Diagnostic Challenges – a perspective from South Africa

Overview• Context• Policy, legislation & services• A systems approach• Prevention to compensation• Some lessons• Conclusion

The World…Village (n=100)

• 57 Asians• 21 Europeans• 14 Americans• 8 Africans

• 52 women & 48 men• 80 persons living in poverty• 70 illiterate• 50 suffering from hunger &

malnutrition• 1 person with a university degree• 1 person with a computer

Lueddeke GR. 2012

Resized World Maps (Lancet. 2011)

More Illness and Fewer Health Workers in Africa

WHO: Human Resources for Health, 2006

Worker Health in South Africa / Sub-Saharan Africa

• 53m South Africans (STATSSA 2013)• 17m work (13m formal & 4m informal) • 3 workers die every day from accidents

• 875m in Sub-Saharan Africa • 258 000 die from work accidents• 98.9/100 000 (73.3 – world) – Fatal Injuries

STATSSA; ILO; WHO

Occupational Health in Africa

• fragmentation of policy and legislative framework (Health, Labour, Mining)• inadequate occupational health system • deficient occupational health services• lack of human resources for occupational health• little access, coverage & equity in compensation systems• vulnerable workers (migrant, mobile, youth, informal (60% – 78%) • no surveillance system for injuries and diseases

The Labour Market in Africa

• Dualistic– Formal / Informal– Urban / Rural– Modern / Traditional– Organised / Unorganised– Gender differentiation

ILO, 2011

Africa’s Growth

A=Fuelling Africa’s Growth

The Mining Economy• 1.8 Trillion USD sector (net asset value)• 7.7% of annual GDP DMR 2010

The Informal Sector

Trade Community Manufacturing Financial Household Construction Agriculture Transport Mining Electricity0

500

1000

1500

2000

2500

3000

3500

4000

2000 2007

Labour Force Survey. Statistics South Africa, 2008

Workers per Employment Sector (‘000)

Labour Force Survey. Statistics South Africa, 2008

Gender Distribution of Workers (2007)

Trade Community Manufacturing Financial Household Construction Agriculture Transport Mining Electricity0

200

400

600

800

1000

1200

1400

1600

1800

2000

Male Female

Migrant Mine Workers in South AfricaYear RSA Mozambique Lesotho Swaziland % Non-

RSA

1920 74 452 77 921 10 439 3 449 57

1940 178 708 74 883 52 044 7 152 49

1960 141 406 101 733 48 824 6 623 62

1980 233 055 39 636 96 308 5 050 44

1995 122 562 55 140 87 935 15 304 58

2000 99 575 57 034 58 224 9 360 57

2010* 152 486 35 782 35 179 5 009 34

* Data from TEBA

Surveillance• “data for action” (Giesecke, 1999)• “ongoing, systematic collection, analysis & interpretation of data for planning, implementation & evaluation” (CDC, 1988)

Occupational Ill-health

• hard to find data; if found, difficult to interpret

Occupational Injuries• Abrupt break in …AGENT – HOST – ENVIRONMENT

balance• Cause established

Occupational Diseases• Not diagnosed / mis-diagnosed• Lack of knowledge• Masked by other diseases• Long lag time• Need special investigations• Difficult to find cause

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

0

50

100

150

200

250

300

350

400

Active pulmonary tuberculosis in African miners at au-topsy, all commodities, 1975 - 2009

Year

Rat

e/10

00

NIOH: Pathaut, 2010

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

0

50

100

150

200

250

300

350

Silicosis at autopsy in gold miners, 1975 - 2009

Year

Rat

e/10

00

Nelson et al. Three decades of silicosis: disease trends at autopsy in South African gold miners. Environ Health Perspect. 2010

Gold Price (2000 – current)

Occupational Exposure Limits for Silica (2008)

Country / Province# OEL (mg / m3)

Argentina 0.05#British Columbia 0.025

Chile 0.04

Ireland 0.05Italy 0.05Japan 0.03Portugal 0.05

USA - ACGIH* 0.025

USA - NIOSH* 0.05

*Advisory organisationSource: Maciejeska A. 2008. Int J of Occ Med & Env Health 21 (1): 1-23

Wilson K. NIOH. 2011

Safe Work, Australia.

2010

– Policy deliberations• ILO Decent Work, Safe Work• Seoul Declaration• ILO Plan of Action (2010 – 2016)• WHO Global Plan of Action (2012 – 2017)• Occupational Exposure Levels• HIV / AIDS • Gender• Environment

ILO / WHO / UNEP

A seat at the table…

– Policy• Safety, Health & Environment /

Occupational Health• HIV/TB• MDGs, African Union

– Legislation• Conventions, codes, guidelines (ILO &

WHO)• Legislation – Departments of Labour,

Mineral Resources, Health, others

Policy & Legislation

– Governance• Government, Trade Unions,

Employers, NGOs, Professional bodies

– Management• Development & maintenance of the

system• Delivery of services

Governance & Management

Occupational Health Services: Core Functions

• Preventive– Risk identification, assessment &

management– Recognise high risk groups & priorities

• Health Promotion– Optimal physical & mental health– Healthy lifestyles

• Curative services– General practice level– Referral to specialists– First aid

• Rehabilitation & Compensation

Conceptual Model – Delivery of Services

PHC / District Health System

General Specialist hospitals

Central hospita

ls

Community / PHC

District Hospital

Gen Spec Hosp

Central

PHC Nurse / CHW

Family Medicine / OHN / Occ Hyg

Occ Med Spec +

Academic / Reference Units

OH Service Model

REFERRAL

SUPPORT

34

One – Stop Service Framework• Health Services

– Benefit medical examinations– Rehabilitation assessment & services

• Health Promotion– Primary Health Care support

• Social Services– Social Development– Counselling

• Financial Services– Compensation– UIF, pension & provident funds

35

Service Delivery Challenges• Human resources (occ. health

practitioners; nurses; occ hygiene, etc)• Curative focus (non-renewable human

capital)• Fragmented service delivery • Little or no quality assurance (radiology,

audiology, spirometry, occ hygiene, laboratory)

• Dumping syndrome / Referral system

Occupational Health Human Resources• 4.1 / 100 000 doctors (712) – 4300*• 0.77 / 100 000 hygienists (100 or 450) -

1340*• 15.4 / 100 000 nurses (2000) – 8670*• 0.6 / 100 000 ergonomists (80) • Safety practitioners, ventilation etc• ? Education and training inputs* need

(Rees, NIOH)

A Systems Approach

Provision of education

Health needs

Demand for education

Educational needs

Labor market for health

professionals

Worker Population

Demand for health care

Provision of health care

EducationSystem

HealthSystem

Supply of health

workforce

Demand for health

workforce

Occupational Health System

Epidemiological and demographic

transitions

Technological innovation

Worker / Community demands

Professionaldifferentiation

Emerging Challenges to the Occupational Health System

Systemic Failures• Mismatch of competencies to need• Weak teamwork• Gender stratification• Curative over prevention & primary

care• Labour market imbalances• Weak leadership

Promoting Occupational HealthPublic Health Approach

• Action beyond workplace

• All health determinants• All workers (contract)• All stakeholders

• Overall policy / legal framework

Traditional Occ Health• Only at workplace

• Only work-related• Permanent employees• Employer’s

responsibility• Workers & employers

Natural History of Disease

• Susceptibility phase - Risk factors

• Pre-clinical phase - Biological process has begun

• Clinical phase - Signs and symptoms

• Recovery - Chronic disease, disability, death

Weiner JP. 2003

Levels of Prevention• Primordial – building healthy environments

• Primary – preventing the emergence of risk factors

• Secondary – treating the risk factors• Tertiary – minimising risk in those with established disease

National Institute for Occupational Health

Services

Research

Education / Training Back

Office

Local & International Partnerships

Government & Public Entities

Universities and other Institutions

Trade Unions, NGOs &

Employers

Services (referred persons, workplace &

laboratory assessments)• Public & private sectors (incl NGO &

Trade Union sectors)• Pathology services (deceased ex-

miners)• Occupational Medicine

– Clinical specialist referral service– Surveillance– Ergonomic assessments– Immunology & microbiology

Services (referred persons, site & laboratory assessments)

• Occupational hygiene (risk assessments & hazard management)

• Analytic services & Toxicology• Information services

– Query handling– Resource centre– Electronic journals– eLearning platform (in development)

Research• Epidemiology• Special emphasis on mining sector,

construction, informal sector, health & public sector

• Nanotoxicology• Scientific (peer reviewed)• Translation of science for popular use• Scientific endeavour for policy change

& service improvement• Support for legal challenges

Health Technology Assessment• Lifecycle analysis of technology• Multidisciplinary team• Standard setting & guidelines

‘fitness testing’

‘gloves’

N95 masks

Revocation of licence

UVGI?GUIDELINES FOR THE UTILISATION OF

ULTRAVIOLET GERMICIDAL IRRADIATION (UVGI)

TECHNOLOGY IN CONTROLLING TRANSMISSION OF

TUBERCULOSIS IN HEALTH CARE FACILITIES IN

SOUTH AFRICA – MRC et.al• does it work?

• implementation• type• fixture• weight• warnings etc

• ventilation

Education & Training• Training in Occupational Medicine,

Occupational Hygiene & Pathology• Continuing educational development

– Short courses– Updates– Journal clubs– Support to universities

• Professional groups, Government, Private Sector & Trade Unions

• Support for training in SADC region

Capital Infrastructure

HPLCTB

Bio-aerosols Records

Implementation• Policy and regulatory change• Cutting across silos in

professional training• Networks / communities of

practice

Traditional modelEducationalobjectives

Competency-based education model

Curriculum

Assessment

Occupational Health needs /Occupational

Health systems

Competenciesoutcomes Curriculum

Assessment

Competency-based Education

Model Pre-secondary education

Post-secondary education Practice

MD

Nursing

Public health

Other

Teamwork

Inter-professional

Trans-professional

Common

Core + specific competencies

Systematic teamwork Teamwork

Core + specific competencies

Systematic teamwork Teamwork

Models of inter- and trans-professional Education

Workplace OHS

professionals

Common

Common

Dominant

Level Objectives Outcome

Informative • Information•Skills

Experts

Formative •Socialization•Values

Professionals

Transformative •Leadership attributes

Change agents

Levels of Learning

Integrative FrameworkProcessStructure

Text

Institutional Design• Systemic Level Governance Financing Development of the teaching

workforce Interface education-health systems• Organizational level Division of labor Incentives Capacity strengthening• Global level Stewardship Networks and partnerships

Instructional Design• Criteria for admission• Competencies (definition)• Curriculum Content Courses• Channels Didactic methods Teaching technologies

Text

Text

OutcomesInterdependence

• Health and education systems• Global and local spheres• Categories of the occupational health

workforce• Context and competencies• Teaching and learning

Transformative learning• Inter-professional and team-based• IT-empowered and pro-active• Life-long• Evidence-based• Locally responsive and globally connected• Adaptive to versatile career paths• Socially accountable for new professionalism

Context

Global-Local

Entry Point for Occupational

HealthTraining

+

AdvancedUniversityCertificate

Masters / PhD

Elective Clinical

Elective Public Health

Elective Occ Hygiene

Diploma

+

1-2 years

1 – 2 years 4 years

OccasionalLearners

Postgraduate Training Centres

Some thoughts on where to start

• Joint accreditation and assessment teams• Critical mass of trainers, materials &

infrastructure• Joint learning activities

– primary care settings– workplaces– clinical care settings– institutes

Networks & Partnerships• WHO Collaborating Centres• ILO – CIS Centres• ICOH• Government, employers, unions• Developmental partners• Special Funds – compensation,

pensions / provident funds65

Three Questions?• Has work caused ill-health?• Has work aggravated ill-

health?• Does the worker have a

health condition that can affect work?

barry.kistnasamy@nioh.nhls.ac.za