EMERGING TRENDS IN OCCUPATIONAL HEALTH

John HowardNational Institute for Occupational Safety and Health

Washington, D.C.

November 6, 2015Valley Health Employer Summit 2015

The George Washington HotelWinchester, Virginia

21st Century in General • Volatility

– Nature, speed and magnitude of change

• Uncertainty– Unpredictability of issues and events– Info about past and present less useful

• Complexity– Multiple, and difficult to sort, causes

• Ambiguity– Research seldom produces unambiguous results– Requires interpretation– Interpretation influenced by individual’s point of

view– Point of view can become entangled with the

science

21st Century Employment

• Jobs

• Employment

• Workers

Jobs

Technology & Jobs• 1914—1 in 3 Americans worked on a farm• 2014—<2% work on a farm, but produce far more food

Automation• Which jobs are safe?

– 47% job categories will be subject to automation in next two decades

• Job Transitions– Like the machine age in the 19th

century, new machine age jobs will look different

– Nobility of jobs controversy• 19h century—working in the

fields, nobler than at the loom?• 21st century—working in

manufacturing, nobler than working in the shared economy?

Robotics

Scope of Robotic Capabilities• Robots are simply better than people at some tasks.

– Mundane, repetitive, and precise jobs as clear candidates. – Robots already taken over as the primary worker in many factories.

• With perfect memories, internet connectivity, and high-powered CPUs for data analysis, robots can also provide informational support beyond any human capability. – Keep perfect record of project progress– Provide real-time scheduling and decision support– Have perfect recall, remind others complex policies and procedures.

• Robots may become reference figures that we learn to trust

• Robots be placed in management positions where they can direct a team to deadlines, ensure proper procedures, and chart and report on progress.

Humanoid Robots

Humanoid Robots• Pepper is a humanoid robot by Aldebaran Robotics and SoftBank Mobile

designed with the ability to read emotions. An emotional robot.– Introduced on 5th June 2014 to enhance human well-being.– Available on February 2015 at a base price of JPY 198,000 ($1,931) at Softbank Mobile

stores.

• Pepper's emotion comes from the ability to analyze expressions and voice tones.

Managerial Robotics• At MIT

– Management robot is learning to run a factory and give orders to cobots (collaborative robots)

• Can robots be managers?– Key element of a manager is the ability to dole out

duties and to have team members perform them– If a robot were placed in a managerial position by

the higher ups, would it have any actual authority over people?

University of Manitoba• Experiment to see if people would follow a robot’s commands to do things, when

they clearly did not want to

– Participants asked to rename files for 80 minutes

• 86% of participants obeying all the way through to the 80-minute mark

• People engaged the robot as if it were a person and argued with it, proposed compromises and used logic to try and sway its opinion

• Post-test, some reported that the robot may have been broken,

• Although they continued anyway, following a potentially-broken robot to do something they would rather not do.

– Young & Cormier, Harvard Business Review, April, 2014– https://hbr.org/2014/04/can-robots-be-managers-too/

Robotic Safety Standards• ANSI/RIA R15.06-2012

– American National Standard for Industrial Robots and Robot Systems- Safety Requirements

• Approved March 28, 2013 (revision of ANSI R15.06-1999)

– Provides guidelines for the manufacture and integration of Industrial Robots and Robot Systems

– Emphasis on their safe use, the importance of risk assessment and establishing personnel safety.

– Offers a global safety standard for the manufacture and integration of robotic systems.

• OSHA (1999)– https://www.osha.gov/dts/osta/otm/otm_iv/otm_iv_4.html

"I'm sorry Dave, I'm afraid I can't do that"

Employment

From Stability to Precariousness• 1880—1980

– Growth of companies created by industrial revolution – Vertical organ structure differentiated jobs from one

another more clearly than ever before– Good job was being an employee of a particular

company for your entire working life– Government built social welfare laws along these

lines• Workers got security, benefits, protections, and steady

wage rises• Companies got stable workforce in which they could invest

with fair expectation of positive returns

Transformation

Organization model in trouble in the 1980s:• Eroding employer-employee relationship

• Declining unionization

• Workplace virtualization

• Distributed governance– Holacracy– Circular management

Incentives for Transformation• Economic and organizational pressures not under the

control of any one employer• Pressures arise from financial markets that incentivize

corporations to shed all but their core business • Gave rise of contractors, temporary or contingent

workers working under a brand name, but actually working for a subcontractor or serial subcontractors

• Pressures to structure work in the most efficient or leanest way possible—a contractor can do peripheral tasks cheaper

Who is an Employee These Days?

• Legally, an employee is only an employee if she has an employer.

• Who is an employer these days?– Not so easy to answer

• Independent contractor or employer?– Is there an Employer—employee relationship?

• OSHA Law: Control and direction test• IRS: 20-item test (http://www.irs.gov/pub/irs-pdf/p1779.pdf)

– Behavioral control– Financial control– Relationship of the parties

Newer Employment Patterns Affecting Worker Health

• Serial Subcontracting• Precarious Employment

– Contingent, Temporary or Independent Contractor• Dual Employers—Employee Leasing • Work Organizational Factors

– Work intensification• Downsizing• Mandatory overtime

– Lack of paid medical and family leave– Stressors arising from work itself

Contingent/Temporary/Leased Worker• More workers are being employed

through “contingent work” – Day laborers hired on a street corner for

construction or farm work, warehouse laborers hired through staffing agencies, and hotel housekeepers supplied by staffing firms are common examples, because their employment is contingent upon short-term fluctuations in demand for workers.

• Little job security, low wages, minimal advancement

• Perform most hazardous work• Not a large percentage, but

disproportionately bearing the burden of workplace injury, illness and death

Health Effects of Contingent Work

• Contingent employment increases negative consequences for the injured worker and society: – Worker might quickly find herself out of a job and, depending on the severity of

the injury, the prospects of new employment might be slim.

– Employer-based health insurance is a rarity for contingent workers, so the costs of treating injuries are typically shifted to the worker or the public at large.

– Employers do not directly pay for workers’ compensation and health insurance—they are insulated from premium adjustments based on the cost of workers’ injuries.

• So, employers of contingent labor escape the financial incentives that drive decisions to eliminate hazards for other workers.

– Are contingent workers as protected by government safety and health regulatory enforcement as are non-contingent workers?

Impacts of the “Fissured Workplace”David Weil

• Subsidiary companies providing services to lead businesses face pressure to reduce costs to win work– Since contracted activity is often labor intensive, pressure to reduce labor cost is severe.

Result many be violations of federal & state minimum wage, overtime and safety laws

• Splintering work activities across companies, often with ambiguously defined responsibility for safety, leads to holes in coordination– Triggers injuries & fatalities a documented in mining, petrochemicals, cell tower

maintenance, and even retail

• Widening income inequality• Wages set for their own employees reflect economic concerns and fairness norms. If

a janitor along side production line worker as a co-employee, wages will be pulled up. Businesses share more of their value creation with their own workforce through wages and benefits.

• If janitor is someone else’s employee, this link is severed

Franchisor Liability – Generally • Common legal advice

– “To avoid incurring vicarious liability, franchisors must take care not to exert too much control over their franchisees.”

Franchisor Federal Liability?• NLRB General Counsel has investigated charges alleging

McDonald’s franchisees and their franchisor, McDonald’s, USA, LLC, violated the rights of employees as a result of activities surrounding employee protests.

• – 181 cases involving McDonald’s filed since November 2012. Of

those cases, 68 were found to have no merit. 64 cases are currently pending investigation and 43 cases have been found to have merit.

– In the 43 cases where complaint has been authorized, McDonald’s franchisees and/or McDonald’s, USA, LLC will be named as a joint employer respondent if parties are unable to reach settlement

• http://www.nlrb.gov/news-outreach/news-story/nlrb-office-general-counsel-authorizes-complaints-against-mcdonalds

“Sharing” or “Gig” Economy• Collaborative Consumption

– Economic model predicated on the sharing or meshing of talents, goods and services

– eBay, Craigslist, Airbnb, Uber– Emerging sectors such as social

lending, peer-to-peer accommodation, peer-to-peer travel experiences, peer-to-peer task assignments, travel advising, or car sharing

– “On the Internet, everything is for hire”

• Value—$335 billion—2025

• Are there any employers or employees in the sharing economy?

Safety in Changing Employment: Who is Responsible?

• OSHA?– No employment relationship – Pulling shared economy contractors under OSHA law would require

substantial reinterpretation of settled law

• Workers’ Compensation? – Contractors responsible for their own workers’ comp

• Tort? – Agency law does not apply to independent

contractor• Contractor?

21st World of Work • Salariat

– Those who hold steady, old-fashioned jobs at fixed workplaces, which are dwindling in the private sector and are now located mostly in government

• Proficians

– Those who are highly educated and sell advanced skills that have grown in value in the knowledge economy and who more and more are multinational and voluntarily migratory workers

• Precariat– Those for whom employment is typically short-lived, uncertain,

involuntarily migratory, and delivered without a health, injury compensation, or social pension benefits package

Workers

Total Worker Health®Keep Workers Safe

Invest More in Worker Health

Create Greater Worker Well-being

Worker “Well-Being” on the Increase

World Health Organization

Healthy workplace is one where workers and managers collaborate to continuously improve, protect and promote the health, safety and well-being of all workers.

• Addresses the health and safety concerns in the physical work environment

• Meets the health, safety and well-being concerns in the psychosocial work environment including organization of work and the workplace culture

• Allows access to personal health resources in the workplace• Provides opportunities for participating in the community to

improve the health of workers, their families and others

Adapted from World Health Organization, 2010http://www.who.int/occupational_health/healthy_workplace_framework.pdf

Critical Strategies for Advancing the Health,

Safety and Well-being of Your Workers

Critical Strategy #1

“Don’t underestimate the connection between our health at

work and our health away from work”

Source: Milken Institute

U.S. Burden of Occupational Disease, Injury and Death

• In the United States in 1970, there were approximately 14,000 fatal work injuries per year

• In 2014, with a workforce about twice as large, 4,679 workers died from fatal injuries

• About 12 workers will die on the job today• In 2010, 3.7 million serious injuries per year• Up to $250 billion in direct and indirect costs• 1.8% of US GDP

Sources: (The 2014 data are preliminary findings of the 2014 Census of Fatal Occupational Injuries) other NIOSH Prevention through Design, 2011. Journal of Occupational and Environmental Hygiene, 11: 326–337; May 2014. (DOI: 10.1080/15459624.2013.863131)

“The iceberg” of occupational disease

Reported

Not Reported

Adapted from Levy et al. 2006

Most occupational disease is below the surface.Most environmental disease is also below the surface.

Recognized as being related to work

Medical attention

received, but relationship of illness

to work not recognized

Symptoms, butno medical attention sought

Affected, but no symptoms

Future Focus

Sources: S. Hertlich, M. Hamilo, S. Kuvalehti [FI], WHO/ILO/J.Takala, as featured in: Journal of Occupational and Environmental Hygiene, 11: 326–337; May 2014. (DOI: 10.1080/15459624.2013.863131)

Critical Strategy #2

“Be mindful of the significant, pervasive risks that work

conditions represent to our overall health and well-being”

What is Total Worker Health™ ?

….policies, programs, and practices that integrate protection from work-related safety &

health hazards with promotion of injury and illness prevention efforts to advance worker

well-being.

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Protecting Workers Is the Cornerstone of Total Worker Health

Photo Credit: Jawad Qasrawi/Hazards Magazine, 22 July 2014

Individually-Focused Behavior Change Interventions Not Enough

“It is unreasonable to expect people to change their behavior when the social, cultural and physical environments around them fully conspire against them….”

Adapted from M. Marmot/Institute of Medicine Report

Models for the Effects of Occupational Risk Factors (ORFs) and Personal Risk Factors (PRFs)

PRF

ORF D

Model 2

ORF

PRF D

Model 3

PRF

ORF

D

Model 1

ORF

PRF

D1

D2

Model 4

Adapted from Schulte et al. 2007, Schulte et al. 2009, and Ottman 1990

What is the difference between TWH and Employee Wellness?

Employee Wellness ≠ TWH• Employee Wellness

– No attention to factors arising from work itself that can lead to, or worsen, adverse health outcomes

– Attention is on health problems of the worker related to lifestyle factors, not on work nor the employer’s responsibility for how work is organized

• Types– Participatory

• Do not provide a reward/do not include any conditions for obtaining a reward that are based on an individual satisfying a standard that is related to a health factor.

– Health Contingent (Activity-Based and Outcome-Based)• Require individuals to meet a specific standard related to their health to obtain a

reward

• Popular – 50% of employers with > 50 employees – 90% of employers with 50K employees

Employee Wellness ≠ TWH • Patient Protection and Affordable Care Act

– “Safeway Amendment”• ACA added employee wellness based on now discredited cost

savings

• Are wellness programs effective?– Medical cost savings

• Lifestyle management—Probably not • Disease management—Probably yes

– RAND (2013) http://www.rand.org/pubs/research_reports/RR254.html

• Other reasons for wellness programs– Productivity– Worker morale– Recruitment and retention

Employee Wellness ≠ TWH

• A program that just uses the workplace as a platform (as opposed to the workplace being a risk factor itself) to improve worker health can only be successful if it makes the health of the worker, as a worker, the centerpiece of its efforts.

• NIOSH believes TWH® is the better example to follow, not a “wellness” program.

Critical Strategy #3

“Focus first on culture-building; policies represent TWH ‘MO and

guide us to sustainable health outcomes”

TWH Policies, Programs and Practices

• Worker-centered operations and worker participation in problem solving

• Paid family & sick leave, paid medical benefits• Equitable wages• Safe staffing, voluntary overtime • Discrimination, harassment, and violence prevention• Health-enhancing work organization and supervision • Work Intensification prevention• Respect, fair performance appraisals & advancement opportunities• Work-Life Integration • Attention to work factors causing chronic conditions• Confidential occupational health services• Support for productive aging across working life

Question:

Can the job I have predict my chances of being

overweight or obese?

Occupational Obesity

Punnett L and the Center for the Promotion of Health in the New England Workplace. Recent Trends and Research in Worker Safety and Health. February 25, 2014 NIOSH Total Worker Health Webinar.

Critical Strategy #4

“ To truly impact the epidemic of obesity among workers, we must

fix fat jobs….not focus on fat workers”

Can We Age Productively?

5. Partnership for Solutions [2004]. Chronic conditions: making the case for ongoing care. Baltimore, MD: Partnership for Solutions. [

http://www.partnershipforsolutions.org/DMS/files/chronicbook2004.pdf].

Center for Productive Aging and Work

Are there differential rates of aging by occupation?

Creating Age-Friendly Workplaces• Prioritize workplace flexibility• Match tasks to abilities• Involve workers in job redesign efforts• Avoid prolonged, sedentary work• Manage physical hazards, e.g., noise, slip/trip• Provide ergo-friendly work environments• Provide health promotion & lifestyle programs• Accommodate medical self-care• Invest in training & skill-building for all workers• Encourage cross-generational interactions• Manage reasonable accommodations & return to work• Require aging workforce management skills training for supervisors

63Loeppke et al., 2013; Silverstein, 2008 in Chosewood & Nigam, 2012; Grosch & Pransky, 2010

Health-Challenged Young Workers

Diabesity and the Future Workforce

• 39 States with 40% of young adults considered to be overweight or obese in just last decade!– In Kentucky, Alabama and Mississippi, >50% young adults are overweight

• Medical Consequences:– High Blood Pressure– High Fats in the Blood– Type 2 Diabetes (formerly called adult-onset, but adolescents have it now)– Hepatic steatosis epidemic (fat deposits in the liver)– Sleep apnea (too much fat around the upper airway)

• Musculoskeletal Disorders – What workers at all ages now have in common!

Critical Strategy #5

“ Train supervisors with health outcomes in mind”

Key Areas• New, younger, older, vulnerable workers• Work stress; work-family integration• Accommodation, return-to-work• Red flags, early interventions, social supports

Impacting Total Worker HealthTM

Lifestyle Issues • Acquired health conditions

– Hypertension– Arthritis– Diabetes– Cardiovascular disease– Cancer– Chronic obstructive lung disease

• Demographic shifts in workforce– Mature workers—aging and medical conditions – Younger workers—obesity

Critical Strategy #6“ Craft benefits programs with

worker safety and well-being in mind; provide flexibilities and

supports so workers can actually use them”

NIOSH Studies on Paid Sick Leave• Examined association between worker access to paid sick leave (PSL)

and incidence of nonfatal occupational injuries – in the U.S. private sector – by industry and occupation, from the employer’s perspective

• Asfaw et al. 2012 http://dx.doi.org/10.2105/AJPH.2011.300482

• Currently examining the business value of providing PSL – Net (benefits) savings or costs to employers who provide PSL

• Asfaw et al. work in progress

• Evidence of economic returns would help employers make informed decisions about providing or expanding PSL

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Paid Sick Leave and Occupational Injury• What did NIOSH find?

– 28% lower injury likelihood of workers with access to PSL compared to workers without access to PSL, based upon data on working adults from the National Health Interview Survey (NHIS) for 2005-2008

– Association varied across different industry sectors – Introducing or expanding PSL might help businesses to reduce

the incidence of nonfatal occupational injuries– More likely to lower risks in industry sectors or occupations

with a high risk of injury– Employers could save $16 - $56 billion per year or $375 - $1,300

per worker per year by offering paid sick leave to their employees, based on cost of $19 billion per year to provide PSL

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Executive Order—Paid Sick Leave for Federal Contractors

• Agencies shall, to the extent permitted by law, ensure that new contracts include a clause, which the contractor and any subcontractors shall incorporate into lower-tier subcontracts, specifying, as a condition of payment, that all employees, in the performance of the contract or anysubcontract thereunder, shall earn not less than 1 hour of paid sick leave for every 30 hours worked.

• Executive order is effective immediately and shall apply to covered contracts where the solicitation for such contract has been issued, or the contract has been awarded outside the solicitation process, on or after: January 1, 2017

• https://www.whitehouse.gov/the-press-office/2015/09/08/executive-order-establishing-paid-sick-leave-federal-contractors

National Aeronautics and Space Administration

University of Colorado Center for Worker Health and Environment

Dartmouth-Hitchcock Medical

Center

Kentucky Department for Public Health

Mount Sinai Health System

Kentucky Injury Prevention and Research Center

National Safety Council

Nebraska Safety Council

University of Michigan

International Brotherhood of Boilermakers

SAIF Workers Compensation

University of North CarolinaUniversity

of Georgia

Laborers’ Health and Safety Fund of North America

Western Kentucky University

Oregon Healthy Work Force Center

University of Iowa Healthier Workforce

Center for Excellence

Center for the Promotion of Health in the New England

Workplace

Harvard School of Public Health Center for Work, Health and

Wellbeing

TWH Centers of Excellence and Affiliates

ISSA -The Worldwide Cleaning Industry Association

August 19 Intervening for Work Stress: Work-Life

Stress and Total Worker Health

February 25Making the Case for Total Worker

Health: An Overview of Opportunities and Approaches

November 14Integrated Safety and Health for

Small Businesses

Laura Punnett, ScD

Ron Goetzel, PhD

Dan Ganster, PhD

Leslie Hammer, PhD

James Merchant, MD, DrPH

Lee Newman, MD, MA

543 registrants357 attendees for live webinar224 views of recording*

582 registrants319 attendees for live webinar711 views of recording+

598 registrants234 attendees for live webinar279 views of recording+

2014 Series Summary

*Current as of 2/10/2015+Current as of 3/12/2015

For more information, please visit http://www.cdc.gov/niosh/twh/webinar.html

July 2015Sedentary Work

Other webinars on the way…..

October, 2015December, 2015February, 2016

March 12Preserving Lung Health: At Work and Beyond

Cara Halldin, PhDDRDS/NIOSH

David Weissman, MDDRDS/NIOSH

Cassandra Okechukwu, ScD, MSNHarvard School of Public Health

603 registrants

2015 Series

For more information, please visit http://www.cdc.gov/niosh/twh/webinar.html

Contact us at TWH@cdc.govVisit website

www.cdc.gov/niosh/TWH

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