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Commentary on the paper by Coggon (see page 281)
This article addresses how changes in occupational morbidity are demanding new research approaches to provide relevant contributions for workers’ protection and the improvement of workers’ health standards in contemporary society. This is a necessary and timely reflection considering that at the turn of a new century, occupational diseases and injuries still represent a relevant health burden in most countries, challenging researchers and policy makers for more appropriate studies and effective actions. In this issue, Coggon1 points to: (1) the fact that current prevailing occupational diseases are musculoskeletal disorders and occupational stress; (2) their distinct relation to work risks, unclear ties between disease and illness expressions, and evidence of association with emotional factors; and hypothesises that they are not diseases (a biomedical concept based on objectively recognisable abnormalities), but illnesses (a subjective state of discomfort and suffering), a distinction proposed by Field (1976)2 and Susser (1973).3 Most controversial is the author’s statement that these occupational diseases are resulting from increased public awareness and media publicity related to the potential risks generated by technological innovation, which leads him to conclude that resources might be spent more effectively on programmes aimed at modifying cultural beliefs and expectations rather than trying to modify or reduce putative risks in the workplace.
The increase of the burden of musculoskeletal disorders and occupational stress is a well documented issue, but the explanations Coggon presents are not quite clear or convincing. First, the statement that the risk approach has been successful in controlling occupational risks is open to question; some authors have shown, for example, that downward trends of fatal accidents may be a result of changes in the production structure that are occurring in developed or developing countries.4,5 Under the restructuring of production, a major aspect is the elimination or reduction of manufacturing jobs, known for their hazardous chemical and physical exposures, and an increase in service oriented jobs, where ergonomic risks and psychosocial stressors are prevalent. Second, there is a growing number of studies showing that risks in the service trade arise not only in the relationships between man and machine, but also in the ways work is organised, co-workers’ relationships are shaped, and how power distribution is democratically managed, particularly in relation to workers’ control.6 “Flexibilisation”—the reduction of stable jobs and their replacement by flexible forms of employment, such as self-employment, subcontracting, or alternative states of full-time, part-time, and unemployment—is also part of this restructuring process.7,8 In large corporations, work redesign reduces personal contact and social interaction, creating isolation and alienation.9 These and several other aspects of this new “work world” have been shown to provoke psychological disorders, stress, and stress related somatic diseases.6 Therefore, it is not plausible to think that the increase in occupational stress diseases derives solely from amplified awareness of work hazards disseminated by media sensationalism. In addition, the somatising tendency Coggon mentions may explain individual illness, but there is no current empirical evidence that somatising tendency is sufficiently prevalent or distributed in a way that explains the patterns of modern occupational illness.
There is no doubt that occupational medicine advanced with the development of toxicology and that the discovery of hazardous effects of toxic chemicals prompted professionals to eliminate or reduce exposures. A similar paradigm flourished in the beginning of public health when infectious diseases were widely preventable using the strategy of avoiding contact with biological agents. At that time, diseases were more relevant than illnesses and the search for a single pathogenic agent was the focus of investigation and the basis of prevention and treatment. Although social determinants are important for every single pathology, the increase of non-transmissible chronic diseases forced researchers and health professionals to consider more complex and dynamic pathogenesis processes that have strong interfaces with social relations, behavioural and psychological factors, perceptions, attitudes, and culture.10 It is not surprising that analogous changes have been also observed in occupational health where acute toxic syndromes are giving place to chronic long term effects with insidious onset and non-specific symptoms, which are largely modulated and mediated by social, behavioural, and psychological factors, as exemplified by stress related and musculoskeletal disorders. As a result, there is a growing interest in the study of subjectivity, and psychological and cultural aspects that advances the concept of health beyond reducionistic biological models10–12 and seeks to overcome the duality underlying disease and illness concepts.
In sum, the lack of objective detectable or measurable biological evidence, as for mental diseases, is not a requirement for their recognition and acceptance of relevant evidence of human suffering. Resources and efforts need to be directed towards a better understanding of the nature of these prevailing occupational diseases which perhaps requires a radical change in the way we think and conceptualise disease, illness, sickness, and disability. Besides improvement in assessment and diagnostic instruments, qualitative research approaches and participatory research focusing on workers’ representation and their symbolic language may contribute to true advances in both theoretical and applied studies.
Commentary on the paper by Coggon (see page 281)
Competing interests: none declared
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