TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Version Date Author Comments: TITLE 0 05/11/03 Likar, M, MD Specific socio-economic and public health aspects in zones Bauer, M. Mag.sci. with highly polluting and high energy - intensive industrial units: professional diseases 1 15/12/03 Likar, M, MD Bauer, M. Mag.sci. 2 Instructions and recommendations for the document: 1. All the pages must respect the next format in order to be valid for the cd-web. 2. It’s recommended not to make more than two screens “only text” successive. 3. Don’t forget to mark the important words for the Glossary. The definition of the concept must be included in a footnote. 4. Bibliography must be in a different document 5. Along the text, you must introduce the question (Open-Response and Multiple Choice, with the answer marked) in the place where you want it appears. For possibilities of the configuration please see ANNEX 1: PATTERNS FOR THE MODULES Distribution list: [list of persons within consortium to whom this deliverable will be distributed] TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES [The content of the deliverable chapters] Specific socio-economic and public health aspects in zones with highly polluting and high energy - intensive industrial units: professional diseases Likar M, MD and Bauer, M Mag sci. Contents 1. Introduction 2. Global environmental change 3. Environment and health 4. Europe's environment and health 5. Environment and health in Slovenia 6. Development of occupational health 7. International issues in occupational health 8. Principal tasks of occupational health 9. Occupational health in clinical praxis 10. Occupation and the New Public Health 11. Summary References TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 1. Introduction Contamination of the environment by biological, chemical, physical or other diseases – causing agents in the external environment and the workplace are major public health and political concerns as we are entering 21st century. Public consciousness regarding these issues has increased during the past several decades. Environmental concern has become an important part of accepted public philosophy in a number of developed countries. In developing countries the efforts to expand economically and struggling with severe problems of population growth and basic services have a high priority. In a number of eastern European countries industrialization has contributed to degradation of environment. The observations are not new as this also occurred in other today developed countries during their industrial development and urbanization. There is a growing concern about the links between the environment and health. Worldwide one quarter to one third of the burden of disease appears to be attributable to environmental factors. Vulnerability and exposure, however, differ markedly between different groups and areas, with children and the elderly being particularly at risk. There is reasonable understanding of cause and effect relationship between water, air pollution and human health. However the health consequences of other environmental factors and exposures such as those resulting from climate and chemicals in the environment, are a result of complex interactions between the environment and humans that that far less understood? For some chemicals, such as endocrine disrupting substances, the effects on humans are particularly difficult to unravel but the impacts on wildlife have been substantial, with implications to human health. Other chemicals in the environment, the disposal of wastes and noise continue to cause worry. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 2. Global environmental change In 1985 the European region of WHO issued consensus statement on health targets for the year 2000. Some of them are listed below and represent a broad social commitment to stop environmental degradation. Global environmental challenges for the 21st century l. Population growth; 2. Economic growth: 3. Food production and distribution; 4. Environment and health in Slovenia; 5. Energy and resource depletion; 6. Soil erosion/desertification; 7. Deforestation; 8. Shortages of water supply; 9. Air pollution; 10. Chemical /toxic wastes; 11. War armament /terrorism costs; 12. Ozone depletion; 13. Global warming; 14. Social, economic and political inequalities nationally; 15. Inequalities between industrial and non - industrial countries. WHO report 1992. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES The effects of global environmental changes cannot be predicted with certainty, as they require an international response rather than the local efforts alone. Poverty, low level of education, and rapid population growth in the poorest countries with limited food production potential are an incredible contrast to high level of consumption and energy used and low rates of population growth in the industrialized countries. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 3. Environment and health The concept of environmental health has been widened in recent decades by the spectrum of global changes to the environment as a result of man – made environmental pollution, and natural events. The greenhouse effect is the warming of the global environment and occurs partly as a result of the thinning of the ozone layer of the stratosphere. Disposal of toxic and radiological waste constitutes difficult public health challenges in many countries. Land degradation, loss of topsoil, deforestation, groundwater depletion, and acidification of water and soil are all challenges in environmental health for the new 21st century. In the developed countries the 10 most frequent work-related diseases and injuries are: l lung diseases; 2. musculoskeletal injuries; 3. cancers; 4. severe trauma; 5. cardiovascular disorders; 6. disorders of reproduction; 7. neurotoxic disorders; 8. noise related hearing loss; 9.dermatologic conditions; 10. psychological strain and boredom. The idea that health transcends geographic, political, economic and natural barriers is gaining ever-wider support. It is also obvious that developing world would never achieve economic and political stability unless the health of its people improved. If not addressed, the health problems of the developing world would pose a global threat. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 4. Europe , s environment and health European environment agency recently (2003) published the third assessment of the state of the environment at the pan - European level. The second report published in 1998 made it clear that the policy measures that had been taken up to the mid-1990s had not yet produced a significant improvement in the state of the environment overall. Most progress on environment improvement continues to come from actions under well-established international conventions and legislation, or as a result of economic recession and restructuring. These gains will be lost again if economic growth continues to be based on traditional, environmental damaging activities. This is a particular risk for the EU accession countries and countries of eastern Europe, Caucasus and central Asia to which large amounts of manufacturing industry have been transferred from western Europe and elsewhere in the world. The accession countries face the major challenge of managing with limited resources, and again competing economic, social and environmental priorities, the transitions to EU membership, sectoral integration and sustainable development at the same time. The eastern European countries have a much lower GDP per capita than elsewhere in Europe, but arguably and competing calls on limited resources yet have relatively limited access to the capital markets for finance to improve the social and economic welfare. Facts and figures illustrate some of the main problems: - occupational exposure to certain pesticides may increase the risk of Parkinson's disease (or Parkinsonism) by 15 to 2o %; - worldwide, it has been estimated that 3 million people die prematurely because of air pollution; - in Europe asthma affects one child in seven. Allergies, notably asthma, have continued to increase dramatically over the past 30 years; - environmental tobacco smoke increases the risk of lung cancers in non-smokers by 20 to 30 %; - some 10 million people in Europe are exposed to environmental noise that can result in hearing loss; - in some European countries testicular cancer is increasing in prevalence and an increasing number of young men face a low sperm counts, but there is so far no clear evidence that environmental exposure to these chemicals affects male reproductive health in TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES humans. Many of the environmental issues are complex and will require recognition and action by a wider range of players than was necessary for sulphur emissions. Examples include climatic change, biodiversity loss and soil degradation. The start of the Kyoto protocol target period for limiting gas emissions is now five years away, the target dates for significantly halting biodiversity loss and to prevent soil degradation have yet to be agreed. New approaches such as the precautionary principle and the ECU's proposals on impact assessment should be considered further to help reduce the lead times between early warning, scientific and policy action and the resulting improvement. Recommendations for future development in order to improve the environmental monitoring capacities in Europe and allow for a real pan - European monitoring and reporting process are among others to : - develop indicators which would need to be widely agreed; - focus on the new information gathering on key issues and perspectives; - maintain the framework for cooperation on environmental reporting; - ensure an appropriate level of investment in basic environmental monitoring infrastructure; - encourage international collaboration to enhance cross border and international compatibility of information; - strive towards the effective implementation of relevant legal instruments such as Aarchus convention and its new protocol on pollutant release and transfer register. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 5. Environment and health in Slovenia What is the today's situation in Slovenia? The government has recently issued a preliminary report on the state of environment in Slovenia for 2002. The report has been prepared in accordance with the law for the preservation of the environment. The content and the structure of the report follow the system of European Union for its report on Environmental Outlook for a period of three years. A shorter report is published yearly with Environmental Signals for the future prospects. We will attempt to summarize the main changes in the environment for Slovenia. Water. The northwestern part of Slovenia has an ample atmospheric rainfall and snowfall but the eastern part suffers in the summer from severe droughts. Potentially each inhabitant of Slovenia can use an average of 16 000 m 3 of water each year what is much higher than in European Union. Underground water is disproportionately divided, as some water is lost in territories with karst. Superficial waters have been classified as to the pollution and the majority belong to class II - III (ARSO 2002). Atrazin has become the main pollutant for the underground water. Limits for all pesticides have reached 0,5 ug/l in the first few years of 21 st century. Air. The emission for S0 2 has been reduced in the last twenty years for 59 %, the emissions of N0x are increasing (the main source being motor vehicles), the emissions of lead have been reduced as from 2001 the gasoline with lead is prohibited. The emissions of CO2, CH 4, N 2O, CF4,C 2 F6 HFC, SF6 have reached a minimum in 1991 and 1992 and later started to increase from unknown reasons. Soil. The main problem in Slovenia is the loss of fertile land. In the period between 1993 -1998 the land used for new buildings and roads has increased for over 4 000, and woods for nearly 75 000 hectares. In contrast the land used for agriculture has decreased for approximately 80 000 hectares. Noise. The noise in natural and populated settings is increasing. The main source of the noise is the transport noise in urban areas. Ambiental sound levels are steadily increasing as a result of the growing numbers of road trips, kilometers driven in motor vehicles and higher speeds of motor vehicles. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Radioactivity. The radon concentrations have been measured in some apartment houses and in some of the schools. In the majority of buildings (over 70 %) the concentrations of radon were >100 Bq/ m 3. Only in 2% the values of radon were higher than 800 Bq/ m3. Some areas in the Alps were contaminated with radioactive 137Cs immediately after Chernobyl disaster but after ten years the surface radioactivity diminished as 137Cs were partly washed by the rainfall to lower zones of the earth. It is obvious that Slovenia is facing in general identical problems as the central European countries. Some changes in the environment have been expected. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 6. Development of occupational health Occupational health is one of the oldest sectors of public health, dating back to Roman times. Ramazzini began documentation of occupational diseases in 1700. Ramazzini on silicosis,1700 “ We must not underestimate the maladies that attack stonecutters, sculptors, quarrymen and other such workers. When they hew and cut marble underground or chisel it to make statues and other objects, they often breathe in the rough, sharp, jagged splinters that glance off, hence they are usually troubled with cough, and some contract asthmatic affections and become consumptive.” RamazziniB.De Morbis Artificium Diatriba, 1700, as quoted in Hunter D, 1969. Historic examples of work related health hazards and diseases include scurvy among sailors, cancer of the scrotum in chimneysweepers, black lung in coal miners, and mercury poisoning in hat makers. Byssinosis in cotton mill workers and mesothelioma in asbestos workers. The list is long and extends to musculoskeletal injuries and hepatitis B in hospital workers, spinal disorders in typists and medial neuritis in computer workers (carpal tunnel syndrome). Recently Republic of Slovenia has accepted a register of occupational diseases. The register divides occupational diseases in three groups: 1.Occupational diseases caused by chemical, physical, and biologic factors, 2.occupational diseases affecting specific body systems and 3.occupational disease caused by cancerogenic substances, preparations and energy. Government responsibility for setting standards, monitoring, intervention and regulating compensation grew slowly over past century. Case reports, epidemiological studies, and advocacy regarding the effects of lead, asbestos, vinyl chloride, silica, an dust fibers led to steps to reduce the hazards to workers and provided the professional support for legislative initiatives. International labor organization (IL0), and other international organizations promoted development of this field. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Thomas Legge ,s axioms on worker , s health and modern equivalent Legge, s axioms Modern version Unless and until the employer has done everything Don, t blame the victim; the health of workman can do nothing. workers is responsibility of the management. Practically all industrial lead poisoning is due to If you stop the exposure you stop the inhalation of dust and fumes. poison. External influences depend on the will of the Educate workers about risk reduction. workers to use them (respirators,goggles and washing conveniences ). Modified from Hunter D, 1969. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 7. International issues in occupational health Occupational health has become an international issue as the global economy transfers manufacturing from one country to another with great speed and ease. This is often motivated by lower wages, but also by lower occupational and environmental regularity controls, and less stringent or nonexistent legal protection against toxic exposures and child labor in developing countries. Transfer of occupational hazards from industrialized to non-industrialized countries has become an issue in international cooperation and trade agreements. Developing countries have stricter environmental regulations and worker organizations than developing countries that are trying to open job-producing industry at any price. In the global economy occupational health issues are of a vital importance. It is often said that in the developed country workers health benefits cost more than the steel to make a car. As a result there is a growing trend to transfer technology from industrial to developing countries or areas within the country, to use child labor, to overuse pesticides, to inadequate health and safety measures in developing countries. Experiences in the past have shown benefits from promoting workers health through improved nutritional monitoring of canteens and cafeterias, antismoking activities, and physical fitness programs. The management interest in a healthier work force to restrict rising health care costs has become a part of the modern corporate culture. The primary responsibility however, legally and morally lies with management, in addition to protecting the workers by monitoring risks, providing a safe environment and care at the time of injury. Government responsibilities are principally legislative: substitute or ban and define legal responsibility (civil and criminal) and compensation, enforce standards for toxic emissions and control, test environment and workers, label hazardous materials, monitor health of workers. Management is responsible among other tasks to substitute less dangerous materials, to monitor general ventilation and health of workers and good manufacturing practices. Occupational injuries and illnesses are social as well as engineering and management concern. Compensation, litigation, class action TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES suits and union action are all associated with increasing awareness of toxic and trauma effects on workers. The field is made more complex because some occupational illness may occur long after the exposure: silicosis, asbestosis-related mesothelioma, and asbestosis may develop after a long latency of up to 20 – 30 years following exposure. Follow - up of exposed workers may be difficult, and issues such as compensation may also be complicated. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 8. Principal tasks of occupational health Citing all the tasks would be nonproductive therefore we are limiting the list to the following: - anticipation of preventive measures as facilities are planned; - surveillance and monitoring occupational disease and injury; - right-to-know for all concerned; - epidemiologic analysis; - exposure reduction to established limits; - substituting toxic with less toxic substances; - promoting awareness at government, management, worker and consumer levels; - compensating for illness and loss of life; - recognizing that worker participation in health and safety is of mutual benefit. Toxicity at the work place and in the environment Toxic substances are widely used in industry, not only in manufacturing but also in services and they constitute a major concern of occupational and environmental health. Extensive information is regularly published on toxic substances by World Health Organization. Much of the interest of occupational health has been on detection, prevention and reduction of exposure to toxic materials at the workplace, but more recently also on contamination of environment. The knowledge of sources and effects of toxins in occupational settings is extensive. Factors such as duration and extent of exposure, age, gender, fitness and additional risk factors such as smoking or alcohol abuse affect the toxicity of an agent. Environmental factors include temperature and air flow and physical and chemical properties of the toxic agent. Examples of toxic substances and the history of control measures to eliminate or minimize their effects illustrate the complexity of the problem. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Factors affecting an aerosol, s toxicity Physical properties Physical state (particles, mist or gas, solubility) Chemical properties Acidity, alkalinity, fibrogenicity, antigenicity Individual susceptibility Immunology status (atopy,HLA type) Modified from Morgan WRC et al, 1984. Silica. Silicosis is one of the oldest known occupational diseases, affecting miners in particular. In ancient Greece and Rome it was described as “fatal dust“. Silica occurs in minerals and rocks throughout the world as fee silica or combined in quartz, flint or sandstone. Workers are exposed to inhalation of silica dust in mining, tunneling, stone cutting, quarrying, iron and steel works, brick making, polishing of stone, glass, metal and many other industries. Silicosis is a condition of massive fibrosis of the lungs caused by a prolonged inhalation of silica dust. It is classified as pneumoconiosis, a general inflammatory fibrotic lung condition. Silicosis can progress from mild symptoms of shortness of breath to radiological evidence of pulmonary consolidation and concomitant tuberculosis. Silica has not been proved to be carcinogenic. The problem remains difficult to prevent and there is still a controversy as to legally enforceable standards and compensation for workers with silicosis. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Sources of emissions of particulate matter Sources % of the total emission Industrial processes 38 Stationary burning of fuels 25 Transport 20 Other 17 EPA, 1984. Anthracosis (coal worker's pneumoconiosis) is a diffuse nodular deposition of dust in the lungs as a result of a long term exposure to bituminous or anthracite coal dust in coal mining. In simple coal worker s pneumoconiosis, coal dust is widely distributed throughout the lungs leading to the development of coal “macules“ around the bronchioles. Later on a mild dilatation known as focal dust emphysema also occurs; however it does not extend to the alveoli and is not associated with airflow obstruction. However, each year about 1- 2 % of miners with simple anthracosis go on to develop progressive massive fibrosis, which can sometimes develop after the exposure has ceased, or it may progress without further exposure. Simple anthracosis is not associated with respiratory symptoms. If present, the airway obstruction is due to either coincidental emphysema from smoking, industrial bronchitis, or to a progressive massive fibrosis. The diagnosis depends on a history of suitable exposure, usually at least 10 years underground, and the characteristic x-ray pattern of small rounded opacities. Occupational Asthma. Numerous allergenic and non-allergenic materials in the occupational environment are recognized causes of a reversible airway obstruction. Examples include castor bean, grain, proteolytic enzymes used in detergent manufacturing, beer-and leathermaking industries, flax, formalin, epoxy resins and hemp. The list is continually growing. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Dust suppression is essential in industries where known allergens or bronchoconstrictors have been identified. However elimination of all instances of sensitization and clinical disease may not be possible. A highly susceptible individual must be removed from a setting known to produce asthmatic symptoms. Byssinosis. A condition known also as “cotton dust“ has been a common cause of chronic obstructive lung disease among the long – term workers in textile industries in some developed countries. Byssinosis is seen almost entirely in workers who come into contact with cotton trash (i.e. unprocessed, unpurified cotton). Evidence suggests that some material in the cotton bract leads to development of bronchoconstriction. Chest tightness develops on the first day after returning to work following a weekend of vacation. Many subjects who complain of chest tightness also demonstrate a drop in ventilatory capacity over the first week of shift. The promulgation of new standards for the ventilation and filtration and machinery used has reduced its occurrence. Replacement of old equipment with modern and automated machines gave an improved production speed, more effective use of the floor space, reduced labor input, and a higher quality product, along with lower dust levels. Economic crisis in textile industry in Slovenia today is opening questions as to its prospects in the future. The costs anticipated for the renovation is unattainable. Asbestos. Asbestos related diseases as an occupational public health problem surpassed all the anticipations after the rapid increase of the use of asbestos during World War In Slovenia it left a gruesome legacy in Anhovo with hundreds of workers affected. Inhalation of asbestos dust over a period of years results in the development of a serious type of fibrosis of the lung. The first reports of an association between asbestos and lung cancer began to appear in the 1930s. Later a synergistic relationship between asbestos exposure and cigarette smoking was scientifically documented. Today exposure to asbestos is accepted as the cause of mesothelioma, a highly malignant cancer of the chest or abdominal lining. The latency period may be 20 –30 years or more and the risk of the disease is related to the extent of exposure. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Occupational diseases caused by asbestos Asbestosis, diffuse interstitial lung fibrosis Diseases of the pleura Plaques in the parietal pleura Diffuse thickening of the pleura Benign pleural effusion Lung cancer Malignant mesothelioma of the pleura or the peritoneal lining Slovenian regulation for asbestos, 1997. The maximal concentrations of asbestos in the air have been given by a number of agencies. According to OSHA at present 1 fiber of asbestos in ml3 for an 8 hours exposition should be the limit. In the future this limit should be reduced to 0,5 and 0,2 fibers in ml 3. The exposure may occur in asbestos - cement production, shipyard workers, garage workers exposed to brake lining, plumbers, and construction workers using asbestos - based products. In the 1990 there is still some concern that asbestos products manufactured in developing countries are being imported to the developed countries. Asbestosis is preventable primarily by effective dust suppression in the work environment. Further industrial hygiene advances are likely essentially to eliminate it. Scientific community has been impressed by the results of a study in United States where a concomitant effect of asbestos and smoking have been identified as causes of lung cancer. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Lung cancer hazard for smokers and nonsmokers exposed to asbestos fibers Group Expected incidence/ 100 000 population Exposure to 0,0004 fibers/ml 3 Exposure to 0,002 fibers 3ml Men smokers 19,2 146 Women smokers 10,5 52,4 Men nonsmokers 2,7 13,2 Women nonsmokers 1,4 6,8 Mesothelioma (all groups ) 15,6 78 Natl Res Council (1984). In 1999, the European Union effectively banned the use of asbestos products. There are still open questions as to what to do with public buildings such as schools, hospitals, and apartment houses in which asbestos has been extensively used for the roof tiles and other construction materials. In Slovenia asbestos was banned in 1996. To enable the transition from the asbestos to the nonasbestos manufacturing a special fund has been approved by the legislative body in the budgets for 1997 and 1998 for the acquisition of new technology and equipment. In the regulation as the asbestos are listed chrysotile, amosit, actinolit, anthophylit, crocidolit and tremolit. All the products containing asbestos must be clearly marked that they can be dangerous. Lead. Lead is used with thousands of applications because of its plasticity and softness. Lead poisoning has been a worker s hazard since ancient times. Lead enters the body though inhalation and ingestion. It is causing intestinal colics, encephalopathy, delirium and even coma in its acute form. Chronic forms of plumbism or lead poisoning can be seen as mental dullness, headache, memory loss, neurological effects (wriest drop), anemia and a blue line on the gums. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Effect of different concentrations of lead in the blood on health Effects on health ug/100 ml Concentrations dangerous for the fetus 10 –15 Changes in the blood enzymes 15 – 20 Lower IQ in children > 25 Anemia in adults 50 Anemia in children 40 Brain damages ( irreparable ) 100 Likar M, 1998. Lead toxicity has been a traditional health problem of glaziers and potters: lead is used in the manufacturing process. We experienced in Slovenia lead poisonings with traditionally prepared kitchen pottery in the northeastern region. Wines and rum stored in lead containers or in pewter utensils were known to be associated with the “dry grips“ in the seventeenth and eighteenth centuries. Lead toxicity and excess exposure in the workplace remain a problem in the most developed countries. The major toxic effects induced by lead are hypertension, neuropathy, carcinogenesis, and reproductive damage for men and abortion for women. Studies have revealed a widespread exposure above permissible limits in many countries. They include traditionally high exposure industries such as primary and secondary lead smelting, battery and pigment manufacturers, brass/bronze foundries and in no less than 50 other industries. In 1997 the CDC adopted a standard of <10 ug/dl, a level at which a negative effect of cognitive development is reported. Despite major improvements 1,7 million children aged 1 – 5 years in the United States still have blood lead levels above 10 ug/dl. Reduction in lead exposure has been achieved in United States by a combination of legislation and professional and social pressures resulting in the adoption of lead – free gasoline, removal of lead from paints, and its substitution in many industrial practices. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Awareness and active lobbying by public health minded groups has had a beneficial effect in reducing lead toxicity in the community and workplace. Vinyl chloride. Vinyl chloride is a flammable gas with a faintly sweet odor. It is an important component of the chemical industry because of its flame-retardant properties, low cost and many end product uses. It is also a carcinogen causing liver, brain and lung cancer, as well as spontaneous abortion. Vinyl chlorides are dangerous primarily when inhaled or ingested. Vinyl chloride usage increased since the 1930s and more dramatically after the end of World War II until the 1970s. In the 1980s, polyvinyl chloride (PVC) was shown to be associated with Raynaud's phenomenon and later with malignancies, including hemangiosarcoma of the liver. OSHA established the carcinogenicity of PVC as a result of the review of all the evidence in 1974. Scientists concluded that that there was no safe level of exposure to vinyl chlorides. OSHA adopted 1 part per million as the maximum possible dose. While the risk assessment issues are still controversial, reduction of exposure to workplace carcinogens such as vinyl chloride is the accepted standard of modern occupational health. Standards for vinyl chloride Agency Location Level Observations FDA food 5 –50 PPM Monomers in polymers in wrappings OSHA air in workplace 1 PPM for an eight hours shift EPA inside air 10 PPM Limitsemission in the environment EPA water 2 ug/l from 1988 to all systems for drinking water( 8 months in a year ) NIOSH air in workplace 0 because of its carcinogenicity Likar M, 1998. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Despite an opposition of the industry to this reduction, full compliance was achieved in United States within 18 months by improving ventilation, reducing leaks, modifying reactor designs and chemical pathways, and using greater automation of the process. Even more effective was a major improvement in the production of PVC using less vinyl chloride. The costs to industry of reducing exposure levels were less than 25 % of anticipated costs because of unanticipated innovations in the production process. In Slovenia we have a claiming a “story of success“, producing seat covers for various car makes and types. They are exporting sat covers to a number of countries. We hope seat covers containing vinyl chloride will not change the story of success to a tragedy. Agent orange. Agent orange is a herbicide used widely by the US armed forces in Vietnam War to defoliate large areas of that country. This agent includes dioxin and is carcinogenic. Dioxin is the most toxic substance man has ever produced. It can be compared only to botulinum toxin. High levels of dioxin have been found in breast milk, adipose tissue in blood of the Vietnamese population. Even though sampling has not been systematic, studies at the beginning of 1990s show that high levels of dioxinlike contaminants are seen in blood samples of the Vietnamese population exposed to Agent Orange during the war. The explosion in Italian town of Sevese in 1976 and dioxin in toxic wastes in Times Beach in the state of Missouri have been warning signals for the future. Additional studies are necessary to establish the effects of dioxin such as increased cases of cancer or birth defects. However, court and compensation decisions have been made in favor of veterans exposed to Agent Orange despite inconclusive epidemiological evidence of its ill effects on health. In Slovenia it was discovered that a factory producing batteries and other electrical appliances has dumped a number of its faulty products near a river in the southeaster part without proper precautions. The place was investigated but no dangerous substances have been discovered. Workplace violence. Violence is endemic in many societies today and affects many organizations and institutions. Violence has become a major cause of fatal injuries in then workplace. Violence in the health setting has a long history, with the first documented cases in the early 1850s when patients fatally assaulted psychiatrists in metal health facilities. Since then there have been many reports of assaults, hostage taking, rapes robbery, and other violent acts in the health care and community settings. During the 1990s, homicide became a leading occupational cause of death for females and the second leading cause, after motor vehicle crashes, for men TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES in the United States. Homicide at work has only recently been addressed as an occupational hazard, and research in this area is in its infancy. There are no known universal standards to protect workers from work–related violence, and no policy has been created to protect workers. It is becoming increasingly obvious that preventing violence in the workplace is essential. Management and workers organization as well as health systems share responsibility. Prevention of drug, alcohol, and sexual abuse and harassment at work are vital to prevent workplace violence TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 9. Occupational health in clinical practice The clinical physician should consider the patient's occupation and previous history. The inclusion of questions related to past employment may be crucial in investigation of the disease. The health care provider should be aware of industries in the community and their potential hazards. The clinician is particularly important because he or she may be the first to see index cases of toxicity. This requires simple observations. Factors observation during walk through inspection of work sites Marker Observations of conditions, safety arrangements, and effects on workers health Sensory observation Eye irritation, poor lighting, noise levels, metalic taste in air, smell, visible fumes, exhaust, temperature (heat/cold ) Safety devices Use of hard helmets, welding masks, safety shoes and clothing ,ear, eyes and face protectors, first aid facilities ,respirators Storage Hazardous chemical substances closet, unlabelled bottles, containers Toilets Cleanliness, fixtures ,soap, toilet paper, waste disposal tins Worker hygiene Changing place; showers ;lockers ;clothing change Eating place Separate tables; cleanliness; washup facilities Worker's complaint Headache, fatigue, dizziness, nausea, breatlessness, skin problems Worker morale Worker morale is reflected in turnover and absenteeism Hazard control Labeling ,process recording, periodic screening Cleanliness Removal of waste products, oil or chemicals on floors, tables Vents, fans Exhaust of fumes, odors,dust Worker-management Consultations and sharing responsibility to reduce hazards cooperation TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Risk assessment. Identifying and quantifying occupational and environmental risks is difficult, but clinical and public health observations, supplemented by epidemiological analysis, can identify toxic or carcinogenic factors that can be reduced or eliminated by public health intervention. High levels of awareness from environmental or occupational exposures can help identify index cases. Similarly, epidemiological small area analysis can identify populations at high risk for professional disease, giving localization for further investigation. Establishment of dose – response relationship requires well-conducted observational studies. In some cases preventable risks can remain undetected but still sufficient to warrant compensation. A known case was febrile illness in veterans suffering effects attributed to toxic exposures in the Gulf War in 1991. Regulatory and compensation decisions must often be made in the face of inconclusive and contradictory conclusions. The topic remains one of the controversy and contradiction with cases providing precedents that affect future court and regulatory decisions. The contribution of epidemiology to resolve such issues remains controversial. Preventing disasters in the workplace Disasters in a workplace are only noted if media become interested to expose some journalistic aspects. In fact even small accidents without a notorious publicity can affect workers and the surrounding community. The major responsibility for prevention major disasters is with management but the workers and society also have roles in the process. Prevention involves education of workers and management, and constant monitoring. Government has the overall responsibility to provide legislative documents and enforce standards, safe conditions of work, and control of toxic materials and ensure a fair compensation for injury or disease. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES Markers and indicators of disaster management capabilities Markers Indicators Administrative Occupational health disaster plan, access to first aid, frequent disaster drills, close supervision of subcontractors Investigation Thorough investigation of complains ,leaks and spills Monitoring workers Monitor worker injuries ,illnesses, toxic levels, use of safety measures Technological Fail- safe monitoring devices, real time monitoring ,minimal on site storage ,automatic alarm/shutdown devices ,local incineration/ neutralization Transportation Vehicle and containers standards ,driver training , fatigue, alcohol and drug abuse, traffic offenses Information Worker information, right to know of workers and community, community disaster plan Richter et al, 1992. The simple qualitative observations listed above can provide a useful picture of the disaster management capacity of a work site. The principle of “good worksite practice” is a parallel to good manufacturing practices required by food and drug authority. It is based on the concept that current standards of acceptable safety involve standards of facilities, staffing, and operational criteria. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 10. Occupation and the new public health Social class, often defined by occupation and education, is a key determinant of then health status. A population of unskilled workers has higher rate of coronary heart disease, strokes, and cancer, and their children have much higher rates of mortality and morbidity than the children of higher skilled workers, or business and professional persons do. The worker who has little say in determining his or her activities may be subject to a higher stress on the job, especially if on the production line, and with lower wages. The main factors responsible for an increasing vulnerability of men especially to a variety of life threatening conditions, including suicide, alcoholism, violence, cardiovascular disease and others are known. The phenomenon of downsizing, or reducing the work force, affects production workers but also reaches middle and upper management levels, so that the danger of losing a position at an age when finding new employment is unlikely, may become a severe health hazard. Awareness and responsiveness to a variety of risks associated with employment and occupation is part of health responsibility. Prevention may reduce in some situation occupational diseases, screening for case finding and clinical management in others. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES 11. Summary Environmental health and occupational health are increasingly important elements of the New public health along with concern for the ecology of the world. The problems of this field have become more complex in the past several decades and some other global ecological concerns emerged. Global warming has been noted, hazards associated with nuclear accidents after Chernobyl, and numerous chemical disasters in all parts of the world. Some environmental issues have become massive such as desertification, destruction of forests and new air pollution. The gap between developed and underdeveloped countries started to increase in spite of tremendous and obvious improvements of life in some parts. Societal issues obtained new characteristics. The economic growth has suddenly shown two faces, one of the satisfied consumerism and the other of extreme poverty and poor health. We are now living in a world in which one billion people have a life expectancy of an average of eighty years and five billion are dying at an average age of 40 to 50. The poorer countries are in vain trying to cope with rapidly increasing number of populations and increasing expectations for a better and longer life. Is the prospect bleak? Are we experiencing the effects of Pandora's box being open suddenly and nobody has been prepared for the consequences of the urbanization and industrialization to the environment? Important progress has been made in many fields such as management of water, waste products, and toxic wastes, in air quality standards especially since 1970s. Workers safety and health have improved over the past century in the industrial countries. But how these improvements have been achieved? It is obvious that some of the gains are at the cost of moving hazardous materials and working conditions to newly industrializing or developing countries in the global economy. Even a well-organized health sector is not capable of dealing with the problems of environment and occupational health. The support of public opinion is not enough; it is requiring the cooperation of many levels of government 's agencies. The new public health can unite the efforts of professionals and politicians as it is used to epidemiological provide the necessary information as to the mortality, morbidity, or physiological change that may occur as a result of environmental damages. It can also be expected that improvements of technology will contribute to provide standards for a cleaner, safer and more pleasant environment. The New Public Health includes the health issues of the environment and occupational health, but widens the field to clinical services TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES for the individuals and communities. For a society there are choices to be made in creating a less toxic and hazardous environment. Choices between private and public transport, between jobs in industries with toxic emissions, or between producing energy from traditional fuels, nuclear or other sources such as using windmills or local hydroelectric power stations. The price of industrialization over the twenties century has reached unacceptable and insurmountable levels even for the most developed countries and more so for the countries in development. The gross pollution will have to be reduced to prevent natural and man made disasters that may involve conventional explosives or biological, chemical, and even nuclear methods of destruction. The investments in a healthier environment have become a necessity, and attained in never before envisaged proportions. The government of Republic of Slovenia has accepted recently a ten years plan to determine the environmental signals. The plan has been divided into several chapters. TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES The situation today and the changes in the environment Water 1997 – 2001 Air 1998 – 2001 Ozon and climatic changes 1992 – 2000 Soil 1995 – 2000 Nature and biodiversity 1992 – 2000 Waste 1995 – 2001 Integration of the policy and the protection of natural resources Agriculture 2001 The use of substances for the protection of vegetation 1992 – 2001 The use of mineral fertilizers 1900 – 2000 Power supply The use of the final power 1990 – 1999 The production of electric power from renewable sources 1990 – 1999 Transport The average age of the vehicles 1995 – 2000 The cargo and the freight transport 1995 – 2001 Health of the population The quality of the drinking water 1999 – 2001 The quality of the recreational waters 1996 – 2001 Financing the protection of natural resources Environmental taxes and other sources 1999 – 2001 TRAC 2002 – RO / 02 / B / F / PP / 141 061 Source: UL Title: SPECIFIC SOCIO-ECONOMIC AND PUBLIC HEALTH ASPECTS IN ZONES WITH HIGHLY POLLUTING AND HIGH ENERGY - INTENSIVE INDUSTRIAL UNITS: PROFESSIONAL DISEASES References Environmental protection agency, 1987. 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