Adverse health consequences due to
occupational factors (at work) and due to environmental factors
are common in all countries and often lead to significant loss for
national economies (see below the data on US and Russian loss due
to occupational illnesses and injuries). Unlike most non-communicable
diseases (e.g. diabetes, duodenal ulcer, etc.), occupational and,
partially, environmental diseases have more anthropogenic origin. All
occupational illnesses and most of environmental disorders are preventable.
Therefore, the questions of legal responsibility for the emergence
of these diseases are acute. The issues regarding this responsibility
often have strong legal and political implications.
Occupational diseases have been more
precisely studied and categorized, than environmental diseases; therefore
it is easier to estimate the loss due to occupational diseases. For example,
the investigation performed in the USA [4] demonstrated that approximately
862,200 occupationally related illnesses were estimated to occur annually
in the civilian American workforce. The total direct ($65 billion) plus
indirect ($106 billion) costs were estimated to be $171 billion. Injuries
cost $145 billion and illnesses $26 billion. These estimates did not
take into account costs associated with pain and suffering, as well as
costs associated with in-home care provided by family members. Overall,
because of the inadequacy of surveillance of disease the numbers of occupational
and illnesses are likely to be underestimated.
Comparatively, the economical burden
of AIDS was estimated at $33 billion, $57 billion for Alzheimer’s disease,
$164 billion for circulatory diseases, and $171 for cancer.
Unfortunately, no official estimates
are currently available for Russia. The rough estimates are derived
from the above-mentioned U.S. figures, and are based on the two following
assumptions:
1) the economic burden due to occupational
illnesses is directly related with national GDP level (reflecting
the overall production level of the national economy).
2) the economic burden is associated
with the registered numbers of occupational patients per annum.
The ratio of the US GDP/Russia GDP was
approximately 20 (for 1994). If we assume that the occupational morbidity
in Russia and the USA is roughly similar, Russian economic loss due
to occupational illnesses might total $8 billion ($3 billion direct
and $5 billion indirect). Still, there is a great difference between
the figures of occupational morbidity in the countries: US Bureau of
Labor Statistics reported 429,800 new cases of occupational diseases
in private industry in 1999 [5]. The Russian Federal Center of State
Committee for Sanitary and Epidemiological Control reported 283,851
cases of occupational illnesses in Russian Federation during last 30
years (1972-2001) [11]. If we assume this Russian figure to be correct,
we have to assume that the economic burden due to occupational illnesses
in Russia is substantially less (45 times) than the calculated estimation
of $8 billions – about $170 million. Given that the latest modest figures
are reliable, and these figures reflect the actual societal burden correctly,
we might agree that little attention is paid by society to the problem
of OEH. But only the expenditures of the Russian Fund of Social Insurance
in 2000 were 12 billion RUR [6] – approximately $400 mln., or significantly
higher than our “optimistic” estimation. The most pessimistic estimate
was made by the chief Russian specialist in occupational health, academician
N. F. Izmerov, who reported it to be “10-20% of Russian GDP” [7].
Nevertheless, a major question is whether
Russian figures of occupational morbidity are reliable. This question
will be discussed in more detail below.
The problem of economic burden estimation
due to environmental health disorders is even more complicated than
the assessment of occupational illness burden, mainly due to the fact
that the definition of environmental illness (health disorder) is
unclear, or at least not as fully developed as the definition of occupational
disease.
WHO stated (draft definition developed
at a WHO consultation in Sofia, Bulgaria, 1993): “Environmental health
comprises of those aspects of human health, including quality of
life, that are determined by physical, chemical, biological, social,
and psychosocial factors in the environment. It also refers to the
theory and practice of assessing, correcting, controlling, and preventing
those factors in the environment that can potentially affect adversely
the health of present and future generations”. It should be mentioned
that there are at least 27 other definitions of environmental health
[8].
It is obvious that a person may inhabit
a series of different environments in the course of his life or even
in the course of the day. Ambient environments vary by geography
and may vary markedly even within a single city.
A broad spectrum of agents has been
associated with chronic health effects in the population. For example:
- Ambient air pollutants (ozone, particulate
matter, toxic chemicals, etc.)
- Indoor air pollutants (formaldehyde,
carbon monoxide, tobacco smoke, etc.)
- Pesticide resides in food (some of
them are suspected carcinogens)
- Disinfection byproducts in drinking
water.
It is important to note that the relationship
between the environment and health status is modified by many factors
(e.g., age, sex, genetic makeup, state of health, dietary habits,
etc.), so in general, an individual’s health response to environmental
factors can be very different. So, a strict legal definition of the
term “environmental disease” remains elusive. This dilemma explains
the hardship in establishing the connection between environmental
factors influence and resulting health disorders. Often the direct relationship
for a single individual cannot be found, and in such cases, the relationship
may be revealed only using statistical methods.
Currently, we live in an age of environmental
alertness. The social (and political) importance of environmental
health cannot be overestimated. Environmental health impacts a wide
strata of the population, or rather, the population at large (i.e.,
if we discuss the problem of ambient air pollution). At the same time,
occupational health is actually only a small part of environmental health,
as the occupational environment is just a small part of the environment
as a whole.
The issues regarding responsibility
for health disorders due to environmental factors (especially, anthropogenic
environment pollution) can be seen as very acute; especially now,
when attention of society has been largely focused on environmental
issues. There is a fragile balance that exists between the interests of
industry and the interests of the population exposed to the industrial
pollutants. The balance of the interests should be established mainly
by political processes.
There are two main types of primary
data in occupational health – the data regarding work conditions
of an individual worker and the data which focuses on his/her health
status. In Russia, the data on work conditions (the hygienic characteristics
of workplace) are collected by local centers of sanitary and epidemiological
control. The person responsible is usually an industrial hygienist, who
may either use the available data on working conditions at the specific
enterprise, or conduct a workplace evaluation (e.g., measure ambient air
in a workplace for concentrations of chemical substances). The data on
working conditions are presented to the occupational physician, to whom
the worker is referred. The occupational physician, usually in a Regional/Republican
Center of Occupational Pathology, compares clinical findings and medical
records of the patient with the industrial hygiene data. Then, a determination
is made by a commission of the Center of Occupational Pathology (according
to the proper normative documents issued by the Healthcare Ministry of
Russian Federation) whether a person has or does not have an occupational
disease.
Obligatory registration of patients
with occupational diseases in Russia was introduced as early as in
1924 [9]. Until 1986, the reports of registered occupational diseases
were submitted quarterly by local sanitary and epidemiological stations
(later renamed “centers of sanitary and epidemiological control”). Since
1986, individual registration of new cases of occupational diseases
began, not just number of cases for each enterprise or territory. The
system of registration was automated, which enabled easier analysis of
the data. Some regions of Russia introduced more complex computerized
systems of registration and analysis of occupational diseases, which
were able to perform deeper statistical analysis [9].
According to the Order of Healthcare
Ministry of Russian Federation #130 (of 23.06.1994), the system of
Centers for Occupational Pathology was created. Previously (during the
Soviet years), a system of several Research Institutes of Hygiene had
to provide occupational health services for all the Russian workers,
but the Institutes were too few and too distant from many of industrial
centers to cover the needs in post-Soviet Russia.
Newly created Centers for Occupational
Pathology were tasked with creating data banks on occupational morbidity,
mortality, and disability. Nevertheless, at some territories the new
Centers were not created (e.g., Vladimir region), and some regions’
“Centers” consisted of no more than 2-3 physicians, and were not real
centers in the full sense of the word (e.g., there was a single occupational
physician working part-time in Mari El Republic with population of
750,000).
Virtually, now there are several parallel
systems of registration of occupational diseases functioning in Russia:
1) within the system of Centers for Occupational
Pathology (led at the federal level by the Research Institute of
Labor Medicine of Russian Academy of Medical Sciences) – the origin
of primary data;
2) within the system of the Centers for
State Sanitary and Epidemiological Control (led by the Federal Center);
3) within the Ministry of Labor and Social
Security;
4) in the Fund of Social Insurance against
Occupational Injures and Diseases
The need for the integrated Registry
of Occupational Diseases was discussed in Russia for several years,
but the creation of the Registry is still in the process.
Beginning in 2001, the first approaches toward the creation
of the Registry were published. According to the published data [11],
The State Registry of Occupational Diseases in the Russian Federation
should be “a system for active dynamic surveillance over the patients
with registered occupational disorders in order to:
1) preserve the worker’s health and capacity
to work ;
2) provide full compensation of health
impairment or disability;
3) minimize the causes for occupational
disorders;
4) develop and implement economically
feasible mechanisms for improvement of working conditions;
5) develop and implement the state policy
toward preservation of workers’ health”.
Unfortunately, until now, the occupational
statistics are limited only to the registration of new cases of occupational
diseases. Summary statistics are not available yet, which prevents
not only estimation of total national burden due to occupational disorders,
but also prevents follow-up of occupational cases (if it results in
disability or not, etc.). Currently, the newly created Fund of Social
Insurance against Occupational Injuries and Diseases has surveillance
data only on a portion of occupational patients, those who have been
compensated. Still, this system only reaches a part of all occupational
patients. The workers who just leave their workplaces due to occupational
diseases, but do not receive any material compensation, miss the records
of Fund of Social Insurance.
In general, several problems are well-known,
preventing adequate surveillance of occupational cases in most countries:
- employers are not interested reporting of occupational
cases (even if compensation to workers with occupational diseases
is not paid directly by them, higher figures of occupational morbidity
at the individual enterprise may result in higher employers’ payments
to the social security institutions);
- employees are also not always interested in reporting
of work related illness or injury (official registration of disease
might mean leaving a rather lucrative job and may also create a hardship
in searching for a new job).
In Russia, some additional negative
factors may also be present:
- There was a tradition of unreliable statistics during
Soviet times. (Until Perestroika, the official figures of occupational
morbidity had to be decreased year by year, despite whatever reality
existed, to prove the “superiority” of the socialist system. A demonstrative
example can be illustrated with a situation at a chemical plant in Nizhny
Novgorod region, where all cases of contact eczema were registered as
“viral respiratory disorders” – so that the workers could leave work
connected with handling allergens for several days without “worsening”
local occupational statistics.
- Currently, a “black-market economy” forms a significant
part of the Russian economy (according to some estimates, up to 40%),
so a portion of workers are considered to be unemployed, but actually,
they are employed at some black-market enterprise, where they might
be handling some hazardous factors. Surely, such workers would never
be eligible for any compensation in case of their disease or injury,
and no occupational health statistics is available for this significantly
large group of workers in Russia.
- A rather low level of monetary compensation for cases
of occupational disorders may keep workers from applying although,
on the other hand, excessive compensation might inflate the actual
number of occupationally diseased workers).
- The number of physicians allowed to diagnose occupational
disease is insufficient (in Russia, only occupational physicians working
in Centers for Occupational Pathology are allowed to make diagnosis
of occupational disease, and the number of such physicians is less
than 1,000, while in the US, there are at least 2,400 physicians certified
in occupational medicine [5]).
- Few workers possess the knowledge to wade through the
bureaucracy of the occupational insurance and compensation system
in Russia, often they are not aware of their rights, and sometimes
they might be mislead by their administration (very little attention
is paid to occupational topics by mass media, including newspapers,
television, and Internet sites).
The latest available figures of occupational
morbidity in Russia seem to be too low to be correct – 2.24 per 10,000
employees (official data for 2001 [11, 12]).
At the same time in the USA, this figure
was 49.8 illnesses per 10,000 full-time workers [13], a 22-fold increase
compared to Russia. This increase cannot be explained by better working
conditions in Russia – officially, up to 25% of all working places in
Russia do not comply with industrial hygiene requirements [12]. The differences
might be slightly less dramatic, when one takes into account that the
US index is calculated per 10,000 full-time workers, while Russian index
is calculated per 10,000 total workers, and the number of part-time workers
at current economic conditions of Russia is substantial.
A scientific assessment should be performed
in Russia to capture a more reliable and accurate occupational morbidity,
which according to rough estimates, should be considered at least
at the level of other industrially developed countries (e.g., the USA),
but may even exceed the figures reported in Western countries. As occupational
mortality in the USA is about 4 times less than the index found in Russia,
we should expect a similar ratio between occupational morbidity – or,
approximately, a 90-fold underreporting of occupational diseases in
Russia.
It is interesting to compare the registration
of occupational morbidity with the registration of intrahospital
infections in Russia. There has been usual controversy regarding
the official statistics of intrahospital infections as well. Recently
The Chief Sanitary Physician of Russian Federation, G. G. Onishchenko,
in his Decree #37 (of 06.11.2002), in reference to the data found in
the investigation of the registered number of intrahospital infections),
stated that the official number was approximately 50 times less than
the real number. His decree was an honest attempt to try to correct what
he saw was a blatant underestimation of the scope of disease, although
it disputed the officially sanctioned statistical data.
The analysis of occupational health
information is mainly a comparison of working condition data and
workers’ health data. Being compared, the data provides healthcare
professionals with information on occupational risks.
The following definition of the term
“occupational risk” is given by Federal Law “On obligatory social
insurance against occupational injuries and diseases”: “The occupational
risk is the probability of a health disorder (loss) or death, connected
with carrying out the duties according to labor contract (or in other
cases, stated by law)”.
Speaking of occupational risks evaluation,
it should be mentioned that the first computerized systems for this
were created in 1970s. The Latvian system KASMON was introduced at the
USSR level in 1980s. The “occupational health unit” was available for KASMON
system, written in BASIC. Now more up-to date computerized systems are
used in Russian occupational health. At the moment, the Research Institute
of Labor Medicine (in Moscow) prepares “The handbook on occupational
risk assessment”. In this handbook the issues of occupational risk due
to noise, vibration, dust and some other hazardous factors will be covered
[9].
The evaluation of occupational risks is very popular now
in Russian medical science. During 2002, 18 Russian articles covering
the topic of occupational risk were quoted by MedLine. The occupationally-related
risks of coronary heart disease, arterial hypertension, carcinogenic
effects, occupational bronchopulmonary diseases, reproductive disorders,
etc. were included.
Though the methodology of occupational
risk estimation is well known, there is an opinion that the risk estimation
must not be correct if it is based on unreliable occupational morbidity
data [15]. Perhaps, this explains a rather skeptical attitude toward
the occupational risk estimation methodology. It is clear that if morbidity
figures are still unreal, risk estimation based on the figures is
also far from being correct, so the practical measures suggested according
to the estimations will always be questionable for society.
Meanwhile, currently the occupational
risk data are not supposed to be used by Social Insurance Fund to
calculate the employers’ dues, only the number of registered occupational
diseases is used compared to the number of them during previous year
[14].
Unlike in most industrially developed
countries, the topic of occupational health is not one that receives
much public attention in Russia. This lack of public and media attention
can be seen by comparing the number of media stories run on occupational
health in leading Russian and American newspapers.
In “Rossiyskaya Gazeta” (“The Russian
Newspaper”, one of the most influential and widely circulated newspapers
of Russia), from 2001 to March 2003, only 6 articles mentioning
the key terms “occupational diseases” were found (no full analogue
of the English language term “occupational health” is available in
Russian language). At the same time, on the website of “USA Today”
312 entries searched by the terms “occupational health” were found
for the same period. In several instances, the articles addressing occupational
health topics appeared on the front page of several American newspapers
as the “lead stories” (e.g., the article “Court to decide scope of disabilities
act” appeared on front page of “USA Today” on 04.17.2001). Such a prominent
place rarely, if ever, has occurred regarding an article on occupational
health in the Russian press.
It can also be demonstrated that virtually
no information on occupation health and safety is available on the
websites of the Russian Trade Unions or any of the political parties
(including even the left-wing parties).
In summarizing the general impression
of today’s state of health informatics within the occupational health
system of Russia, we must explicitly state that the system is unsuitable
for the current needs of Russian society – it is generally based on old-style
Soviet principles, and strongly needs to be up-dated. There are some
positive “seeds” in the system, such as the risk assessment methodology,
that must be kept; but the system of primary data collection should be
restructured. Other measures should also be taken to draw the attention
of the Russian society (in particular, the trade unions, journalists, and
politicians) to the opportunities that occupational health offers in promoting
health and quality of life by preventing and controlling workplace disease,
injury, and disability.
In the 1990s, the system of social and
hygienic monitoring (SHM) was launched in Russia.
The legal basis for the SHM system originated
from the “Statement on Social and Hygienic Monitoring”, which was
approved by RF government on June 1, 2000. “The Statement” described
SHM as “the state system of surveillance, analysis, estimation and
prognosis of the state of population health and human environment”. The
same statement established the Federal Information Fund of SHM data as
“the repository for data on the state of population health and human
environment, which includes information acquired through long-term surveillance,
as well as legal documents and reference materials on the analysis, prognosis
and relationship between environmental factors and human health.”
The primary data are collected in their
entirety: population health indices, social and economical indices,
ambient air pollution, drinking water quality. According to Order
# 334 of the Healthcare Ministry of Russian Federation (of 27.08.1999),
there are two levels of data represented:
- from the local level to the regional
level;
- from the regional level to the Federal
level.
There is a comprehensive list of the
health, social and hygienic indices to be used [16]. The indices provide
mainly basic statistical information, whose standard methodologies
have been utilized for decades (e.g., mortality indices). There are also
data on environmental pollutants from the most widely used chemicals.
Because most of such indices are based on standard measurable outcomes
(e.g., specific levels of chemicals or number of deaths from specific
causes) they may be more accurate and reliable than e.g. occupational
morbidity data.
The SHM system inherited the ideas of
some previous systems for health effects surveillance. For example,
by the end of 1990s the system of birth defects registration was
created in Russia (based on several normative documents, including
The Order of Healthcare Ministry #268 of 10.09.1998). Unfortunately,
initially the data of birth defects were collected in the regions of
Russia without any connection with pollution data. Currently the comparisons
between environmental pollution and birth defects rate can be performed.
Russian investigators V. M. Cherepov,
D. I. Timokhin, O.V. Klepikov, V. V. Zhukova (2000) have emphasized
that SHM data should be detailed enough to allow their use in making
effective managerial decisions [17]. However, according to the same
authors, there are some specific features which might limit the possible
use of the SHM system:
- the character of the data and their
variability;
- the limitations of the algorithms used
for making managerial decisions;
- the technical limitations;
- a time lag between the collection of
the data and their analysis and publication;
- a time lag before any intervention
evaluation can be performed;
- lack of cost-effectiveness of the informational
systems;
- inherent complexities of social and
political interpretation of the data.
It should also be mentioned that there
is controversy involving the need for the timely flow of information
versus the accuracy and reliability that comes with this faster
transfer of information. Two approaches have been mentioned – first,
whether to limit the raw data at the input level (to prevent the “flood”
of data at the higher levels), or second, to allow the passage of the
raw data directly to the higher level, which would then provide some
data verification and analysis. The first approach would be preferred
if the primary level of data collection were made fully reliable, and
then at least, partial analysis of the data could be performed at this
level.
Usually, the supposition is that the higher levels of organizations
or government (regional, Federal) are better equipped and have more
qualified personnel to a more thorough analysis of raw data.
Specific software was designed to provide
data flow within the SHM system. Perhaps one of the best is the automated
system “Social and hygienic monitoring”, developed by “Krista”, a software
company of Rybinsk, Yaroslavl region [18]. This is a distributed database,
which is able to provide SHM data flow within the whole region (from
local districts to regional offices, and finally, to the Federal level),
and it fulfills the requirements of the Healthcare Ministry with regards
to SHM. It is adaptable to the needs of specific users, and certain features
can be added upon users’ request.
Russian medical scientists and authors from other countries
have suggested that it would be advantageous if certain environmental
data (e.g., air and water pollutants) were collected by automated quantitative
sampling devices, so that the data could not be tampered with or falsified
by personnel [19, 20].
According to “Statement on Social and
Hygienic Monitoring”, the aims of SHM system in Russian Federation
are the following:
- to document and assess risk factors
able to cause harmful effects on human health;
- to identify, evaluate, assess and predict
the state of human health and environment;
- to define urgent and long-term measures
for prevention of harmful environmental effects on human health;
- to formulate recommendations on controlling
and reduction of exposures, illness, and injury regarding human health
and environment
- to disseminate information to state
and local authorities, other institutions, and the citizens on the
SHM results.
The concept of SHM is based on the principles
of environmental risk assessment which were introduced by the Chief
State Sanitary Physician of Russian Federation G. G. Onyshchenko and
Chief State Inspector for Nature Protection of Russian Federation, A.
A. Solovianov (common document of 10.11.1997). It was stated that at
the beginning of the work on environmental risk assessment in Russia,
the U.S. EPA experience would be widely used, after adjusting for Russian
conditions. The project was sponsored by some international organizations,
e.g., US Agency for International Development, International Bank for
Reconstruction and Development.
The term “risk” as defined was very
close to the definition given in the U.S. EPA glossary: “The potential
for realization of unwanted, adverse consequences to human life,
health, property, or the environment; estimation of risk is usually
based on the expected value of the conditional probability of the event
occurring times the consequence of the event given that it has occurred”
[21].
Using the SHM system information on
a regional level, many regions of Russia were able to calculate environmental
risks, or were able to compare the environmental risks with other health
risks. One of the first regions able to perform such analysis was the
Yaroslavl region, where the above mentioned SHM software was introduced
[22]. Some interesting data were obtained in Udmurtian Republic [23]
on risk factors associated with adverse health effects among the Udmurtian
population. For example, it was found that alcohol abuse increased the
risk of overall health disorders 3.1 times, smoking increased the risk
2.9 times, environmental pollution increased the risk 1.8 times. In Saratov
region, nine main risk factors were identified, associated with the
occurrence of overall health disorders in the population [24]:
1) Pesticide-containing food products (18.8%);
2) Air pollution at work (16.4%);
3) Nitrate containing food products (12.8%);
4) Marriage status (11.2%);
5) Air pollution at home (10.7%);
6) Elevated noise levels at home (8.2%);
7) Water pollution (7.6%);
8) Elevated noise levels at working place (5.9%);
9) Poor living conditions (4.7%).
Investigators of the Nizhny Novgorod
Research Institute for Hygiene and Occupational Pathology reported
on the health status of approximately 1000 newborn infants in one of
the main centers of Russian chemical industry, Dzerzhinsk [25]. Children
of the mothers handling potentially teratogenic chemicals at work
were found to have slightly better performance and health indices than
children born from mothers who had never worked in the chemical industry.
Although the results seemed unexpected, the differences in income rates
offered some explanation. According to these additional data, mothers
working in chemical industry had much better salaries than those who
never worked with chemicals (teachers, librarians etc.). This example
supports the assertion that the data for SHM should be as detailed as possible,
and should be analyzed in their entirety, without missing social indices.
Missing the comprehensive nature of
the data may result in neglecting some important aspects of human
health.
Some examples of the use of existing
data based on the SHM system were given above. We suppose that SHM
data might be used to rank previously identified risk factors, rather
then finding new ones. For example, if we look at the list of potential
risk factors provided for Saratov region [24], it can be agreed that
all the factors listed were considered to be harmful decades ago. Still,
the importance and impact of social factors (e.g., salary rate) upon
health outcomes has recently been introduced into the social consciousness
in Russia. After many decades of declared “social equality”, it has taken
some time for the importance of social factors’ impact on public health
to be officially acknowledged.
SHM system is rarely discussed in public;
now it seems to remain just a working system inside The Healthcare
Ministry of Russian Federation.
Though “The Statement on Social and Hygienic Monitoring”
described that one of the aims of the SHM system to be “to inform
state and local authorities, other institutions and the citizens
on the SHM results”, little information on these results is available,
excepting several proceedings of the scientific conferences, published
as no more than 1500 copies.
The mass media seldom pays attention
to so “dull” a topic; it usually focuses only on events such as large-scale
environmental disasters. On the Internet, the most interesting information
could be found at the website of the Federal Center of State Sanitary
and Epidemiology Control [26], but SHM data are restricted from the
public viewing by password protection and is available only to certain
healthcare authorities.
The ability of managers to use the SHM
system to make improvements in the quality of health care will be the
single best criterion in evaluating its effectiveness [17]. Nevertheless,
if the ability to use the system is delayed (and part of its utility
will necessarily be delayed for decades – e.g., in case of tracing the
carcinogenic activity of some identified pollutants) – the efficacy of
the system as a whole will remain questionable.
Unfortunately, neither “The Statement
on Social and Hygienic Monitoring” nor other government documents
delineate how the results of SHM can be used by the authority to improve
the health of the population. In Russian history we have several examples
where good intentions paved the way to undesirable effects. For example,
if the Udmurtian authorities decide that alcohol abuse has the most detrimental
effects on the Republic’s population – should they outlaw the production
of alcohol? Or should they prohibit alcohol consumption in Udmurtia?
Either decision may have untoward consequences.
For the moment, the Russian SHM system
is considered to be mainly a passive information system, not a system
for proactive response. To suggest to the politicians some alternatives
for action within the sphere of public health, the system must also
provide a possibility for impact assessment of such alternatives. Such
assessment would be used to elaborate proper health care actions, to
maximize positive effects, and to minimize negative effects.
As for now, it is especially important
to reiterate that “the results of risk estimation shall not be used
to adjust the payments to ecology funds, or by State Control institutions
to impose sanctions” (Chief State Sanitary Physician of Russian Federation
G. G. Onyshchenko and Chief State Inspector for Nature Protection of
Russian Federation A. A. Solovianov (common document of 10.11.1997).
In general, the Russian system of medical
informatics pertaining to environmental health is considered to
be much more comprehensive than that of occupational health, on the
level of primary data collection, as well as information analysis.
Nevertheless, speaking of knowledge distribution level, the system
is considered to be rather weak. The SHM system seems to be an isolated
databank, its data are not likely to be often used even in other departments
of The Healthcare Ministry, not saying about other Ministries or politicians.
Much more public attention should be
driven to the SHM results to provide proper managerial decisions in
sphere of public health, beneficial for the society.
6. Possible use of foreign experience in reform of information flow within
Russian system of occupational and environmental health
6.1.
The USA experience
In 1970 Congress passed the Occupational
Safety and Health Act “to assure so far as possible every working
man and woman in the Nation safe and healthful working conditions”.
The National Institute for Occupational Safety and Health (NIOSH) was
created to perform research concerning the causes of occupational injuries
and illnesses and to make recommendations for the prevention of work-related
disease and injury. To target national-wide research and prevention efforts,
NIOSH uses a number of occupational health surveillance systems, including
those developed on its own, as well as some external systems, e.g., the
annual Survey of Occupational Injuries and Illnesses, conducted by the
Bureau of Labor Statistics (BLS) since 1972. The information is
collected using a scientifically selected probability sample from private
U.S. industry establishments (about 165,000 establishments each year) [27].
The annual summary statistics can be found on the BLS website [28].
It should be mentioned that even the
lists of recordable occupational diseases in the USA vary from state
to state. There is no national registry of occupational illnesses or
injuries, though now NIOSH is working with 36 states to develop state-based
systems for surveillance of occupational disease and injury [5].
It is important to note that statistical
data concerning occupational health in the USA are not always based
on recordable cases alone, but are also based on special epidemiological
studies are performed at targeted enterprises, performed in a manner
so that the data can be extrapolated to the whole industry. This approach
may allow for more reliable national-wide data than the data obtained
from counting the recordable cases (which has the recognized limitations
of underreporting and underregistering). There is a great temptation
to introduce this approach in Russia immediately, but the first obstacle
is lack of financing; the second obstacle is that the healthcare decision
makers are not ready for such an approach. Still, as mentioned above, a
positive indication for such an approach was given by healthcare authorities
at the end of 2002 (the estimation of intrahospital infections for surveillance
purposes). In light of the mentioned obstacles, some additional preparations
are needed in the introduction of this practice concerning occupational
injury and illness surveillance, for the ultimate goal of providing more
reliable primary data on occupational morbidity.
It is important to mention, that in
the USA a large number of different data sets on occupational and
environmental health are fully available within the public domain,
while in Russia, the public, journalists, and politicians do not have
access to these data.
Environmental health data in the USA
are collected mainly by the Environment Protection Agency; these data
are also widely available, including access on the World Wide Web.
There is an wide belief that a lack of public awareness of occupational
and environmental health issues in Russia leads to an inability to suggest
proper managerial and political decisions in these spheres.
The European countries have a long experience
of collection, analysis and distribution of occupational and environmental
health data.
The German Accident Insurance Act (from
July 6, 1894), launched by the efforts of Otto von Bismarck, was
the first of its kind in the world. The health insurance scheme, pension
funds and so-called Berufsgenossenschaften (literally –occupational
comradeships) were established in Germany by the end of XIX century.
Later, the system was adopted with some
adjustment by the Scandinavian countries. By the end of XX century
the experience of the Scandinavian countries – Sweden, Finland, and
Denmark – in occupational and environmental health became recognized
world-wide.
In Sweden, official statistics on occupational
injuries have been available since 1906. Since 1918, the National
Social Insurance Board was responsible for data collection on occupational
health; since 1955, the data were officially published in the series
Sveriges officiella statistic (Swedish Official Statistics). Currently,
the data are collected by ISA (Work Injury Information System). The purpose
of ISA is to provide supportive documentation for policies regarding a
preventive work environment [28]. The statistics are generated from
the data of a special work injury report form; this report is also
filed with a public social insurance office. The ISA consists of a computerized
registery and also an archive containing microfilms of work injury
reports. The Swedish Work Environment Authority (SWEA) conducts special
processing of primary data. The data with personal identifiers removed
are available for individual researchers. The results can be found at
SWEA website (www.av.se), as well as in the form of annual printed reports.
There was a special study performed
in 1990s, which compared data from several survey studies of work-related
health problems and registered work injuries. It was demonstrated
that no more than about a half the cases that were presumed to be work-related
illnesses were reported to ISA. It was also found that a certain percentage
of so-called administrative dropouts existed (up to 21%),hen the health
problems were reported to Social Insurance Office, but the data of
the workers were not found in ISA later [29].
There is also Cancer registry, which
collects data on cancer cases. As the occupation of a cancer patient
is also registered, the Cancer registry can also be used for occupational
health statistics, and has the ability to examine associations between
cancer and certain occupations.
It is very important that the National Institute for Working
Life (Arbetslivsinstitutet) is not concentrated only on working health
issues, but covers a much wider spectrum of problems. One can speculate
that it therefore has much better connections with political circles
than most of the institutes in other countries (especially if compared
with similar institutes in former socialist countries).
It can be seen that occupational health
problems are well covered in the Swedish press currently, especially
those dealing with issues of occupational stress, the
health problems of office workers (e.g. due to indoor environmental quality,
video display terminals, etc.). An interesting book named “Medicine in
press and under press” was published by a collaborator of National Institute
for Working Life in Malmö Dr. Bo Hagström [30]. The relationship
between Swedish medicine and Swedish mass media are described in the book.
In general, the Swedish system of occupational
data surveillance and analysis is probably one of the best in Europe,
satisfying most of needs, and providing the decision makers with reliable,
accurate data.
It should be emphasized that such a
system was created because of decades of strong and productive cooperation
between employers’ organizations and trade unions; such co-operation
was also strongly endorsed and nurtured by governmental bodies.
Unfortunately, it seems that at present level of the political
system in Russia, very few positive features of the Swedish system
could be directly borrowed. Nevertheless, certain approaches might
be replicated and, perhaps, the Russian trade unions could participate
more actively in the planning stage of policy regarding the sphere
of occupational health.
As an example of a former socialist
country, Hungary still has its economy in transition, though few
remains of socialist system can be seen now.
For example, the Hungarians have held
onto the list of occupational diseases introduced in 1970s. Though
there is a newer list of occupational diseases, which has been modified
according to EU recommendations, workers with occupational diseases
from the new list do not receive financial compensation yet.
There is a registry of occupational diseases in Hungary,
led by the Institute of Occupational Health, as well as a system
for biological monitoring of more than 30 hazardous chemicals. (In
Russia, it is thought that it will take at least 10 years to develop
a similar biological monitoring system. Sweden currently requires biological
monitoring of only two chemicals – lead and cadmium). Annually, the
Institute of Occupational Health publishes a special report on the state
of occupational health in the country, based mainly on the registry data.
Despite this timely information, there are still complaints that few necessary
political decisions are based on the annual report data.
The Hungarian mass media has also remained
uninterested in covering the problems of occupational and environmental
health, unless there is some sensational case.
So, the Hungarian system seems to present
the case where scientists possess all the necessary data, but have
no opportunity to present them to society to focus more attention
on the issue.
Historically Ukraine had strong connections
with the same Soviet system of occupational and environmental health
where the roots of the current Russian system began. Nevertheless,
certain changes have taken place.
Being a smaller country than Russia,
Ukraine did not need to implement the system requiring “regional centers
for occupational medicine”, as did Russia in 1994. The Soviet system
of the Research Institutes of Labor and Hygiene responsible for several
neighboring regions has remained in the Ukraine. On one hand, it has
prevented the creation of “regional centers” that lack the proper group
of specialists in most fields of occupational medicine (e.g., occupational
neurology, occupational surgery, occupational ophthalmology, etc.).
On the other hand, presently, the Kharkhiv Institute of Labor Hygiene
is responsible for e.g. Odessa region of Ukraine. This presents a problem,
unfortunately, as illustrated by the 600 km distance between the occupational
physicians and the workers who have to be under their care. Although there
is no national occupational registry in Ukraine currently, there are registries
in some regions. Work on implementation of a registry on national level
has recently begun.
The caliber of work among certain Ukrainian
occupational medicine physicians is much greater than the general
level of occupational medicine in the country as a whole. This progression
can be seen in the surveillance work concerning occupational and
environmental exposure to ionizing radiation (the result of Chernobyl
disaster) and the resultant health effects (Kiev Research Institute
for Labor Medicine). Also, major advances can be seen in the collection
and analysis of health data of computer users (Kharkiv Research Institute
for Industrial Hygiene). In both Kiev and Kharkiv Institutes there has
been surveillance of data occurring for more than 10 years.
During a recent visit to Kharkiv, there
was a discussion devoted to introduction of the so-called “Health
passport” in Ukraine. According the Healthcare Ministry Order, the
“Health Passports” are individualized data banks kept on recordable
CDs (CD-R) minidisks which catalogue patient information. These CD-R
minidisks are to be kept by the citizens of Ukraine, and brought with
them every time they seek medical care. The data from these visits are
added to these disks after any new visit of the patient to the hospital/polyclinic.
Despite of approval of such a system,
even by President Kuchma (as it was announced), it is difficult to
understand how all the data (including X-ray images, ultrasound video
etc.) will fit onto 180 MB minidisks. Each new cycle of adding information
onto a CD-R disk requires at least 20-30 MB of additional service data.
With regards to mass media interest, unfortunately, occupational
and environmental health is not a topic driving interest in Ukraine.
The following three items of reforms
were suggested in the letter of the Nizhny Novgorod Research Institute
for Hygiene and Occupational Pathology to the Health Care Committee
of State Duma (The Lower Chamber of Parliament) of The Russian Federation.
The letter described possible directions of reforms in occupational and
environmental health, including the following proposals regarding medical
informatics:
1. Development of a system to organize
and carry out investigations to evaluate the most accurate, reliable,
and valid occupational morbidity rate in Russia in order to guide managerial
and political decisions aimed at the promotion of workers’ health.
Currently, the officially registered
occupational morbidity in Russia is substantially less than that of
industrially developed countries. The State Report “On Sanitary and
Epidemiological Situation in the Russian Federation in 2000” pointed
out that “incomplete documentation and surveillance of patients with
occupational diseases were due to flawed labor safety legislation…,
due to shortcomings in the organization and quality of preventive examinations
of workers.” To reveal the true rates of occupational morbidity in Russia,
special investigations should be organized and performed, using e.g.,
the American experience: carefully selecting representative enterprises
in targeted industries and agriculture, and then carrying out investigations
to better assess occupational morbidity at these enterprises. The results
could then be extrapolated to the larger industrial sector.
The results of such a study would be
used as a scientific base for managerial and political decisions aimed
at worker health and safety prevention.
2. Development of computer software
to create and conduct a national registry of patients with occupational
diseases, and the implementation of this software in Federal and regional
centers of occupational medicine in Russia.
Presently, there is no registry of patients
with occupational diseases in Russia. Though the Social Insurance
Fund conducts a data base of patients with occupational injury and
illness who receive financial compensation, this database does
not give a complete picture of occupational morbidity in Russia and
its structure. Therefore, a surveillance system should be created in
Russia to provide the systematic collection, analysis, interpretation,
and dissemination of morbidity data which documents labor conditions,
various occupational hazards, and possible occupational disability.
This mechanism of a a continuing surveillance system, when implemented,
will be able to be used to predict the state of occupational health in
the country, as well as in separate regions.
3. The expansion of the scientific basis
of modern telemedical technologies, enabling greater transfer of medical
information through telecommunication channels which will then increase
the availability of qualified medical service for inhabitants of
the distant regions of Russia.
During last several years, telemedical
technologies have been actively developed in Russia. The technologies
have allowed qualified medical services to be available for certain
populations in a few regions of Russia, where such services had not
been available otherwise.
Nevertheless, certain problems with
telecommunications exist: legal and some organizational questions
remain unclear; there is no standardized scientific method or basis
for telemedical consults. Establishing a standard methodology, and
addressing legal concerns will help expand the use of modern telemedical
technologies, hastening their implementation in the sphere of occupational
and environmental health.
1. http://www.who.int/health_topics/medical_informatics/en
(last checked February 7, 2003).
2. E. Coiera, Guide to medical informatics,
the Internet and telemedicine. Chapman & Hall, 1997.
3. R. Gibson Parrish II, S. M. McDonnell.
Sources of health-related information, in: Principles and practice
of public health surveillance. Ed. by S. M. Teutsch, R. E. Churchill,
Oxford University Press, 2000.
4. Leigh JP, Markowitz SB, Fahs M et
al. Occupational injury and illness in the United States. Estimates
of costs, morbidity, and mortality. Arch Intern Med 1997 Jul 28;157(14):1557-68.
5. Occupational health. Recognizing and
Preventing Work-Related Disease and Injury. Ed. by B. S. Levy, D.
H. Wegman. Lippincott, Williams & Wilkins, 1999.
6. I. Yurgens. Reform of social insurance
system. Nezavisimaya gazeta, June 26, 2001(in Russian).
7. N. F. Izmerov, E. I. Denisov. Methodology
of occupational risk assessment in labor medicine. In: Social and
hygienic monitoring – practice and scientific basis. Moscow, 2000.
P. 181-186 (in Russian).
8. http://www.health.gov/environment/DefinitionsofEnvHealth/ehdef2.htm
(last checked February 7, 2003)
9. Occupational diseases: Handbook. Ed.
by N. F. Izmerov. Moscow, 1996 (in Russian)
10. O. Vasiliev, S. Stepanov. Federal
register of occupational diseases is needed. Meditsinsky vestnik, September
26, 2002 (in Russian).
11. On occupational morbidity in Russian
Federation in 2001. Report of Federal Center for State Sanitary and
Epidemiological Control. Moscow, 2002 (in Russian).
12. http://www.safework.ru/RISOT/tables/T1.htm
(last checked February 7, 2003, in Russian)
13. Workers Health Chartbook, 2000. NIOSH,
2000.
14. http://www.dadp.dgu.ru/NS.htm (last
checked February 7, 2003, in Russian)
15. E. Vlasova. Reform of insurance.
Nezavisimaya gazeta, April 4, 2001(in Russian).
16. http://www.depart.drugreg.ru/doc/p_334_99.html
(last checked February 7, 2003, in Russian)
17. V. M. Cherepov, D. I. Timokhin, O.V.
Klepikov, V. V. Zhukova. Methodical approaches to building information
systems for social and hygienic monitoring. In: Social and hygienic
monitoring – practice and scientific basis. Moscow, 2000. P. 14-19
(in Russian).
18. http://www.gsen.ru/soft/expsoft/krista/sgm.html
(last checked February 7, 2003, in Russian)
19. N.V. Matveev. Contemporary communication
technologies in hygiene and occupational health. In: Social and
hygienic monitoring – practice and scientific basis. Moscow, 2000.
P. 80-84 (in Russian).
20. N. B. Harmancioglu, O. Fistioglu,
S. D. Ozkul, M. N. Alpaslan. Decision making in environmental management.
In: Environmental data management. Kluwer Academic Publishers, 1998.
21. http://www.sra.org/ gloss3.htm#R
(last checked February 7, 2003)
22. S. A. Melyuk, N. L. Karpov, N. A.
Solonenko. Software and hardware for social and hygienic monitoring.
In: Social and hygienic monitoring – practice and scientific basis.
Moscow, 2000. P. 90-95. (in Russian).
23. N. A. Zabrodin, N. A. Kirianov,
R. A. Kharten. Ranking the risk factors for population health. . In:
Social and hygienic monitoring – practice and scientific basis. Moscow,
2000. P. 230-233. (in Russian).
24. V. F. Spirin, M. A. Mironenko, A.
D. Doblo. Hygienic priorities social and hygienic monitoring in rural
area. . In: Social and hygienic monitoring – practice and scientific
basis. Moscow, 2000. P. 137-141. (in Russian).
25. Yu. P. Tikhomirov, M. P. Gracheva,
I. V. Fedotova et al. On methodology of estimation of technogenic
risk for female reproductive health. In: Ecological and environmental
problems of population health preservation. Nizhny Novgorod, 1999
(in Russian).
26. http://www.fcgsen.ru (last checked
February 7, 2003, in Russian)
27. A NIOSH look at data from the Bureau
of Labor Statistics. NIOSH, 2000.
28. http://www.bls.gov/iif/home.htm#tables
(last checked March 17, 2003)
29. ISA- The Swedish Information System
for Occupational Accidents and Work-Related Diseases. SWEA Rapport
2000:16.
30. The information system for Occupational
Injuries and the Work-related Health Problem Survey. Statistics Sweden
2002:2.
31. Bo Hagström. Svensk sjukvård
i och under press. Studentlitteratur, Lund, 2002 (in Swedish).