Occupational
Safety and Health
PH 150
11/17/08
Population Health




Focuses on improving health of
communities – saves lives millions
at a time, not just one at a time
Prevents disease and disability
Promotes healthy environments
and behaviors
Assures high quality, cost-effective
health care
Linkages and Overlaps
Public/Health
Care Systems
Population
Health
Personal
Health
20th Century Advancements
In the 20th Century public health
worked hand in hand with medical
advances to:




Decrease infant mortality by 99%
Reduce the incidence of coronary
disease by 51%
Eradicate many crippling and deadly
infectious diseases
Add 25 years to our lifespan
Investments Not Effectively
Targeted
The 97/3 Problem
Population Health
3%
Health care
97%
Investments Not Effectively
Targeted
Value of Investment
Population
Health
Individual Healthcare
…”the one thing that we all really care about: a medical
system that focuses on our lifelong health and prioritizes
prevention as much as it does treatment.”
Bill Gates, Wall Street Journal, 10/05/07
An Ecological Model of Health
Population health modeled on evidence
that there are multiple determinants of
health





Medical care
Behavior
Biology (genetics)
Physical
environment
Social environment




Education
Socioeconomic Status
Employment
Housing
Magnitude of the Problem


10 million work-related injuries/year
430,000 new work-related
diseases/year
Each day:
 9,000 sustain disabling injuries
 16 die from injury
 137 die from work-related disease
Annual Toll of Occupational
Injury and Illness
Injuries
 Fatal
 Non-fatal*
 Total costs
Diseases
 Fatal**
 Non-fatal
 Total costs
* 46% disabling (6.09 million)
** Based on cancer, cardiovascular disease, chronic
respiratory disease, neurologic and renal disorders
6,529
13.25 million
$145 billion
60,300
862,200
$26 billion
Costs in Billions
Annual Economic Burden of
Disease and Injury
200
180
160
140
120
100
80
60
40
20
0
171
164
170.7
Circulatory
Diseases
Cancer
67.3
33
Occupational
Diseases and
Injuries
1997; Leigh et al. Arch Int Med.
AIDS
Alzheimer
Disease
Global Burden of Occupational
Injury and Illness

Among 2.7 billion workers
 Each year:
 2 million deaths from disease
and injury
 270 million workers sustain nonfatal injuries
 12 million injuries among youth
workers (12,000 fatal)
 4% gross domestic product
(GDP) lost per year
Occupational Risk Hazards
Attributable Fraction (%) of Global Disease and Injury
Due to Occupational Risk Factors
32
Low Back Pain (37)
41
11
Hearing Loss (16)
22
6
COPD (13)
18
7
Asthma (11)
14
Unintentional Injuries
(10)
2
15
Trachea, bronchus
or lung cancer (9)
5
10
2
2
Leukemia (2)
0
10
20
Male
30
Female
40
50
THE US WORKFORCE
Size of workforce:
Unionized:
Unemployed:
140 million
12%
6.5%
Changing Demographics
Projected Changes in Civilian
Labor Force 2004 to 2014
2004
50
45
40
35
30
25
20
15
10
5
0
2014
46.8
46.4
35.7
31
21.2
15.6
Minorities
Over Age 55
Women
Women Participating in the
Global Workforce
Developed Countries







Sweden and Denmark
United States
France and Germany
Switzerland
Netherlands
Italy
Spain
Source ILO, 1995
% of women who work
75%
60%
57%
53%
38%
37%
26%
Women Participating in the
Global Workforce
Developing Countries
 China
 Mozambique
 Vietnam
 Thailand
 Brazil and Chile
 Mexico /Argentina
 Egypt, Saudi Arabia,
Oman, and Jordan
 Algeria
* Includes the informal workforce
% of women who work*
80%
78%
77%
67%
33%
32%
10%
8%
Source, ILO, 1995
Aging Workforce
Workers Over Age 60
20
percent
15
1995
2030
10
5
0
Japan
Source Health Affairs, May/June 2000
U.S.
France
Projected Changes in
Employment by Industry
80
Percent of Total
70
60
50
1986
1996
2006
40
30
20
10
0
Goods Producing
Source: Franklin, 1997
Service Producing
Growth of the
Contingent Workforce
30
Millions
25
20
15
10
5
19
70
19
75
19
80
19
85
19
90
19
95
20
00
20
05
0
Source: Bureau of Labor Statistics
Temporary employees
Part-time workers
Multiple-job holders
Self-employed
workers
Informal Sector


Majority of new jobs in developing countries
Subcontracting


Household-based


Independent, cater to markets at low end of income
scale
Unpaid female labor, family members
Independent service sub-sector


ILO 1999
Bulk of informal sector, lowest skills
Maids, street vendors, cleaners, casual unskilled
laborers
Informal Workforce
(% of Total Urban Employment)







ILO 1999/WHO 1995
Africa – 60%
Bolivia and Madagascar– 57%
Tanzania – 56%
Colombia – 53%
Thailand – 48%
Venezuela – 46%
Industrialized Countries – 5-10%
Annual Hours Worked
United States
1,966
Japan
1,889
Canada
1,732
Britain
1,731
Norway
1,399
0
500
1,000
1,500
2,000
Average annual number of hours worked per person
Source: International Labor Organization (1999)
2,500
Changing Nature of Work:
Increased Stress
Three-fourths of employees
believe the worker has more
on-the-job stress than a
generation ago
Work Organization/Stress Severity of the Problem




No good surveillance systems and few studies in
the U.S.
Estimated 13% of U.S. worker compensation
claims are for stress-related disorders
27% of U.S. workers reported jobs are greatest
single source of stress
60% sampled women workers cited job stress as
biggest problem at work
Employment Trends Index (ETI)
and Labor-Market Indicators








Percentage saying “jobs hard to get”
Initial claims for unemployment insurance
Percentage of firms with one or more jobs
open
Number of employees hired by temporaryhelp industry
Part-time workers for economic reasons
Job openings
Industrial production
Real manufacturing and trade sales
U.S. Health System:
You Don’t Get What You Pay For




Highly fragmented at all levels
Most expensive (16.3% of gross
domestic product)
One of least accessible (48 million
uninsured, more underinsured)
U.S. pays for half of all personal health
care (e.g. Medicare/Medicaid, DOD, VA,
federal worker insurance)
U.S. Health System:
You Don’t Get What You Pay For, con’t.

WHO ranked 191 countries



U.S. 37th in overall performance
U.S. 24th in overall health attainment
U.S. among its peers

Of 29 countries in OECD—Organization for
Economic Cooperation and Development



Ranked 23rd in infant mortality
Ranked 21st in male life expectancy
Met only 15% of Healthy People 2000 objectives
(deteriorated in 20% of objectives)
Does Being Uninsured
Matter?
YES




20% uninsured (vs. 3% insured) did not get
medical care for a serious medical problem
30% uninsured (vs. 12%) did not fill a
prescription
39% uninsured (vs. 13%) skipped a
recommended test or treatment
13% (vs. 4%) had trouble getting mental
health care
Percent
Employer-Sponsored Health
Insurance
72
70
68
66
64
62
60
58
56
54
52
1987
1991
Source: U.S. Census Bureau/ Kaiser Family Foundation
1995
1999
2003
2006
Insurance for Work-Related
Conditions



Workers’ compensation no fault, state
by state
Illnesses > injuries often contested
Worker may be uninsured or
underinsured for set of conditions
despite being deemed fully insured
Occupational Injuries in U.S.
Incidence
rates of nonfatal occupational injuries (total recordable cases) by
selected industry sectors, 1980 - 2000
20
Injury rate per 100 full-time workers
18
16
14
12
10
8
6
Agricultural production
Construction
4
Nursing and personal care
2
0
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Year
Health Care Industry



Health care workers = 8% of U.S.
workforce
1996-2006: 2 of the 4 fastest growing
industries are HC-related (health services
and health practitioners’ offices)
Health care services are growing at twice
the rate of the overall economy
Health Care Worker Hazards

Biological hazards
bacteria, viruses, fungi, parasites

Chemical hazards
medications, solutions, gases

Physical hazards
radiation, electricity, extreme temperatures,
noise, lifting

Psychosocial hazards
factors causing stress, emotional strain,
interpersonal problems
Needlestick Injuries



Exposure to bloodborne pathogens (HIV,
Hepatitis B, and Hepatitis C)
In the United States, approximately 800,000
needlestick injuries occur in hospitals annually
-- an average of one injury every 10 seconds
1/3 of all sharps injuries have been reported
to occur during disposal activities
Infections in Health Care Workers
(35 million worldwide)
Percentage
Attributable fraction of Hep C, Hep B and HIV
Attributable
fraction
of Hep care
C, Hepworkers
B and HIVdue
infections
in healthcare
infections
in health
to injuries
workers
due to ages
injuries
with contaminated sharps, ages 20-65
with sharps,
20-65
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
HCV
HBV
HIV
Africa
Americas E Med.
Europe
SE Asia W Pacific
Overall: of all Hep B&C, ~40% due to sharps
Of all HIV, about 1 – 12% due to sharps
Occupations of Victims of Nonfatal
Workplace Violence 1992-96
Occupation
Total
Annual Average
2,009,400
# per 1,000
Workers
14.8
10,000
69,500
24,500
56,800
15.7
24.8
21.4
10.7
50,300
8,700
43,500
79.5
63.3
64.0
Medical
Physicians
Nurses
Technicians
Other
Mental Health
Professional
Custodial
Other
Source: Bureau of Justice Statistics, 1998
BLS Data on Nonfatal Workplace
Assaults, by Source of Injury (1995)
Health Care
Patient, 51%
Worker/
Former
Coworker, 8%
Other Person,
29%
Other
Source,
12%
Work Organization Stressors
in Health Care Settings







Death and dying
Floating
Work overload
Work environment
Family stress
Role conflict
Shiftwork
Effects of Medical Error
 IOM estimates that medical errors cause 44,00098,000 deaths annually
 Medical error = 8th leading cause of U.S. deaths
 Medical error causes more deaths than auto
accidents, breast cancer and AIDS
 Chicago Tribune: “To compensate for understaffing,
hospitals often rely on machines with warning alarms
to help monitor patients’ vital signs. At least 216
patient deaths and 429 injuries have occurred in
hospitals where registered nurses failed to hear
alarms built into lifesaving equipment, such as
respirators and blood-oxygen monitors.”
More registered nurses are associated
with shorter length of stay and fewer
complications
Outcome
%Lower
Length of Stay
3.5%
Urinary Tract Infection
Upper Gastrointestinal
Bleeding
9.0%
Pneumonia
6.4%
Shock/Cardiac Arrest
9.4%
Failure to Rescue
3.9%
Source: Needleman et al., Nurse-Staffing Levels and Quality of Care in Hospitals, NEJM, 2002
5.1%
Hospital Nurse Staffing and Patient Mortality,
Nurse Buyout and Job Dissatisfaction
Design: Linked data from discharge of 168 adult
hospitals in PA, 10,000 nurses (random survey),
230,000 patients
Results:
Nurses –
94% women
43% high emotional
exhaustion
42% dissatisfaction with
current job
Source: Aiken et al. JAMA 2002; 288:1987-93
After adjustment for
patient and hospital
characteristics, each
additional patient per
nurse →
23% ↑ burnout
15% ↑ job
dissatisfaction
7% ↑ patient
mortality
Fewer People, Same Work
Work organization factors




Downsizing
Deskilling and collapsing of job titles
More patients at higher acuity levels
Decline of non-profit facilities
Fewer people + same work added stress and
fatigue compromised patient care
Improving Worker Health
and Safety Leads To:




Improved health status
Decreased health care/related
costs
Increased productivity
Increased quality
Job Creation 1992-2008
The Last Eight Years


Worker productivity (2000-2007) 20%
Real income working, middle-class
households ( $2,000)
3%
The Next Four Years
Job Creation – Infrastructure Support




Education
Health and Health Care
Energy/Transportation
Research