Medicine, Occupational

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MEDICINE, OCCUPATIONAL, attempts to maintain workers' health, prevent disease, and treat the results of occupational disease or accident. The field of occupational medicine in its modern form developed largely through the efforts of women reformers during the Progressive Era, although preliminary efforts to ameliorate occupational ill-health date back to the nineteenth century. Adverse working conditions can cause acute and chronic illnesses and disabling accidents. Low wages, long hours of work, emotional stress, and inferior status or social role may also adversely affect the general health of the worker. Health counseling and health maintenance have evolved as important facets of contemporary occupational medicine, along with psychological testing and industrial psychiatry. As safety engineering has emerged as a key aspect of accident prevention, so environmental engineering has emerged as a concern of occupational medicine.

Occupational medicine is a relatively recent phenomenon, and although work hazards were many in early America, injured workers had little access to medicine directed toward their specific problems. In the United States before the Civil War, the worst and most dangerous work was usually performed by enslaved people, although free people also performed some extremely dangerous work—for instance, the building of the Erie Canal and many other of the large-scale projects of the nineteenth century. Some occupational diseases began to be recognized as such in the eighteenth century; for example, Benjamin Franklin noted that typesetters suffered from abdominal cramps and wrist or foot paralysis from the lead used in their work. However, recognition did not bring treatment, for the most part.

Access to health services was the first principal theme in occupational medicine. In 1798, the U.S. Congress created the Marine Hospital Service to provide care for American seamen, since their disabilities and illnesses had exceeded the abilities of local communities to handle them under poor-law arrangements. In the early nineteenth century, labor unions began to concern themselves with safe working conditions, among the earliest being the Pennsylvania Society of Journeymen Cabinetmakers, founded in 1806. In the cities, mutual benefit societies multiplied; 38,000 societies formed by 1867, although many were financially unstable and failed. A high proportion had a lodge doctor, and some built and administered hospitals. However, working women and numerous working men rarely had access to union membership, and the most exploited workers continued to labor under very dangerous conditions.

Not until 1837 was a systematic examination of occupations and related health problems published in the United States. In that year, a New York physician, Benjamin W. McCready, modeling his study after the work of the Englishman C. Turner Thackrah, wrote a prize essay for the Medical Society of the State of New York entitled "On the Influence of Trades, Professions and Occupations in the United States in the Production of Disease." McCready dealt with the health problems of agricultural workers, laborers, seamen, factory operatives, artisans, professionals, and literary men, and also discussed housing and "the general conditions of life" stemming from poverty and unhealthy cities. McCready identified long hours of work, slum living, and the effects of insufficient fresh food and sunshine as culprits. Far ahead of his time, he also commented on anxiety as a negative health factor.

As the nineteenth century unfolded, some diseases were diagnosed as occupational. In 1860, J. Addison Freeman of Orange, New Jersey, coined the expression "mad as a hatter" to describe mercury poisoning in hattery workers (clearly, hatters in C.S. Lewis's England also were known to exhibit these effects). In 1869, the Transactions of the Medical Society of Pennsylvania vividly described lung problems among anthracite coal miners, particularly the illness now known as black lung. In 1884, the Saint Louis Medical Journal described lead colic among lead miners. In the late nineteenth century, safety conditions were considered a national scandal. Railroads, factories, mines, the construction industry, and lumbering all vied for "worst place" in work-connected accidents. Safety inspection and compensation for the results of accidents became leading subjects of public discussion.

Some companies organized mandatory forms of health insurance for their employees, in which employees prepaid their care. The first major industrial medical-care prepayment plan to endure was organized by the Southern Pacific Railroad in 1868. The first company-financed medical department with a full-time staff providing complete medical care for employees and families was established by the Homestake Mining Company of Lead, South Dakota, in 1887. Although some U.S. coal miners had been prepaying their medical and accident care at $1 per month at least since 1869, the check-off for hospitalization, doctor care, and drugs became general throughout U.S. coalfields by the end of the century. It was a compulsory deduction required by the coal companies until the 1920s, after which it became voluntary in most places. The coal companies' doctors practiced both industrial medicine and family medical care. This system was a cause of much protest and dissatisfaction on the part of workers, who found it inadequate and paternalistic, and resented the payment requirement. Dr. Alice Hamilton (who died in 1970 at age 101) was the powerhouse behind creating the field of occupational medicine in the twentieth century. Hamilton, a resident of Jane Addams's Hull House settlement, wrote on lead poisoning in 1911, and followed it with work on coal-tar dye toxicities and many other hazards. Her Industrial Toxicology (1934), and Wilhelm Hueper's Occupational Tumors and Allied Diseases (1942), were crucial breakthroughs in identifying the toxic effects of numerous substances. Later in the century, Dr. Harriet Hardy, a protégée of Hamilton, detected the toxicity of beryllium as the cause of "Salem sarcoid" in workers in fluorescent bulb factories and in beryllium-smelter workers. Hamilton's contemporary, John Andrews, tackled the use of phosphorus in making matches in the United States, recognized as the cause of "phossy jaw." Andrews founded the American Association for Labor Legislation in 1906, and, in 1910, the first U.S. Conference on Industrial Diseases was held under its auspices. In 1911, an excessive prevalence of tuberculosis among garment workers in New York City was clearly demonstrated by a Public Health Service physician, J. W. Schereschewsky. Harvard University established the first American academic program in industrial medicine in 1917. In the following year, the Journal of Industrial Hygiene made its appearance, followed in 1932 by the Journal of Industrial Medicine. In 1914, the U.S. Public Health Service created a Division of Industrial Hygiene and Sanitation, which became the National Institute of Occupational Safety and Health. The 1935 Social Security Act stimulated the formation of state industrial hygiene units. In 1937, the American Medical Association created the Council on Industrial Health and joined in work with the National Safety Council.

State legislation, pushed largely by women Progressives from the settlement houses, began protecting workers to some extent, although inadequately, in the first half of the twentieth century. The first legislation took the form of protection for women workers, particularly limiting hours. Such protection was two-edged: Opponents of women's rights had long cited women's purported fragility as a reason for their political subordination ("protection"), and some women's rights advocates decried advocates of protective legislation particularly aimed at women, fearing it would perpetuate the stereotypes used to justify women's subordination. On the other hand, advocates of such legislation—most of whom were women themselves—argued that women carried much heavier home responsibilities than men, and feared that without laws limiting their paid work hours, women's burdens would prove overwhelming and physically dangerous. Furthermore, although many reformers also wished to improve conditions for working men, they viewed women's health as the wedge through which they could press through the first worker protection laws, since legislators and the public tended to view women as weaker and in need of protection. (Such views had not applied to enslaved women, nor to hardworking women farmers, or a host of other women, but pleas based on women's fragility resonated in late Victorian and Progressive urban America.) Reformers also used middle-class fears of the spread of disease to try to abolish practices such as "home work, " in which manufacturers contracted out work to women and children who were paid by the piece and worked in their own homes uninspected and unprotected. Working mothers often resented reformers' interference, since such work was the only sort they could perform while caring for their children.

Legislation for workers came slowly and piecemeal. The first state to enact a workmen's compensation law was New York, in 1910, but not until 1955 had all the states enacted such legislation. By 1960, dissatisfaction with state workers' compensation and safety rules led Congress to pass the federal Coal Mine Safety Act. In 1970, Congress authorized the use of the Social Security system to compensate for industrial diseases by providing work-connected disability payments and required the inclusion of occupational health and safety inspection and occupational health services in the Industrial Health and Safety Act of 1970.

Labor organizations also began using collective bargaining contracts as sources for medical-care payment, a practice that grew rapidly during World War II and afterward. Mining has been dangerous to health throughout history. In 1947, the United Mine Workers of America began services to miners paralyzed from rock falls and to silicotics. It then developed a comprehensive medical care program. Lawsuits over coal miners' "black lung disease" had some success, but mining of all kinds remained highly hazardous. Although employers provided most industrial workers with insurance coverage for hospitalization costs in the 1970s, the coverage was inadequate, and agitation for a national health security or insurance program was widespread. Numerous occupational health hazards remain for workers in the United States (and elsewhere). Excessive heat, cold, noise, and vibration are among the basic hazards. Each technical advance has tended to produce its own occupational and environmental problems. For example, radioactivity burst upon the scene as a killer of fluorescent wristwatch workers who painted luminous dials. After World War II, uranium mining and fallout from atomic bomb testing constituted a new health hazard. Radiation hazards remain a problem. Carbon tetrachloride, used in cleaning establishments, causes liver poisoning. Coal tar derivatives emerged as major contributors to cancer of the bladder, of the skin, and of the blood-forming organs. Hot metal fumes, which arise in the smelting of mercury cadmium, lead, nickel, and beryllium, have come to be recognized as major causes of occupational disease. Dusty trades, such as pottery-making, glassworking, quarrying, sandblasting, tunneling, and mining, cause the lung diseases silicosis and black lung. Textile industries tend to cause brown lung, or byssinosis. Exposure to asbestos fiber became a major problem, in some cases causing lung cancer; 3.5 million U.S. workers were exposed as of 1970, and fiber-glass, too, is suspect. Organic solvents are common producers of skin disorders, called dermatoses. Polyvinyl chloride used in plastics is a cause of liver cancer.

Environmental hazards in the community and home, first broadly publicized in the 1970s in Rachel Carson's Silent Spring, are also widespread. In the 1990s, health hazards came to include what was termed "sick building syndrome, " a range of illnesses, often undiagnosed, which plagued workers and residents in newly-built or renovated buildings—the glues and other substances used in construction combined with a lack of ventilation proved highly deleterious. The airtight character of some building strategies also produced a toxic mold, outbreaks of which panicked new homebuilders in the early 2000s.

The computer age has brought a new host of occupational health hazards to workers of many types. One highly publicized, and still prevalent, problem is carpal tunnel syndrome, a condition arising from excessive typing; other forms of tendinitis often accompany it. Sitting for hours on end typing at poorly designed workstations causes not only carpal tunnel syndrome but a host of back and neck problems, as well as eyestrain and headaches. Although publicized largely as a problem of white-collar office workers, the dangers are even more severe and widespread for the lowest-paid workers, mostly women, who work in the data-entry field. Unlike middle-class office workers, these workers are unlikely to be able to afford, or have the workplace clout to demand, the new ergonomically designed furniture and computer accessories that have arisen in response to the problem.

Even as office workers' occupational health problems command widespread publicity, huge numbers of other Americans continue to labor in dangerous conditions. Farm workers, some of the least protected of America's workers, often work in fields laden with toxic pesticides. Some consumers buy organic produce because they worry about the effects of those pesticide residues on their food, but the people picking the produce are immersed in such substances throughout their long workdays. The United Farm Workers of America is fighting to protect its members and improve farm work conditions, but migrant workers, sometimes undocumented immigrants, have a difficult time finding protection. Workers in America's meat-processing industry also labor under often highly dangerous and unhealthy conditions; chicken and seafood processors bend for hours on end in icy water, developing back and circulation problems in addition to chronically compromised immune systems, and meat-packers labor among sharp surfaces, on floors slippery with blood and feces, in an increasingly deregulated and uninspected industry. Throughout America's history, domestic workers—paid and unpaid—have been exposed to numerous hazards. In recent decades, those hazards have included not only backbreaking labor, but also increasing amounts and varieties of toxic chemicals. A movement to unionize office cleaners, called "Justice For Janitors, " is seeking to ameliorate these and other poor work conditions for its constituents. Soldiers, too, face occupational health hazards, aside from the most obvious of battle fatality; they have been consistently exposed to dangerous toxins, from Agent Orange during the Vietnam War to radioactive poisoning and gas exposure in the Persian Gulf War. Usually from working-class backgrounds, these military workers have little political clout in matters of occupational health, despite their willingness to sacrifice their lives for their nation.

Occupational medicine has made huge strides in the past century, and numerous workers have access to both protections and medical treatment that did not exist in previous times. At the same time, many workers remain without access to those protections and treatment, and, while scientific advancements have solved some old workplace hazards, they also have created new ones. Occupational medicine thus remains a crucial and rapidly developing field.


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Leslie A.Falk


See alsoAutomobile Workers v. Johnson Controls, Inc. ; Health Insurance ; Medicine and Surgery ; National Institutes of Health ; Occupational Safety and Health Act ; Progressive Movement ; "Silent Spring" ; United Mine Workers of America ; United Steelworkers of America ; United Textile Workers ; Women in Public Life, Business and Professions ; Women's Health ; Workers' Compensation .

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