Dr Chris Ide reports on the occupational health improvements made over the past 30 years and identifies some of the future challenges.
When I graduated in 1974, I saw my future in general practice. However, after ‘house jobs’, six and a half years in the regular army and 20 months doing locum work, much of it in the Middle East, I noticed an advertisement in the British Medical Journal from the Health and Safety Executive.
They sought four employment medical advisers, one to be based in Dundee, where I lived. Since I enjoyed the undergraduate course in social and occupational medicine, I applied. Somewhat to my surprise, I was shortlisted and interviewed on my way out to Saudi Arabia. To my amazement, I was offered the job and the rest, as they say, is history.
When I started in September 1983, I suppose that I arrived at the tail end of the ‘traditional’ system, where the ‘big hitters’ of the speciality were employed by the in-house services of the nationalised industries, such as coal, steel, the utilities, railways, and civil service. In the private sector, there were the petrochemical behemoths, the pharmaceutical industry, heavy engineering, the food industry and the major retailers.
The recessions of the late 1970s/early 1980s and early 1990s resulted in considerable downsizing, particularly in the private sector. Reducing head-counts resulted in a corresponding diminution of need for occupational health staff, since the private sector did not envisage being a source of ‘parish relief’ for the professional classes, a view that spread into the public sector as well.
However, the need for competent occupational health advice did not diminish, and was met by the increase in the number of private sector and NHS-based occupational health providers, who sold physician/nurse/technician time to organisations presumably at a lesser cost than that of an ‘in house’ service.
It’s been an enormous privilege being an occupational physician. Looking back over the 30 years I spent in the discipline, while not everything I have touched has turned to gold, I feel a certain amount of pride in my achievements. However, I thought it appropriate to take a straw poll of colleagues in the UK, North America and elsewhere of the challenges, which face us up to the halfway point of this century.
There seemed to be a strong consensus that considerable strides had been made in controlling hazards involved with traditional manufacturing and extractive processes. Therefore, the well-known toxins like lead, mercury and arsenic, various asthmagens and physical hazards like noise and vibration appear to be causing much less disease.
In part, this could be because the hazardous processes have simply been removed to the developing world (‘out of sight, out of mind’).
The advent of disability legislation, sensibly applied, has resulted in individuals with health problems being able to enter, or remain in, the workforce, and continue to lead productive lives. This has been aided by safety advisors undertaking informed risk assessments, and involving managers and others in devising solutions, often at little cost.
Having slain all these dragons, what are the challenges of the future? Well, for a start, there are still the dragons. Far from being slain, they are merely dormant. For as long as employees work with lead/noise/pathogenic micro-organisms/display screen equipment/ionising radiation, etc., then the possibility of work-related disease or injury exists, unless controls remain in place and subject to increased sophistication, to continue to reduce the risk.
Strictly speaking, we have only really controlled gross disease, such as acute/chronic plumbism and erethism. For some decades, it has been known that, for example, lead affects a wide variety of biochemical, neurological, haematological and psychological systems, at blood levels far below half those which, if sustained, result in suspension of adult male workers (currently 60 ug/dl in the UK).
But how do these findings translate into impairment, if they do at all? For example, the incidence of gastro-intestinal and neurological symptoms starts to rise once the blood lead level passes 30 and 25 ug/dl respectively. 
When I sat in my hospital occupational health clinics, my thoughts sometimes turned to the nearby Lanarkshire or Lancashire gastro and neuro outpatient departments, where patients would be receiving their diagnosis of irritable bowel syndrome, or unexplained neuropathy.
Yet how many would be asked what they did for a living and, where appropriate, have their blood lead measured? Even when blood lead levels were as low as 10, deaths from heart disease were increased by about one third. 
Hearing loss has been demonstrated once blood lead levels pass 7 ug/dl,  so pressure is likely to continue to further reduce blood lead levels. However, heart disease is multifactorial in origin, and to what extent do these other factors affect the overall risk, and to what extent does a very small degree of hearing loss affect overall quality of life?
‘Today’s solution = tomorrow’s problem’. Substitution of hazardous materials by less hazardous ones has often been advocated, where it is not possible to eliminate the hazard. Early in the last century, polychlorinated biphenyls were introduced as insulators, following a series of disastrous underground fires in mines. However, starting in the last quarter of the 20th Century, evidence has started to accumulate with regards to their potential for causing cancers, particularly melanomas and liver tumours. 
Asbestos, particularly its crocidolite and amosite forms, has given rise to the greatest fatal work-related health hazard in the UK and western world, with upwards of 2,000 deaths per year in the UK alone due to mesothelioma, to which must be added the mortality from asbestos-related lung cancer, other tumours, such as those of the voice box, and asbestosis.
Ceramic fibres are frequently advised as substitutes, but although research suggests that they do not appear to be associated with any particular respiratory hazard at current levels of exposure , previous workers may have been exposed to higher levels, in any case, since many ceramic fibres have structural properties similar to asbestos, vigilance will have to be maintained for many years yet, in view of the known mesothelioma latency of up to 60 years.
What about nanoparticles, many of which are marketed on the basis of their being very reactive? How do they react on the surface of, or once they enter, the body?  Are we gathering the right health and attendance data to enable a good assessment to be made as further data accumulates?
Similarly, in terms of widespread hazards, the impact of climate change needs to be considered. Irrespective of the views one holds on the extent to which change is driven by human activity and fossil fuels use, it’s happening. Should temperatures rise then outdoor workers in agriculture and construction may become more vulnerable to skin cancers from sunlight. In the event of heavier rainfall, then greater hazard of flooding, and mud, resulting in more slips, trips and falls.
The future workforce
Finally, to quote the old Marxist agitators cry “What about the workers?” The future workforce will be unlikely to consist of homogenous groups of blue and white-collar employees. It is already morphing into a complex of multi-ethnic and multi-abled, and increasingly ageing medley, in which gender-based stereotypes will become less relevant.
While the incidence of severe and enduring mental health problems remains relatively small, according to the Labour Force Survey, stress, depression and anxiety remains a substantial perceived health hazard at work, second only to musculoskeletal disorders, but accounting for the greatest number of days lost. 
This diminution in the quality of working life is of at least as much relevance as (long term) harm arising from exposure to workplace hazards mentioned previously. Successfully tackling this will require safety advisors and their occupational medicine colleagues to think ‘out of the box’ to avoid medicalising matters, developing novel strategies to maintain and improve communications within and between organisations which will help reduce uncertainty by improving resilience and morale.
I’ll keep this article to find out what I should be writing should I still be around aged 96, and still working.
Chris Ide is retired and has a background in occupational medicine
Clive Johnson, head of health, safety and security at Land Securities, explains what the differences are between occupational health, hygiene and wellbeing, particularly in relation to construction.
Although the awareness and management of occupational health in construction has received far less attention than safety over the past ten to fifteen years, there is a great deal more activity now in the more enlightened areas of the industry.
The construction industry has demonstrated its ability to respond to serious injury and fatalities, as we did in 2001, when the then Deputy Prime Minister, John Prescott called the industry to arms. Thirteen years on, we are in a much better place having reduced fatalities by two thirds.
Although the industry and many of the supporting body’s couple health and safety together to manage and control both, health has traditionally taken the back seat due the cause and effect in many cases taking decades to present symptoms and unlike safety, the burden of managing health falls predominantly to the employer . For these reasons the industry must find the means to elevate the status of health and make it an equal partner to safety.
Health is the most challenging topic and where most confusion reigns. Many engaged within the industry do not understand what is required of them as an employer and couple this with insufficient occupational health resource that is familiar with construction, then it is easy to see why we struggle with a workforce that is transient in the extreme.
There is confusion within the industry between occupational health management, occupational hygiene and well-being. All have a role to play and they are complimentary in engaging employers, employees and the population at large.
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