InitiativePartners in Occupational & Environmental Health

Vision for Training of

OEH Hygienists, Nurses, Doctors in Asia-Pacific

Hong Kong28-29 October 2013

Thomas H Gassert, MD, MScHarvard University School of Public Health

University of Massachusetts Medical School

Vision of Partners in OEH Asia-Pacific 2

Overview• Why we are here• Legal Basis – O&E Health is a global

– Human Right guaranteed by law– State and Employer Obligation

• Burden of Occupational Disease (injuries & illnesses by country)

• Capacity: now and future (country needs assessments)

• Resources to identify:– Medical training capabilities (local, regional, international) – National regulatory and accreditation standards– Local and international labour and NGO guidance– Financial

• Challenge: tasks, goals and timelines• Organization: name, mission, base, website, collaboration

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Why this meeting?• Other meetings, but what has been the practical outcome?• Other organizations (ICOH, AAOH, SPH, etc.)• Nothing unified or labour driven (but we are!)• Very little capacity building (little clinical substance)• Little regulatory movement; few dedicated resources• Our emphasis is preventive medicine and health protection

– Primary, Secondary, Tertiary Prevention• OEH is needed for climate change, and clean water, air, soil• OEH means economic gain for all• We have strengths and a vision, a good base, and need a system that

works to achieve OEH for all

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Preventive Medicine & Health

Occupational & Environmental Health (OEH) is part of a specialty called Preventive Medicine

Three levels of prevention in OEH:1. Primary: prevent or control hazards at source

• Hierarchy of controls (Occupational / Industrial Hygienist)• Wellness – health promotion with health protection (nurse, doctor)

2. Secondary: detect early disease risk by medical surveillance, health monitoring (doctors, nurses)

3. Tertiary: prompt medical care to prevent complications of death, disability, job loss (doctors, nurses)

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Define “Asia” – per U.N. nation listings• There are a total of 193 U.N. member nations (2013)• Asia list: Afghanistan (west) to Pacific islands (east)

– Including Oceania (Australia, New Zealand, Pacific isles)• Does not at this time list:

– Western Asian nations of the Middle East– Other “…stans” of Central Asia:

• Kazakhstan• Kyrgyzstan• Tajikistan• Uzbekistan

– Siberia (Russian Federation)– Guam (a U.S. territory)

• Taiwan (ROC) membership was replaced by China (PRC)• North (PDRK) and South (ROK) Korea are both members28 Oct 2013 HK-THG

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Legal Basis: Human Rights

• Entitlements because of being human, extends naturally to workers• Form: political, social and material claims• Guarantee protection of basic freedoms and dignity• Origin: to protect against abuse by those with power• Political rights extend to socio-economic realm• Implies a party with duty to impart/honor those rights:

– Governments– Employers, including Trans-National Corporations– Inter-Government Agencies– Banks and Aid Agencies

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Governments and Human Rights

• Nation States are obligated (must…)• Protect (disability, pregnancy, gender, ethnicity,

minorities, children)• Take active steps (budget, services, infrastructure)• Educate about Human Rights• Improve rights (progressive realization)• No constraint by int’l lenders (e.g., IMF, ADB)

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Health & Human Rights

• Global (all workers, citizens, environment)– Double standards or constraints are forbidden

• Rights as Enforceable Laws• Tied to Standards of Ethics• Dimensions of Gov’t and Corporate obligations:– Respect– Protect– Fulfill– Promote

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Brief History – Health and H.R.• ILO estab. 1919, first addressed global right to healthy work conditions• Franklin Roosevelt’s Four Freedoms speech 1941 proclaimed freedom from want,

taken up by• UN Conference on International Organization, San Francisco, 1945• Article 55 of UN Charter 1945 and WHO 1946

– “universal respect for and observance of human rights”• Articles 57 and 62 of UN Charter

– “health” is the responsibility of the UN Economic and Social Council (ECOSOC)• Universal Declaration of Human Rights (UDHR) 1948

– Affirmed in Article 25(1) that “everyone has the right to a standard of living adequate for the health of himself and his family, including food, clothing, housing and medical care, and necessary social services.”

• UN Commission on Human Rights 2002– Appointed a Special Rapporteur on the right of everyone to the highest attainable

standard of physical and mental health

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Basis of Legal Right to Health• United Nations Declaration of Human Rights (all members obliged)• WHO uses a voluntary policy approach (e.g., Covenants)

– If adopted or ratified, have legally binding authority• ILO uses a treaty approach (Conventions, Protocols, Recommendations)

– Legally binding– Tripartite basis (Employee, Employer, Government)– Applies to ALL workers irrespective of age, gender, nationality, migration status

• ILO Conventions for worker health rights (key ones):– No. 155 – Occupational Safety & Health (1981)– No. 161 – Occupational Health Services (1985)– No. 169 – Indigenous & Tribal Peoples (1989)

• Equal but culturally sensitive health care and protection

• ILO Convention re Child Labour– No. 182 – Child Labour

• Article 3(d) – deems children’s health as an essential criterion for the definition of the term “worst forms of child labour.”

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U.N. International CovenantsCivil & Political Rights

(ICCPR)

• To organize independently

• To bargain collectively• To information

– Hazard Communication– Community Right-To-Know– Investigation and Surveillance

Economic, Social & Cultural Rights(ICESCR)

• To safe living and working environment

• To health protection and services

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UN ICESCR 1966 (in force 1976)• Article 12

– 1. “The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”

– 2. “The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for:• (a) The provision for the reduction of the stillbirth-rate and of infant

mortality and for the healthy development of the child; • (b) The improvement of all aspects of environmental and industrial hygiene; • (c) The prevention, treatment and control of epidemic, endemic

occupational and other diseases; • (d) The creation of conditions which would assure to all medical service and

medical attention in the event of sickness.”

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Dimensions of Right to Health

• CESCR (Committee on ESC Rights) in 2000– General Comment 14 details dimensions– Freedoms dimension: • To make decisions about one’s own health data• To make decisions about sexual and reproductive care• From being subject to non-consensual treatment

– Entitlements dimension:• To a system of health care protection, including

emergency care• To underlying determinants of health

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Health Determinants

• Referenced in CESCR General Comment 14 (2000)

• Underlying determinants of health:– Adequate sanitation– Safe and potable water– Adequate food and shelter– Safe and healthy work conditions– Healthy environment

• If not met, right to health cannot be protected

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CESCR Definition

• CESCR General Comment 14 on definition of “right to health” in ICESCR:– Restricts “right to health” to a right to enjoy a variety of

facilities, goods, services and conditions needed to realize the right to health

– Contains both freedoms and entitlements– Contains four elements (AAAQ):

• Availability• Accessibility• Acceptability• Quality

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CESCR Definition (cont.)

• CESCR General Comment 14 (continued) on the “right to health” states it requires of health facilities and practitioners that they must:– Respect medical ethics– Be culturally appropriate– Be gender sensitive– Offer health education of high quality

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State Obligations

• ICECSR Article 2(1)– Progressive realization

• States must show how they progressed in realization of rights protections between two reporting phases (4 yrs)

• A clear and immediate legal obligation• If no progress, or worse, State must explain

– Resource availability• Not a carte blanche for States to do what they please• Must take reasonable and targeted steps toward goals• Poorer States, if unable, must request help• Richer States must provide help

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ICESCR-12: Respect, Protect, Fulfill• ICESCR Article 12 obligations, three levels:– Respect (not interfere with) right to health– Protect (e.g., by legislation, access) right to health

• Make sure medicines, facilities are regulated for access• Ensure practitioners meet appropriate standards of education, skills, and

ethical codes of conduct– Fulfill right to health

• Give sufficient recognition in political and legal systems• Adopt national health policy with detailed plans• Provide adequate health care facilities, vaccines• Formulate, implement and review periodically a coherent national policy

to minimize risk of occupational accidents and diseases [CESCR 2000 General Comment 14, para 36]

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State Obligations for O&E HealthProvision Respect Protect Fulfill PromotePromote Safe Healthy O/E Conditions

Labor and Community Rights

OESH Regs; Refusal Right; Inspect

O/E Health Services; BioMonitor; Child services

Educate, hearings, RTK, Risk Com

Improve O/E Protections

Multivalent Inspectorate

OESH Regs update and enforce

IH training, engineering, env impact

Community RTK, Hazcom

Treat and Control O/E Disease

Compensation Prevent employers from blocking

Health maintenance

Education & care for workers & communities

Apply Scientific Progress

Evidence-based; Limit vested interests

Oppose trade agreements that limit access to safer technologies

Prevention research

Share research findings, provide support to implement

Adapted from London L, IJOEH 2011;17:80-92

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ICESCR

• Art 7: just, safe, healthy work conditions• Art 12: improve all aspects of environment

and industrial hygiene• Art 12: prevent, treat, control occup disease• Art 15: benefit from scientific progress• Many other global and regional rights

conventions re OE health

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ICESCR

• Right to health care:– “…not only…timely and appropriate but also…

the underlying determinants of health”– Food, nutrition, sanitation, water, shelter and…– “healthy occupational conditions, and access to

health related education and information”– “…benefits of scientific progress…”– Ensure the “diffusion of science”

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ICESCR Parties & Signatories

Dark green: signed and ratified Light green: signed but not ratified Grey: neither signed nor ratified** in Asia: Brunei, Malaysia, Myanmar, Taiwan, some Pacific isles

161 parties, 70 signatories (there are a total of 193 U.N. member nations)

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U.N. Declaration of Human Rights

• All 193 member states are subject to the terms of the UNDHR

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Ratification of ILO OSH ConventionsConvention Number, Name, Year of Adoption No. of Countries* (update)

45 Underground work (women) 1935 97

115 Radiation protection 1960 47

119 Guarding of machinery 1963 50

139 Occupational cancer 1974 35

148 Working env. (air pollution, noise and vibration) 1977 41155 Occupational safety and health 1981

42 (60, 8 in A-P)161 Occupational health services 1985

22 (31, none in A-P)167 Safety and health in construction 1988

17 (24, 2 in A-P)170 Chemicals 1990

11174 Prevention of major industrial accidents 1993 9176 Safety and health in mines 1995

20 (28, 1 in A-P)184 Safety and health in agriculture 2001 4

(15, 2 in A-P)P155 Protocol and 194-Rec to C155 2002

n.r. (9, none in A-P)187 Promotional Framework for OSH Convention 2006 n.r. (25, 4 in

A-P)*—number of countries (out of 193 members) that ratified the convention as of 2006Source: http://www.ciop.pl/18286 Table A (JOSE, 2006, Vol. 12, No. 3, 255–266)

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ILO C155 OSH (1981)

• To establish a national OSH policy and program• Asia-Pacific signatories (8 of 60 total):

1. Australia2. China (PRC), incl. Hong Kong (2007) and Macau (1999)3. Fiji4. Kazakhstan5. Mongolia6. New Zealand7. Tajikistan8. Viet Nam

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ILO P155 Protocol (2002) to C155

• Establish periodic OSH program reviews, record and report occupational diseases, etc.

• Asia-Pacific Signatories (1 of 9 globally):1. Australia

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ILO C161 Occ Health Services (1985)

• Establish OSH program services for/at enterprise levels

• Asia-Pacific Signatories (None of 31 globally)– None

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Agriculture, Construction, Mines

• ILO C184 Agriculture 2001 (2 of 15 globally):– Fiji– Kyrgyzstan

• ILO C167 Construction 1988 (2 of 24 globally):– China (PRC)– Kazakhstan

• ILO C176 Mining 1995 (1 of 28 globally):– Philippines

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Cancer and Chemicals

• ILO C139 Occ. Cancer 1974 (3 of 39 globally)– Afghanistan– Japan– Korea (ROK)

• ILO C___ Chemicals 1990 (2 of 17 globally)– China– Korea (ROC)

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Global Burden of Occupational and Environmental Death and Disease

• 300,000 work injury deaths per year• 2 million work illness deaths per year• Environmental disaster M+M unknown• 10-20% workers have access to OH services• 10% developing nations have OSH laws• Globalization and Free Trade Agreements have

protected some, but marginalized many

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Migrant Labour

• “Regular vs. Irregular”• Both formal and informal sectors• Most jobs are low-skilled, labour-intensive• “3-D Jobs” – dirty, degrading, dangerous • Often: mining, textiles, agriculture, construction,

heavy manufacturing, sweat shops, sex work• In Europe: migrants have 2-times rate of

occupational injuries (Bollini, 1995)

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Migrant Labour Health Rights• Rights endorsed in U.N. 1985 “Health Rights of Individuals Who Are Not

Nationals of the Country in Which They Live” - Article 8(1)(c) right to health protection and medical care

• Right to access health care and preventive public health services • Cannot be returned home without treatment of an active medical condition• ILO Conventions apply to migrant workers, including work hour limits,

maternity, paid holidays• “Non-discriminatory principle” – regardless of state status (including

undocumented workers), employment establishes between migrant and employer a series of economic and social rights (including health protection and medical care for work injuries)

• Rights include: prohibition of forced labour, freedom of association and right to organize and join union, right to adequate working conditions including OSH

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Obstacles to OEH Rights and Protections

• Deregulation • Promotion of labour flexibility (anti-union, migrant)• Shift to informal sector employment• Outsourced production (SEZs, FTZs, EPZs)• Export of hazardous technologies and materials• Double standards, both national and TNCs• Government collusion and competition• Trade agreements that obstruct or inhibit rights

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ILO C187 Promotional Framework for OSH (2006)

• Requires gov’ts to develop national policy, laws, programs with enterprise and labour representation (tripartite) per Article 4 of C155

• Asia-Pacific Signatories (4 of 25 globally)1. Japan2. Korea (ROK)3. Malaysia4. Singapore

Also, Russia, if one considers Siberia is part of Asia

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Asia-Global OEH Activity• ILO technical training efforts• OEH (medical and hygiene) courses by western Universities • Mount Sinai Hospital (New York City)

– 1-week OEH training in Bangkok, April 2013• ~ 50 regional participants• Bhutan, Brunei, Cambodia, Indonesia, Laos, Nepal, Sri Lanka, Thailand, Viet

Nam– Discussions with Myanmar Minister of Health

• Finnish Institute of Occupational Health– Asia-Pacific Newsletter (quarterly; nation profiles)

• Triennial Asia Conference Occupational Health (AAOH) since 1956• NGOs – ANROEV (and GOSH); AMRC; Solidarity Center; Hesperian

Foundation; others

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Taiwan OH Services• Problem: under-reporting of occupational injury and disease (OD)• Response: government founded and financed the Network of Occupational Diseases and Injuries

Service (NODIS) for occupational disease and injury services and established a new Internet-based reporting system

• NODIS comprised of: the Center for Occupational Disease and Injury Services and their local network hospitals

• Objectives: (1) Analyze possible influence of NODIS on compensable OD; (2) Describe distribution of OD across occupations and industries (2005-2010)

• Methods: Analyzed two datasets: (1) NODIS reporting dataset for demographics, OD distribution and time trends, and OD annual incidence; and (2) National Labor Insurance (NLI) scheme dataset of compensated OD for annual incidence

• Results: After NODIS was established, both the reported (NODIS) and compensable (NLI) OD incidences increased 1.2 and 2.0 fold from 2007 to 2010, respectively; the most frequently reported OD (2008 to 2010) were carpal tunnel syndrome, lumbar disc disorder, upper limb musculoskeletal disorders, and contact dermatitis

• Conclusions: NODIS system succeeded in providing more occupational health services, providing more workers with compensation for OD, and reducing under-reporting of OD

Chu PC, et al. The impact of occupational health service network and reporting system in Taiwan. Int J Occ Env Health, 2013; 19(4): 352-362

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OE Medical & Hygiene Training in Asia

• Few for Occ Hygiene and Clinical Medicine– OEM Residencies; Occ Hygiene Master/Doctorate– Continuing Professional Education– OEM for Primary Care Doctors (none?)

• Many turn out researcher MD/PhD• Mostly MPH degrees (not clinical; few OEH)• Training in OEM– Japan, Korea (ROK), Taiwan (ROC), Hong Kong, China (PRC),

Singapore (other-?), – Australia (Monash Univ.)

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OH Nursing and Mid-Level Providers in Asia

• Training of certified occupational nurses (none?)• Training of mid-level providers (none?)– Nurse Practitioners (Master/Doctorate levels)– Physician Assistant (separate training)– Can act like MD, with MD oversight collaboration

• U.S. has OHN certification for RNs and NPs

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National OEH Associations in Asia

• Few• Philippines College of Occupational Medicine– Offers a diploma course

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Trade and OEH

• World Trade Organization (WTO)– 153 member nations– Diminish and regulate commerce barriers

• Regional– NAFTA, EC, MERCOSUR (4 So. Amer.), bilateral

• Trade rules restrict extent to which States can limit imports in order to protect public health, including OEH

• Implications often for medications (patent protection; generic drug compulsory licenses) and pharmaceutical industry practices

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Needs Assessment and Tracking• Each nation baseline

– See next slide• OEH goal setting to affect real change

– Decrease occupational M&M (morbidity & mortality)– Decrease environmental degradation– Improve health and safety of work places and communities– Reverse man-made climate change

• What is your country’s situation?• What OEH strengths does your country have?• What are the OEH needs?• What OEH priorities does your country have?• What plan could help solve some of them?• What long-range OEH goals for your country?28 Oct 2013 HK-THG

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Each Nation Need Determinants1. Burden of occupational disease (injury, illness)2. Labour force (by industry - union, gender, age)3. Laws on OSH and environmental protection4. Government agencies and institutes for OEH5. Emergency preparedness and response for OEH6. Public health, medical, laboratory services7. OEH training programs (hygienists, nurses, doctors)8. OEH support organizations (unions, NGOs, etc.)9. Funding sources for OEH capacity building10. Existing international partnerships (medical, NGO, etc.)11. OEH links to community primary health care12. Priority needs and vision

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OEH Clinical Training Structures• Core specialty– Medical residency– Post-graduate degree or clinical fellowship

• Additional component to core training– OEM or OEHN curriculum added to basic medical or nursing

degree program• Certification or Diploma courses– Comprehensive vs. Hot Topic– OEM for primary care doctors and nurses

• Continuing education– Education credits for board certification maintenance

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Occupational Hygiene Training

• Core degree program• Occ Hygiene and Safety Professional

certification or diploma courses• Continuing professional education needed to

maintain certification

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Training Modes• Regional and International established programs• Standardization

– ACGME International (e.g., Ecuador)• Category 1 vs 2 level of continuing education credits• Internet learning (podcasts, curricula, videoconf)• Face-to-face• Field work and clinical work apprenticeships (these are essential!)• Work site visits• Occupational health clinical rotations• Goal: establish national capabilities after transfer of knowledge

and skills to local core teams of professionals; integrate with community primary health care

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Training Topics – 1 • Lung disease

– Asthma – Pneumoconioses (Coal, Silica, Asbestos)– See handout examples of resources– Simple spirometry (diagnosis restrictive & obstructive OD)– ILO digital radiography for pneumoconioses

• Emergency/disaster preparedness and response• Conducting an occupational history and physical exam, lab testing,

diagnosis, treatment plan• Disability management and return-to-work• OH Nurse case management• Leadership skills for OH

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Training Topics – 2 • Hazard identification, prevention and control:

– Physical (temperature, pressure, vibration, noise, repetitive strain, falls, struck by/against)

– Radiation (ionizing, non-ionizing– Chemicals, Gases, Metals Toxicology– Biological– Psychological & Social

• Epidemiology and biostatistics• Medical surveillance for the more hazardous jobs• Running an occupational health service• Substance abuse, workplace violence, wellness at work• Regulations, recordkeeping, reporting• Privacy protection

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Training Topics – 3

• OSH for specific industries and/or jobs– Construction– Mining– Transport– Agriculture– Automobile– Electronics– Textiles, garments and shoes– Chemicals– Hospital and health care workers

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Institutional Partners in North America

• US National Institutes of Occupational Safety and Health (NIOSH, International Support)

• American College of Occupational & Environmental Medicine (ACOEM, International Section)

• US Accreditation Committee for Graduate Medical Education (ACGME, International Standard Setting)

• Harvard University School of Public Health, Department of Environmental Health, Environmental & Occupational Medicine and Epidemiology Program

• Emory University, Mayo Clinic, Univ. of Washington, Stanford Univ., Univ. California San Francisco, MIT, etc.

• Next Generation University (Univ. of British Columbia)

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Training Jump Start Proposal• New Generation University Preventive Occupational &

Environmental Medicine Program• Links existing top OEH training institutions with local and

regional participating OEH institutions in Asia-Pacific, or directly to students

• Raises financial support from donor agencies (WHO, ILO, Africa Fund, independent foundations, governments, private Individuals) to:– Pay trainers and their institutions– Pay cost of curriculum development and delivery– Pay stipends and expenses for trainees– Thus, trainees pay nothing and earn something (no debt)

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NextGenU.org

Erica Frank, MD, MPH Founder and President, NextGenU.org

Professor and Canada Research Chair, UBC

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Health workers save lives, and WHO says the world needs 4.2 million more of them ...

Source: WHO, 2008, Scaling Up, Saving Lives

57 countries have crisis-level shortages of health workers.

Competency based education deliveredthrough information communication technologies is highlighted as a solution.

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4 Freedoms– Cost– Barriers – Ads – Carbon

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Founding Collaborators & Funders

• American College of Preventive Medicine • Annenberg Physician Training Program • Centers for Disease Control and Prevention in USA • NATO Science for Peace• University of British Columbia• World Bank • World Health Organization • World Medical Association • Grand Challenges Canada 28 Oct 2013 HK-THG

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17 Ways NextGenU Differs from MOOCs* and Traditional Education

• Credit• Free • Financial sustainability• Higher level education• Best available resources • Coordinated curriculum • Competency-based foundation• Multiple languages• Extensive human interactions

• Interactive computerized learning• Extensive computer and human assessment• Open use • Customizable • Active educational partnerships • A new way to teach• Open research policy• Warm prestige

*MOOCs=Massive Open Online Courses28 Oct 2013 HK-THG

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Courses Launched Since April 2013

Climate Change and Health Emergency Medicine

Environmental Health

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Registrants in 94 Countries

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First Results

• 1,530 course registrants (NextGenUsers) in 94 countries*• Pilot #1 – EM course in 2 US Medical Schools

– NextGenUsers and traditionally trained controls performed identically on the US national EM test

• Pilot #2 – EH course in Public Health program at Simon Fraser University– Test scores identical + course ratings higher for NextGenUsers

• Pilot #3 – Physical Activity Counseling course in Colombia – NextGenUsers learned >2x as much as controls and offered

positive qualitative feedback

*As of Oct 3, 201328 Oct 2013 HK-THG

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Introduction to Emergency Medicine Course in Partnership with

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Summary• OEH is founded in law, economically sustainable, and direly needed• Each nation requires a needs assessment baseline• Each nation needs OEH team training, community based, linked to

labour, government and medical-legal experts• International partnerships must start with labour groups, NGOs, and

OEH friendly professionals and institutions in medicine and law to press for OEH capacities

• Permanent goals (progressive realization, capacity):– Each nation becomes self sufficient in OEH training, capacities– Each nation integrates OEH with primary health care and public health needs

at the local community and workplace level– Mobile, outpatient, team approach, linked communication and expert support

• Tasks at hand…. What are they?

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Future• Future – Asia only or all developing world nations (Africa, Latin Am?)• Organization and partnerships?

– Name (reflect partnerships of all dedicated parties, nations?) • ? – Global Partners in Occupational & Environmental Health• ? – Partners in Occupational & Environmental Medicine (POEM)

– Mission (labour and NGO partners always at the table)– Objectives, Goals– Program(s)

• Short-term• Long-term

– Training (by whom?) – build partnerships• Institutional links (e.g., through NextGenU to WHO, ILO, leading Universities)• Labour and NGO links (e.g. Partners in Health, others)

– Communications (internet, website, other?)• Other projects?

– Each nation baseline needs assessment and alliance guided action plan; measure progress• Meet again? If yes, when and where?

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Vision, Love and Imagination

Primum non nocere (First, do no harm).Hippocrates

Where there is no vision, the people perish.Proverbs 29:18

We believe that love and imagination are potent weapons in the fight for the poor.

Ophelia DahlPartners in Health (www.pih.org)

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