OccupationalSafety and Health

PH 15011/17/08

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

Health care 97%

Population Health 3%

The 97/3 Problem

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

Medical care Behavior Biology (genetics) Physical

environment Social environment

Education Socioeconomic

Status Employment Housing

Population health modeled on evidence that there are multiple determinants of health

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 IllnessInjuries

Fatal 6,529 Non-fatal* 13.25 million Total costs $145 billion

Diseases Fatal** 60,300 Non-fatal 862,200 Total costs $26 billion

* 46% disabling (6.09 million)** Based on cancer, cardiovascular disease, chronic respiratory disease, neurologic and renal disorders

Annual Economic Burden of Disease and Injury

171

33

67.3

164 170.7

020406080

100120140160180200

OccupationalDiseases and

Injuries

AIDS AlzheimerDisease

CirculatoryDiseases

Cancer

Co

sts

in B

illio

ns

1997; Leigh et al. Arch Int Med.

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 non-fatal 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

2

10

15

14

18

22

41

2

5

2

7

6

11

32

0 10 20 30 40 50

Leukemia (2)

Trachea, bronchusor lung cancer (9)

Unintentional Injuries(10)

Asthma (11)

COPD (13)

Hearing Loss (16)

Low Back Pain (37)

Male Female

THE US WORKFORCE

Size of workforce: 140 million

Unionized: 12%Unemployed: 6.5%

Changing Demographics

Projected Changes in Civilian Labor Force 2004 to 2014

3135.7

15.6

21.2

46.4

46.8

05

1015

2025

3035

4045

50

Minorities Over Age 55 Women

2004 2014

Women Participating in the Global Workforce

Developed Countries % of women who work Sweden and Denmark 75% United States 60% France and Germany 57% Switzerland 53% Netherlands 38% Italy 37% Spain 26%

Source ILO, 1995

Women Participating in the Global Workforce

Developing Countries % of women who work* China 80% Mozambique 78% Vietnam 77% Thailand 67% Brazil and Chile 33% Mexico /Argentina 32% Egypt, Saudi Arabia, Oman, and Jordan 10% Algeria 8%

* Includes the informal workforce

Source, ILO, 1995

Aging Workforce

0

5

10

15

20

perc

ent

Japan U.S. France

Workers Over Age 60

1995

2030

Source Health Affairs, May/June 2000

Projected Changes in Employment by Industry

0

10

20

30

40

50

60

70

80

Goods Producing Service Producing

Perc

ent o

f Tot

al

198619962006

Source: Franklin, 1997

Growth of the Contingent Workforce

0

5

10

15

20

25

30

Mill

ions

Temporary employees

Part-time workers

Multiple-job holders

Self-employedworkers

Source: Bureau of Labor Statistics

Informal Sector

Majority of new jobs in developing countries Subcontracting

Independent, cater to markets at low end of income scale

Household-based Unpaid female labor, family members

Independent service sub-sector Bulk of informal sector, lowest skills Maids, street vendors, cleaners, casual unskilled

laborers

ILO 1999ILO 1999

Informal Workforce (% of Total Urban Employment)

Africa – 60% Bolivia and Madagascar– 57% Tanzania – 56% Colombia – 53% Thailand – 48% Venezuela – 46% Industrialized Countries – 5-

10%ILO 1999/WHO 1995ILO 1999/WHO 1995

Annual Hours WorkedAnnual Hours Worked

1,731

1,732

1,889

1,966

1,399

0 500 1,000 1,500 2,000 2,500

Norway

Britain

Canada

Japan

United States

Average annual number of hours worked per person

Source: International Labor Organization (1999)

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

temporary-help 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

Employer-Sponsored Health Insurance

5254565860626466687072

1987 1991 1995 1999 2003 2006

Perc

ent

Source: U.S. Census Bureau/ Kaiser Family Foundation

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

0

2

4

6

8

10

12

14

16

18

20

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Year

Inju

ry r

ate

per

10

0 fu

ll-t

ime

wo

rke

rs

Agricultural productionConstructionNursing and personal care

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 hazardsbacteria, viruses, fungi, parasites

Chemical hazardsmedications, solutions, gases

Physical hazardsradiation, 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)

Attributable fraction of Hep C, Hep B and HIV infections in health care workers due to injuries with sharps, ages 20-65

Overall: of all Hep B&C, ~40% due to sharps Of all HIV, about 1 – 12% due to sharps

0%10%20%30%40%50%60%70%80%90%

100%

Per

cen

tag

e

Attributable fraction of Hep C, Hep B and HIV infections in healthcare

workers due to injuries with contaminated sharps, ages 20-65

HCVHBVHIV

Africa Americas E Med. Europe SE Asia W Pacific

Occupations of Victims of Nonfatal Workplace Violence 1992-96

# per 1,000

Occupation Annual Average Workers

Total 2,009,400 14.8Medical

Physicians 10,000 15.7Nurses 69,500 24.8Technicians 24,500 21.4Other 56,800 10.7Mental Health

Professional 50,300 79.5Custodial 8,700 63.3Other 43,500 64.0Source: Bureau of Justice Statistics, 1998Source: Bureau of Justice Statistics, 1998

BLS Data on Nonfatal Workplace Assaults, by Source of Injury (1995)

Health CarePatient, 51%

OtherSource, 12%Other Person,

29%Worker/Former Coworker, 8%

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 44,000-98,000 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 9.0%

Upper Gastrointestinal Bleeding 5.1%

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

Hospital Nurse Staffing and Patient Mortality, Nurse Buyout and Job Dissatisfaction

Nurses –

94% women

43% high emotional exhaustion

42% dissatisfaction with current job

After adjustment for patient and hospital characteristics, each additional patient per nurse →23% ↑ burnout15% ↑ job dissatisfaction 7% ↑ patient mortality

Design: Linked data from discharge of 168 adult hospitals in PA, 10,000 nurses (random survey), 230,000 patients

Results:

Source: Aiken et al. JAMA 2002; 288:1987-93

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 YearsJob Creation – Infrastructure Support

Education Health and Health Care Energy/Transportation Research