MEDICAL SERVICES AT AIRPORTS

the corporate practice of medicine by the air-
port authority. Second, it would permit direct
participation by the airport authority at any
level desired, short of providing professional
services, Participation by the airport au-
thority could include such matters as provid-
ing space, equipment, and nonprofessional
personnel. Third, control of this activity
could be established by the airport authority
at any level deemed desirable and accepted
by the contracting medical establishment.
Fourth, legal control would be maintained by
the airport authority. Fifth, both the author-
ity and the contracting medical establishment
would be immune from personal liability suit
to the extent that the state laws provided im-
munity from suit. Individual physicians
providing service in such a facility would
not be immune.. Sixth, it would permit the
authority to enter into contracts with em-
ployers for medical service and would offer a
means of ensuring fulfillment of the contract.
Finally, it would avoid the employee status
of physicians practicing at the facility. Such
an organization would presume that the phy-
sicians would have representation through a
contract with the established medical institu-
tion, similar to contracts between participat-
ing physicians and Blue Cross-Blue Shield
plans. This point should be emphasized in
any discussions with local medical associa-
tions which might have a concern for the
professional relationships involved.

A disadvantage in this type of organiza-
tional arrangement is that the airport au-
thority, in planning and contracting for the
professional services, would need to possess
considerable knowledge of medical policy and
professional matters in order to ensure that
the medical establishment entering into the
contract and the provisions of. the contract
itself would provide the most appropriate
medical service. This problem, and an as-
sociated one involving selection of a given
medical establishment from a number of com-
peting establishments, could be avoided by
initial appointment of a preplanning advisory
group composed of representatives of a num-
ber of institutions and/or agencies. These
advisors could continue, in an unofficial ca-

85 Reighard

355

pacity, to advise the authority on specific
matters requiring attention after establish-
ment of the medical service. Some sources
of advisors might be the local medical society,
the local health department, medical teaching
institutions, recognized industrial medical
specialists, or medical specialists of the Fed-
eral Aviation Agency.

The only significant legal issue which
would be involved deals with the corporate
purposes of the airport authority. It would
have to be determined that the establishment
of such an additional function is permitted,
or at least not excluded, by the corporate
charter. If doubt exists concerning the in-
terpretation which might be made of the
charter with respect to this matter, the advice
of the state attorney general should be
sought.

VII. Summary and Conclusions

1. The value of medical programs in im-
proving the performance and effectiveness of
employees in industry is well known and has
been extensively demonstrated.

2. Airport populations constitute sizable
industrial communities, The nature of the
operations conducted has important implica-
tions for the safety of air operations.

3. Employers at the airport studied have
attempted to assess their medical needs in
various ways, but thus far none have pro-
vided more than a few of the basic elements
of an effective occupational health program.

4. Employers have demonstrated, in a
number of ways, their interest in promoting
the health and effectiveness of their em-
ployees by the means now available.

5. The size of individual employee groups
is generally too small to justify the establish-
ment of a comprehensive medical program by
a single employer.

6. The nature of the employee population
and the limited nature of medical services
now provided are sufficient reasons to justify
the establishment of a comprehensive occu-
pational health program at the airport.

7. An airport medical facility, primarily
established for other purposes, should be


346

vides a comprehensive program for a large
concentration of their employees. A current
FAA study is designed to develop in more
detail the exact status of health service facil-
ities and other safety provisions at municipal
airports.

The specific benefits which might be an-
ticipated from a comprehensive medical pro-
gram. at an airport can be considered in
relation to the employee, the employer, the
airport authority, and the public.

For the employee, benefits would be ex-
pected through (1) promotion of health by
health education and control of environ-
mental health hazards; (2) specific protection
in the form of appropriate immuniza-
tions, identifying the need for and recom-
mendation of specific protective devices,
recommendations for the removal of health
hazards, and selective placement to accom-
modate health deficiencies; (3) early diagnosis
and’ treatment as a function of availa-
bility of a medical facility and the conduct
of periodic examinations ;-(4) limitation of
disability due to illness or injury by coordina-
tion between medical care given by the
employee’s physician and the demands of the
job; (5) effective rehabilitation, as the result.
of spécific knowledge of job requirements.

For the-employer, in addition to the ex-
pected benefits listed above (all of which
have an associated monetary value), there
would be readily available consultation for
employee or operational problems having a
medical component. The value of the con-
sultation should be greatest if held with medi-
cal personnel already an integral part of the
airport community.

The airport authority, by virtue of its
managerial status, has the potential of assum-
ing the most important role in any medical
effort within the airport industrial complex.
To the extent that it exercises its managerial
prerogatives in assuring the quality of medi-
cal service (as it must assure the quality of
other airport services), and participates in
the establishment and maintenance of such a
service, it can determine the amount of bene-
fit to the airport community as a whole. In
addition, certain benefits could be expected

ARCHIVES OF ENVIRONMENTAL HEALTH

to accrue to the authority directly. Among
these would be the benefits expected for other
employers, since the authority is itself an
employer of significant numbers of persons
working in the airport community. Another
benefit relates to the physical presence of
very large numbers of the general public on
airport property, a factor of importance in
the extent of exposure to liability. Many of
the services provided by an airport authority
have a direct effect on the level of safety
provided to the public. Adequate early medi-
cal care and proper coordination of subse-
quent care can be very significant factors in
reducing the liability potential in personal
injury cases. A further benefit would be a
favorable public image resulting from the
existence of such a service, both for the
prompt and appropriate initial care of illness
and injury at the airport and for effective
rescue and medical care services in:the event
of a major aircraft accident. A significant
function of airport authorities is service to
the general public. There are few areas of
public service more likely to be recognized
and given appropriate public attention than
the humanitarian programs established to
save lives and reduce suffering.

III. Procedure Used in This Study

The basic approach to the study was the
interview of managers of employee units lo-
cated at the airport studied. The interview
dealt with specific items deemed significant
to the purpose of the study, and selected for
this purpose. In developing this interview
approach the first step was to review pub-
lished material on industrial health statistics,
industrial health programs generally, health
programs for small employee groups, work-
men’s compensation, and airport manage-
ment. .

The interview portion of the study was
supplemented by liaison with the Director of
Research of the airport authority, who sup-
plied a list of employers and the names of the
local managers together with a count of em-
ployees, listed by nature of employment. The
research director also provided assistance in
identifying the types of inquiries likely to

Vol. 5, Oct., 1962 76





MEDICAL SERVICES AT AIRPORTS

The nature of employment of approxi-
mately 70% of the employees (aircrew, me-
chanic and maintenance personnel, air traffic
controllers, and food service personnel)
clearly demonstrates the need for periodic
medical examinations for reasons of safety,
health maintenance and public protection.
However, except for aircrew (excluding
flight attendants) and control tower opera-
tors who are subject at least to periodic FAA
certification examinations, periodic examina-
tions are not now performed. The almost
complete absence of any form of health
maintenance and support for administrative
and clerical personnel while at work was also
apparent. The types of occupations and num-
bers of employees identify this population as
an industrial community of a size sufficient
to justify a comprehensive occupational
health program.

That there is now no integrated occupa-
tional health program for any employee
group cannot be interpreted as lack of inter-
est on the part of employers. It was apparent
that the problems referred to earlier in the
report, bearing on medical programs for
small employee groups, are real ones which
have not been satisfactorily solved for this
group of employers. Of necessity, all have
made some arrangement for the most press-
ing medical needs, especially for emergency
care of on-the-job illness or injury. It is
interesting to note that none rely on a single
source of assistance even for emergency care.
It is perhaps for this reason that most indi-
cated an interest in a full-time airport medi-
cal facility for this purpose. It is believed
that the extent of interest in other functions
considered essential to an occupational health
program could be determined only after con-
siderable further study and discussions with
employers, or after a facility to provide such
a program has been established.

Although the number of persons in need
of medical attention at the airport could.not
be established reliably, the total number of
persons using the airport would seem large
enough to predicate a sizable chance occur-
rence of illness or injury while they were on
airport property. Another factor which

81 Reighard

351

would be expected to increase the number in
need of assistance at this airport is the many
patients traveling to and from world-re-
nowned medical institutions in the local area.
The lack of a standard method of assuring
prompt and appropriate care for such per-
sons, even in the absence of an airport medi-
cal facility, is clearly a deficiency.

Accident rates among employees were not
readily available. However, since all em-
ployers have workmen’s compensation cover-
age by private insurance companies, these
companies should be a source of data for
comparison with the experience of similar
types of employers. This study did not ex-
plore this potential source of data.

The universal lack of data on the extent
of absenteeism would seem to indicate a lack
of appreciation of the value of such data for
management and evaluation purposes. The
lack of data on this and other items con-
sidered significant indicators of the effective-
ness of health services could probably be
corrected over a period of time by a coopera-
tive effort between employers and persons
interested in the promotion of occupational
health programs.

That all employers have established a
health-benefits program in some form indi-
cates that they already contribute significant
sums for the medical care of employees.
Measures of the extent to which these have
increased employee effectiveness are lacking,
however. The existence of identifiable safety
programs in all employee units—some of
them quite comprehensive—indicates a gen-
eral interest in promoting employee effective-
ness, and reducing employee time loss.
Although safety programs can be adminis-
tered for perhaps one-fourth of the cost of
administering occupational medical pro-
grams, it is believed that adequate justifica-
tion for medical programs for the same
general purposes would promote similar
acceptance.

The medical component of the present
crash-rescue plan, which was effected during
the course of this study, is believed to be a
very effective substitute for an even more
effective program which should result from


348

This group also included the field service and
other maintenance personnel of the port au-
thority. For this category of employees there
are a variety of exposures to health hazards.
Since an industrial hygiene survey was not a
part of this study, only the general nature of
such hazards was identified. Among these are
(1) the physical hazards resulting from the
large amount of materials handled, exposure
to noise, the presence of many items of mov-
ing equipment, the use of motor-driven tools,
working at heights and in positions conducive
to falls and injury, handling of large amounts
of aviation fuel; (2) toxic and chemical
hazards as the result,of exposure to a wide
variety, of materials used as solvents,
cleaners, servicing fluids, fabrication and
machining agents, and those produced by the
combustion of hydrocarbon fuels; (3) other
environmental factors including weather
elements, work under the stress of critical
completion times, shift work, etc.

There were 1,165 workers (24.5%) who
were classified as administrative and clerical
personnel. This classification included
administrative staff, office employees, super-
visors, ticket. agents, dispatchers, and cus-
tomer service personnel.

The food service personnel classification
contained 218 persons (4.6%) and included
those engaged in preparing and handling
food, such as kitchen employees of the res-
taurants, snack bar and in-flight food cater-
ers, waitresses and counter girls.

A general -group containing 627 persons
(12.1%) represented a wide variety of ac-
tivities. Examples of types of employees in-
cluded in this group are professional and
communications personnel, mail handlers and
clerks, truck drivers, domestics, bus boys, etc.
Some 400 employees of the Federal Aviation
Agency, including air traffic controllers, com-
munications specialists and safety officers,
were included in this group. In addition, 132
employees of the U.S. Post Office were in-
cluded, since the duties of each involve a
variety of administrative, clerical and manual
activities.

ARCHIVES OF ENVIRONMENTAL HEALTH

The following is a summary of the more
significant findings obtained by interview
with employers:

1. No employer has provided health serv-
ices for employees which could be considered
as constituting an integrated occupational
health program. The most comprehensive
programs found were those of several air-
lines, especially those having a central medi-
cal department. Even the most comprehensive
programs, however, included, at the most,
preemployment examinations; periodic ex-
aminations of flight crew only (usually con-
ducted by an airline medical department
located at a base other than the one studied) ;
periodic audiometric examination of selected
ground personnel, and provisions for emer-
gency medical care at the offices of appointed
physicians in the local area.

Aside from the flight-crew members of
the airlines, no employees received periodic
health examinations. Three airlines reported
periodic audiometric examinations for se-
lected maintenance personnel. Many em-
ployers, especially nonairline employers, do
not require preemployment examinations of
any employees; some others require exam-
ination before employment only for selected
groups, such as administrative personnel or
persons expected to perform heavy work. No
employer provided medical inspection of the
worker environment.

Although some airlines with central medi-
cal departments provided some form of
health information for distribution to local
employees, this did not involve contact be-
tween health personnel and employees. Other
airlines and most nonairline employees had
no active health information program. Other
functions considered vital components of an
occupational health program (listed earlier)
were essentially absent for all local employ-
ers. For 14 of the 19 employers interviewed,
programs consisted of only preemployment
examination and some provision for emer-
gency care, or provision for emergency care
alone.

2. Emergency medical care was obtained
chiefly from 3 sources. The majority of pa-

Vol, 5, Oct., 1962 7



MEDICAL SERVICES AT AIRPORTS

yield results, as determined from his knowl-
edge of the nature and manner in which
operations are conducted by various conces-
sionnaires.

The initial descriptive phase of the study,
completed with the help of the port authority
research director, attempted to determine the
total number of employees and the nature
of their jobs, using relatively broad descrip-
tive categories for convenience in grouping.
Refinements in the data obtained were made
in the course of the actual interview with
employers. I conducted the interview: itself
directly with the respective managers or with
persons delegated by managers for this pur-
pose. In most cases the interview was con-
ducted with the ‘manager (or “officer in
charge”) of the particular activity.

Items covered in the original interview are
listed in Appendix 1. Preliminary interviews
revealed that data on many items generally
could not be obtained from employers unless
a specific data collection program could be
established. This would have required a time
period greater than that available. As a con-
sequence, a revised list of interview items
was developed (Appendix 2).

Information on each of the items was ob-
tained from all employers with more than
25 employees. This included 19 of the total
47 employers, providing data on 4,758 of the
total 5,006 employees. Most of the airlines
and all of the major concessionnaires were in
this category. Since one of the conclusions
which resulted from the study was that a
centralized occupational medical facility
should be established, the legal, ethical, and
public relations considerations relating to
each of the several possible methods of estab-
lishing the facility were reviewed. The final
recommendations concerning possible means
of establishing and operating such a facility
are limited to those which passed this review.

IV. Findings
Though information on a number of items
about which information was desired was not
available, findings did include certain infor-
mation descriptive of the numbers of persons
constituting the airport population (Ap-
7 Reighard

347

pendix 4) ; the types of work done by em-
ployed persons (Appendix 3) ; the detailed
results of inquiries into the items of the ab-
breviated questionnaire, and the results of a
review of certain legal factors. The types of
activities at the airport will be apparent from
the titles of employers listed in Appendix 4.

From the airport authority, it‘ was de-
termined that approximately 3,000,000 pas-
sengers are accommodated each year. It is
anticipated that this number will increase to
approximately 6,000,000 over the next 10 to
12 years. In addition, it is estimated that, at
present, there are 3,000,000 nonpassenger
members of the general public who spend
some time at the airport each year. This
would include relatives, friends, and associ-
ates of passengers, as well as suppliers,
ground transportation personnel, and other
persons having business at the airport but
not actually employed there.

The total number of employees considered
based at the airport was found to be 5,006.
Of these, 4,758 were grouped by type of
employment into one of the five general
classifications: (Appendix 3).

The following discussion deals with the
4,758 persons who work for companies or
businesses having more than 25 employees at
the airport. The remaining 258 employees
fall into a variety of groups. The nature of
these groups can be surmised from the titles
of the last 28 employers listed in Appen-
dix 4.

Aircrew personnel accounted for 1,266, or
26.6%, of the employees. This classification
includes all air carrier pilots and co-pilots,
navigators, flight engineers, and cabin attend-
ants primarily based in the local community.
It does not include aircrew personnel who
fly into or out of this community but are
based elsewhere. The duties of aircrew
personnel are generally known.

There were 1,482 persons (31.2% of the
total) who performed as mechanics or in
other technical and maintenance capacities.
This category included aircraft and other
mechanic personnel, equipment and commu-
nications specialists, aircraft servicing per-
sonnel, and other shop and line employees.


350

pany-sponsored medical plan as a supplement
to the group health insurance program. All
employers also maintain a specific, paid sick-
leave policy.

9, All employers maintained some form of
safety program for the review of occupa-
tional hazards and education of employees in
accident prevention. For the smaller em-
ployers this tended to be informal but identi-
fiable as a program. The larger employers
all had formal programs consisting usually
of periodic scheduled meetings of safety
committees composed of employees and
supervisors, specific safety instruction by
supervisors or safety officers, and poster and
bulletin programs.

10. Except for employees of the Federal
Aviation Agency there was no indication of
an attempt, on the part of other Federal
agencies, to implement employee health pro-
grams such as those authorized by Public
Law 658. The FAA is currently developing
means by which such services may be ex-
tended to its employees. This would include
at least periodic health maintenance examina-
tions and on-the-job medical care on a con-
tractual basis at locations where an actual
FAA medical facility does not exist.

11. Most employers interviewed indicated
a need for a comprehensive medical facility
located at the airport. One of the largest
employers had written to the port authority
recommending the inclusion of a medical
facility in plans for a new terminal building.
Most employers indicated that they would
use it as the source of a more comprehensive
medical program. Others stated that the ex-
tent of use, other than for emergency care,
would depend on central office approval.

The reasons most frequently given for
desiring a medical facility at the airport
were: (a) the availability of immediate
emergency care; (b) the need for medical
service on a 24 hours a day, 7 days a week
basis; (c) the large amount of time con-
sumed by employees who develop minor ail-
ments while at work and for whom there is
no alternative except consulting a family
physician at some distance from the airport.
Several employers stated that as much as a

ARCHIVES OF ENVIRONMENTAL HEALTH

half to a full day of time was often lost in
such cases.

No effort was made to estimate the interest
of employers in other specific functions of
an occupational health program. It was be-
lieved that such an estimate would have no
value in the absence of extensive preparatory
discussions detailing the more indirect bene-
fits of such a program. The type of study
which was conducted did not permit such an
approach.

Inquiry into some of the legal aspects was
limited to those which might affect the or-
ganization and status of a medical facility,
should one be established. The more signifi-
cant legal issues are discussed in some detail
in the section dealing with recommendations

The medical component of the existing
crash-rescue program was found to consist of
an on-call procedure involving a large general
hospital, with direct communication from the
airport control tower. The hospital is located
8 to 10 minutes from the airport. The route
to the airport from the hospital involves driv-
ing through a heavily traveled tunnel, with
considerable slowing of traffic in the tunnel
and approach areas at many periods during
the day. In an attempt to facilitate rapid on-
the-scene medical service in the event of an
emergency at the airport, the airport crash
program had been coordinated with the police
department for the handling of this specific
problem. No drills had been held to deter-
mine the effectiveness of this arrangement.

There had been no advance coordination
with additional possible resources for rescue
and evacuation operations, such as nearby
military installations ; the U.S. Coast Guard ;
other city, state and Federal agencies.

V. Comment on the Findings

The airport population was found to be of
considerable size, consisting of some 5,000
employees, 3,000,000 passengers per year
and 3,000,000 other transients per year. The
mere existence of a population of such size
at distances somewhat removed from ordi-
nary medical facilities would appear to justi-
fy an airport medical facility.

Vol, 5, Oct, 1962 80



AM- (6 9~%

Medical Services at Airports

HOMER L. REIGHARD, M.D.
BOSTON



MEDICAL SERVICES AT AIRPORTS

operation of the program. Among the meas-
ures for which a data collection program
should be established with all employers are:
(a) employee injury rate, (b) compensation
experience, both clinical and financial, (c)
rate of absenteeism, (d) nature and fre-
quency of employee-employee and employee-
supervisor problems, (e¢) rate of labor
turnover, (f) magnitude of alcoholism and
other personality problems affecting per-
formance, and (g) data on environmental
exposures, preferably collected by an in-
dustrial hygienist or similarly orientéd per-
sons.

Such a program, in addition to serving as
an important tool in evaluating the contribu-
tion of the medical program, would serve to
establish contact with employers, and would
demonstrate the skills of occupational medi-
cine.

6. Preliminary data, of the type described
in this report, should be obtained for the
specific airport population involved, before
a decision to establish a medical facility.
These data should be used, additionally, to
determine the type of facility to be estab-
lished.

7. In promoting the utilization of an air-
port medical facility by employers, the con-
tact should be with a physician acquainted
with industrial and/or aviation medical prob-
lems. Full use should be made of information
having a direct bearing on the particular op-
erations. Consideration of the extent to
which the employer has already demonstrated
an interest in promoting the health and effec-
tiveness of employees should also provide a
basis for discussion.

8. The contract for medical service with
individual employers should specify the
level of service to be provided. Some unit
of service should be established to determine
equitable charges. The unit could be (1)
time required to provide estimated service
or (2) a functional unit such as cost of pre-
placement examinations, estimated treatment
demand, etc.

9. The organizational framework of the
medical facility should be determined by the
airport authority and should take into con-

83 —-Reighard

353

sideration the nature of needs to be supplied,
the local medical environment, the availability
of appropriate professional staff, and the
quality of medical care desired. Ideally,
the airport authority should initially seek the
services of a body of informed medical con-
sultants and advisors to study and recom-
mend the most appropriate method of
establishing the facility.

10. The airport authority should assume
responsibility for, and participate directly in,
the operation of the medical facility.

11. Various methods of organizing an air-
port medical facility should be considered.
Some possible methods are discussed below
together with their respective advantages and
disadvantages:

(a) A cooperative plan initiated and ad-
ministered by an association of airport com-
pany employers who, collectively, would
provide a sufficiently large employee group to
justify an effective medical program. The
chief advantage of such a plan is the extent
of direct control which the user has over the
nature, scope, and quality of the service pro-
vided. A considerable disadvantage for air-
port populations is the varied nature of the
operations performed by individual em-
ployers, making it difficult to reach agree-
ment on the type of service to be provided.
Such plans now in existence in other indus-
tries have been developed by employers with
similar employee populations and types of
operation. No significant legal problems
would be involved in such a plan.

(b) A private clinic, operating as a con-
cession in a relationship to the airport
authority similar to that of other concession-
naires. This arrangement would have the
advantage of preserving the tradition of the
private practice of medicine to the fullest and
would relieve the airport authority of re-
sponsibility for participating in its operation.
A disadvantage of this type of program re-
sults from the necessity of operating such a
program at a profit, thus subjecting it to con-
siderable pressure to minimize potentially
nonprofitable functions such as crash rescue,
research, etc. No significant legal problems
should arise in the establishment of such a


352

the existence of a medical facility at the air-
port. An airport medical facility should be
able to capitalize on day-to-day knowledge of
the types of operations and familiarity with
the varied sources of assistance available in
planning an effective medical program for
crash rescue. This facility, by specific assign-
ment, could be held accountable for develop-
ing and operating the program.

One of the more significant observations
relates to suitability of airports as sites for
the supervised training of specialists in avia-
tion medicine. First to be considered is the
fact that large airport populations are gen-
erally found just outside (or within) munici-
palities likely to have medical teaching
institutions. This is important to the extent
that existing institutions participate in plan-
ning a program of instruction for trainees,
both at the airport facility, and on assign-
ment to other appropriately selected duties in
the area. The existence of such institutions
should not be considered prerequisites for
such programs, however.

A second consideration is the availability
of an environment suitable for the practice
of aviation medicine principles and the con-
duct of research in this field. With an em-
ployee population of 5,000, more than half
of whom are employed in activities directly
related to air operations, more than sufficient
material would appear to be available. The
actual availability would depend, of course,
on the cooperation of employers and em-
ployees in any research efforts and on the
patronage of the medical facility. A third
and most significant requirement would be
the presence of an already qualified aviation
medical specialist to supervise the training.
Such a specialist, as director of the medical
facility, is justified by the nature of the em-
ployee population.

In summary, it would appear that (1) all
desired data to determine the magnitude of
need for medical services in airport
communities are not available; (2) airport
populations constitute sizable industrial com-
munities; (3) employers at the airport
studied have attempted to assess and provide
for their medical needs in various ways, but

ARCHIVES OF ENVIRONMENTAL HEALTH

none has provided more than a few of the
elements of an effective occupational health
program; (4) employers have demonstrated
their interest in promoting health and effec-
tiveness among employees by the means now
available; (5) the size of employee groups
is generally too small to justify the estab-
lishment of a comprehensive medical pro-
gram by a single employer ; (6) an effective
occupational medical program has not been
started at this airport; (7) the nature of the
employee population and extent of needs not
now supplied are sufficient to justify the
establishment of a medical facility at the
airport to provide a comprehensive aviation
and occupational health program ; (8) an air-
port medical facility, established for other
purposes should be most effective in provid-
ing the medical component of crash-rescue
plans and operations, and (9) a medical facil-
ity at a large municipal airport could be an
ideal training site for civilian physicians
pursuing aviation medicine as a career.

IV. Recommendations

From the preceding findings and discus-
sion, the following recommendations seem
appropriate:

1. A medical facility should be established
at the airport to provide a comprehensive
program of occupational and aviation medi-
cine.

2. Considering the nature of the employee
population, the director of the medical facil-
ity should be a physician qualified in the field
of aviation medicine. Additional professional
staff should include a physician, or physi-
cians, experienced in industrial medicine.

3. Established medical institutions, espe-
cially teaching institutions, should be in-
cluded as active participants, advisors, or
consultants.

4. In establishing a medical facility, the
need for, and the benefits to be derived from,
providing research and training facilities in
aviation and occupational medicine should
be considered.

5, The medical facility, immediately upon
establishment, should develop measures to
assess the effectiveness of the subsequent

Vol. 5, Oct., 1962 82



MEDICAL SERVICES AT AIRPORTS

tients needing immediate attention apparently
went to a nearby emergency room, a local ex-
tension of the city hospital. A significant
number were also referred by: employers to
a doctor in a nearby section of. the city,
located about 2 miles from the terminal build-
ing. This physician had been appointed by
at least 2 airlines to conduct company pre-
employment examinations. It appeared that
other employers also used this physician’s
services when available. However, none con-
sidered him the exclusive source of emer-
gency treatment. Most also named the
emergency room previously mentioned and
the single doctor located at the airport as
other sources of treatment.

The doctor whose office is located in the
airport terminal building was named by many
of the employers. Apparently, because of the
nature of his facility and the hours‘of attend-
ance, fewer cases are referred to him than to
the other 2 mentioned. It appeared that his
primary function is the conduct of periodic
medical examinations of pilots for FAA cer-
tification.

In addition to the 3. chief sources of emer-
gency care, a few employers indicated ar-
rangements with other selected physicians as
a supplement to the services of the doctor
located at the airport and the emergency
room extension.

3. Of the 218 food service employees only
2 (those employed by one of the airlines)
were given preemployment examinations.
There was no periodic medical examination
or medical inspection of any of the food
service personnel.

4. Knowledge of the health needs of non-
employee occupants of the airport. varied
among employers. There was also consider-
able variety in the methods of disposing of
these problems. No standard plan appeared
to exist. The reported frequency for such
cases ranged from 2 to 3 per week to 4 per
year, depending on the employer. None kept
actual records of such occurrences. The state
police unit at the airport had record of 80
cases for which it furnished transportation
to the nearby emergency room extension in
the preceding year. The officer interviewed

79 Reighard

349

indicated that no record existed on the dis-
position of many more cases which may have
come to the attention of this unit.

A variety of arrangements existed among
airlines for handling’ incoming passengers
about whom advance notice of need for medi-
cal attention had been received. This usually
consisted of arrangements for transportation
to a nearby hospital. Occasionally a physician
appointed by the company for the perform-
ance of preemployment examinations would
be summoned to the airport for such cases.

5. The Federal Aviation Agency requires
periodic medical examinations of all pilots,
co-pilots, navigators and flight engineers. Ar-
ranging and paying for these examinations
is the responsibility of the individual airman.
Numerous physicians. have been appointed in
the local area by the FAA for this purpose.
Two of the FAA-appointed medical ex-
aminers are the doctor located at the airport
and the one located in a section of the city
nearby, previously referred to. No effort was
made to determine the various places of ex-
amination of pilots based locally, or the num-
bers examined by the examiners Cited.

6. All employers, except Federal govern-
ment units, had workmen’s compensation
coverage through private insurance com-
panies. None were self-insured. Employee
compensation for Federal employees is ad-
ministered through a government agency.

7. The employee absentee rate was ob-
tained from a rough estimate made by the
interviewed employer. Only one employer
had kept records to substantiate the estimate.
The range of estimates among all employee
units was from 1% to 4% of the work force.
Because of a similar lack of availability of
accurate data, no effort was made to obtain
information on some of the other common
indicators of the level of effectiveness of
available health services. (Some of these
were listed previously.)

8. All employers interviewed had estab-
lished some form of health benefits program
consisting of at least a group health insurance
plan. The premiums of most plans are con-
tributed jointly by employer and employee.
At least 2 airlines have an additional com-


MEDICAL SERVICES AT AIRPORTS

chronic accidentism, and many other social-medical
problems.

7. The occupational medical service should help
nianagement become or remain a good corporate
citizen in areas involving health, for example, at-
mospheric and water pollution problems, coopera~
tion with official and nonofficial health agencies,
cooperation with the health professions, participa-
tion in community activities having to do with
health programs and facilities.

8. It should help managers plan wisely in the
areas of social insurance and welfare by maintain-
ing adequate records concerning disability, use of
community health facilities, deaths, incidence or
prevalence of disease, and many other things having
to do with health,

9. And finally, the occupational health service”
should help management achieve a profit, not only
by making the above contributions, but by! doing
so in an economical manner—i.e., in the most eco-
nomical manner that is compatible with the highest
possible moral and ethical principles of medicine.

Many of the services and operations per-
formed by employees at airports have a direct
bearing on (1) the airworthiness of aircraft,
and (2) the safety of operation of aircraft
carrying the general public.

The quality of performance of-employees
servicing and maintaining aircraft is a real
concern of those charged with assuring the
safety of air commerce, It has been ade-
quately demonstrated that quality of per-
formance can be significantly related to the
level of physical and mental ‘health main-
tained. This is especially true when the health
status of the employee is specifically related
to the job demands,

Also related to air safety are provisions for
crash rescue and associated emergency medi-
cal care. More than one-half of air transport
accidents occur ator near airports, The in-
frequent occurrence of accidents at a given
airport makes it impossible to justify a medi-
cal facility solely for this purpose. However,
a medical facility in existence for other pur-
poses could render invaluable service in pre-
planning and providing valuable medical
support for such events.

There is an increasing need for qualified
civilian aviation medical specialists. Aviation
Medicine has been recognized officially by
the American Medical Association as a
a5 Reighard

345

special field of medical practice. Certification
in this specialty is granted to applicants who
meet certain requirements. Two essential re-
quirements are: (1) supervised residency
training to include active participation in an
organized program of aviation medicine, and
(2) supervised practice of aviation medicine
for at least 1 year. These 2 requirements are
adequately met for military physicians by
established military facilities, but such facil-
ities for civilians are extremely limited.

Certain important observations, in the na-
ture of background material, bear directly or
indirectly on the subject of airport health
services. First, the cost of providing occu-
pational health programs is prohibitively high
for small employee groups. Because of this,
only a few of the 3,000,000 small business
establishments have in-plant health services
beyond elementary first-aid. “Small” busi-
ness establishments, in this discussion, are
those with fewer than 500 employees. Of
approximately 50 firms employing a total of
5,000 workers at the airport studied, only 2
have more than 500 employees. ‘This is of
practical importance, since accident rates in
small industries are 2 to 3 times greater than
in large industries with medical programs,
and absentee rates are comparably higher for
small employee groups.

Occupational health programs significantly
and favorably affect the following: (1) ac-
cident rate, (2) occupational disease, (3)
labor turnover, (4) absenteeism, (5) com-
pensation insurance premiums, (6) em-
ployee-employee and employee-supervisor
problems, (7) alcoholism, and (8) certain
indirect effects, such as efficiency, morale,
quality of performance, etc.

A recent survey of airports by the Federal
Aviation Agency revealed that of 20 airports
with more than 5,000 employees, only 2 had
medical programs of sufficient scope to meet
most needs, These 2 facilities are private
establishments not directly responsible to the
respective airport authorities. Other air-
ports meet the need in varying degrees, rang-
ing from many with only on-call emergency
services supplied by private physicians, to a
few where an airline medical department pro-


356

most effective in providing the medical com-
ponent of crash rescue plans and operations.

8. A medical facility at a large municipal
airport could be an ideal training site for
civilian physicians pursuing a career in avia-
tion medicine. Such facilities for civilians
are not now available.

9. Medical facilities should be established
at airports to provide comprehensive pro-
grams of occupational medicine and for other
related purposes.

Much advice and counsel were obtained from Dr.
Ross A. McFarland, Professor of Environmental
Health and Safety at Harvard School of Public
Health. Additional assistance on certain legal ques-
tions was obtained from Professor William J.
Curran, Director of the Law-Medicine Institute of
Boston University.

Homer Reighard, M.D., Chief, Medical Stand-
atds Division, Aviation Medical Service, Federal
Aviation Agency, Washington 25, D.C.

REFERENCES

1. The National Health Council: The Health of
People Who Work, 1959 National Health Forum,
New York, 1960.

2. U.S. Public Health Service: Small Plant
Health and Medical Programs, U.S. Government
Printing Office, Washington, D.C. 1952.

3. Bollinger, L. L.; Passen, A., and McElfresh,
R. E.: Terminal Airport Financing and Manage-
ment, Harvard University, 1946.

4, Fleming, A.J.; D’Alonzo, C. A., and Zapp,
J. A.: Modern Occupational Medicine, Philadelphia,
Lea & Febiger, 1960.

5. Somers, H. M.; and Somers, A. R.: Work-
men’s Compensation, New York, John Wiley &
Sons, 1954.

6. U.S. Small Business Administration: Health
Maintenance for Greater Efficiency, Washington,
D.C, 1954.

7. Wade, L. J.: Needed: A Closer Look at In-
dustrial Medical Programs, Harvard Bus. Rev. 34:
2, 1956.

8. National Industrial Conference Board: Com-
pany Medical and Health Programs, New York,
1959.

9. National Fire Protection Association: Crash
Rescue and Fire Fighting for Airports, revised edi-
tion, Boston, 1960.

10. McFarland, R. A.; Human Factors in Air
Transportation: Occupational Health and Safety,
New York, McGraw-Hill Book Co., Inc., 1953.

11. Armstrong, H. G., Editor: Aerospace Medi-
cine, Baltimore, Williams & Wilkins, 1961.

ARCHIVES OF ENVIRONMENTAL HEALTH

12, World Health Organization: Guide to Hy-
giene and Sanitation in Aviation, Geneva, 1960.

13, American Medical Association, Council on
Occupatiorial Health: Scope, ‘Objectives and Func-
tions of Occupational Health Programs, 1960.

Appendix 1

Suggested Outline for Assessing Needs
for Medical Service at Airports

I. Nature of employee population

II. Employee health provisions
1. Workmen’s compensation
(a) Type and carrier
(b) Premium
(c) Experience past 2 years
(1) Number and types of claims
(2) Case examples

(a) Direct
(6) Referral
(c) Examinations (preemployment,
etc.)
(d) Immunizations
(e) Consultation
3. Health benefits program
4. Health information activities
5. Medical surveillance of work envi-
ronment
III. Employee health experience
1. Accident rate
2. Absenteeism
3. Occupational disease
4. Labor turnover
5. Employee-employee and employee-
supervisor problems
6. Alcoholism
7. Health insurance claims
IV. Interest in medical program
1. Preplacement
2. Preventive
(a) Consultation
(b) Periodic examination
(¢) Immunization
(d) Environmental medical surveil-
lance
3. Treatment
(a) Occupational injury and disease
(b) On-the-job illness
4. Certification

Vol. 5, Oct, 1962 86





344 Reprinted from the Archives of Environmental Health
October 1962, Vol. 5, pp. 344-357

Copyright 1962, by American

edical Association

Medical Services at Airports

A Study of the Need for Comprehensive Medical Programs at Large

Airports

HOMER L. REIGHARD, M.D., BOSTON

I. Introduction and Purpose

For some time a number of health- and

aviation-oriented persons have considered

airport populations as unique industrial com-
munities. At a large municipal airport there
are many groups of workers, concentrated
geographically, and sharing certain interests
in a major component of the nation’s large
transportation industry. Such a population
is unique because although a large number
of personnel are concentrated in one area,
the number employed by a single company
is relatively small. This is due to the wide
variety of operations and services provided,
and the duplication of services and opera-
tions by various competing airlines.
Generally no single employer has a suffi-
cient number ef employees at a given airport
to justify a comprehensive industrial medical
program. Thus, benefits from health pro-
grams in large industrial communities have
not been realized at airports, though thou-
sands of employees may be found there.
This is a report of a study to determine
(1) the nature and extent of medical service
desirable at large airports; (2) the manner
in which such services are now met, and (3)
the means by which these services might be
provided in a more effective and compre-
hensive manner. The study was made at one

Submitted for publication March 9, 1962.

Chief, Medical Standards Division, Aviation
Medical Service, Federal Aviation Agency, Wash-
ington 25, D.C. ;

Study completed July 1, 1961 at Harvard School
of Public Health.

The opinions or assertions contained herein are
those of the author and are not to be construed as
official or reflecting the views of the Aviation Medi-
cal Service or the Federal Aviation Agency.

civil airport reasonably representative of
other large municipal airports.

In addition to the primary purposes men-
tioned above, attention was given to 2 other
considerations: (1) the possible medical con-
tributions to air safety, especially those which
are, or might be, achieved through medical
service to airport populations, and (2) the
possible role of airport medical services in
correcting the general lack of available facil-
ities for the supervised practice of aviation
medicine by civilian physicians.

II. Background Information

No attempt will be made to review the ex-
tensive literature which provides evidence of
the value of employee health programs. It
seems appropriate, however, to quote from
the 1959 National Health Forum concerning
the functions considered essential in any oc-
cupational health program ?:

1. Provide a safe and healthful working environ-
ment for each and every worker.

2. Select the best all-around, qualified candidates
for employment by providing an evaluation—not a
diagnosis—of physical and emotional factors which
may be of consequence in the available job.

3. Help management by providing emergency
first-aid medical services to employees, wherever
the nature of the industrial operation justifies or
requires such services and/or these services are not
readily available in ‘the immediate vicinity of the
plant.

4, Help management by helping employees main-
tain a state of health compatible with high pro-
ductivity and job attendance.

5, Help the sick and the injured employees—
where indicated—secure the best possible medical
service in the community.

6. Help management deal constructively with the
medical and social problems of. the employees, such
as nonproductivity, problem drinking, (partial or
total) permanent disability, chronic absenteeism,

4




354

program so long as the professional staff
‘was not organized as a corporation. The more
appropriate type of organization would be a
partnership-trust association of a group of
doctors contracting with the airport authority
for space as a concessionnaire.

(c) Federal regulation to require and
specify the nature of medical services to be
maintained by airports. The Federal Avia-
tion Agency has been concerned for some
time with the general lack of medical services
for airmen and others directly concerned
with the safety of air operations. At the time
of this report the Agency is in the process
of conducting a comprehensive survey of the
facilities of major airports to determine the
adequacy of provisions for the safety of air
operations, crash rescue, etc. A part of that
survey deals with the nature of available
medical support at airports. The Agency also
knows of instances in which major aircraft
accidents might have been averted, or fatality
and disability reduced, by the existence of
adequate medical support and surveillance.

Legislative authority already exists, in the
Federal Aviation Act of 1958, to require this
regulation, should it be deemed necessary in
the furtherance of air safety. Such a re-
quirement, if adopted, could conceivably be
directed toward the responsibilities of: air-
port authorities, operating air carriers, other
groups whose activities have a direct bearing
on air safety, or any combination of the
three.

(d) Independent operation by the airport
authority. The advantage of this type of pro-
gram would be the extent to which the au-
thority could assure the scope, nature, and
quality of the program to suit the purposes
of the particular airport. A disadvantage for
most airport authorities would be the prob-
lems inherent in operating a program ordi-
narily far different from the types of
operations to which it is accustomed. Legal
considerations of significance are those per-
taining directly to the corporate purposes for
which the authority was created and to the
legal interpretation which might be made con-
cerning the establishment of a medical facil-
ity for provision of service to persons other

ARCHIVES OF ENVIRONMENTAL HEALTH

than its own employees. Since physicians in
such a program would assume the status of
employees, laws prohibiting the corporate
practice of medicine would apply unless the
corporate purposes of the authority clearly
supported the establishment of such an ac-
tivity. A fact to be considered, however, is
that an airport authority, being a quasi-public
body, may be excluded from laws pertaining
to the corporate practice of medicine. In any
case, the state laws which apply to the cor-
porate practice of medicine and the corporate
purposes of the particular airport authority
should be carefully reviewed before any at-
tempt is made to establish such a facility. If
the corporate purposes do not support such
action and/or the state laws prohibiting the
corporate practice of medicine apply, the only
alternative would be to seek special legislation
authorizing this activity at the airport in
question.

(e) Port authority operation of the facil-
ity, contracting with a local medical society
for professional care. The organizational
matters involved would be similar to those
discussed immediately above. The contract
could assume the form of contracts currently
in existence under the Medicare program.

An advantage would be found in the level
of acceptance by physicians in the communi-
ty represented by the medical society. A dis-
advantage is that medical societies as
organizations are not generally accustomed
to operating actual medical facilities and
would not have the supporting clinical and
teaching facilities at their immediate disposal
to the same extent that existing medical
establishments do. A second disadvantage
is the variation of interest in, and supervision
of, such a facility—variation which could
result from the frequent changes in leader-
ship which are customary in medical societies.
The legal aspects of such an organizational
arrangement are similar to those discussed
under f below.

(f) Operation by the airport authority
contracting with an established medical insti-
tution for professional services. Several
advantages would result from such an ar-
rangement. First, it would avoid the issue of

Vol. 5, Oct., 1962 84



MEDICAL SERVICES AT AIRPORTS

V. Knowledge of nonemployee medical
needs
1. Patrons
2. Passengers
3. Transients
VI. Safety program
1. Description—scope, type, technique
2. Level of supervision and administra-
tion
Appendix 2
Outline of Interview Used

Nature of employee population

Compensation, type

Physician services, scope (examinations,
treatment, consultation, etc.)

Health benefits program, type

Absenteeism, estimate

Interest in formal medical program (pre-
placement, preventive, treatment)

Knowledge of nonemployee medical needs,
handling

Safety program, type and coverage

Appendix 3
Airport Population
Passengers 3,000,000/yr.
Nonpassengers

(general public) 3,000,000/yr. (est.)
Full-time employees

(total) . 5,006

Type of occupation

(4,758 employees)

Aircrew 1,266
Mechanics,. other

technical and

maintenance 1,482
Food service 218

Administrative and
clerical (including
airline customer

service) 1,165
Other 627
4,758

The author is presently Deputy Federal
Air Surgeon, Federal Aviation Agency.
January, 1965

7 Reighard

Printed and Published in the United States of America

357

Appendix 4

Operators and Concessionnaires
at Airport Studied

Airline A 1,602
Airline B 740
Airline C 449
U.S. Federal Aviation Agency 447
Airline D 230
Airline E 219
Air National Guard 169
U.S. Post Office 132
Airport Authority 130
News Company 130
Motel 83
Aviation Service 78
Caterer 70
Airline F 62
Airline G 60
U.S. Weather Bureau 39
Airline H 33
Airline I a
Airline J 28
Motor Transport 28
Cocktail Lounge 25
Express Company 21
Hertz Corporation ai
Avis Rent-a-Car 20
State Police 18
Aviation Service 16
Railway Express 14
Air Freight Company 13
Air Freight Line 12
Airline K ee
State Aeronautics Commission 9
Insurance Company
Airline L 9
Barber Shop 9
Chapel 6
U.S. Department of Justice 6
Air Charter Service 4
" National Bank 4
U.S. Department of Agriculture 3
Air Charter Service 3
Flower and Gift Shop 3
Airline M 3
Transportation Company 3
Air Freight Service 2
USS. Dept. of Health, Education and Welfare 2
Physician
Travelers Aid 1
5,006
65-4700