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November 1, 2012

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Construction – Constructive approach

Construction is consistently at, or near the top of the list of most dangerous industries in which to work but while fatality and injury figures are relatively easy to collate, the same cannot be said for incidences of ill health. Dr Chris Ide provides an overview of the main occupational-health issues in the sector.

Even in these depressed times, the construction industry is a significant contributor to the UK economy. It comprises more than 300,000 firms, ranging from the ‘one man and his dog’ outfits, which advertise availability for general jobbing work in the local free press, to much larger companies, who tender for contracts on a national and international basis.

Between them, these organisations employ in the order of two million people1 –about 7 per cent of the working population. These two million include itinerant labourers, as well as the traditional construction trades, such as bricklayers, operators of plant and machinery, joiners, plumbers, electricians, painters and decorators, heating, ventilation, air conditioning and refrigeration engineers, as well as members of professions, such as architects and surveyors.

Pat Cooksey’s poem ‘Why Paddy’s not at work today’2 provides a humorous view of health and safety (or the lack of it) in the construction sector but the reality is no laughing matter. The industry consistently ranks near the top of work-related deaths and injuries tables but the figures have gradually improved in recent years. Much of the improvement can be attributed to legislation, its application by enforcement agencies, and efforts of safety professionals and others to identify and implement safer working practices.

But we must also factor in levels of economic activity, since the construction industry has been relatively depressed for the past few years, with a much-reduced workforce and fewer opportunities for things to go wrong. Then again, this might be offset by an increasing tendency to cut corners.

Nailing jelly to the wall

It has always been more difficult to gather systematically data about ill health in construction – partly because of the low penetration of the industry by well-organised occupational-health services but also owing to the fragmented and peripatetic nature of the industry, with employees moving from one job to another on completion of contracts. In addition, ill health often develops insidiously and it is difficult to distinguish between work-related and coincidentally arising disease.

Because of the lack of training in occupational medicine at both undergraduate and postgraduate levels, general practitioners and specialists may fail to appreciate the significance of occupation when confronted with an unwell patient. Thus, medical certificates are inappropriately completed and lack information, making it difficult for an employer to comply with legislation like RIDDOR.

Construction work has traditionally been regarded as a young man’s job, but the industry is not immune to the demographic challenges posed by an ageing workforce. Alternative career paths mean there may be fewer school-leavers coming through the apprenticeship system, and employers may have to depend more heavily on older workers. Taking steps to reduce the toll of illness, particularly work-related illness, might result in an older, but healthier workforce.

There have been some attempts to gauge the size of the problem – the aforementioned RIDDOR system, for example, though this has its well-documented problems. There are also the cases of Prescribed Diseases compensated each year, but the award scheme imposes strict criteria and it does not include the self-employed. Damages awarded by courts and successful prosecutions by enforcing authorities offer another way of estimating the size of the problem, but they are not generally widely publicised, and many civil cases are settled out of court.

Useful data is regularly generated by the Labour Force Survey (LFS), which is carried out quarterly by the Office of National Statistics. Once a year, questions are incorporated about the health of the respondents and, based on this, of the 2.3 million days lost through work-related sickness absence in the construction industry in 2010/11, about 75 per cent were due to illness, and the 36,000 new cases of musculoskeletal disorders was 75 per cent higher than expected, although mental-health problems were fewer than anticipated.3 Interestingly, 56 per cent of all work-related cancers were found in construction workers.4,5

The principal criticism of the data in the LFS is that it is self-reported and not validated. Inevitably, this means that some individuals will incorrectly attribute their health problems to their work; the flip side of this being that a proportion will have work-related health problems of which they are unaware.

More precise data might be expected from diagnoses that are endorsed by doctors. A recent publication6 drew on information available from THOR (The Health and Occupation Research) network, based at Manchester University. This report studied the incidence of contact dermatitis, asthma, long-latency respiratory disease (lung cancer, mesothelioma and pneumoconiosis – non-malignant chest disease caused by exposure to inorganic dusts), skin cancers and musculoskeletal disorders in a variety of trades associated with the construction industry. Since some of these tradesmen can be found working in other industries – e.g. metalworkers and welders may have jobs in vehicle repair – rates were also calculated for all workers.

These findings, based on data gathered over a six-year period, showed convincingly that construction trades generally, and roofers in particular, were about six times as likely to have skin cancer, and this rose to 12 to 14 times when compared with workers generally.

For long-latency respiratory diseases, elevated rates were found among pipe-fitters, electricians and scaffolders but, interestingly, construction managers were seven times as likely to suffer these disorders. I wonder if these people were promoted ‘from the ranks’, reflecting past exposure? Welding trades working in construction were almost four times as likely to develop asthma, although the highest rates were found in trades not employed in construction. Musculoskeletal problems feature strikingly on those engaged in road building.

These figures, independently derived, do tend to support the findings of the LFS. Where differences emerge, particularly with regard to the long-latency respiratory diseases, may be because the LFS obtains its data from people who are of working age, whereas many of the respiratory disorders are diagnosed after retirement.

From the point of view of maintaining a healthy and productive workforce, focusing on diseases that are only diagnosed after retirement may seem a rather futile exercise. An alternative – or additional – technique might be to focus on diseases that are associated with sickness absence and ill-health retirement, since these, by definition, remove workers prematurely from the labour force on a temporary or permanent basis.

A study of Irish construction workers used data derived from The Construction Employees Health Trust.7 Of 28,800 spells of sickness absence, each of four or more days, injuries were responsible for 30 per cent, infectious disease for 25 per cent, musculoskeletal problems for 13 per cent, and respiratory disorders for about 5 per cent. A total of 3100 took ill-health retirement, with cardiovascular causes accounting for 31 per cent of those, musculoskeletal disease for 30 per cent, and respiratory disorders for 14 per cent.

Although 11 of the 424 respiratory retirements were attributed to asbestosis, and two to silicosis, there appears to have been no attempt to determine the extent to which work contributed to illness or injury. Sickness absence resulted in the loss of more than 677,000 working days, and the mean age of ill-health retirement was 58, representing a loss of more than 24,000 working years.

The causes of ill-health retirement in a cohort of German workers were ranked similarly, although just under half were attributed to musculoskeletal disorders, and one fifth to cardiovascular causes.8 I suspect that one of the main reasons the proportion of cardiovascular ill-health retrials in the German study was so much lower was because the Irish data had been accumulated from 1972, almost two decades before the German research started, at a time when heart attacks and related disorders were rather more prevalent. A subset of these workers – the older ones – was followed up over a five-year period. Their mortality and ill-health retirement rates were roughly double that of an equivalent population of white-collar workers.9

A good start is half the work

What can be done to reduce the current burden of ill health in construction workers? An obvious start is to take feasible steps to lessen exposure to known health hazards. Reduction of exposure to asbestos will, in the longer term, substantially reduce the incidence of mesothelioma, currently by far the biggest-known cause of occupational cancer. A formidable contribution to this aim would be to ensure the whereabouts of asbestos in buildings is known, and that it is labelled in order to prevent workers blundering upon it. If in poor condition, it needs to be removed by a licensed contractor.

Chromium-containing compounds are a potent cause of dermatitis. Following the implementation of the Chromium (VI) Directive (2003/53/EC), there was a significant reduction in allergic contact dermatitis due to chrome in German building-trade workers,10 with similar findings in Denmark11 and the UK.12 Furthermore, since hexavalent chrome is a known carcinogen, perhaps sometime in the future we will note a decline in the incidence of some cancers in building workers.

Nonetheless, the Danish researchers did point out that the decline in the incidence of chrome allergic dermatitis began several years before the imposition of the chromium directive. Just to show that every silver lining has its cloud, the German authors drew attention to the fact that, over the same period, the incidence of dermatitis triggered by epoxy resins – often used as cement substitutes – rose from about 8.5 to 12.5 per cent! Also, how many bags of high chrome-content cement are still lurking in the back of poorly-lit warehouses, just waiting for the unwary?

Skin cancers occur more commonly in building-trade workers, the highest incidence, as already mentioned, being in roofers and other trades who often work outside. Long-established protection measures include wearing loosely-fitting long-sleeved garments, use of sunscreens, protection against the sun’s rays and early detection of skin changes. Employers have been encouraged to educate workforces in the use of these safeguards, and research has demonstrated that, even in the UK, workers will often act on this advice.13 However, for this to be fully effective, it needs to be carried over into the non-working environment as well.

The increased rates of cardiovascular disease are often used to drive health promotion campaigns. Obviously, these are long-term efforts, and success is often reported purely in terms of reductions in risk factors. This is, at best, a surrogate measure and awaits longer-term confirmation. Even so, the targeting of high-risk workers might be expected to show the greatest benefit soonest.

This was attempted by Dutch researchers, who devised a special counselling and educational programme for a group of workers identified as being at high risk of developing disabilities within the next four years. They were followed up over a period of just over two years, and the number of disability pensions granted was compared to a control group of workers who received the usual care (which also included medical assessments!). Assessment of the programme’s effectiveness was hindered by a high drop-out rate, but the anticipated reduction in the award of disability pensions to the intensively supported group was hardly noticeable.14

While I’m sure that occupational-health services have a role in improving the health and safety of workers in the construction industry, I’m not certain what form these should take. Perhaps we need to become much more research-orientated and critically evaluate what we do, rather than just stating that ‘occupational health is a good thing, and you need more of it’. This way, we might be able to provide safety advisors with useful information to enable them to protect more effectively the health and safety of employees in one of the most hazardous working environments. 

References

1    www.bis.gov.uk/policies/business-sectors/construction
2    www.songsforteaching.com/paddysicknote.htm
3    www.hse.gov.uk/statistics/overall/hssh1011.pdf
4    www.hse.gov.uk/statistics/industry/construction/construction.pdf
5    www.hse.gov.uk/statistics/lfs/0809/hubresults.htm
6    Stocks SJ, Turner S, McNamee R, Carder M, Hussey L & Agius RM (2011): ‘Occupation and work-related ill-health in UK construction workers’, in Occup Med 2011,61;6:407-415
7    Brennan H, Ahern W (2000): ‘Sickness absence and early retirement on health grounds in the construction industry in Ireland’, in Occup Environ Med 2000, 57;9:615-620.
8    Arndt V, Rothenbacher D, Daniel U, Zschenderlein B, Schuberth S, Brenner HH (2005): ‘Construction work and risk of occupational disability: a ten-year follow-up of 14,474 male workers’, in Occup Environ Med 2005,62;8:559-566
9    Arndt V, Rothenbacher D, Brenner HH, Fraisse E, Zschenderlein B, Daniel U, Schuberth S, Fleidner TM (1996): ‘Older workers in the construction industry: results of a routine health examination and a five-year follow-up’, in Occup Environ Med 1996,53;10:686-691
10    Geier J, Krautheim A, Uter W, Lessmann H, Schnuch A (2011): ‘Occupational contact allergy in the building trade in Germany:influence of preventative measures and changing exposure’, in Int Arch Occup Environ Health 2011; 84:403-411
11    Johansen J, Menne T, Christophersen J, Kaaber K, Veien N (2000): ‘Changes in the pattern of sensitisation to common contact allergens in Denmark between 1985-86 and 1997-98 with a special view to the effect of preventive strategies’, in Br J Dermatol 2000;142:490-495
12    Stocks SJ, McNamee R, Turner S, Carder M, Aguis RM (2012): ‘Has European Union legislation to reduce exposure to chromate in cement been effective in reducing the incidence of allergic contact dermatitis attributed to chromate in the UK?’ in Occup Environ Med 2012, 69;2:150-152.
13    Madgwick P, Houdmont J, Randall R (2011): ‘Sun safety measures among construction workers in Britain’ in Occup Med 2011,61;6:430-433
14    De Boer AGEM, Burdorf A, van Duivenbooden C, Frings-Dressen MHW (2007): ‘The effect of individual counselling and education on work ability and disability pension: a prospective intervention in the construction industry’, in Occup Environ Med 2007,64;12:792-797

Dr Chris Ide is an occupational physician and regular contributor to SHP.
 

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