures in the workplace. Emphasis on health system goals
that deal with occupational safety and health problems in small
businesses can have a significant impact in many planning areas.

ENVIRONMENTAL MONITORING AND SAFETY SERVICES

There is a clear relationship between occuptional health and community
health. Hazardous substances in the workplace often affect the
community by emission of gaseous or solid waste products through venting
or dumping, or by workers as hazard carriers e.g.(asbestos in work
garments). Since the worker receives the greatest exposures, worker
health can serve as an "early warning system” for community health.

Work environments should be monitored to assure that Federal exposure
limits are not exceeded, and that safe work practices are fOllowed.
This is required by law for the more than 400 substances regulated by
the Occupational Safety and Health Administration (OSHA). Employers
using many of these materials must monitor the work environment to
assure compliance with permissible exposure levels. Should
environmental levels exceed the standards, a variety of controls are
indicated. These include engineering controls such as isolation or
ventilation of sources, administrative controls such as substitution of
less hazardous materials or rotation of workers to reduce individual
exposure to within acceptable levels, and use of personal protective
devices such as respirators for protection from exposure to dusts,
vapors, or gases.

Environmental monitoring and safety services are generally provided by
industrial hygienists and safety engineers working in plants, or with
agencies responsible for environmental protection or occupational safety
and health. HSA's should identify resource and manpower needs for these
services in their planning areas, and include this information in their
planning statements. They can evaluate and encourage existing agencies
providing services and promote the delivery of services through
facilities that have been established to meet clinical occupational
safety and health needs. This could include promotion of a working

 

relationship between the clinical services providers and local providers
of environmental services such as local health departments and local
representatives of state and Federal environmental regulatory agencies.

SURVEILLANCE AND DISEASE REPORTING SYSTEM

Surveillance is the key to the control of occupational disease. Many
occupational diseases manifest themselves only over a long duration of
time. Additionally, chronic symptoms may be incorrectly diagnosed
largely due to lack of information about worker exposures to toxic
agents. For these reasons, surveillance programs which collect the most
accurate medical data available are essential for diagnosing and
controlling diseases associated with specific occupational exposures.
HSA's should identify the need for such surveillance programs, as well
as alert community agencies such as health departments that should be
responsible for these programs. By promoting the collection of these
data, the HSA can help develop a valuable information base for
formulating goals and objectives for their HSP's and AIP's.

A coordinated surveillance system should identify known problems in
order to control exposure, permit treatment of those affected, and lead
to the prevention of other workers being exposed to the hazard.
Surveillance programs may also identify new or previously unsuspected
health hazards, so that control measures may be implemented as early as
possible (7).

A system should be developed to assist health providers in correctly
diagnosing, recording, and reporting all work-related diseases. The
program should be designed to develop an awareness within the medical
community of the prevention benefits to be derived from a standard
reporting system for occupational diseases. The system should consider
reportable disease categories, reporting agencies, reporting officials,
methods of reporting, and cooperative efforts for standardization.

For example, summary data reported to agencies such as local health
departments could be collected and evaluated on a regional basis by
HSA's, thus giving a large enough response to identify trends of
occupational disease in the region. Reporting agencies could include
hospitals, clinics, emergency rooms, nursing homes and extended care
facilities, health maintenance organizations, and health departments.
Reporting officials may include physicians, nurses, administrators of
health care institutions, and OSHA compliance officers. Reporting by
management, labor organizations, and employees can also be encouraged.

An important factor in effective control of occupational safety and
health problems will be reliable data resulting from surveillance and
disease reporting systems. Additionally, the basic measurement of the
magnitude and potential impact of problems will better allow for the
allocation of resources between occupational health and competing
programs. If of sufficient detail, the surveillance and disease

5

 

reporting system can provide the foundation for evaluating the success
of occupational safety and health control programs (7).

HSA's have an essential role in coordinating data gathering networks
relating to surveillance systems. HSA's can be effective in influencing
medical care practitioners and institutions which have a major role in
the surveillance of occuptional disease.

Tools for development and implementation of comprehensive surveillance
systems are discussed in greater detail in the following chapter, "Data
Collection and Utilization."

HEALTH EDUCATION

Worker health education programs are needed to make employees aware of
occupational hazards and ways to avoid illness and injury. Although
this is a basic reaponsibility of employers, HSA's could play a role by
promoting these programs and perhaps distributing information and
materials throughout their areas. For example, some Region VI HSA's
have capitalized on a readily available implementation activity by
coordinating employer and employee health education courses available
through "Department of Labor (DOL)" funds. This program is coordinated
by the American Industrial Hygiene Association (AIHA) under contract
with the DOL. The training is provided by selected colleges and
universities.

The "New Directions Program", is another DOL funded activity which will
provide grants to unions, educational institutions, and others for the
development and provision of short term training courses for employees
and employers. Such programs conducted through the place of employment
also offer the opportunity for broader health education whereby the
employee could be informed on such subjects as proper nutrition,
exercise, and other healthful changes in lifestyle.

The HSA should encourage involvement of those health education agencies
that deal with mental health and substance abuse. The combination of
work and personal stresses can lead to a state of mental fatigue,
boredom, or some other less than optimal mental condition; and substance
abuse (alcohol, drugs, etc) is a recognized problem in the work
environment. The HSA can play a role in developing appropriate
workplace programs by bringing together industry and local substance
abuse and mental health agencies. The present HSA activity with some
modification can become compatible with and complementary to health care
institution or employer based programs for workers. This is possible
without great effort because many of the existing ESP and ATP goals,
objectives, and agency activities are already related in varying degrees
to a comprehensive and coordinated occupational safety and health
program. (See also Appendix B, Organizational Approaches)

 

 

MANPOWER NEEDS

The professional force specially trained to address occupational safety
and health problems is comprised of occupational physicians,
occupational nurses, industrial hygienists, safety engineers, and
others. The majority of physicians and nurses in the field are not
board certified by their respective professional specialty boards,
although many have taken formal post-degree training in occupational
health. Industrial hygienists are concerned with assessing and
controlling workplace hazards and toxic agents such as dusts, gases,
vapors, and fumes; physical agents such as noise, heat, and radiation;
biological hazards such as enzymes; and job related stress such as
monotony. The major functions of safety engineers include development
of accident prevention, loss control procedures, and measurement and
evaluation of the effectiveness of accident prevention and loss control
systems.

Area health plans should describe available manpower resources in these
professional categories, project (health service area) needs for the
period covered by the plans, and identify sources for these professional
services. NIOSH, a major resource to which HSA's may turn, has begun to
address manpower shortages through the development of Educational
Resource Centers, with a goal of sponsoring at least one in each of the
ten regions of the Department of Health, Education, and Welfare. These
centers are designed to help meet both national and regional needs by
full-time, part-time, continuing, and other educational programs
addressing each of the four professional groups listed above. These
centers will attempt to evaluate the needs in their region and create
progra 3 designed to fill current gaps and to meet projected needs.
HSA's are in an ideal position to call upon, as well as assist, these
centers in identifying regional requirements and focusing on special
manpower distribution needs. See Appendix E for the name and address of
the Educational Resource Centers by region.

An additional problem area is that the family practitioner is generally
not trained to correlate disease with the patient's occupation. Through
planning activities, programs can be encouraged in cooperation with the
NIOSH funded Educational Resource Center, the local medical society,
medical schools, etc., to provide seminars and continuing education
courses for area physicians.

THE HSA REVIEW FUNCTION

The review of health system changes and existing programs by HSA's can
be an effective implementation tool and method of integrating
occupational safety and health programs and services into the health
care delivery system.

Project review procedures, criteria, and guidance on the development of
additional criteria are provided in PL 93-641 (1). This Act 1) states that
health services to be offered in or through a health care facility or
health maintenance organization are subject to review, 2) requires the
adoption of procedures and review criteria prior to review, and 3)
requires the utilization, as appropriate, of specific criteria for the
reviews.

In conducting reviews of proposed or existing health services, each HSA
is mandated to follow procedures and apply criteria developed and
published by the agency. Criteria appropriate for the review of
occupational safety and health program proposals and existing services
are needed. They can be developed using local expertise or be adapted
from criteria recommended by others, possibly NIOSH. The criteria
should address community medical and environmental health resources that
will be needed, especially to provide services to small and medium
businesses which lack in-house medical and environmental control
capabilities. Appropriate planning is also necessary to assure
continuity between occupational and non—occupational health care
services. In addition, development of occupational safety and health
review criteria will, by itself, stimulate interest in occupational
safety and health services that have the potential for significant
impact on health status and on the reduction of inappropriate and
inefficient health care utilization.

The specific criteria are listed for use by HSA's and the criteria
adopted "may vary according to the purpose for which a particular review
is being conducted or the type of health service reviewed." (8) The need
for proposed services is probably the most critical element in the
review process, and predecessors to the HSA's had the most success with
criteria for need based on specific services and criteria for desirable
standards for level of service (9). The need for a service should also
be based on the desirable health system characteristics of
accessibility, continuity, acceptability, and quality that were
enumerated in the Act.

In addition to assuring that review criteria are based on requirements
of PL 93-641, and Section 122, Title 42, CFR, the experience of
predecessors (10) to the HSA's should be used to provide a sound basis
for developing specific criteria concerning occupational safety and
health services.

Two additional developmental aids for establishing review criteria for
occupational health services have been suggested by Webb (11) and Ayer (12).

Webb (11) describes a basic model occupational health
program and an objective evaluation and scoring scheme.
The model is based on guidelines and suggested
components proposed by the Council on Occupational Health

8

 

of the American Medical Association, the Occupational
Health Institute, and by Jean Spencer Felton, M.D.

Ayer et a1. (12) discusses improving performance of
such programs through the development of standards.
Standards, interpretations, and audit criteria for
occupational health services, including medical,
nursing, industrial hygiene, and health physics, are
provided.

Based on the studies made for this report the following is a list of
suggested basic occupational safety and health program and service
criteria. They may require further development based upon specific data
collected by HSA's and local expertise.

Provides preventive, diagnostic, treatment, and rehabilitation services.
Provides medical and environmental surveillance and control.
Provides worker health education.
Provides an adequate supply of trained occupational safety and health
manpower - nurses, physicians, industrial hygienists,
safety engineers, and others.
5. Provides coordination with available services at the
workplace and in the community, and with local,
state, and Federal activities and programs.
6. Provides medical care at the workplace, including first aid
and emergency medical services.
7. Provides services that are mandated by the Occupational Safety
and Health Act; e.g., medical, environmental, and educational.
8. Provides auxillary services to support the occupational safety
and health programs such as laboratory services.
9. Provides for input by labor, industry, and medical providers.
10. Provides services that are acceptable, accessible, providing
continuity, of high quality, and available at a reasonable cost.

L‘UJNH
o ..

Explicit review criteria for occupational health services,Suggested by
NIOSH,should address the following items regarding program
characteristics and specific services. These are suggested criteria
which require further development based upon specific data collected by
the HSA's and local expertise.

1. Provides medical and environmental services that conform to
existing occupational health and safety laws.
2. Provides the following specific services:

 

 

. preplacement and transfer medical examination

periodic examinations as appropriate
health and safety education

care of illness and injury at work

health counseling and appropriate referral
environmental control and surveillance
preventive health services

1. immunizations

2. substance abuse programs
rehabilitation services

coordination of services with other related
community and industry programs.

 

DATA COLLECTION AND UTILIZATION

Information is needed that addresses the following questions:

1. What health problems would be anticipated from industrial
exposures in the planning area?

2. Are these health problems indeed present?

3. If so, what health services are available to handle them?

4. In what kinds of activities can the HSA involve itself that would
reduce these problems through prevention or early detection, or
which would facilitate their treatment?

SOURCES OF INFORMATION

A principal source of evaluated occupational safety and health
information and data is the National Institute for Occupational Safety
and Health (NIOSH), an applied research organization in the Department
of Health, Education, and Welfare. It has offices in each of the ten
DHEW regions throughout the country. The NIOSH regional representatives
will be able to provide the following information:

1. National Universe Facility File - NIOSH recognizes the need to
acquire and utilize accurate and comprehensive demographic information
on the full range of American workplaces in order to develop the
intelligence necessary to carry out surveillance and field study
activities. To this end, the Dun & Bradstreet computer—based listing of
the national universe of facilities has been purchased and is currently
finding wide application in various NIOSH activities. It is possible to
extract facility data by geographic designation, (county, state, SMSA or
zip code) by SIC code, (2, 3, or 4—digit), or any other file data
element. The file currently contains data on nearly 4 million
establishments. The file has been organized to facilitate data
retrieval by 4—digit SIC code. Any data requests should therefore
specify the 1972 SIC code relevant to the inquiry.

2. The National Occupational Hazard Survey - NIOSH conducted the
National Occupational Hazard Survey (NOHS) from 1972 through 1974 to
determine the extent of the exposure of the American worker to possibly
hazardous chemical and physical agents in the working environment. From
the survey's results NIOSH compiled a comprehensive data base, outlining
by industry, occupation, and hazard the estimated number and percentage
of workers in the United States exposed to such agents. The NOHS data
base provides a thorough and reliable study on the potentially hazardous
chemical and physical agents found in the U.S. working environment.
NIOSH itself uses the survey data to determine research priorities, to
measure and forecast occupational health trends, and to develop guides
which describe health hazards typically associated with a particular
industry or occupation. Moreover, NIOSH furnishes NOHS data to any
individuals requesting information on occupational health matters. The

11

data base lends itself to direct problem solving action by trade
associations, plant management personnel, unions, and individual
employers. These capabilities make the NOHS a unique and valuable
resource for all individuals concerned with occupational health.

3. Recommended Health Standards - NIOSH is responsible for recommending
standards for occupational exposure to hazardous agents. Some 80
criteria documents have been transmitted to OSHA for consideration for
rulemaking. Subjects of these documents include physical agents,
chemical substances, related groups of chemicals, and industrial
processes. The criteria documents include recommendations for medical
surveillance, environmental limits, engineering controls, and work
practices.

4. Occupational Health Guidelines for Chemical Hazards — These
Guidelines contain information and recommendations intended to assist
small businessmen, union representatives, and employees, as well as
occupational safety and health professionals, in designing and
implementing an occupational health program. The technical data have
been compiled into a readily accessible reference document and training
tool which will aid in the assessment and control of hazards under
widely varying operating conditions. The data will be published by
NIOSH as individual "Guidelines" for each of 380 chemicals.
Supplementary guidelines also published by NIOSH will provide specific
information on medical surveillance, respiratory protection, personal
protection, and sanitation.

5. Health Hazard Evaluations — NIOSH conducts specific evaluations
based on reports of health problems at a specific site. These are
specific to one plant and are designed to determine whether a health
hazard exists. Results of these evaluations should be helpful in
planning for other similar plants.

6. Industrywide Studies — These studies are epidemiologic
investigations of health hazards associated with selected industries.
These studies will show whether or not there is excess injury or ill-
health associated with employment in specific industries.

7. Technical Reports — The results of scientific studies supported by
NIOSH in the areas of toxicology, industrial hygiene, epidemiology,
safety, behavioral science, control technology, and analytical chemistry
are published as technical reports. The NIOSH regional office will have
lists of available reports, and in most cases copies for distribution.

8. Other Technical Information from Scientific Journals, Textbooks,
etc.

OSHA is represented locally by an area office, a state program, or both.
The local OSHA office should be able to provide the following
information:

12

 

 

1. Special Emphasis rrograms - A review of findings under this
program should identify the level of progress being made in the
planning area on problems in industries which have been designated
for special emphasis.

2. Occupational Health Inspections and Enforcement — A review of

the results of inspections for compliance with Federal or state standards
should identify problems which have been found in the planning area,

and should indicate the effectiveness of efforts toward correcting

the problems.

Trade unions can also be a useful source of information. The State
Labor Council, or the regional organization representing non-AFL-CIO
unions, will be able to provide information on the occupational health
efforts of the unions in a particular industry.

Contact with area employers may provide information on local programs in
occupational safety and health. Questions to employers might include:

1. What kind of occupational health services are available for employees?

2. Where is industrial hygiene advice obtained?

3. Are there any special occupational health problems which they are
having difficulty solving and which might benefit from a cooperative
effort with the HSA?

A possible source of local data is the hospital discharge summary
synopses abstracted for Utilization Review. These provide information
on demographic characteristics of the patients and discharge diagnosis.
The HSA might explore the possibility for an area-wide or selected
subsection review of discharge summary disease patterns to correlate
employment or industry with diagnosis. Many examples exist for
correlating employment with disease at the state, regional or HSA level
for example: 1. HSA's could encourage those selected hospitals which
report congenital disorders to the Center for Disease Control to work
with agencies such as state health departments to code occupations and
work histories for parents and to look for trends. 2. Additionally,
local coroner offices may have information on occupationally related
death or trauma.

State Workers' Compensation agencies may have data on workplaces that
are frequently the source of claims. The State Insurance Commission may
be able to provide information on "uninsurable" industries. In
addition, third party payers may be able to provide information
regarding the utilization rates of industrial subscribers.

A bibliography of pertinent references and data sources is provided in
Appendix C.

13

DEVELOPING AN INDUSTRIAL PROFILE

An industrial profile is a grouping of information which presents area
employment patterns, an analysis of hazardous exposures and related
diseases associated with industries in the planning area, and an
assessment of the manner in which the regulatory environmental control
and the medical care system are detecting and treating identified
problems. The HSA should develop an industrial profile which identifies
both special problems existing in area industries, and industries where
hazards are severe or numerous but are potentially controllable. Two
data sources are essential for developing an industrial profile for a
health service area.

The Standard Industrial Classification (SIC) taxonomy (13) is used to
classify places of employment by major type of activity. Statistical
data collected by Federal agencies, state agencies, and trade
associations are usually assembled using these categories. Any
industrial establishment can be classified. The classification is
three—tiered. A two—digit classification represents the broadest
category, e.g., manufacturing. Within each two-digit classification are
three- and four—digit refinements. The three-digit classifications tend
to represent specific functional divisions within the broader category.
The four-digit classification usually gives a more detailed breakdown of
the industrial activity.

A special compilation of data gathered by the U.S. Department of
Commerce (14) lists the number of establishments in each SIC, by county,
as well as the number of production workers and the total number of
employees for each group. Agricultural totals are incomplete in that
they are tabulated as agricultural services only. In planning areas
where agriculture is an important industry, data should be supplemented
with information from the appropriate agricultural extension service
unit or from the Division of Employment Security or a similar agency of
the state government.

Sample worksheets that may be useful for presentation of pertinent data
are provided in Appendix D.

The kinds of information that might be included in an industrial profile
are as follows:

1. The number of establishments in a planning area.
2. The total number of people employed in the industry.
3. The type and significance of the hazards associated with the industry,
their associated diseases, and available screening methods and controls.
4. Identification of special high risk groups, such as
working women of child-bearing age and handicapped workers.
5. The proportion of the employees in an industry who actually
hold jobs where the specific hazards are present.
6. Occupational safety and health problems that have occurred.

14

7. The amount of lost time that occurs, causes of lost time,
and identification of groups principally affected (age,
sex, race, etc).

8. The nature and extent of occupational safety and health services
available to the industry.

9. Identification of an industry by NIOSH, OSHA, employees, or a union as
being particularly hazardous.

10. Identification of major employers, trade associations, and
others whose relationship to the industry would provide a
vehicle for implementation of occupational safety and
health strategies.

11. Current occupational safety and health activities in the area.

PROBLEMS IN DEVELOPING A MEANINGFUL INDUSTRIAL PROFILE

Although the industrial profile is based on industrial categories,
occupational categories which may cross industry lines determine the
type and extent of exposure a worker experiences. What may often seem
like minor distinctions can represent an enormous difference in
exposure. For example, one would not expect a bookkeeper in a steel
mill to be subjected to the same exposures as a coke oven worker in the
same plant. However, even among coke oven workers, different disease
patterns are discernible according to the type of job activity and the
place it is performed (15).

It would not be unlikely for two plants with identical occupational
distributions to show very different disease patterns. Not considering
the confounding effects caused by demographic differences among workers,
there remain intra—industry differences to consider. Industrial
processes and materials vary from plant to plant. Likewise, equipment,
attention paid to the handling of the materials, the design of the
plant, substitution of less hazardous materials, and the availability of
protective equipment is not uniform throughout industry.

This discussion of occupational safety and health deals with groups
covered by the Occupational Safety and Health Act and OSHA regulations
and the industrial SIC's. It should be recognized, however, that in
many states public employees, including employees of many hospitals, are
not covered by the Act. Hospitals, a workplace with which HSA's are
familiar, also need effective employee safety and health services (16).
These services should be planned for and implemented.

The industrial profile will help to make it possible to select specific
SIC's to be emphasized in the HSP. The number and type of SIC's
selected will depend on several important characteristics of the health
service area.

15

The more heavily industrialized an area, the greater the impact of
emergency situations and large scale industrial safety and health
problems on residents of the area. These same conditions are more
likely to be an identifiable component in the status of general

community health and therefore should be considered in the organization ‘

of a health delivery system. In effect, certain HSA's can benefit from
planning around occupational safety and health problems more than
others. In all cases, covering occupational safety and health
requirements should complement the goals and methods set forth in other
sections of the Health Systems Plan and the Annual Implementation Plan.

Another consideration is the special resources in the area. For
example, in cases where the private sector is paying sufficient
attention to the associated occupational safety and health problems, the
HSA might want to develop an approach which emphasizes unattended
industries, e.g. small and medium businesses.

In the final analysis, selection of occupational health problems for
special attention must be determined within the context of the entire
Health Systems Plan. In selecting particular SIC's, certain
occupational safety and health problems are chosen also. What remains
is the development of a local approach consistent with other aspects of
the HS? to control occupational safety and health problems to improve
the health of area residents.

16

 

 

SUMMARY AND CONCLUSIONS

This handbook presents issues, problems, approaches, and recommended
actions that an HSA should consider in developing ESP and AIP goals,
objectives, and recommended actions for meeting the occupational safety
and health needs of employees and employers in the health service area.
It discusses the range of clinical and environmental services of a
comprehensive program. The need for and value of an effective
surveillance and disease reporting system that identifies diseases (both
acute and those with long latency periods) and the program components of
health education and manpower development are presented.

The relationship of the agency review functions to the delivery of
occupational health services and the need for developing review criteria
are discussed. In addition, data collection and utilization including
sources of information, methods of summarizing and displaying the
information (the industrial profile), and utilization of the information
are presented. The industrial profile is a necessary step for each HSA
due to variability of health service areas.

The material, rationale, and method presented in this handbook, as
supported by the appendices, should assist HSA's in efforts to develop
effective and comprehensive occupational safety and health programs for
workers and, at the same time, provide a valuable and needed service to
area employers. The HSA has a mandated role, an identified approach,
and the opportunity to effectively implement occupational safety and
health services for the benefit of workers, their employers, and the
community.

Existing implementation efforts are, while not comprehensive and often
lacking coordination, impressive. Future efforts that benefit from
local experience, expertise, and HSA encouragement and coordination,
will achieve greater success in developing occupational safety and
health programs that improve worker health status as an integrated
component of an improved health care delivery system.

17

 

10.

11.

12.

References

PL 93-641. National Health Planning and Resources Development Act,
1974. Section 1513, and Section 1532. U.S. Government Printing Office,
Washington, D.C.

Unpublished data. National Health Interview Survey, National
Center for Health Statistics, Public Health Service, HRA,
Rockville, Maryland 20852, 1976.

Accident Facts 1976. National Safety Council, Chicago, Illinois.

The President's Report on Occupational Safety and Health.
U.S. Government Printing Office, washington, D.C. 1972, p. 111.
Office, 1972), p. 111.

A Taxonomy of the Health System Appropriate for Plan
Development. DHEW Publication No. (HRA) 77-14534. May, 1977.

Egdahl, R.H. ed., Background Papers on Industry's Changing
Role in Health Care Delivery, Springer Series on Industry
and Health Care, Volume 3, Springer - Verlag, New York, 1977.

Rose V.E., Reliability and Utilization of Occupational
Disease Data, National Institute for Occupational Safety and
Health, Publication No. 77-189, Cincinnati, Ohio, 1977.

Code of Federal Regulations, Title 42, Parts 122.304, 305, 308.
U.S. Government Printing Office, Washington, D.C., 20402.

Developing Complying Review Programs: PL 93—641, New Institutional
Health Services/Certificate of Need. Midwest Center for
Health Planning, HEW Region V, Chicago, Illinois, 1977.

Project Review: A Guide to the Reviewing Process in Health
Care Proposals. American Association for Comprehensive Health
Planning, May, 1975.

Webb, Samuel B. Jr., Objective Criteria for Evaluating
Occupational Health Programs American Journal of Public
Health, Vol. 65, No. 1, January, 1975.

Ayer, H.E., Emmett, et al., Standards, Interpretations,

and Audit Criteria for Performance of Occupational Health
Programs, Contractor's Report to National Institute for
Occupational Safety and Health (NIOSH) July, 1975.
Occupational Health Institute, Contract No. (HSM) 99-72-109,
Chicago.

18

 

 

14.

15.

16.

Standard Industrial Classification Manual. Bureau
of the Budget, Government Printing Office,
Washington, D.C., 1972.

County Business Patterns, Social and Economic Statistics
Administration, U.S. Department of Commerce, Superintendent of
Documents, U.S. Government Printing Office, Washington, D.C., 40402.

Lloyd, J.W., Long-term Mortality Study of Steelworkers:
Respiratory Cancer in Coke Plant Workers. J. Occupational
Medicine, 13(2):56, 1971.

The Hospital Occupational Health Service Study:

Highlights of the NIOSH Hospital Health Service
Study. NIOSH, April, 1976.

19

 

 

APPENDIX A

EXAMPLES*OF HEALTH PLANNING STATEMENTS FOR OCCUPATIONAL
SAFETY AND HEALTH

The following are examples from the occupational health sections of various
Health Systems Plans from around the U.S., as noted. These examples
are based on the first generation of HSP's and AIP's.

Example 1. (Based on the HSP and implementation actiyities
of the Health Planning Council, Inc. of Madison.

Wisconsin 1978 (1).)

Priority I Goal

Employee Health Promotion Programs implemented by at least

25 percent of all employers with 30 or more employees in
Southern Wisconsin. (In 1977, there were no health promotion
programs in the area.)

HSP Objective

By 1981, employee health promotion programs implemented
at least 5 percent of all employers with 30 or more
employees in Southern Wisconsin (30 programs).

AIP Objective

By June, 1979, three working demonstrations of employee
health promotion programs in Southern Wisconsin.

HSP Priority I Goals

At least 4 of the 10 largest health insurers offering policies with
financial incentives for good health practices.

Prospective medicine (health risk appraisal) incorporated
into regular practice of at least eight medical clinics.

More than 95 percent of children immunized against communicable
disease (In 1976, 60 percent were fully immunized.)

One hundred percent of school districts providing health education
programs meeting minimum requirements of Wisconsin Statutes.

School health programs which meet the Department of Public
Instruction's guidelines provided by at least 25 percent
of school districts.

*These examples are excerpted from current protocols of various
existing organizations as identified; and the opinions, recommendations,

and conclusions expressed therein are not necessarily those of the NIOSH.

20

 

 

HSP Priority II Goals

Establishment of at least 1 Wellness Resource Center in
Southern Wisconsin.

Example 2 (fiased on the Annual Implementation Plan for the People
of New York City, 1978,)

 

OBJECTIVE

To achieve, as rapidly as possible, a quality of environment in the workplace
and in the community at large that will protect citizens from disease and
disability and promote the enjoyment of good health.

Recommended Action

1. HSA will maintain surveillance and provide comment on proposed Federal,
state, and municipal budgets, and will examine funding levels
recommended in proposed legislation in order to assure, to the greatest
degree practicable, levels of funding that will enable control, planning,
and enforcement agencies to achieve environmental and occupational health
and safety goals.

2. HSA will meet with legislators, union leaders, public officials, and
affected constituents, will evaluate legislation, and testify where
appropriate to advocate needed environmental and occupational health
and safety legislation and programs.

3. HSA will work to establish common goals and linkages between the
environmental community and health leaders as represented on HSA
boards, leading to mutually supportive action on programs and
legislation.

4. District and central Project Review Committees will be encouraged to
examine the relevant activities of institutions coming before them as
to their compliance with occupational health and safety standards.

5. HSA will review available research on the relationships between

pollution and incidence of disease, and will recommend that additional
studies be undertaken by appropriate parties where needed.

Resources Reguired
No additional resources are required.
OBJECTIVE

To develop a system for the monitoring and effective regulation of toxic
substances in the workplace prior to entry into the environment.

21

 

 

Recommended Action

1. HSA will monitor progress under the Occupational Safety and Health
Act of 1970 (OSHA) and the Toxic Substances Control Act of 1976 (TOSCA),
as well as programs which are the responsibility of the National
Institute for Occupational Safety and Health (NIOSH).

2. HSA will advocate adoption by the legislature of a law bringing
OSHA coverage to public employees now specifically exempted from
coverage.

3. OSHA should commence development of an inventory of workplaces in
which known hazardous substances are handled, or in which hazardous
conditions are common to the industry. Such workplaces should be
inspected at least annually.

Resources Required

1. Appropriate budget levels are required for the Occupational Safety
and Health Administration of the U.S. Department of Labor and its
regional enforcement personnel, U.S. EPA and its regional offices,
and NIOSH within HEW.

2. No additional resources are required for Action 2 until passage of
legislation.

OBJECTIVE

To determine significant correlations between occupation and premature
mortality and disability as a preface to seeking reduction of relevant
exposures.

Recommended Action
1. HSA will work with the State Department of Health to examine the

feasibility of amending the State Hospital Code to require reporting
of occupational history on medical records.

 

2. HSA will design and seek or provide funding for the conduct of a
study to detect relationships between occupation and premature death
and disability.

Resources Reguired

1. No additional resources are required for examination of the State
Health Code.

2. Costs of the study will depend on final determination of its scope.

22

 

OBJECTIVE

To assure that all personnel who operate and/or supervise radiological
or nuclear medicine devices should be appropriately certified.

(HSP Chapter V, Goal 13, p. 314)
Recommended Action

A recognized board of certification should be identified and standards
established so that all personnel who operate or supervise radiological
or nuclear medicine devices may be certified by 1980.

Resources Required

No additional resources are required.

Example 3 (Based upon a draft plan by the Southeastern Wisconsin
Health Systems agency, Inc.)

Goal

Adequate services for work environment monitoring and employee health
promotion should be available within the area.

Rationale: Based on the analysis of available information and the
expertise of professionals involved in the occupational safety
and health field in the area, there appears to be a consensus
that current practices of work environment monitoring and
employee health screening are often inadequate, there are too
few programs directed at employee health maintenance and
professional resources are insufficient.

Private sector consultative services, which appear to be
sufficiently available, are underutilized largely due to the
cost of such services to the employer. Financial incentives
(e.g. tax breaks) for employers to promote the use of such
services are lacking.

In addition, there is general consensus that manpower resources
provided through State and local governmental agencies for
consultation to private business and industry are insufficient
to meet present demand. Deficiencies are perceived to exist
regarding the number of industrial hygiene and occupational
health nursing personnel available for consultation within
local and State governmental agencies -— particularly to the
small employer. An in—depth investigation of unmet demands

and requirements for additional personnel has not been
undertaken.

23

 

 

Objective: By 1979 the characteristics of work environment monitoring
and employee health screening practices in the area should
be assessed, including the adequacy of professional manpower
to provide such services.

Recommended Actions and Resource Requirements

A study of work environment monitoring and employee group health screening
practices in the area should be undertaken to determine the nature and the
adequacy of existing practices, and to determine the characteristics and the
adequacy of the manpower currently providing such services. In addition,

the study should determine the need for the further development of industrial
hygiene and occupational health nursing consultation services provided in both
the private and public sectors. Specific needs for the development of con—
sultative services should be documented and appropriate recommendations made.
Barriers to the use of private consultative services should be explored, as
well as the use of specific incentives which would promote their use more
widely.

Such studies should be undertaken jointly by local area organizations involved
in occupational safety and health prevention activities with the assistance
of the HSA. Such organizations could include the following:

— State Medical College, Department of Preventive Medicine.

- Local area universities, colleges, and technical schools.

— Local area manufacturing associations.

— Organized labor,

— Appropriate governmental agencies, among which could include: City
Health Department, and other local health departments as appropriate;
State Division of Health, Occupational Health Section; OSHA.

- Workers' Compensation insurance carriers.

- Local medical societies.

Goal

Adequate resources should be available to meet the needs for occupational
safety and health education at all levels in the area.

Rationale: A lack of knowledge exists regarding the nature and scope
of existing occupational safety and health educational
resources in the area. Such lack of knowledge results in
underutilization of programs by professional occupational
safety and health personnel, business and industry, labor
and the general public.

Objective: By 1979 an analysis of all existing occupational safety and
health education resources in the area should be completed.

24

 

 

Recommended Action and Resource Requirements

An inventory of all occupational safety and health educational resources

in the area should be conducted in order to accumulate descriptive

information regarding the characteristics of current occupational safety

and health educational programs. Such resources inventory should include

(1) basic and continuing education programs for all occupational safety

and health personnel, including program description, entrance requirements,
fees, degree(s) granted, and current enrollment and program demand; (2) manage-
ment seminars/conferences; (3) conferences for plant supervisors and labor
representatives; and (4) resources for general public education.

At a minimum, the completed resources inventory should be published and
disseminated to all providers of basic and continuing education in the
region, professional associations, manufacturing associations, insurance
carriers, and labor unions.

Such inventory of educational resources should be conducted under the
sponsorship of the HSA. Financing and manpower resources would be
sufficient to conduct the resources inventory. Publications and
dissemination of the accumulated information would require funding from
other sources, which could include local manufacturing associations and
labor councils. The amount of funding required would be largely dependent
upon the scope of distribution desired.

Sub-Goal: Adequate and quality professional occupational safety and
health education should be available in the area.

Rationale: A lack of coordination exists among providers of professional
occupational safety and health education in the area.

With limited resources for providing professional occupational
safety and health education evident in southeastern Wisconsin,
the capabilities for providing high quality, specialized
programs for individuals seeking professional careers in the
occupational safety and health field could potentially be
further strengthened through joint program efforts between
educational providers.

Objective: By 1980 an assessment of the need for, and desire to form an
educational resource consortium among universities, colleges, and
technical schools providing basic education for occupational
safety and health professionals in the area should be conducted.

Recommended Action and Resource Requirements
A feasibility study should be conducted to determine the desire among

educational institutions in the area to form an occupational safety and
health educational resource consortium. Such a study should identify specfic

25

 

 

needs for program development, specific functions of a consortium, and
financial commitments of interested institutions.

Objective: By 1979 additional needs for occupational health education
within schools of nursing in the State should be determined.

Recommended Action and Resource Requirements

The current Statewide Study for Nursing and Nursing Education should include
in its investigation the extent of the need for the development of occupational
health nursing curricula through the State and particularly within the area.

Objective: By 1979 the State university system should strengthen the
development of an occupational health nursing program within
the School of Nursing.

Recommended Action and Resource Requirements

While the current Statewide Study for Nursing and Nursing Education is
intended to determine the extent of needs for future nursing education
program development, the immediate need has been identified in the area
and the School of Nursing is prepared to provide a Masters-level
occupational health nursing program.

It is recommended that the State university system give immediate
consideration to the initiation of such a program in subsequent budget
allocations.

Goal

Adequate data should be available to describe the nature and extent of
occupational morbidity and mortality occurring in the area.

Rationale: Occupational morbidity and mortality data currently
available for the area is inadequate for defining specific
occupational health problems. Although the Worker's
Compensation reporting system currently provides the best
source of information to describe the more obvious
occupational morbidity and mortality conditions, it is
deficient as a data source to adequately describe the nature
and scope of occupational illnesses.

Objective: By 1979 an investigation of the means for improving State
reporting of occupational injuries and illnesses should be
completed and recommendations made to the appropriate State
agencies.

26

 

 

Recommended Action and Resource Requirements

HSA's throughout the State should jointly determine the existing deficiencies

in available data in describing the nature of occupational illness and

injury occurrences at the local area level and formulate recommendations

for changes which should occur in the present Worker's Compensation data
collection system. Such investigation should include consideration of

the size of industry and the type of occupational illness (ICDA code) as specific
data items which should be included in current reporting mechanisms.

The investigation should be carried out by a subcommittee of the State

Data Coordination Committee, with representation from local HSA's, the
Department of Industry, Labor and Human Relations, expertise in occupational
health epidemiology, and other organizations as appropriate.

Objective: By 1979 it should be recommended to each major industry group
in the area that joint employee-management studies be made of
the morbidity and mortality of the industries in order to
identify specific trends, and which would indicate the needs
for the development of specific preventive action and health
promotion strategies.

Recommended Action and Resource Requirements

The Worker's Compensation Council should investigate the feasibility of
industry groups conducting such study efforts and should promote such
undertakings, where deemed feasible, in order to more clearly define the
nature of occupational illnesses occurring in the area and provide a
substantial data base for the allocation of preventive services.

Example 4. (Based upon the approved plan by Northwest Oregon
Health Systems Agency, 1978.)

OCCUPATIONAL HEALTH
Introduction

Determinants of occupational health are complex and difficult to define.
How can one separate the working individual from the home environment,
the recreational environment, and the occupational environment?
Individual attitudes and behavior of the worker are other important
factors to be considered. For example, smoking, alcohol consumption,
and use of drugs are modes of behavior which can adversely affect
health, especially of the worker who is exposed to chemicals and toxins
in the work environment. The worker is also exposed to chemicals and
toxins through air pollution as well as through chemicals used at home
such as cleaning and garden products. The exposure to so many different
degrees of chemicals and toxins illustrates the problem with defining
determinants of occupational health. It also illustrates the futility

27

 

 

of trying to monitor the effects of these substances in the place of
employment without monitoring the effects of substances on the worker
outside of the place of employment.

Problem Description

There are enough laws in the state to protect the health of the workers.
Many date back to 1915. The main problem is that there has never been
enough money available from industry or from the taxpayers to implement
and enforce laws that exist. There is another problem of ill—prepared
manpower to administer and implement these laws. Incentives are lacking
to persuade employers to invest money and time in employee health
promotion programs. A clean, safe working environment occupied by
healthy workers can improve production and cut down on work loss which
can keep costs down reflecting good management. It is recognized that
the economic status of small employers hampers the ability to provide
employee benefits; however, small industry is most likely to have
inadequate measures for worker safety.

Assessment of Need for Services

According the the Tri—County Community Council's Regional Priority Needs
Survey for 1976, the unmet needs for occupational health and safety
programs cannot be quantified at this time. The actual need according
to number of individuals is almost impossible to measure.

While cost is not a barrier to individuals to obtain this service,
budgetary limitations affect the amount of service which can be
provided. There is a shortage of trained personnel in this area,
especially occupational specialist and industrial hygienists.

A renewed interest in occupational health and safety was stimulated by
the passage of the Occupational Safety and Health Act of 1970. This was
also reflected at the state level with the passage of the Safe
Employement Act in 1973. As a result of these legislative acts, more
money and emphasis was placed on the problems of occupational health and
safety. This emphasis should continue.

Given the complex nature of the problem, community resources need to be
brought together to develop an occupational health plan. A task force
should be organized with representatives from industry, unions,
business, public health, health professional groups, Workmen's
Compensation, Occupational Safety and Health Administration, Department
of Environmental Quality, and others as needed for technical expertise.

Inventory of Existing Services (1)
Occupational Health Concerns is a program designed to promote and

maintain community health through provision of a wide variety of
occupational health and safety measures geared to the prevention and

28

 

 

control of occupational diseases and injuries. Program elements may
include some or all of the following: 1) activities of safety engineers
to detect work hazards and to correct them; 2) provision of pre-
employement health examination, and, in some instances, annual physical
examinations of employees; 3) provision of on-site or off-site medical
departments for employee groups for medical examinations, for treatment
of work-related injuries, and for detection of incipient health problems
of employees; 4) conducting industrial hygiene investigations on a wide
variety of industrial and occupational health problems in response to
complaints thereto; and 5) conducting routine investigations to
determine whether existing occupational health and safety laws are being
observed.

(Persons working in this field indicate that this description does not
reflect accurately current concepts of this field of service. For
example, program elements under 1, i.e., safety programs and accident
prevention, are now under Workman's Compensation Board. Program
elements 2 and 3 are not new, receiving the emphasis they did in the
past years. The activities in general under this field of service are
geared to public health rather than the individual. Numbers 4 and 5 in
program description more adequately state and present program elements
in this field of service.)

The services in this field are provided for this area by the
Occupational Health Section of the Health Division. By virtue of
Federal and State laws, the State is the authoritative and enforcement
agency. It is also the standard—setting and inspection agency. The
staff of the Occupational Health Section of the State Health Division
consists of a Director, Assistant Director, Occupational Health Nurse
Consultant, Chief Chemist, Chemist, and eight field people (five
positions filled now).

In 1975, the legislature passed SB 440 which provided that insurance
companies must provide consultative services to clients. Most of the
education and training of health and safety affairs for industries is
done by these companies. The largest company is the State Accident
Insurance Fund (SAIF).

Goal

All employers should have an active occupational health program which
implements the following areas of concern.*

1. Compliance with State and Fedearal laws and standards as they
pertain to the use of and exposure to toxic materials in places of
employment.

*It is realized that employers of less than 100 employees may have

difficulty implementing programs as complete as those of larger
employers. Nevertheless at least a minimal program is recommended.

29

 

 

2. Enforce prudent measures to safeguard industrial workers from loss
of hearing and vision by use of appropriate protection methods in
compliance with existing laws.

3. Maintain high standards of air quality within and in the proximity
of industrial sites in the interest of the health and well-being of
industrial employees.

4. Maintain adequate sanitary facilities and a sanitary working
environment within and in the proximity of industrial sites in the
interest of the health and well-being of industrial employees.

5. Initiate pre—employement examinations for all new employees to
assure that those employees who are at risk seek appropriate care to
reduce their at-risk condtion.**

6. Maintain an active accident prevention and health education program
with emphasis on CPR training, first aid, smoking cessation, and others
as needed to promote health and physical fitness in the employee.

7. Provide employees with on the job access to readily available
medical care on the job site or through formal arrangements with a
medical back-up system.

8. Initiate and maintain a program to educate employees on how to use
the health care system appropriately. (See Physical Problems and Health
Education Subject Areas.)

**There is a concern with the possibility that such pre—employment risk
screening measures may be used punitively to discriminate against
workers who themselves are not at risk but whose illness status may be
of concern for other non-job related reasons, e.g., insurance rates.

(1) This section is taken from: Tri-County Community Council, Regional
Priority Needs Survey, 1976, pp. III-119, 120.

OBJECTIVE

By 1983, a plan to promote the health of the working person should be
available for implementation.

Action

1. Experts in the field of occupational health should be identified and
form a task force to develop a plan to promote the health of the working
persons.

Annual Implementation Plan

Occupational Health

30

 

 

HSP Long Range Objective
OBJECTIVE

By 1983, a plan to promote the health of the working person should be
available for implementation.

AIP Short Range Objective
OBJECTIVE

By 1979, an occupational health task force will be established to begin
the development of an occupational health plan.

One Year Recommended Actions

1. During 1978 the agency will cooperate with the State Accident
Prevention Division, Industrial Physicians Association, Occupational
Nurses Association, and Oregon State Health division to identify experts
in the field of occupational health and form a voluntary steering
committee representative of the six-county area.

2. The steering committee will provide names for the establishment of a
task force.

3. By the end of 1978, the task force will convene and develop a plan
format and guidelines.

4. Staff assistance will be obtained from public health officers.

Example 5 jfiased on "Planning for chgpational Health in the
California Inland Counties,fl 1978 121.1

Goal
Create and maintain an occupational environment which contributes
positively to the health and well being of the workers, their families,

and the community at large through elimination of the risks of illness
and injury in the work environment and surrounding area.

Objective A

Reduce to the lowest level possible all the ill—health related to the
working environment.

Sub—objectives:

a. Reduce to the lowest level possible the hazards to health due to the
use of chemical and material agents in the working environment.

b. Reduce to the lowest level possible health and safety hazards caused
by unsafe mechanical devices in the working environment.

31

 

 

c. Reduce to the lowest level possible, psychological and environmental
factors such as noise, inadequate ventilation, lighting, space,
heat, and inadequate sanitary facilities and procedures which contribute
to ill health in the working environment.

d. Encourage a local level program in the area of occupational health
of consultation, education, and training for employees and employers
which emphasizes prevention measures in the workplace.

e. Study the occupational health manpower needs of the area.

Objective B

Encourage all interested and affected parties to engage in planning a
comprehensive approach designed to eliminate occupational health hazards,
to secure a healthy and aesthetically pleasing working environment, and
to promote continuing research into occupational health problems.

Objective C

Continue to advise all interested parties in the private, public,
and governmental sectors of the presence of an occupational
health and safety hazard of considerable magnitude.

Objective D

Promote the development of a comprehensive public policy and program in
occupational safety and health through utilization of available resources
in the area.

A detailed discussion of the plan follows:

Objective A

Reduce to the lowest level possible all the ill-health related to the
working environment.

Implementation

1. Intensify efforts of interested parties to broaden the concept of
occupational health, to include not only a greater concern for
on-the—job health of the worker, but his or her total health and
well being.

2. Work with the Federal Occupational Safety and Health Administration
(OSHA), the National Institute for Occupational Safety and Health
(NIOSH), the State Department of Industrial Safety (DIS), the Bureau
of Occupational Health within the State Department of Health, or State
Department of Labor, Federal and State legislatures, the local health
departments, local health and medical professional associations, and

32

 

 

centers of education and training, representatives from a broad range of
labor and industry, and other interested public and private agencies and
groups such as the American Public Health Association, The State
Environmental Health Association, the local Industrial Hygiene
Association, and county medical societies, in developing an

occupational health education and research program. This program

should specifically aim at the local level that would provide for a better
understanding of the nature and extent of occupational health processes,
their consequences to the individual worker, the worker's family and

the community, and the effectiveness of occupational health controls.

Promote the development of a health services delivery system in the
area in which the prevention, diagnosis, treatment, and rehabilitation
of occupational illness and injury will be coordinated and integrated
with all health services provided for the worker and the worker's
family.

Encourage the development of techniques designed to make the full
range of health services available and accessible, including those
usually classified as occupational, at all work places. This should
include promotion of innovative and experimental programs in the
education and use of health personnel.

Encourage the federal government to legislate national health insurance
with provisions for uniting on-the-job medical and health care with all
other services provided the worker and his/her family; emphasize and
fund environmental health and preventive health activities to a much
greater degree than at present (HEW's new Forward Plan for Health

makes it abundantly clear that health legislation must shift emphasis
from curative medicine to prevention); and give serious attention to
the Hazardous Substances Act.

Encourage the State Division of Industrial Safety to work with the Occupational
Health Section of the State Health Department or State Labor Department and
local environmental health jurisdictions, to train state inspectors in a
comprehensive manner regarding both health and safety; and to develop

an evaluation mechanism which would emphasize preventive measures now

employed by industry as a direct result of the State/OSHA program.

Encourage the Occupational Health Section of the State Department of Health
or State Department of Labor to increase its capacity for inspection

and surveillance of occupational health hazards; to increase its training
program efforts for state inspectors, employers, and employees regarding
occupational health; to support legislation which would encourage the state to
establish a priority for health research in occupational diseases

and training for needed medical and scientific personnel; to increase
capacity for laboratory analysis and evaluation of both cumulative

and synergistic effects of substances and conditions in the work—

place; to work with the State Department of Health, local health
departments, and other appropriate agencies and citizen groups in

33

 

 

developing criteria for a work related illness history usable as a
standard part of a medical history; and develop a system of evaluation
which could measure the actual effectiveness of the industrial health
program under State/OSHA.

8. Encourage and support environmental health jurisdictions to develop
programs for the protection of the health and safety of working people
within their respective counties; to expand information of its
consultive services to stress a program which emphasizes occupational
health, safety education, and preventive measures for voluntary
compliance with health and safety standards; to work with the State
Department of Health to implement a funding agreement for supportive
services on the local level; to provide more training to district
sanitarians in the area of occupational health and safety; to provide
internships (field study) for students enrolled in degree programs
in industrial hygiene, and to increase their manpower and resources
to meet the demands of these critically needed services.

9. Encourage industry (management) within the area to accept responsibility
for maintaining a healthy workforce as a basic operational cost, to
develop, in concert with workers and their representatives, active
health and safety committees, educational programs, and training
pertinent to the workers' occupational health and safety needs; to
recognize the particular problems of small industry and work in concert
to develop shared programs in the area of medical services, training,
and consultation to reduce costs, prevent duplication of efforts; and
to become participants in the efforts of the Health Systems Agency.

10. Encourage labor unions to recognize occupational health and safety
as a logical extension of health provisions in the collective
bargaining agreement; to utilize the consultative services of
environmental health departments or divisions; to increase concern
for the health aspects of the work environment and encourage
the State7OSHA program to do the same; to support national health
insurance which includes provisions for on-the-job health care as
a part of all other health care services offered to the employee;
and to become participants in the Health Systems Agency.

11. Seek sources of funding for and promote the establishment of an
Occupational Safety and Health Consortium. The Consortium would
consist of representatives from industry, labor, employee
associations, the insurance industry, elected officials, educational
institutions, representatives from citizen groups, and the public
at large.

Sub-objective a.

Reduce to the lowest possible level the hazards to health in operating
mechanical devices in the work environment.

34

 

 

Implementation:

Encourage manufacturers to establish health and safety as a priority in
the manufacturing of mechanical devices. This can be done by publicizing
the magnitude of the health and safety problems through Chambers of
Commerce, trade associations, and various commercial channels.

Sub-objective b.

Reduce to the lowest level possible long and short term hazards to health
caused by the use of chemical agents in the work environment.

Implementation:

Strengthen and expand the concept of a registry of sources and users
of chemical agents as now conceived by the State Health Department in
connection with its support of the State's Occupational Safety and
Health Plan. Manufacturers, suppliers, stores, transporters, and
users would be required to furnish data on toxicity, carcinogenicity,
combustibility, explosive potential, and any hazardous characteristics
in the use, singularly or in compound, of such chemical agents. Such
a registry would:

a. Insure that all the locations of such substances would be known.
b. Insure that proper information on handling, storage, ventilation,
personal protective measures, and other safety precautions be

available to everyone involved in their use.

c. Permit newly discovered technical and safety information regarding
the substances to be disseminated.

Sub-objective c.

Reduce to the lowest level possible hearing disability in the working
environment.

Implementation:

1. Work with management and labor to institute engineering controls to
reduce noise at its source.

2. Encourage management to maintain an effective hearing conservation
program including the use of suitable acoustics and ear protection.

3. Encourage the vigorous enforcement of standards regulating the noise
levels.

4. Press for national and state legislation to require the manufacture
of low noise output equipment for use by industry.

35

 

 

Sub-objective d.

To reduce to the lowest level possible the psychological and environmental
factors in the work environment that contribute to ill health, including
inadequate heat, light, space, and sanitary facilities.

Implementation:

1. Presently there are no enforceable standards of heat, light, and space
regarding the working environment. The Federal Occupational Safety
and Health Administration, the State Department of Health, the State
Division of Industrial Safety, the counties environmental health
divisions, and representatives from labor and other citizen groups
should thereby work together to formulate enforceable standards for
heat, light, and space in the working environment.

2. Encourage more vigorous enforcement of sanitation standards by the
state and local agencies.

Sub-objective e:

To study the occupational health manpower needs of the area.

Implementation:

1. Conduct a study in conjunction with other concerned county agencies
to project the needs in each professional and paraprofessional
category of occupational health.

2. Formulate plans based on results from the proposed Occupational Health
Manpower Needs Study.

3. Encourage schools of medicine to include occupational health in their
curriculum, and to offer residency training in occupational medicine,
thereby increasing the number of physicians in the area who can properly
diagnose occupational illness.

4. Conduct a study of educational institutions in the area to determine
which institutions offer programs in occupational health and safety,
and the nature and extent of their curriculum in occupational health
and safety.

5. Encourage local colleges to offer programs and courses in occupational
health and safety, and support the further development of those
that exist.

6. Identify funds available for research and training of personnel in
occupational health and safety.

7. Encourage the State Superintendent of Public Instruction and the

36

 

 

various school districts to expose students in the secondary schools

to occupational health and safety —— possibly as part of courses in
civics, social studies, the biological sciences, or special courses, —-
and engender an awareness of career opportunities in the field.

Objective B

To encourage all interested and affected parties to engage in planning a
comprehensive approach designed to eliminate occupational health hazards.
To secure a healthy working environment, and to promote continuing
research into occupational health problems.

Implementation:

1. Determine the extent to which Federal, State, and county agencies
are planning to meet the stated health objective.

2. Determine the resources required to establish occupational safety
programs in the area capable of attaining the stated health goal.

3. Determine through expert opinion and employee surveys, what
constitutes "lowest rates possible" regarding accidents and illness
on an industrywide basis.

4. Provide the public with the information necessary to express their
judgment regarding the cost, effectiveness, and desirability of
present and proposed occupational health and safety programs.

Objective C

To advise all interested parties in the private, public and governmental sectors
of the presence of an occupational safety and health
problem of considerable magnitude.

Implementation:

1. Organize or hold forums, meetings, hearings, and workshops for all
interested parties, advising them of the results of the HSA inquiries
and findings.

2. Identify sources of funding to increase distribution of information,
such as surveys, statistical compilations, reports, and similar materials.

Objective D

To promote the development of a comprehensive public policy and program in
occupational safety and health through utilization of available resources
in the area.

37

 

 

Implementation:

1. Encourage the development of a network or system of coordinated efforts
in the form of an ”Occupational Health Consortium," to monitor and
analyze existing programs and to recommend alternate occupational
health policies and programs in the area.

2. Such a consortium is to include all interested and affected parties:
industry, labor, educational institutions, insurance agencies, medical
and public health personnel, and the public.

c. In terms of other forms of disabilities and human suffering, the cost
of otherwise preventable diseases and injuries is hard to calculate
in conventional terms.

Sound occupational health planning can serve as one of the viable mechanisms
to reduce needless human suffering and economic loss. Here, the HSA is
determined to play, along with other interested parties, a key role in
developing preventive measures.

Example 6 (Based on the Health Systems Plan for Los Angeles CountyL
Environmental Health Plan for 1976.)

GOAL

Create and maintain an occupational environment which contributes to the
good health and well—being of the workers and their families, and
thereby the community .

Sub—Goal:

A working environment in which the risks of illness and injury are
eliminated.

OBJECTIVE

To reduce to the lowest level possible all the ill-health related to the
working environment.

Sub—objectives:

Reduce to the lowest level possible the long term and short term
hazards to health due to the use of chemical and material agents
in the working environment.

Reduce to the lowest level possible health and safety hazards caused
by unsafe mechanical and engineering devices in the working environment.

Reduce to the lowest level possible psychological and environmental
factors such as noise, inadequate ventilation, lighting, space, and

38

 

 

heat, inadequate sanitary facilities and procedures which contribute
to ill-health in the working environment.

Encourage a local level program in the area of occupational health
of consultation, education, and training for employees and employers
which emphasizes preventive measures in the workplace.

OBJECTIVES FOR HEALTH SYSTEMS AGENCY

To continue to advise all interested parties (workers, unions, employers,
governmental agencies, medical and public health personnel, insurance
companies, and the community) of the presence of an occupational health
and safety problem in the area of epidemic proportions.

To continue to engage all interested and affected parties in planning
a comprehensive approach in securing a healthy Working environment by
eliminating occupational health hazards and by promoting continuing
research into occupational health problems.

To promote a coherent public policy and program for occupational health and
safety and to monitor the functional development of existing public policies
and programs in this area.

Given the priority of preventing occupational disease, to expand and
nationalize current wage loss compensation provisions for work related
illness such that a program would be comprehensive, efficiently administered,
timely, and equitable.

RECOMMENDATIONS AND IMPLEMENTATION

The process of planning for any form of social change is incumbent upon

a network/system of coordinated effort by a great many agencies, groups,
and individuals toward an agreed upon goal or objective. Planning efforts
must focus on both immediate and long range goals; and how the implementa—
tion of the one will effect the other. The recommendations and implemen—
tation strategies which follow will be useful only if the full range of
resources called upon are (l) utilized; and (2) if each segment of a

given implementation strategy is consciously linked by the participants

of that segment to all the others. While a certain number of recommendations
are necessarily long range, the emphasis for occupational health and safety
in the area is focused in an implementation strategy which will:

Develop a cooperative and comprehensive community policy and
program for occupational health by including a broad coalition
of representatives from labor, industry, and the general public
in both the planning and regulatory process.

OBJECTIVE

To reduce to the lowest level possible, all ill—health related to the

39

 

 

working environment.
IMPLEMENTATION

1. Strengthen the power of interested parties as a catalytic force for a
broadened concept of occupational health, to include not only a greater
concern for the on—the-job health of the worker, but his or her total
health and well—being.

2. Work with the Federal Occupational Safety and Health Administration
(OSHA), the National Institute for Occupational Safety and Health
(NIOSH), the State Department of Industrial Safety (DIS), the Bureau
of Occupational Health within the State Department of Health, Federal
and State legislatures, the County Department of Health Services, local
medical and health professional associations and centers of education
and training, representatives from a broad range of labor and industry,
and other interested public and private agencies and groups such as the
American Public Health Association and the State Environmental Health

Association, in developing an occupational health, education, and research

program aimed specifically at the local level that would provide for a
better understanding of the nature and extent of occupational health
processes, their consequences to the individual worker, the worker's
family and the community, and the effectiveness of occupational
health controls.

3. Promote the development of a health services delivery system in the
area in which the prevention, diagnosis, treatment, and rehabilitation
of occupational illness and injury will be coordinated and integrated
with all health services provided for the worker and the worker's
family.

4. Aid in the integration and coordination of the diverse sectors of Federal

and State government, and specifically county government,currently
responsible for some portion of occupational health and safety, in
order to increase the effectiveness of all groups. This would include
current control programs (OSHA, the Bureau of Occupational Health and
Radiation Management), the county government's Personnel Department
program for county employees, the city occupational health and safety
programs for employees, and all health care facilities treating
persons with work related illness, injury, or disability.

5. Encourage the development of techniques designed to make the full
range of health services available and accessible, including those
usually classified as occupational, at all work places. This should
include promotion of innovative and experimental programs in the
education and use of health personnel.

6. Encourage the Federal Government (NIOSH) to:

a. Increase its scientific and technical staff in order to

40

 

 

f.

upgrade its research capabilities. Each year should see a
substantial decrease in the need to subcontract the research

needed to prepare criteria documents for exposure to occupationally
used substances.

At the present time, almost the full staff must be pulled away
from on going and long range projects whenever a serious single
health-related disease is unearthed. Vinyl chloride is an
example.

We believe that there should be a single Federal agency charged with
standards setting for occupational substances. NIOSH, at the
appropriate time, would be most suitable. At present, EPA, for
example, is responsible for pesticides. The Department of Energy

is responsible for radiation. State OSHA last year spent $200,000
for its own standards setting board which did nothing except
duplicate federally set standards. That is $100,000 alone which
could be allocated to a national federal program and $100,000 of
state funding which could be utilized by other aspects of the State/
OSHA program.

Work more closely with OSHA to provide the technical assistance
needed for adequately training Federal enforcement officers in
industrial health.

Increase the number of health related materials available for
educational and training purposes. Real emphasis should be given
to providing materials useful to community and worker education
programs.

Work more closely with other programmatically-related divisions
within HEW. Encourage them to follow up on projects begun within
NIOSH and have NIOSH do the same. Some efforts have been made

in this direction, but more is needed.

Continue to emphasize the long term effects of chemical substances
which eventually can have adverse health effects on the human body
even if such is not the case for the short range. NIOSH must
continue to support the concept that short and long range effects
of exposure to toxic substances cannot be rendered with any final
exactitude, and that if error is made it should be on the side of
protecting human health.

Have input regarding proposed program requirements of PL. 93-641
which deals with occupational health.

Encourage the Federal Government to:

3-.

Legislate National Health Insurance with provisions for uniting
on—the—job medical and health care with all other services provided

41

 

 

the worker and his/her family.

At the present time, National Health Insurance legislation is
unlikely to pass Congress. The pr0posal we are making would not
only aid in regulating costs, but would shift the emphasis of
such insurance towards actually reducing ill health.

The Health Systems Agency: Los Angeles County should, as a part of
its occupational health implementation planning, draw up a more
extensive statement in this area and present it to appropriate
national representatives.

b. Emphasize and fund environmental health and preventive health
activities to a much greater degree than at present. HEW's new
Forward Plan for Health makes it abundantly clear that health
legislation must shift emphasis from curative medicine to
prevention.

c. Give serious attention to the Hazardous Substances Act which is
presently before Congress.

d. Understand that there is a very real connection between unemploy—
ment and ill health. Economic policies must begin to reflect these
concerns.

The American Public Health Association, among others, has recently
begun efforts to interject into discussions of national occupational
and health policy, vital interdependencies such as these. Much more
work is needed at all levels of government.

At this point we turn our attention back to the immediate concerns of state
and local government and the private sector at these levels. It is of
concern that the different branches and levels of government, all charged
with some aspect of promoting the health and well—being of working men

and women continue to act in an isolated and fragmentary manner, instead

of mounting the mutually cooperative effort which is needed. In the

matter of occupational health, it is incumbent upon the Health Systems Agency
to (l) impress upon Federal program divisions the real need to begin inter—
acting with local level programs directly; and (2) to point out to Federal,
State, and local agencies that effective implementation of all occupationally
related health legislation requires coordinated efforts on the part of all.
It is no real excuse, for example, that the enforcement provisions of
State/OSHA are a deterrent to the effective workings of a local level
program. No one is, or can, do a very good job alone in this area, but

all levels of government are dependent upon each pulling its own weight in
terms of program mandate and responsibility.

8. Encourage the state government (the Governor and the Legislature) to:
a. Carefully reexamine the effectiveness of the State/OSHA program

42

 

 

in order to determine whether it should be continued or returned
to Federal OSHA.

The question of primary importance is: has the health and safety
of the working people in the state been improved since the
implementation of State/OSHA? If it has, how has this improvement
been demonstrated? If it has not, why not, and is it possible to
implement the necessary changes?

We believe that on the local level there is little which points
to an improvement in working conditions as a result of State/OSHA.
Program mandates have not been adequately met, monies have been
ill—used, local resources have not been utilized, small industry
has not been substantially helped to improve working conditions,
and working people have not received the help which was mandated
under the 1970 OSHA Act.

At this time, we believe that it is, however, impossible to make
a quick or final decision to return State/OSHA to the Federal
government. For all the apparent problems which State/OSHA has,
experience to date indicates that Federal OSHA is not equipped to
do a better job.

There is strong evidence to support the concept that implementation
of the 1970 OSHA Act can only be achieved in the long-run through
a single, comprehensive national program.

What needs to be ascertained at this point is: given the needs
of working people at the local level today, what is the most
effective short-range program and policy of health and safety
available?

Ensure adequate funding levels for State/OSHA and for the training
and manpower programs necessary within the state university

system to provide physicians, nurses, occupational hygienists,
industrial sanitarians, and support personnel for the effective
implementation and maintenance of the program.

In 1975, State/OSHA had budgeted only $70,000 for its training
programs. Such an amount is decidedly insufficient.

Additionally, without specific funds for occupational health
training, the State university system is not going to increase
its attention and resources toward this need.

Support a coherent policy of occupational health which gives
priority to both the short and long-range health consequences

of the workplace environment.

As with the Federal program, State/OSHA is designed to place

43

 

 

safety far in excess of health considerations. This has resulted
in inadequate training of enforcement personnel and a generally inadequate
State occupational health program.

9. Encourage the State Division of Industrial Safety to:

3-

Increase its State inspection force to provide the manpower needed
to run an adequate enforcement program.

A six-month backlog of answering complaints points to this need.

Work with the Occupational Health Section of the State Health
Department to train State inspectors in a comprehensive manner
regarding both health and safety. There have been far too many
complaints from both employers and employees about inadequate
training of inspectors, both technically and administratively.

Penalties for violations of health and safety standards have
repeatedly been successfully appealed by employers because proper
administrative processes were not followed.

Finally, regardless of the competence of a state inspector, he or
she is severely limited by a caseload which is impossible to keep
abreast of.

Make all necessary changes in the program as directed by the
federal Department of Labor's "On Site Evaluations." If technical
assistance is required from the federal level for a given aspect of
the program, it should be sought.

Develop an evaluation mechanism which would emphasize preventive
measures now employed by industry as a direct result of the
State/OSHA program.

What engineering changes have been made?
What changes have been made in the use of materials?
What changes have been made in choice of processes?

An effective industrial health and safety program should emphasize
control at the source of hazardous substances.

In line with a. - d. support policies and programs which would
make State/OSHA prevention-oriented as opposed to its present
"crisis-orientation".

This can be done by:

1. Supporting legislation which would license industries which

use toxic substances (known carcinogens, for example).
Knowledge in advance of industries which are likely to be

44

 

 

highly hazardous to health and safety of employees should
substantially aid the director of program efforts.

2. Supporting a strong contractual program with local government
for technical assistance and consultation to employers and
employees at the local level.

3. Development of programs which would aid small industries in
solving their health and safety programs. (One day "training
seminars" are not adequate.)

Federal OSHA has not been successful to date in implementing
an adequate program of consultation to small industries.

4. Work closely with organized labor and community agencies to
develop materials and programs which would aid the worker
in understanding and dealing with health and safety programs.

10. Encourage the Occupational Health Section of the State Department of
Health to:

8..

Recommend that its technical advisory functions for establishment
of standards regarding the use of workplace substances be returned
to the Federal level.

This task is only duplicative of Federal standards, is time
consuming, and is wasteful of actual research needs in occupational
health.

Increase its capacity for inspection and surveillance of
occupational health hazards.

It is disturbing to note that State/OSHA reports less health
related hazards than national estimates indicate exist. We feel
that one reason for this is poor coordination of activities
between the Occupational Health Unit and the DIS.

In line with b. increase its training program efforts for State
inspectors, employers, and employees regarding occupational
health.

Finalize contractual agreements for technical and consultative
assistance with local health departments.

Support legislation which would encourage the State to establish
a priority for medical research in occupational diseases and
training for needed medical and scientific personnel.

Increase capacity for laboratory analysis and evaluation of both
cumulative and synergistic effects of substances and conditions

45

 

 

in the workplace.

It seems that to date a sizable portion of funds available to the
State/OSHA health program have gone into the purchase of laboratory
equipment. There is some question as to the necessity of this
equipment in order to effectively implement it.

Work with the State Department of Health, local health departments,
and other appropriate agencies and citizen groups in developing
criteria for a work related illness history usable as a standard
part of a medical history.

If cases of occupational disease were effectively reported, there
would be a good foundation (epidemiological) for determining
causes of occupational illness.

As previously stated, the State requires physicians to report
cases of occupational illness, but lack of training and knowledge
about such illnesses keep the system from being of value.

Programs which encourage occupational health units coordinated
with hospital emergency rooms are being developed in other parts
of the country. Training of hospital staffs to check for work
related illness at the point of "in—take" is being stressed.

Develop a system of evaluation similar to that recommended of the DIS
which could measure the actual effectiveness of the industrial
health program under State/OSHA.

Implement the necessary changes as directed by the Federal
Department of Labor's "On—Site Evaluations".

Above all, the State Department of Health must improve coordination of
resources and services with the County Department of Health Services.

11. Encourage the County Government (Department of Health Services) to:

a.

Recognize their responsibilities for the protection of health and
safety of working people within the County by:

Increasing the amount of funding for a comprehensive
occupational health and safety program useful to both
employers and employees.

The budget allocation for the Division of Environmental
Management should be substantially upgraded; and

the proposed Health Licensing Fee program for selected
manufacturing establishments should be passed.

46

 

 

12.

Promote the coordination of resources and services between the
Health Department's Bureau of Occupational Health and the
occupational health program operated through the County's
Personnel Department.

It is astonishing to know that the Personnel Department program
is better funded than the Bureau which is responsible for the
entire County population.

Recognize their contractual agreements for occupational health and
safety services with the majority of cities within the county.

Encourage the Bureau and the Department of Health Services to
initiate a program of occupational health services within the county
hospitals.

Encourage the County Department of Health Services, Bureau of
Occupational Health and Radiation Management to:

a.

Act upon its mandate to provide consultative services to both
industry and workers throughout the county.

It can be argued that the reason services are not more widely used
(provided) is due to the decisive lack of manpower within the Bureau.
However, we believe that the Bureau is obligated to actively inform
local employers and employees that specific services do exist and
can be requested.

If the Bureau could point to a request caseload for assistance
from a broad range of industries and workers, then a substantial
case could be drawn from the need for more funding.

Expansion and information of its consultive services should stress
a program which emphasizes:

l. occupational health and safety education
2. prevention measures for voluntary compliance with health
and safety standards.

Upgrade its staff such that it can increase its mandated inspection
potential by approximately 20 percent of the present rate per year for
five years so that every place of employment could be inspected at
least once every five years, with most frequent inspections accorded
to places of employment with hazardous types of processes and
materials.

The Health Licensing Fee program would substantially aid program
efforts made under this recommendation.

This recommendation was made in the 1973 Occupational Health Plan.

47

 

go

We believe that without the increased funding which is necessary
to upgrade this program, the increased efforts must be made to train
and utilize district sanitarians in such inspection efforts.

Only a program which pursues its mandated responsibilities actively
can suffice to encourage industry to voluntarily comply with health
and safety standards.

Actively meet its mandate to provide services in health and safety
to the cities within the county with which it has contractual
agreements for such services.

It is incumbent upon the local city governments, and employers and
employees within a given area to request from the Bureau the full
amount of services due under the contractual agreements.

In line with 12.d., work with appropriate State and local agencies,
including medical associations, to strengthen the reporting
requirements of physicians regarding cases of occupational disease.

Work with the State Department of Health to implement a funding
agreement for supportive services on the local level.

Although the State did not sign any agreements with local governments
in 1974 - 1975, the Bureau did not sufficiently press their proposal
to the State. It is understood that the Bureau was aware that the
State was not going to implement this vital aspect of State/OSHA,

but we feel more energy could have been directed to public awareness
of the State's inaction. By not pursuing efforts vigorously

from the local level, the State was in a position to simply say

that local government had not made a full proposal.

Both State/OSHA and the county would benefit enormously from
such a funding agreement:

(1) it would strengthen the disease recognition capabilities
of both agencies;

(2) it would increase the capacity to investigate and conduct
epidemiological studies on occupational disease.

Increase its capability to respond to complaints of workers
regarding their work environment and aid in referring such
complaints to the local branch of the DIS.

Such a cooperative information and referral service could be
activated with a minimum of effort if the DIS and the Bureau
could work out a basic program of materials and adequate admin-
istration of referrals. The Bureau could also inform the party
of consultative services which it has available, making clear

48

 

 

k.

that such services do not constitute an authorized inspection.

Employees remain uncertain of their rights under State/OSHA and
are primarily concerned that hazardous or potentially hazardous
workplace situations be brought under control as quickly as
possible. If proper assistance could be provided to them, the
necessity for having to file a complaint to State/OSHA could be
reduced.

More training must be provided to district sanitarians in the area
of occupational health and safety under a program directed by the
Bureau and coordinated throughout the Division of Environmental
Services.

Additional efforts must be made on the part of the Bureau to
encourage the Department of Health Services to (1) at a minimum
cooperate much more closely regarding its own personal department
occupational health and safety program; and (2) at a maximum

to merge these program activities completely under the management
of the Bureau.

This is an incredible waste of money and duplication of effort
in the sole interests of a special interest group at the expense
of the community.

Provide internships (on-the-job training) for students enrolled
in degree programs in industrial hygiene.

13. Encourage Industry (Management) within the county to:

a.

Accept responsibility for maintaining a healthy workforce as a
basic operational cost.

There must be full realization that all diseases, occupational
and non-occupational, are the concern of industry if there is to
be a productive environment both for the short and long-range.

Develop, in concert with workers and their representatives,
functional health and safety committees, educational programs,
and training pertinent to the workers' occupational health and
safety needs.

There are a number of international union plans which could be
used as a prototype for such a committee, as well as several
good company plans.

Additionally, many companies subscribe to some form of occupational
health and safety insurance which is supposed to provide consul-
tative services to the company in the area of employee health and
safety training.

49

g.

Too often such insurance is seen by the industry as a protective
device against OSHA. If properly utilized, such insurance could
become a preventive and diagnostic tool aiding in the process of
voluntary compliance.

We believe that employees do have a right to participate fully

in decisions which will have an effect on their health and welfare.
We believe that it is in the best interests of employers to accept
that right of their employees, although the financial costs are
the primary responsibility of the employer.

Utilize the consultative services available from the County
Department of Health Services.

Support the County's Bureau of Occupational Health in their request
for a "Health Licensing Fee."

Certain segments of local industry have expended time and money far
in excess of the proposed licensing costs to keep the County from
instituting such a program. When such choices are made, we believe
that they are at odds with the long-range needs of the industry,
the employees, and the community.

In planning for occupational health and safety services, recognition
must be given to the interdependence between this form of "pollution"
and abatement procedures, and processes called for to bring the
industry into compliance with external pollution standards such

as air, water, waste, and noise.

It would be ideal if the industrial problems of pollution could
be seen as of a piece, instead of continuing to fragment and
isolate them. In the long run, we believe that costs could be
substantially reduced if this viewpoint were sufficiently
implemented.

Recognize the particular problems of small industry and work in
concert to develop shared programs in the area of medical services,
training, and consultation to reduce costs, and prevent duplication
of efforts.

This is an area where the State and the county should be asked to
give technical and planning assistance.

As stated in the text, too often a large industry will sub—contract
out to a smaller, more marginal company work which may be highly
hazardous. Such practices need correction.

Become participants in the efforts of the Health Systems Agency.

50

 

 

14. We believe that it is essential that the worker's knowledge, capabilities,
and cooperation be fully utilized for the successful maintenance of a
healthful and safe working environment. Labor unions and employee
associations are encouraged to:

a. Make sure that their members are knowledgeable about their rights
and responsibilities under Federal OSHA and State/OSHA.

b. Broaden and strengthen ongoing education programs in occupational
health and safety.

There are an increasing number of groups throughout the country,
primarily coalitions of labor, science, and medicine, who have
developed excellent educational materials and courses for workers.

0n the local level there is a small coalition of this nature which
has some support from organized labor, but which in order to really
aid the worker, community needs much more. The work of this group
indicates that rank-and-file workers are eager for assistance.

c. Recognize occupational health and safety as a logical extension
of health provisions in the collective bargaining agreement.

At a minimum, a good collective bargaining agreement should contain
provisions for an equalized labor-management health and safety
committee which functions to improve the reporting and correction
of occupational health and safety deficiencies in the workplace.

d. Utilize the consultative services which the County Bureau of
Occupational Health is mandated to provide.

e. Increase concern for the health aspects of the work environment
and encourage the State/OSHA program to do the same.

Safety problems are but the tip of the iceberg. Not only do
Federal and State program efforts devote too few resources to
health, but labor also continues to emphasize safety to the
neglect of health problems.

f. Support National Health Insurance which would include provisions
for on-the-job health care as a part of all other health care
services offered to the employee.

3. Become participants in the Health Systems Agency.

15. Seek sources of funding for and promote the establishment of an
Occupational Safety and Health Consortium. The Consortium would
consist of representatives from industry, labor and employee
associations, the insurance industry, elected officials, representatives
from citizen groups, and the public at large.

51

 

The duties of the Consortium would include but not be limited to:

(1) Review and comment on proposed Occupational Safety and Health
Programs relevant to the County.

The evaluation can be implemented through reports presented by
the agency submitting the program, followed by an assessment
of the presentation by an HSA Occupational Safety and Health
Task Force and representatives of community groups.

(2) Coordinate public education efforts in the area of occupational
safety and health.

(3) Prepare an annual report for publication summarizing its inquiries,
findings, and conclusions.

Sub-Objective: Reduce to the lowest level possible the hazards
to health in operating mechanical devices in
the work environment.

IMPLEMENTATION
1. See 15-1 under the previous Objective.

2. Encourage manufacturers to establish health and safety as a priority
in the manufacturing of mechanical devices. This can be done:

a. By publicizing the magnitude of the health and safety problem
through Chambers of Commerce, trade associations, and various
commercial channels.

b. By printing instructions for the operation of machinery in more
than one language.

c. By appealing to the humaneness of the manufacturer.

Sub-Objective: Reduce to the lowest level possible long and
short-term hazards to health caused by the use of
chemical agents in the work environment.

IMPLEMENTATION

1. Strengthen and expand the concept of a registry of sources and users
of chemical agents as now conceived by the State Health Department
in connection with its support of the State's Occupational Safety
and Health Plan. Manufacturers, suppliers, stores, transporters, and
users would be required to furnish data on toxicity, combustibility,
and volatibility, explosive potential and any hazardous characteristics
in the use, singularly or in compound, of such chemical agents.

52

 

 

Such a registry would:

a. Insure that all the locations of such substances would be known.

b. Insure that proper information on handling, storage, ventilation,
personal protective measures, and other safety precautions be

available to everyone involved in their use.

c. Permit newly discovered technical and safety information regarding
the substances to be disseminated.

Encourage passage of a law requiring the labeling of chemical substances
in more than one language.

Sub-Objective: To reduce to the lowest level possible hearing
disability in the working environment.

IMPLEMENTATION

l.

2.

Work with management and labor to institute engineering controls to
reduce noise at its source.

Encourage management to maintain an effective hearing conservation program
including the use of suitable acoustics and ear protection.

Encourage the vigorous enforcement of standards regulating the noise
level as contained in the Amendments to the Walsh-Healey Act.

Press for National and State legislation to require the manufacture
of low noise output equipment for use by industry.

Encourage the automation of certain work processes to remove the
individual from a high noise level work environment. Certain types

of operations are inherently noisy and such noise cannot be eliminiated.
However, the individual can be removed from the environment by using
automation or remote control. Since automation generally replaces

the individual worker, a conflict of social values emerges which
society must ultimately resolve.

Seek to revise current laws relating to standards regulating noise
levels.

Sub-Objective: To reduce to the lowest level possible the psychological
and environmental factors in the work environment that
contribute to ill health, including inadequate heat,
light, space, and sanitary facilities.

IMPLEMENTATION

1.

Presently there are no enforceable standards of heat, light, and space

53

regarding the working environment. The Federal Occupational Safety
and Health Administration, the State Department of Health, the State
Division of Industrial Safety, the County Bureau of Radiation
Management, and representatives from labor and other citizen groups
should thereby work together to formulate enforceable standards for
heat, light, and space in the working environment.

2. Encourage more vigorous enforcement of sanitation standards by the
State particularly in workplace locations having a large number of
poor, minority, and non-English speaking employees.

Sub—Objective: To study the Occupational Health manpower needs of
the County.

IMPLEMENTATION

1. Conduct a study in conjunction with the Department of Human Resources
Development to project the needs in each professional and non—
professional category of Occupational Health, adequate to provide
a reservoir of trained personnel.

2. Formulate plans based on results from the proposed Occupational Health
Manpower Needs Study.

3. Encourage Schools of Medicine in the State to:
a. Include Occupational Health in their curriculum.

b. Offer residency training in Occupational Medicine, thereby
increasing the number of physicians in the area who can properly
diagnose occupational illness.

4. Conduct a study of educational institutions in the State to determine:

a. Which institutions offer programs in occupational health and
safety.

b. The nature and extent of their curriculum in occupational health
and safety.

5. Encourage community colleges to offer courses for plant managers and
supervisors designed for certification in occupational health and
safety.

6. Identify funds available for research and training of personnel in
occupational health and safety.

7. Encourage the State Superintendent of Public Instruction and the
various school districts to expose students in the secondary schools
to occupatioal health and safety - possibly as part of courses in
civics, social studies, the biological sciences, or special courses, -

54

 

 

and engender an awareness of career opportunities in the field.
OBJECTIVE — HSA

To continue to engage all interested and affected parties in planning

a comprehensive approach designed to eliminate occupational health hazards,
to secure a healthy working environment, and to promote continuing research
into occupational health problems.

IMPLEMENTATION

1. Determine the extent to which Federal, State and county agencies are
planning to meet the stated health objective.

2. Determine the resources to establish an occupational safety
program in the county capable of attaining the stated health
goal.

3. Determine through expert opinion and employee surveys, what
constitutes "lowest rates possible" regarding accidents and
illness on an industrywide basis.

4. Provide the public with the information necessary to express
their judgement regarding the cost, effectiveness, and
desirability of present and proposed Occupational
Health and Safety programs.

OBJECTIVE - HSA

Continue to advise all interested parties (i.e. workers, employers,
governmental agencies, physicians, public health personnel,
insurance companies, and the public) of the presence of an
occupational safety and health problem of considerable

magnitude.

IMPLEMENTATION

1. Continue to hold forums, meetings, hearing, and workshops for
all interested parties advising them of the results of
our inquiries and findings.

2. Identify sources of funding to increase distribution of information,
such as surveys, statistical compilations, reports, and similar
materials.

OBJECTIVE — HSA

To promote the development of a coherent (systematic) public policy and
program in occupational safety and health.

55

IMPLEMENTATION

1.

In conjunction with the proposed consortium, (see Section 17 above)
review and comment on the following:

a. The State Occupational Safety and Health Plan and the Federal
Occupational Safety and Health Act of 1970.

b. The County's proposed Health Licensing Fee Program.

REFERENCES

Schramm, Carol Winkler, "Wellness in Wisconsin", American Journal
of Health Planning, Vol. 3, No. 3, July, 1978.

El—Ahrar, Amer, "Planning for Occupational Health in the California

Inland Counties", prepared for the Health Systems Agency,
San Bernardino, California, 1978.

56

 

 

APPENDIX B

CLINICAL ASPECTS AND ORGANIZATIONAL APPROACHES TO THE
DELIVERY OF OCCUPATIONAL SAFETY AND HEALTH SERVICES

The following two tables are presented to describe the association
between general categories of industry and specific occupational safety
and health problems, and to introduce the scepe of clinical services
required for comprehensive occupational disease surveillance. These
tables are intended to serve as guides only; they are not fact sheets.
They do not consider behavioral and motivational factors which may
predispose accidents and illness, nor do they furnish concrete data for
an analysis of specific operations vs. exposure. Disease patterns will
vary according to the substances and processes used within an industry
and with the individuals who use them. Not all workers within a given
SIC will be adversely affected, nor will those affected be stricken
either in an identical manner or to the same degree. There are also
existing service delivery mechanisms, for occupational safety and health
that are illustrative of the range of approaches that can be effective.
Examples of delivery approaches are provided.

Table l, SIC — Disease matrix is an attempt to specify several types of
occupational health problems which may occur in these major industrial
groups. The matrix was constructed by first examining health hazards
associated with the materials and processes used within each SIC
category. The results of this examination were grouped by organ system.
The final outcome identifies disorders of possible occupational origin
experienced by workers in the SIC. Only the most common health problems
which would arise as a result of usual on—the—job activity are listed.
Recognized health problems are signified with an ”x"; an "0" represents
suggested associations. The health problems may refer to an SIC as a
whole or an industry contained within it. Those industries which exceed
the U.S. median accident rates in frequency (”F") or severity ("S”) are
noted. Column titles are two-digit 810's or subcategories thereof.

Table 2 contains the medical surveillance recommendations from some
NIOSH criteria documents. This table should demonstrate the range of
clinical services associated with occupational disease surveillance. It
should be kept in mind that this is only one facet of the totality of
occupational safety and health services, which also include
environmental monitoring, safety services, and health education.

57

APPENDIX B
Table l. SIC-DISEASE MATRIX

c

o

”-4

4.)

x o
O U) ('5 DD
0 o n a
4-3 U - U 'H
m m -H o w x c
Q 0 > u c m -H
o > u m -H z

a -H o a m
o H m m . -H m H
u w z o m
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U U U U) 'H H #6 O.)
-H -H -H m L m H E
H u w H w u m H a
w w m o -H m o H 0
<1 <1 <1 Ln Ln 2 L) 0 Z

Blood—Lymphatic Disorders 0

 

Cardiovascular Disorders
Musculo—Skeletal Disorders
Neurologic Disorders

Respiratory Disorders
Extrin. Allerg. Aleveolitis
Pneumoconioses & Fibrosis
Chronic Bronchitis
Emphysema
Edema
Up. Resp. Tract Irrit.
Pneumonitis
Asthma
CA of Resp. Tract

Skin Disorders
Dermatitis
Skin Cancer

Dis. of Physical Hazards
Cold Stress
Heat Stress (Cramps,
stroke, etc.)
Hearing Loss

Poisoning
Lead Poisoning
Metal Fume Fever
Systemic Poisoning
(Miscellaneous)

Miscellaneous
Accidents
Allergy
Liver or Uro-Gential
Disorders

58

 

 

Blood—Lymphatic Disorders
Cardiovascular Disorders
Musculo-Skeletal Disorders
Neurologic Disorders

Respiratory Disorders
Extrin. Allerg. Alveolitis
Pneumoconioses & Fibrosis
Chronic Bronchitis
Emphysema
Edema
Up. Resp. Tract Irrit.
Pneumonitis
Asthma
CA of Resp. Tract

Skin Disorders
Dermatitis
Skin Cancer

Dis. of Physical Hazards
Cold Stress
Heat Stress (Cramps,
stroke, etc.)
Hearing Loss

Poisonings
Lead Poisoning
Metal Fume Fever
Systemic Poisoning
(Miscellaneous)

Miscellaneous
Accidents
Allergy
Liver or Uro—Genital
Disorders

Table l - Continued

Build. Construct.

Other Construct.

   

0 Special Contract.

O

0

Food Mfg.

Tobacco Mfg.

 

o Textile Mfg.

Clothing Mfg.

 

o Lumber, Wood

  

0 Furniture Mfg.

 

 

Blood-Lymphatic Disorders
Cardiovascular Disorders
Musculo—Skeletal Disorders
Neurologic Disorders

Respiratory Disorders
Extrin. Allerg. Alveolitis
Pneumoconioses & Fibrosis
Chronic Bronchitis
Emphysema
Edema
Up. Resp. Tract Irrit.
Pneumonitis
Asthma
CA of Resp. Tract

Skin Disorders
Dermatitis
Skin Cancer

Dis. of Physical Hazards
Cold Stress
Heat Stress (Cramps,
stroke, etc.)
Hearing Loss

Poisonings
Lead Poisoning
Metal Fume Fever
Systemic Poisoning
(Miscellaneous)

Miscellaneous
Accidents
Allergy
Liver or Uro—Genital
Disorders

Table l — Continued

Paper Mfg., Etc.

  

O

0 Print, Publish.

Chemicals

  

N

O

xxxxxxxxx

60

x Petroleum Refining

  

x Rubber, Plastics

  

0 Leather

& Glass

Stone, Clay,

Primary Metal

  

O

N

><O><><><><><><

0 Fabric. Metal

    

O

 

 

Table l — Continued

x
. 0
>: a . s
s H - a u
m s H m H
a U u a -
-H m m m w - a
n c H > w
o - H H . p c
h m u w m m m
H 2 H o m v D m H
m o M r m m H
c . a u o F
-H u m z - u . m u
L o 5 F1 0 H -H u m
o w m m m H x m u
m d H c M m m o m
E m B < S? x H m E
Blood—Lymphatic Disorders 0 0 O

          

O
O

Cardiovascular Disorders

Musculo-Skeletal Disorders
Neurologic Disorders

Respiratory Disorders
Extrin. Allerg. Alveolitis
Pneumoconioses & Fibrosis
Chronic Bronchitis
Emphysema
Edema
Up. Resp. Tract Irrit.
Pneumonitis
Asthma
CA of Resp. Tract

Skin Disorders
Dermatitis
Skin Cancer

Dis. of Physical Hazards
Cold Stress
Heat Stress (Cramps,
stroke, etc.)
Hearing Loss

Poisonings
Lead Poisoning
Metal Fume Fever
Systemic Poisoning
(Miscellaneous)

Misellaneous
Accidents
Allergy
Liver or Uro-Genital
Disorders

61

 

Table l - Continued

U
m
4.)
(/2
U) c
- c - m >
:> O > (5 L4 L4 -
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D. 03 (D u q) a U) .H CU 5-4
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w a m E -H u u u m m
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0

Cardiovascular Disorders
Musculo-Skeletal Disorders
Neurologic Disorders

Respiratory Disorders
Extrin. Allerg. Alveolitis
Pneumoconioses & Fibrosis
Chronic Bronchitis
Emphysema
Edema
Up. Resp. Tract Irrit.
Pneumonitis
Asthma
CA of Resp. Tract

Skin Disorders
Dermatitis
Skin Cancer

Dis. of Physical Haxards
Cold Stress
Heat Stress (Cramps,
stroke, etc.)
Hearing Loss

Poisonings
Lead Poisoning
Metal Fume Fever
Systemic Poisoning
(Miscellaneous)

Miscellaneous
Accidents
Allergy
Liver or Uro—Genital
Disorders

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Examples of Organizational Mechanisms for the Delivery
of Occupational Safety and Health Services

The examples provided below demonstrate the range of possible
organizational arrangements that have been implemented to deliver
occupational and non—occupational health care services to workers and
their families.

Example 1. A corporate health care management system addresses both
occupational and non—occupational health care services for workers (1).

In describing the program it is stated, ”the truth of the matter, of
course, is that any disease in an employee is influenced by the job. In
fact, the health of employees who have no demonstrable disease in the
ordinary sense is also significantly influenced by the job."

This program approach, termed Health Care Management (HCM), is based on
authority, provided voluntarily by the employee, for the company to
manage the health care provided to employees, a "mechanism through which
a positive effect on the real health of employees can be achieved while
containing health related cost and optimizing efficiency of the health
care system."

The Health Care Management concept is based on the premise, "that if the
health of an employee could be managed by competent professionals in the
company's medical department in its entirety, it would be possible ...
to guarantee that individual the best health for the longest time and to
guarantee that the health services delivered would be of the highest
quality at the lowest cost." The concept also suggests, "that if a
majority of the individuals in an industrial population were managed in
this way, the health care of the entire working population could, for
all practical purposes, be brought under effective control.”

HCM is divided into three levels, 1) management of a specific illness or
injury, 2) planning a lifetime health strategy for the employee, and 3)
the employee's full cooperation with the health plan outlined for him.

While this particular example indicates assumption of responsibility for
total health care, other approaches are developed based on variations of
this, often including only those health problems more specifically
associated with and attributed to the workplace.

Example 2. The Industrial and Occupational Health Clinic at the Peter
Bent Brigham Hospital, Boston, Massachusettes (2) "provides a type of
ambulatory health care to greater Boston employees and employers that is
not available in any other area hospital."

The clinic was started in 1959 for the purpose of providing medical
services and followup for persons with work-related injury or disease.

68

There is no formal arrangement with the employers that utilize the
service and after hours coverage is provided by the emergency room. The
clinic serves 5,000—6,000 patients per year. The staff consists of a
medical director, a nurse practitioner, a secretary and a receptionist.

This service has developed from an inhouse employee occupational safety
and health service into the provision of consultation and medical
services to local industry. This was accomplished by utilizing
resources of the Harvard School of Public Health in combination with the
hospital clinic.

Example 3. The problems involved in providing services on an
economically feasible basis to employees of small plants requiring
outside resources to support effective programs, are discussed (2).

The free standing industrial medical clinic servicing such industry has,
in the case of the Detroit Industrial Clinic, P.C., Southfield,
Michigan, proved to be an effective and economically feasible delivery
system for occupational safety and health services.

Example 4, One local health department in Ohio (3) has established an
occupational safety and health nursing and environmental consultation
service. The service is provided to local industry based on a
contractual arrangement with the health department for several hours of
nursing service per week at a nominal fee.

The nurse maintains the first aid station and provides employee health
counseling and other services as authorized by the employees family
physician, (e.g., administering medications, checking patient progress
etc.) In addition, walkthrough surveys, first aid services, routine
tests (blood pressure, T.B. skin testing), pre-employment histories,
recordkeeping, and health referral are provided.

The service, while not expanding significantly and providing minimal
services, has been well received by both employers and employees.

_§xamp;e_§, The Kansas "Program to Lower the Utilization of Services"
(PLUS) (4), should be of particular interest to health planners as it
developed out of the priority setting process required in State plan
development under P.L. 93—641. It "is a health promotion and
maintenance program geared to workers in business and industry...to
identify precursors to chronic illness...and to provide the worker with
incentive, information, opportunity, and support to change behavior by a
series of programs called "interventions". The program was modeled from
a test with health department employees. This will be followed by
introducing the concept to business and industry in the State. The
program is to be designed so industry can use all or part. The goal of
the agency is operational programs at the workplaces of at least 20
major employers. '

69

 

The project PLUS implementation scheme is based on adding it to employee
benefit packages. This will be shared by health insurers, employers,
employees, and government.

A major incentive of this program is the fact that insurers will be
asked to negotiate a premium rate lower than expected if the employer
participates in the prevention program. The local health department
staffs are considered a potential resource for the program operation.

Example 6. Rapid company growth and the Occupational Safety and Health
Act caused one company (5) to consider developing a new medical
facility. Other companies in the area were without occupational medical
services. The result, the Columbus Occupational Health Association, a
voluntary, non—profit association of business and industry for the
provision of comprehensive occupational medical services. The capital
for equipment, building, land, etc. was put up by one company. Services
are available on a fee-for—services basis. The growth has been
impressive, from the original seven to 100 businesses since 1970. This
will include a workforce of over 25,000 employed in business and
industry in 15 states.

Example 7. The Kimberly—Clark Corporation (6) has develOped a
comprehensive program of health management for salaried employees. The
company hopes for improved productivity, reduced absenteeism, and a
reduced rate of health and medical insurance cost increase.

It is described as one of the most extensive programs for illness
prevention for a large group of employers, in a company's own
facilities. The company spent $2.5 million for a 7,000 square—foot
multiphasic health testing facility and a 32,000 square-foot physical
fitness facility for the 2,100 employees at its corporate offices.

Example 8. One HSA, the Health Planning Council, Inc., (HPC) Madison,
Wisconsin, has ”a long standing commitment to the prevention of illness
and the promotion of health." (7) This is supported by a State
initiative for illness prevention and for wellness promotion. The work
place was identified as the health care setting with highest priority
because 1) employers are now motivated due to rising cost, 2)
reinforcement of improved behavior can take place in this setting, 3)
the work place is convenient, 4) the HPC service area had an existing
employee program usable as a base and local interest in expansion.

This model was developed by adding prevention components to an ”existing
Trouble Employee's Program...expanded to deal with both physical and
mental health and...basic screening services, consumer information,
health education, and other preventive services." Implementation is now
taking place with programs operational at the work places of three major
employers.

7O

 

These examples indicate the range of possible approaches to health care
delivery including occupational health, at th workplace. They further
demonstrate that the line between planning for health care services for
area residents and planning for occupational and non—occupational health
services for workers is indeed a fine one.

71

 

 

2A.

ZB.

REFERENCES

Collings, G.H., Jr., "Health — A Corporate Dilemma; Health

Care Management — A Corporate Solution." Egdahl, Richard H. (ed),
"Background Papers on Industry's Changing Role in Health

Care Delivery." Springer Series on Industry and Health Care,

No. 3, 1977.

"Development of Clinic—Based Occupational Safety and Health
Programs for Small Businesses" DHEW (NIOSH) Publication
No. 77—172, August, 1977.

Silver, Robert R., M.D., "Workshop: A Model System for the Delivery
of Occupational Health Services in a Pre—existing Medical Facility."

Kingsley, Barbara A., R.N.,N.P., "Workshop: Role of the
Clinic Nurse in the Provision of Occupational Health Services
for Small Businesses."

Ralston, Glenna, R.N.,B.S., "Keeping the Small Plant
Healthy". Ohio's Health, Vol.XXV, No. 9, September, 1973.

Lockhart, Virginia, M.P.H., "The Kansas Program for

Health Promotion for Workers in Business and Industry"
Presented at the 24th Annual Meeting of the Conference

on Health Training, APHA, Washington, D.C., November, 1977.

Weisenberger, B.W., "Companies Combine Resources in Midwest Medical
Facility" Journal of Occupational Health and Safety, November,
December, 1977.

"Kimberly-Clark Health Management Program
aimed at Prevention.” Occupational Safety and Health,
November, December, 1977.

Schramm, Carol Winkler, "Wellness in Wisconsin."
American Journal of Health Planning, Vol. 3, No. 3, July, 1978.

 

 

APPENDIX C
SELECTED BIBLIOGRAPHY OF REFERENCES AND DATA SOURCES
The following Bibliography has a two—fold purpose: 1) to describe
generally available sources of information of potential value in assessing

occupational health needs and 2) to cite basic reference works in occupa—
tional health which provide an overview useful in health planning.

73

 

 

Basic References in Occupational Safety and Health

This is a concise guide to industrial health problems with emphasis on
the specific associations which exist between occupations and disease.
The major types of occupational diseases and hazards are covered:
dermatoses, pneumoconioses, and effects of chemical, physical,
biological, and psychological hazards. The section dealing with
chemical hazards is especially detailed, noting for each compound
listed: local effects, systemic effects, route of entry, diagnostic
tests, and references for further information.

Hamilton, Alice and Hardy, H.L. "Industrial Toxicology." Third Edition
Publishing Sciences Group, Inc., Acton, MA., 1974.

For common industrial hazards, specific use, and harmful effects are
described. For substances, treatment and control are also discussed.
Especially valuable is the attention given types of compounds, e.g.,
aliphatic hydrocarbons, since it is in these forms that hazards are
generally encountered in industry. The book was written for physicians
and may at times be more detailed than desired. Extensive bibliography.

Hunter, Donald "The Diseases of Occupations," Fifth Edition.
The English Universities Press, Ltd., London, 1975.

Hunter has managed to synthesize two histories — the medical history of
workers' health problems and the industrial history of the 19th century.
His primary emphasis is clinical. However, he is mindful of the
importance of environmental factors in producing a clinical syndrome.
Consequently, he describes the chemical composition of the materials
handled in various occupations as well as their industrial processes
and work conditions. Also examined is the problem of health manpower
distribution and the European approach to occupational health services.

Hutchison, M.K. "A Guide to the Work-Relatedness of Disease." USDHEW
(NIOSH) Publication 77—123. U.S.Government Printing Office,
Washington, D.C., 1976.

This monograph addresses the complexities inherent in determining the
work—relatedness of disease. Factors associated with establishing the
link between disease and occupation are discussed. The book presents

a method for collecting, organizing, and evaluating medical, occupational,
and other evidence, which might be useful in establishing, for purposes

of workers' compensation, the work—relatedness of disease.

International Labour Office. "Encyclopaedia of Occupational Health and
Safety." Two Volumes. International Labour Office, Geneva, 1971.

74

 

These volumes are comprised of articles by experts from all over the
world. Drawing on the literature of many countries, the articles deal
with materials, industries, industrial processes, occupational diseases
and their treatment, early detection and prevention, and hazard control.

Key, M.M., et al. "Occupational Disease: A Guide to Their Recognition.”
National Institute for Occupational Safety and Health, (NIOSH).
Cincinnati, Ohio, 1977.

NIOSH. "Industrial Environment—Evaluation and Control." USDHEW, PHS, CDC,
NIOSH. Cincinnati, Ohio, 1973.

NIOSH Research Report, "Guidlines on Pregnancy and Work", DHEW (NIOSH)
Publication No. 78—118, Rockville, Maryland, September 1977.

The guidelines are a framework for the application of clinical judgement.
They are designed to help the practicing obstetrician assemble and
interpret the information necessary to make clinical recommendations

to protect the health of the pregnant worker and her fetus.

NIOSH, "Comprehensive Bibliography on Pregnancy and Work", DHEW (NIOSH)
Publication No. 78—132, Rockville, Maryland, March 1978.

A bibliography of English and foreign articles dealing with the
influence of the work and home environment on the health of mother
and fetus.

Patty, F.A. (Ed.). "Industrial Hygiene and Toxicology" (Vol. II) Third
Edition. John Wiley and Sons, New York, In press.

As its title suggests, this is a basic reference in industrial hygiene.
Volume II discusses groups of materials commonly used in industry and, for
each, notes the following: (1) sources, uses, properties, and industrial
exposures, (2) physiological response, and (3) Threshold Limit Values. For
many compounds, methods of environmental monitoring and warning properties
are listed. A final chapter examines occupations and industries of

special interest to industrial hygiene. It has excellent references and
extensive bibliography.

Zenz, Carl (Ed.) "Occupational Medicine: Principles and Practical
Applications." Yearbook Medical Publishers, Inc., Chicago,
Illinois, 1975.

Zenz examines the role small business, hospital clinics, and community
out—reach efforts can play in providing occupational health services
within the context of an industrial hygiene and occupational medicine
program. He deals with major types of diseases and major types of
controls available. Special attention is given to industrywide problems
such as dermatoses and occupational hearing loss, as well as to the many
parties who can influence the healthfulness of a workplace.

The chapters of this syllabus were written by a group of distinguished
professionals selected from industry, universities, consultant groups

75

  

 

and government, to reach the beginners in the profession. It

compiles into one source the diversity of expertise needed to attain
competency in the recognition, evaluation, and prescription of methods
of control of environmental problems.

Data Sources
I. Industry -— Employment Data Source

A. County

"Census of Agriculture, 1974: Area Reports" (Volume I). Bureau of the
Census, Department of Commerce. Government Printing Office,
Washington, D.C., 1972.

Published every five years, these reports list the number of farms,
types of crops raised, chemicals used, and machinery on hand. Number of
employees is not listed. In addition, "Special Reports" (Volume V of
this series) gives detailed information on aspects of the agricultural
industry, e.g., dairy farming.

"Census of Manufacturers, 1972: Area Reports” (Volume III). Bureau of
the Census, Department of Commerce. Government Printing Office,
Washington, D.C., 1972.

For cities, counties, and SMSA's, detailed statistics regarding employment,
production, payroll, and work conditions are presented. "Location of
Manufacturing Plants” shows the number of manufacturing plants by size

and by county. ‘

"County Business Patterns.” Social and Economics Statistics Administration,
U.S. Department of Commerce. Washington, D.C., 1973.

Published annually since 1964, this series lists the number of
establishments in each SIC as well as the number of production workers
and the total number of employees for each group. Government, most
railroad, self—employed, domestic service, and agricultural workers are
not included, nor are employees of ocean borne vessels. Available from
the Superintendent of Documents, U.S. Government Printing Office,
Washington, D.C. 20402, or often in local libraries.

"Division of Employment Security,”
County State

DES keeps a listing by county and SIC of the number of persons employed and the
number of establishments. This is usually the most timely source

available for these items. This Division can generally be located by
contacting the State Department of Labor. It is likely to be useful, not

only for the timeliness of its data, but also for detail not easily

obtainable elsewhere, e.g., agricultural employment and names of

76

  

 

establishments.

 

”Industrial and/or Manufacturing Directories."

These are usually published annually for each state and are usually available
for the previous five years. In most cases, the following items

are included for each establishment: address, product,

SIC, number of employees, year established, and name

of person to contact regarding general information. These directories
exclude agricultural and government establishments, most service

industries, and many construction and home businesses. Since a fee is
sometimes charged for listing, many small manufacturers may not be included.

B. SMSA and Large Areas

"Census of Mineral Industries, 1972." U.S. Bureau of the Census, Department
of Commerce. Washington, D.C.

Data for this census is aggregated solely by regions to ensure the
industries' confidentiality. The following information is assembled by
SIC, by type of establishment, and by region: number of establishments,
number of employers, total wages, total man hours. Information will be
useful to the HSA to the extent that it gives a sense of the Regions'
relative involvement in a particular mining industry.

"Census of Retail Trade, 1972." Area Statistics, (Volume II and III).
U.S. Bureau of the Census, Department of Commerce. Washington, D.C.

This is published every five years. For SMSA's and major retail centers,
it notes the number of establishments and employees by SIC.

"Employment and Earning," (Volume 23 #5). Bureau of Labor Statistics,
Department of Labor. Washington, D.C.

This is a monthly serial which lists the number of employees, average
weekly and hourly earnings, and average hours worked by SIC. Production
workers are separated from total. It also examines labor turn—over.

The number of "quits" (voluntary termination of employment, including
health) by SIC, and the unvoluntary termination of employment,
(including health) by SIC are listed for the nation, states, and
metropolitan areas.

II. Disease and Injury Data Sources

A. County

Mason, T.J. and McKay, F.W. "U.S. Cancer Mortality: 1950—1969." U.S.
Cancer Institute, National Institutes of Health (DREW—NIH 74—6—15).
Bethesda, Maryland, 1974.

77

 

 

The total number of cancer deaths for each county in the U.S. during the
period 1940—1969 is presented. Also included by county are age—adjusted
death rates according to sex, race, and site of neoplasm. The county
referred to is the county of usual residence as it is recorded on the
death certificate. The total U.S. population for 1960 is used as the
standard for the period.

"Vital Statistics of the United States: Annual Mortality Report, 1974."
Mortality (Volume II). National Center for Health Statistics,
U.S. Department of Health, Education, and Welfare. Government
Printing Office, Washington, D.C., 1975.

This lists the number of deaths by county for selected diseases.

"Vital Statistics of (state), 1975." Division of Vital Statistics,
State of .

 

This publication usually lists death rates by cause for the state,
making allocations for broad disease categories to counties. Industrial
accidents and deaths investigated are specifically enumerated.

B. National
"Federal Railroad Administration"

This department keeps all statistics relating to railroad employees, a
group often excluded from workforce statistics gathered by the Department
of Labor. Publications are available through the U.S. Department of
Transportation. Principal health and safety publications are:

”FRA Guide for Preparing Accident/Incident Reports, 1975."

This book contains a list of all reports which must be filed as well as extensive
definitions of terms included in the reports. It is necessary for
interpretation of FRA statistics.

"Accident Bulletin: Summary and Analysis of Accidents on Railroads in the
United States (No. 143)."

This annual publication includes selected ten year history tables
showing trends, detailed tabulations of casualties, and damages by cause
and by railroad. A monthly report, "Summary of Accidents/Incidents
Reported by All Line Haul and Switching Terminal Railroad Companies" is
also published.

"Preliminary Report of Railroad Accidents/Incidents and Resulting
Casualties, April, 1976."

The equivalent of OSHA's reporting form, this monthly publication
enumerates accidents, fatalities, injuries, and illnesses (called incidents).

"Minerals Yearbook, 1973." U.S. Bureau of Mines and Mining Enforcement
Safety Administration, Department of the Interior.

78

This annual report lists the number and type of injuries by SIC within
mining and discusses in summary fashion, employment, injury, and
technological trends.

”Occupational Injuries and Illnesses in the United States by Industry, 1974."
Bureau of Labor Statistics, U.S. Department of Labor. Washington, D.C.

Based on a sample of 650,000 OSHA summary reports, this survey lists
number and incidence rates for disease and accidents by SIC and industry
size, and type of disease as a percent of the total.

III. Related References

"Occupational Employment in Manufacturing, 1971." Series 430 #1-113.
Bureau of Labor Statistics, Department of Labor. Washington,
D.C., 1974.

In this series, 113 selected industries as defined by SIC are described.
Each industry is analyzed with respect to its occupations, principal
locations, and distribution of establishments and size.

"Standard Industrial Classification Manual." Bureau of the Budget,
Government Printing Office, Washington, D.C., 1972.

This taxonomy is used to classify places of employment by major type of
activity. Factories, businesses, and farming establishments are included.
Statistical data collected by the U.S. Government, state agencies, and
trade associations are usually assembled using these categories.

Any industrial establishment can be classified. The classification is
three-tiered. A two—digit classification represents the broadest category,
e.g. manufacturing. Within each two—digit classification are three— and
four-digit refinements. The three-digit classifications tend to represent
specific functional divisions within the greater category. The four—digit
classification usually gives a more detailed breakdown of the industrial
activity.

"Detailed Characteristics, (state): 1970." Social and Economic Statistics
Administration, Department of Commerce. Government Printing
Office, Washington, D.C., 1972.

These volumes contain demographic information based on current census and
compiled for small areas including counties.

"State Estimates of Disability and Utilization of Medical Services,
1969—71." Health Resources Administration DHEW Pub. #(HRA) 77—1241.
Government Printing Office, Washington, D.C.

Using the Health Interview Survey and population estimates from the 1970
Census of Population, state estimates of health services used have been

79

compiled. An assumption is made that a state's health—related character-
istics will differ from national estimates only to the degree that social
or demographic characteristics deviate from the national profile. Health
related services examined are: limitation of activity due to chronic
conditions, short term disability days, utilization of short-stay hospitals,
utilization of physicians, and dental services.

"Census of Construction Industries, 1972." (Volumes I and II). U.S.
Bureau of the Census, Department of Commerce. Washington, D.C.

Every five years the Bureau samples 1,000 establishments and estimates

the following: number of establishments by size, average number of
employees, mean number of construction workers per establishment, mean number
of all other employees, and the number of employers.

"Employment and Earnings: Household Interview Data, November, 1976." Bureau
of Labor Statistics, Department of Labor, Washington, D.C.

This monthly survey is designed to estimate (1) characteristics and
past work experience of unemployed, and (2) number who left a job or
took reduced employment as a result of illness or disability.

"National Safety Council." 444 North Michigan Avenue, Chicago, Illinois.

This public service organization is a major source of accident statistics
and safety information. Services include specialized journals,
newsletters, and educational equipment.

"Program on Current Employment Analysis." Bureau of Labor Statistics.
U.S. Department of Labor. Washington, D.C.

Using data gathered by the Bureau of Census's Current Population Survey,
this program analyzes special aspects of the labor force. Estimates are
published monthly of characteristics such as age, sex, race, ethnicity,
marital status, occupation, industry, and class of worker. Special
topics are covered on a one-time or annual basis. These include:
characteristics of special groups in the labor force, long-range
projections of the labor force, tables of work life expectancy, and
socio—economic studies of the American worker.

"Social Security Administration." Department of Health, Education, and
Welfare. Baltimore, Maryland.

Because most workers in the U.S. are covered by Social Security, this
Department is a valuable source of industry—occupation information as
well as disability statistics. Data available to the public include:

1. Beneficiary Data (OSADI—SSI) —— Data on primary diagnosis and
occupation of disabled workers under the Social Security Program
and the supplemental Security Income Program. These are maintained

80

 

through separate statistical systems. A stratified state sample
secures information for approximately 25% of each year's new awards.
Neither county nor SMSA data are available.

2. Continuous Disability History Sample (CDHS) —— A partial sample of
disabled workers is coded annually. The following information is
stored for each worker sampled: primary diagnosis, occupation, county
of residence, SIC. County of residence was not stored between
1970 and 1975.

3. Basic Statistical Data Files -— Four 1% samples are drawn annually
from the universe of social security numbers for which employment
was reported that year. These are:

a. Employee-Employer Sample (EE — ER) —— Relevant data elements
include demographic information, wage, industry (SIC), and county
of employment.

b. Self—Employed Sample (SE) -— This is identical in analysis to
EE-ER with the exception that benefit status is also included.

c. Longitudinal Employee-Employer Data Sample (LEED) —— This file
merges EE—ER files for an extended period with the result that
all of the records associated with a single employee over the
time span of the file appear together and in sequence.

4. Social Security Disability Statistics, 1975 —- Social Security
Administration, Department of Health, Education, and Welfare.
Washington, D.C.

This publication lists characteristics of applicants for whom
determinations were made during the proceeding calendar year including:
(1) disability rates by state, (2) disease rates by state, (3)
occupation by diagnostic group, and (4) occupation by state.

Other Resources

"Analysis of Workmen's Compensation Laws, 1975." U.S. Chamber of Commerce.
Government Printing Office, Washington, D.C., 1975.

This study describes the coverage available under law to workers in the
United States for job—related accidents and illnesses.

Bingham, Eula (Ed.) Proceedings: "Conference on Women and the Workplace."
Society for Occupational and Environmental Health,
Washington, D.C., 1977.

This meeting addressed the subject of placement of workers in high risk

areas, sex related health risks associated with job placement patterns, and

81

    

  

current legislation and its implications for women workers.

Burkart, J.A. and de Groot, N.F. ”An Analysis of Worker's Compensation
Case Data in Agriculture." ARAL Program (TR201—001). Utah Biomedical
Test Laboratory, Salt Lake City, Utah, November, 1975.

This report analyzes 84,576 case records of agricultural workers who
suffered occupational—related illnesses or injuries in six states and
Puerto Rico. Data availability and limitations are discussed.

Carnow, B.W., et al. "A Bookshelf on Occupational Health and Safety."
65:503—520. American Journal of Public Health, 1974.

Lists major texts, important articles, and the most significant symposium
and conference proceedings using the following topic headings: Industrial
Hygiene and Toxicology, Safety and Accident Prevention, Occupational
Medicine, Legislation, and Source of Information.

Discher, D.P., Kleinman, G.D., and Foster, J.F. "Pilot Study for
Development of an Occupational Disease Surveillance Method."
USDHEW (NIOSH) 75-162. Government Printing Office, Washington,
D.C., 1975.

Presents the results of a pilot study designed (l) to determine the
utility of procedures designed for finding occupational disease in a
cross-sectional survey, and (2) to ascertain how much new data the

method would generate. The survey questionnaire is included.

This monograph is useful in that its findings illustrate the potential

for index—reporting of occupational health problems and presents an
instrument of possible usefulness in a local survey or plant investigation.

”National Clearing House for Alcohol Information (NCAI)." Rockville,
Maryland.

This organization offers numerous services to those interested in
alcoholism, whether for purposes of research, treatment, or service
delivery. Alcoholism is an occupational problem in that two of its
major consequences are absenteeism and industrial accidents. The
following is by no means an exhaustive list of NCAI publications and
services.

Bibliographic References —— These are available "on-line.” NCAI will
search a topic of your choice, e.g. "Alcoholism and Occupational Safety."

Hayward, B.J., Mathews, C.M., and Threat, R.M. "Occupational
Programming: An annotated Bibliography." (FR 30—75). Human
Ecology Institute, Raleigh, North Carolina, July, 1975.

”Alcohol and Health: Second Special Report to the U.S. Congress from the
Secretary of HEW. (017—024—00 399). U.S. Government Printing Office,

82

Washington, D.C., June, 1974.

This compilation of recent research describes broad areas where alcohol
is a problem. Of special interest are the sections dealing with the
health consequences of alcohol use, and with "problem drinkers on the
job."

National Council on Alcoholism, Inc., 733 Third Avenue, New York, N.Y.

This voluntary organization publishes materials particularly useful in
health education. Selections from their Department of Education and
Prevention and Labor and Management follows:

Trice, Harrison. "Alcoholism in Industry, Modern Procedures."

"Advances in Secondary Prevention of Alcoholism through the Cooperative
EffOrts of Labor and Management in Employer Organizations."

"Company/Union Programs for Alcoholics.”
"Health Insurance Coverage for Alcoholism."

Rose, V.E. "Reliability and Utilization of Occupational Disease Data." U.S.
Department of Health, Education, and Welfare, Public Health Service,
Center for Disease Control, NIOSH, 1977.

Recommendations are presented for the modification of the occupational
disease surveillance system used in the U.S. The primary focus

involves the development and application of guidelines for determination
of specific diseases with emphasis on surveillance as a by—product of
prevention. The goal of the recommendation is to make occupational
disease reporting a part of the overall control effort.

"Health Planning Related to Environmental Factors." United States
Department of Health, Education, and Welfare, Bureau of
Health Planning Resources Development. Government Printing
Office, Washington, D.C., In press.

Developed by Drexel University under contract no. HRA 230-76—0247,

this report includes one volume of guidelines to HSA's regarding a
general approach to dealing with environmental hazards in developing
HSP's and AIP's. It also includes four volumes which provide
illustrations of specific strategies in the acqusition of data, setting
of goals and objectives, and analysis of actions and resources

needed to effecuate plans for health status and health systems
improvement.

"Directory of Poison Control Centers." (FDS 72-7001). United
States Department of Health, Education, and Welfare, Division of
Hazardous Substances and Poison Control. Government Printing

 

Office, Washington, D.C., 1971.

Lists over 600 centers which provide for the medical profession on a 24-
hour basis, information concerning the treatment and prevention of
accidents involving poisons or potentially poisonous substances.

"Directory of Health Officers, Registrars, Principal Statisticians,
and Research Directors in the United States." United States
Department of Health, Education, and Welfare, National Center
for Health Statistics, Rockville, Maryland, 1977.

A list by state of the names, titles, organizational locations and
telephone numbers of health officers, etc. Published annually.

”Selected National Data Sources for Health Planners.” (DHEW (HRA) 76—1236).
United States Department of Health, Education, and Welfare,
National Center for Health Statistics, Rockville, Maryland.

A survey of existing data sources which may be useful to health planners.

The name, maintaining agency, data elements and the manner aggregated are

specified.

”Criteria Documents.” United States Department of Health, Education
and Welfare, NIOSH. Government Printing Office, Washington, D.C.

These reports contain official NIOSH recommendations to OSHA for

occupational health standards, and evaluations of supporting scientific

evidence. There are 80 of these documents thus far, each dealing with a

specific industry, substance, or group of substances. Major sections of

each are: recommendations for a standard, biologic effects of exposure, '
environmental data, engineering controls, and work practices. These may

be useful for details about an industry or hazardous agent.

Seidman, Bert, AFL-CIO; Binns, Gordon W., Jr., General Motors Corporation;
Co—Chairman. "Labor—Management Group Position Papers on Health
Care Cost." Labor-Management Staff Health Care Task Force, 1978.
Department of Social Security, AFL-CIO, Washington, D.C.

84

 

 

 

APPENDIX D

Sample Worksheets for Development of an Industrial Profile

The worksheets which follow have been designed to facilitate the
development and use of an industrial profile for a planning area. They
are provided to demonstrate one method of displaying summary information
on area industry including a listing of potential exposures to hazardous
substances and physical agents. This information will indicate some
occupational conditions, diseases, and injury types of importance in the
health service area. In addition, it will provide a basis for the
development of goals, objectives, and implementation strategies for
environmental control, health education, and the delivery of medical
services.

The worksheets are intended to help the HSA select those industrial
classifications and occupational categories which are most appropriate
for emphasis in the HSP and ATP. Specifically, this will identify major
employers and potential exposures of the employees to health and safety
hazards. It also identifies the community resources available to
effectively deal with the identified problems, resource gaps, and
resource coordination. Therefore, this or a similar process of
information collection and analysis should be carried out to identify
the high priority occupational problems, resources, and resource gaps.

85

Worksheet I

MAJOR INDUSTRIES

Rank order by size of employment the HSA's largest three-digit SIC's.
List number of employees and number of establishments for each.

Number Number Hazardous Associated
Rank SIC Employees Establishments Exposures * Diseases *

 

10

ll

12

13

14

15

TOTAL

% of Total Working Population

* See Appendix B

86

 

 

 

Worksheet IIa

INITIAL GROUP AND AGENCY CONTACT

 

Contact OSHA, NIOSH, state unions, and state employer associations to
gain an overview of current occupational health and safety activities.

OSHA

Designation Person to Contact Current Activities

 

87

 

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Worksheet IIc.

NIOSH

Based on information obtained from the Regional Office and any
appropriate National Office, note the following:

 

Designation Person to Contact Surveys, Investigations
and Evaluations

 

89

 

 

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Worksheet IV

INITIAL SIC SELECTION

Based on the preceding information, select those SIC's which seem
apprOpriate for further examination and possible emphasis in the HSP.
The following factors should be considered in the process of selection:
1) size of workforce; 2) number of establishments; 3) nature of
hazardous exposures and associated diseases; 4) information obtained
from OSHA, NIOSH, unions, or other agencies contacted; and 5) available
occupational safety and health resources.

Complete the following chart including major groups and agencies within
the Health Service Area which may be of specific help regarding the
selected SIC's.

SIC Reason for Inclusion Resources to be Consulted Comments
(1, 2’ 3’ 4’ 5)

 

 

 

 

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APPENDIX E

DHEW REGIONAL OFFICES

Region I — Boston, Massachusetts,
Connecticut, Maine, Massachusetts,
New Hampshire, Rhode Island,
Vermont

Region II - New York, New York,
New Jersey, New York, Puerto Rico,
Virgin Islands

Region III — Philadelphia,
Pennsylvania, Delaware, District
of Columbia, Maryland, Virginia,
West Virginia

Region IV — Atlanta, Georgia,
Alabama, Florida, Georgia, Kentucky,
Mississippi, North Carolina,

South Carolina, Tennessee

Region V — Chicago, Illinois,
Illinois, Indiana, Michigan,
Minnesota, Ohio, Wisconsin

Region VI - Dallas, Texas,
Arkansas, Louisiana, New Mexico,
Oklahoma, Texas

Wesley E. Straub

Regional Consultant, NIOSH

DHEW, Region I

Government Center (JFK Fed. Bldg.)
Boston, Massachusetts 02203

Tel: 617/223-6668

Mary L. Brown, R.N.

Regional Consultant, NIOSH

DHEW, Region III — Fed. Building
26 Federal Plaza

New York, New York 10007

Tel: 212/264—2485

William E. Shoemaker

Regional Consultant, NIOSH

DHEW, Region III

P.0. Box 13716

Philadelphia, Pennsylvania 19101
Tel: 215/596-6716

C. Paul Reper

Regional Consultant, NIOSH
DHEW, Region IV

101 Marietta Tower, 502
Atlanta, Georgia 30303
Tel: 404/221-2396

FTS: 242-2396

Richard Kramkowski
Regional Consultant, NIOSH
DHEW, Region V

300 South Wacker Drive
Chicago, Illinois 60607
Tel: 312/886-3881

George L. Pettigrew

Regional Consultant, NIOSH

DHEW, Region VI

1200 Main Tower Bldg., Rm. 1700-A
Dallas, Texas 75202

Tel: 214/767—3916

FTS: 729-3916

 

 

 

(REGIONAL OFFICES - Continued)

Region VII - Kansas City, Missouri,

Iowa, Kansas, Missouri, Nebraska

Region VIII - Denver, Colorado,
Colorado, Montana, Utah, Wyoming,
North Dakota, South Dakota

Region IX — San Francisco,
California, Arizona, California,
Hawaii, Nevada

Region X — Seattle,Washington,
Alaska, Idaho, Oregon, Washington

Ralph J. Bicknell

Regional Consultant, NIOSH
DHEW, Region VII

601 East 12th Street

Kansas City, Missouri 64106
Tel: 816/374—5332

FTS: 758—5332

Stanley J. Reno

Regional Consultant, NIOSH
DHEW/PHS/Prevention — Region VIII
11037 Federal Building

Denver, Colorado 82094

Tel: 303/837-3979

FTS: 327-3979

Douglas L. Johnson

Regional Consultant, NIOSH

DHEW, Region IX

50 United Nations Plaza - Rm. 231
San Francisco, California 94102
Tel: 415/556-3781

Walter E. Ruch, Ph.D.

Regional Consultant, NIOSH

DHEW, Region X

1321 Second Avenue (Arcade Bldg.)
Seattle, Washington 98101

Tel: 206/442—0530

FTS: 399-0530

95

   
  
 
    
  
   
 
   
   
 
 
   
   
   
   
 
 
   
   
 
   
   
 
    

EDUCATIONAL RESOURCE CENTER PROGRAM DIRECTORS

Marcus M. Key, M.D.

The University of Texas Health
Science Center

P.0. Box 20186

Houston, Texas 77025

(713) 792—4300

Gareth M. Green, M.D.

The Johns Hopkins University

School of Hygiene and Public Health
615 North Wolfe Street

Baltimore, Maryland 21205

(301) 935—3720 or 3537

David A. Fraser, Sc.D.

Dept. of Environmental Sciences and
Engineering

School of Public Health

University of North Carolina

Chapel Hill, North Carolina 27514

(919) 966—1023

John T. Wilson, M.D., Sc.D.

Dept. of Environmental Health

University of Washington

Seattle, Washington 98195 '
(206) 543—6991

Raymond R. Suskind, M.D. ‘
Dept. of Environmental Health

University of Cincinnati

College of Medicine

3223 Eden Avenue

Cincinnati, Ohio 45267

(513) 872—5701

John M. Peters, M.D., Sc.D.
Harvard University

School of Public Health

665 Huntington Avenue
Boston, Massachusetts 02115
(617) 732—1260

Conrad P. Straub, Ph.D.
University of Minnesota
School of Public Health

420 Delaware Street, S.E.
Minneapolis, Minnesota 55455
(612) 373-8080

 

 

(ERC'S - Continued)

Herbert K. Abrams, M.D.

Dept. of Family and Community Medicine

University of Arizona
Health Sciences Center
Tucson, Arizona 85724
(602) 882—6244

Bertram W. Carnow, M.D.

School of Public Health

University of Illinois at
the Medical Center

P.0. Box 6998

Chicago, Illinois 60680

(312) 966—7811

Irving J. Selikoff, M.D.

Mt. Siani School of Medicine
5th Avenue and 100th Street
New York, N.Y. 10029

(212) 876-1178

William N. Rom, M.D.
University of Utah

Medical Center

DFCM, Room BC 106

Salt Lake City, Utah 84132
(801) 581-8719

97

OSHA REGIONAL OFFICES

Region I

U.S. Department of Labor

Occupational Safety and Health Administration
18 Oliver Street, Fifth Floor

Boston, Massachusetts 02110

Telephone: 617/223—6712/3

Region II

U.S. Department of Labor

Occupational Safety and Health Administration
1515 Broadway (1 Astor Plaza)

New York, New York 10036

Telephone: 212/971—5941/2

Region III

U.S. Department of Labor

Occupational Safety and Health Administration
15220 Gateway Center, 3535 Market Street
Philadelphia, Pennsylvania 19104

Telephone: 215/597-1201

Region IV

U.S. Department Of Labor

Occupational Safety and Health Administration
1375 Peachtree Street, N.E., Suite 587
Atlanta, Georgia 30309

Telephone: 404/526-3573/4 or 2281/2

Region V

U.S. Department of Labor

Occupational Safety and Health Administration
300 South Wacker Drive, Room 1201

Chicago, Illinois 60606

Telephone: 312/353—4716/7

Region VI

U.S. Department of Labor

Occupational Safety and Health Administration
7th Floor, Texaco Building,

1512 Commerce Street

Dallas, Texas 75201

Telephone: 214/749-2477/8/9 or 2567

Region VII

U.S. Department of Labor

Occupational Safety and Health Administration
Waltower Building, Room 300, 823 Walnut Street
Kansas City, Missouri 64106

Telephone: 816/374—5249 or 5240

98

 

 

(OSHA REGIONAL OFFICES - Continued)

Region VIII

U.S. Department of Labor

Occupational Safety and Health Administration
Federal Building, Room 15010, 1961 Stout Street
Denver, Colorado 80202

Telephone: 303/837-3883

Regional IX

U.S. Department of Labor

Occupational Safety and Health Administration
9470 Federal Building, 450 Golden Gate Avenue
Post Office Box 36017

San Francisco, California 94102

Telephone: 415/556—0584

Region X

U.S. Department of Labor

Occupational Safety and Health Administration
1808 Smith Tower Building, 506 Second Avenue
Seattle, Washington 98104

Telephone: 206/442—5930

99 g,- U.S. GOVERNMENT PRINTING 0mm I978-757-l4l/1845 Region No. 5-”

 

 

DEPARTMENT OF
HEALTH. EDUCATION. AND WELFARE
PUBLIC HEALTH SERVICE

CENTER FOR DISEASE CONTROL
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
ROBERT A. TAFT LABJRATORIES
4676 COLUMBIA PARKWAV. CINCINNATI. OHIO 45226

OFFICIAL BUSINESS
PENALTY FOR PRIVATE USE. saoo

—
usmuL
—

POSTAGE AND FEES PAID
U 5. DEPARTMENT OF MI W

NEW 396

DHEW (NIOSH) Publication No. 78-203