PL06 DEVELOPMENT OF OCCUPATIONAL HEALTH SERVICES IN A MEDICAL COLLEGE SETTING IN INDIA – LOOKING BACK OVER 25 YEARS TO INFORM THE FUTURE
Authors: Joseph Bobby 
Published: July 2024

That Occupational Health is a neglected field is a fact that has been discussed, deliberated and debated upon for many decades. In a developing country like India, where priorities in the delivery of preventive health services – whether publicly driven or privately promoted – the attention has always been focussed on several other aspects of public health including maternal and child health, family planning, infectious diseases and more recently non-communicable diseases. Occupational Health has always been given the short shrift – not only in the teaching of the subject at universities but also in the practice of medicine in hospitals. Authors have for long lamented about the absence of occupational history in patient records and the importance of the same. Evidently not much heed has been paid to Ramazzini’s circa 1700 plea to add that one more question: what occupation does he (the patient) follow?

The International Labour Organisation identifies occupational health and safety as “the discipline dealing with the prevention of work-related injuries and diseases as well as the protection and promotion of the health of workers”. This definition lands the specialty directly into the laps of community health/medicine practitioners or those who were previously referred to specialists in “preventive and social medicine”. This term, probably, more accurately describes the mandate of a modern-day occupational health practitioner – if not elsewhere in the world, in developing nations. In India, wherever reference to Occupational Health is made in academic circles, it is considered to be the domain of Community Medicine – a subject that is a mandatory part of the course work leading to the award of the undergraduate MBBS degree.

It was not surprising then that the Ross Institute of Occupational Health (a Unit of the London School of Hygiene and Tropical Medicine) relocated from the tea-growing region of Jorhat in the state of Assam in Northeast India to the Department of Preventive and Social Medicine at St. John’s Medical College, Bangalore in South India. Though the exact reasons for this shift have been unclear, it was at the behest of South Indian plantations that a three-cornered link was created between the United Planters’ Association of Southern India (UPASI), the Department of Preventive and Social Medicine (now Community Health), St John’s Medical College (SJMC), Bangalore and the Ross Institute, London. The Occupational Health Unit (Ross Institute Unit of Occupational Health) was established at SJMC in July 1974. Fifty years ago, it was the first medical college with a division devoted to the health of the working population. During the initial years of its functioning, most of the work centered around the plantations in South India and to a smaller extent the agricultural sector in the rural field practice area of the College. This Unit went into decline within the first decade of its establishment – there are a number of reasons attributed to this fall; foremost among them being the loss of key personnel at all three organizations involved in the pioneering partnership. The Unit became practically non-functional in 1984. Following its resurrection, the Division is still one of the few providing occupational health services in any of the 700 medical colleges in the country.

Almost fifteen years later, in 1997, it was serendipity that drew the author to the plantation sector. The focus of the health care services in the Estate Hospitals were on the provision of medical facilities for labouring mothers and their children; and on the provision of mandated housing, water supply and environmental sanitation. The health and welfare audits were initiated and developed with a focus on the preventive and promotive health services that were being provided by the Medical Officers of the tea estates. These are required by the Plantation Labour Act that governs the health and welfare services in the plantation sector. The concentration was on the provision of primary health care. These audits helped identify lacunae in the existing systems and provided solutions to the estate management. Over the years, the estates have ensured that health promotion, disease prevention and standards of treatment of common illnesses were maintained at the highest possible level. Despite facing challenges like falling prices of South Indian tea in the international auctions, the emigration of skilled workforce to other sectors and the immigration of uninitiated employees from East and Northeast India – the estates have succeeded in maintaining their superior primary health care indicators. The focus has now shifted to health and safety at the workplace. While initially these audits have been voluntarily employed by a few plantation companies to monitor the progress of their health services, others have also followed suit and ensured that the health, safety and welfare of the employees and their families are well taken care of. With decreasing absenteeism and the consequent improved productivity, companies have recognized the value of investing in the health of their employees.

In the apparel manufacturing sector, the importance of investing in the health and welfare of employees was brought into focus in the 1990s by the growing concept of corporate social responsibility and was a direct reaction to the newfangled incursion of social compliance audits. This entire situation was an outcome of the outcry of university-going youth in the western world to the atrocious working conditions of employees in vendor factories in the global south manufacturing apparel for popular brands. The Department’s involvement started with the Occupational Health Services Division (no longer the Ross Institute Unit of Occupational Health) facilitating the establishment of functional crèches, canteens and clinics (3 Cs) for factories belonging to one large corporate organization in Bangalore. This caught the attention of international not-for-profit organizations which soon established links with the Occupational Health Services Division. Investing in the 3 Cs and promoting the health of employees through a peer education model were pioneering interventions that have found worldwide acceptance – thanks to the reach of our international partners. In recent years, the focus of our attention has shifted to the mental health of employees (and staff and management) – the investment in training and support provided to “lay counsellors” is already providing rich dividends to factories. Currently, research on the return-on-investment of these interventions is in progress.

While dabbling with other occupational sectors, our third most significant sector has been the health care system. Starting with our own institution – St. John’s Medical College and its allied establishments (Hospital, Nursing College and Research Institute) employ more than 4000 individuals. The Staff Clinic is the fulcrum around which all the interventions are provided which include training in hospital health and safety, clinical services (care during acute illness and preventive health care including vaccinations) and environmental checks.

“No survey without service” has been a long-standing dictum of the Department. In keeping with this, the published studies emanating from the Occupational Health Services Division have been rather muted. The reluctance of managements of our partnering companies to permit dissemination of data has also played its role in the relative paucity of published papers. Even so, small studies have been conducted and published – more in national and regional journals (where they are more relevant) and also in international publications.

Our experiences over the past 25 years indicate that the initial focus on primary health care services makes for a better investment before moving on to occupational health and safety interventions. The faculty associated with the Occupational Health Services Division have made conscious efforts to teach Occupational Health to the undergraduate and postgraduate students – with specific focus on the lessons learnt in the field. Exposure visits to factories, plantations, mines and other work settings have given emphasis on the importance of occupational health and the impact of occupational exposures on health outcomes among employees. In a country where trained occupational health physicians are a rare breed, it is hoped that the training imparted to a small group of students will have a ripple-effect – calling to attention other medical colleges where the focus on the domain is poor. Simultaneously, drawing the attention of existing health care providers to basic occupational health services at the primary health care level both in the private and public health sectors through training programmes at the provincial level is the way forward.