I agree with Aaron Blair that it would be premature to assume that toxic chemical and physical hazards in the workplace are all under control. The continuing high incidence of disorders such as occupational asthma, contact dermatitis, and noise induced deafness, even in countries with well developed occupational health services, provides clear evidence that this is not the case. Thus, I am not suggesting that we should reduce the resource that we allocate to investigating and managing hazards of this type. However, I do believe that the classical approach to risk management may be quite inappropriate for much of the occupational illness that now challenges us in developed countries.

Both Aaron Blair and Vilma Santana highlight my suggestion that such disorders might usefully be addressed by attempting to modify cultural beliefs and expectations. This is certainly a possibility, but more important, I think, is the need for us to be aware that the classical approach to risk management may not work for these illnesses, and could even be counter-productive. In other words, at the very least, we should avoid wasting resource and possibly making things worse.

I agree with Vilma Santana that somatising tendency is unlikely to explain temporal trends or geographical differences in the occurrence of modern occupational illness. However, such variation could reflect differences in cultural beliefs and expectations. I hypothesise that the role of somatising tendency is more as a determinant of which individuals within a cultural group are most susceptible to disorders such as low back pain, non-specific arm pain, and multiple chemical sensitivity.

Manolis Kogevinas correctly points out that apparent temporal and geographical differences in the occurrence of occupational illness may be an artefact of incomplete reporting. However, I doubt that this is the full explanation. Fortunately, the uncertainty, particularly with regard to geographical variation, can readily be addressed by research, and this is one of the lines of further investigation that I propose in my paper.