Job-related diseases and injuries a major problem in New York state, report says

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Reducing or eliminating hazards in the workplace could help reduce or eliminate work-related diseases. And yet occupational disease remains a major public health problem in New York state. With me to share a new report on occupational diseases in New York state is Dr. Michael Lax. He's a professor of family medicine at Upstate and the medical director of the Occupational Health Clinical Center. Welcome to "The Informed Patient," Dr. Lax.

Michael Lax, MD: Thank you.

Host Amber Smith: I think we ought to start with a definition of "occupational disease," if you don't mind. What counts as an occupational disease?

Michael Lax, MD: Sure. I mean, one way to look at it might be a contrast to an occupational injury, to begin with. Occupational injury is what I think a lot of people think of when they think about workplace health and safety. And so an injury is something like a sprained ankle or a broken leg, or when your back goes out because you lift something heavy, and those are the kinds of things that would qualify as injuries.

And the things that characterize them as injuries are, they happen pretty quick. I mean, they happen over almost an immediate time period. So the exposure is quick, and then the effect on the body, the injury itself, is instantaneous. As soon as they fall, they get injured. So to contrast that with the idea of a disease, a disease is more like something that occurs as a result of an exposure that may occur over a prolonged period of time.

And the effect that it has on the body may also take a prolonged period of time to actually show up. An example that would be a classic example in workplace health and safety would be a scarring of the lungs that occurs as a result of exposure to asbestos. That's called asbestosis. So people generally get exposed to asbestos over a period of time. And then later they experience a scarring of the lungs, but usually that scarring doesn't occur for at least 15 years after the initial exposure takes place,so that's kind of an obvious example that contrasts what I mean by a disease as opposed to an injury.

And diseases are, as I think it says somewhere in our report, at the beginning of the report, what's interesting, for us in the field, disheartening actually, about occupational disease is that it's so common, yet it's also so overlooked that it doesn't get paid attention to.

Michael Lax, MD: And doing this, report was an attempt to quantify how much occupational disease there is in New York state, and also to give some idea of the scope of it: What sorts of things are we talking about when we talk about occupational diseases?

So I gave you the basic definition there of an occupational disease. But I think that it's worth it to spend just another minute talking about adding some complexity.

Host Amber Smith: Let me ask you, when you mentioned diseases: In the past couple years, has COVID been counted as an occupational disease if the person got sick at work?

Michael Lax, MD: Right. Well, that's a good example that sort of gets at exactly what I was trying to talk about, that, in some ways, yes, COVID, because we heard a lot in the news, I think, about essential workers, and we learned about health care workers becoming infected with COVID, for sure.

But also, people may or may not be aware, there are other types of workplaces where COVID became epidemic, like in meatpacking plants, for example, was a big one. But also here locally, I don't know if people remember, but at some point in the pandemic, there was a large greenhouse operation that's over near Oneida, and there's several hundred workers there, and I think, 200 of them or more became infected with COVID.

And actually, then that's a good segue into, what I'm talking about by more complicated idea of occupational disease, because COVID obviously is not only an occupational disease. You can get COVID from picking it up from somewhere in the community, as well. Just to give you an example of a situation I know that shows some of the complexity, I know a massage therapist and, she was working early on in the epidemic, and she was working unmasked. The person she was working on was unmasked, and the patient didn't tell her that they were having symptoms or were sick. The massage therapist becomes ill and finds out that that patient had COVID.

So that's clearly a work-related thing for that massage therapist. She goes home. She lives with her husband and her daughter. So she goes home, she passes it to her husband. He gets sick. So there we have a home exposure. Her husband then goes to work. He goes to work, and he infects his boss. So there's a workplace exposure.

Meanwhile, the daughter gets sick as well. She calls her employer. Her employer says, "Don't come in to work." Fortunately, good advice, but then gives her bad advice and tells her, "But don't go get tested, either," because, he says to her, "We don't want to know because of the consequences for us at the workplace." So, that episode for me really epitomizes some of the complexities of not just COVID, but other occupational diseases where the pathway is not so straightforward, you know, with it's only at work where the exposure occurs. So to get back to your question, yeah, some of COVID is work-related but I'm not sure that everybody at this point really thinks of it anymore that way.

This is speculation, but I think there was not a lot of eagerness on the part of many to recognize it as occupational, because, I think, of the implications of that. And so New York state and a lot of other states actually didn't even keep statistics, to allow a good analysis of how much is work-related. So it's been really difficult to tell. And so that's a good example of, when I say complexity of nowadays, when you're talking about occupational disease, that's not necessarily so simple, straightforward "get exposed to asbestos in the workplace, get asbestosis," right?

Now it's like, "OK, I have COVID. Did I get it in the workplace? Did I get it from home? How do I tell the difference?" And a lot of diseases are like that, where there's possible non-working exposures. Sometimes it's multifactorial, like I think you mentioned stress as an example.

Stress is something that people have out of work. So they can have stress at work. Lots of people find their family to be a huge, their biggest, source of stress. So it's not uncommon for people to have stress at work, away from work, and so in the end, they may have a stress-related health problem, but more than work may be contributing.

In a sense, it's not really that problematic in that if you forget about legal issues or medical/legal sorts of issues, from a sort of medical/scientific point of view, it's, I think it's important to figure out that work is playing "a" role, but in any individual case it's not necessarily so important to figure out was it "the" cause or was something else the only cause. Because the bottom line is that if we recognize that work is playing a role, at least we'll pay attention perhaps to work as one of the factors that could be causing the problem. And we'll start paying attention to what can we do in the workplace as well as outside of work to try and reduce the hazard and avoid these sorts of health problems.

I think what makes it difficult is the medical/legal environment is such that the health context that we operate in has, because of historical reasons, has separated occupational disease into this own thing that's separate from general health concerns from an insurance standpoint, so that there's a completely separate system, the workers' compensation system, set up to handle occupational disease problems. And as a result of that, when you get put in that system, the system requires you to prove that your disease was caused by work. And so you get into this either/or dichotomy thinking that, from a public health or from a strictly medical standpoint isn't necessarily all that useful.

Host Amber Smith: Well, let's get into your report a little bit, because I'm curious about the incidence of occupational disease in New York state, and whether it's changed since, you know, 30 years ago, New York had all of these manufacturing jobs, so things are different today. What did you find?

Michael Lax, MD: Well, exactly. And that was one of the major impetuses for us wanting to do this report, because the last time that anybody, I think, as far as we know, tried to take a comprehensive look at this question in New York state was in the mid-1980s.

Michael Lax, MD: And like you said, boy, a lot has changed since then in terms of where people are working and the conditions under which they are working. And, having been around since, almost that time -- I came here in the late 1980s -- I've seen the changes every day I drive to work. My office is out just north of Carrier Circle, so just driving by the Carrier plant where there used to be two or 3,000 jobs is just a clear indication of where things have gone in the last 30 years. So, yeah, we've lost a lot of those big manufacturing plants, and the manufacturing that does exist is now in smaller, more dispersed kind of workplaces.

We've had an explosion of service-sector- related jobs. So office jobs, and here in Central New York, like a lot of parts of New York, now the sort of major industries areeducation, health care, food service and hotels, restaurants, kinds of things. Office jobs are really big. So yeah, there's been a big change in where people are working, and that obviously has an impact on what sorts of illnesses people may incur in the workplace. The other thing that's important to recognize is that it's not just the hazards themselves or the jobs themselves that are important in terms of posing a risk for occupational disease, but also the conditions under which people are actually doing that work. So in other words, what I mean by that is that, for example, a lot of the work our report found that had been increasing over the last couple of decades, is work that we call low wage that we group into a category of low-wage work.

And those low-wage jobs tend to be non-union jobs, where workers work at will, so they have no contractual protections from their employer. They tend to be in workplaces that are not necessarily high-profit; they're operating on a low margin.

And workers are pretty much working under conditions that are pretty difficult a lot of times. From a stress standpoint, they have very little control over their jobs. They've got little control over when they work. They have little control over the conditions under which they're working.

Michael Lax, MD: And they oftentimes have no outlet to be able to go, or they don't know about resources that might help them in terms of dealing with those issues. But if they do, they may be quite worried about utilizing those resources because, the job is precarious. They fear that if they're labeled as a troublemaker, as a person that's making waves, that they could just be out of a job.

So I think that tends to really tamp down people's willingness to step forward and say, "Hey, I think something is going on here that needs being addressed." So that I think is also an important change that's occurred over the last couple of decades because, really labor unions in New York state are still relatively strong compared to other states, but we've seen a huge hemorrhaging of labor union jobs, even in New York state, over the last two or three decades.

And when it comes to safety and health, in New York, nationally, even internationally, labor unions are one of the strongest voices that stand up for workers and for their health on the job, historically speaking. And so when those unions are weakened or when they're gone from an industry, then workers lose that voice and that protection. And that's another sort of big thing that's happened here in New York affecting work, I think.

Host Amber Smith: Do you have a sense for how many serious injuries or deaths happen per year that are tied back to the workplace?

Michael Lax, MD: We estimated that, and people have to understand these are just estimates, because one thing we found and people can see from the report, is that just a lot of data is not collected, so you have to find different data sources to be able to put it all together into some kind of coherent picture. In terms of occupational disease, we estimated that a little over 7,000 people per year die in New York state from an occupational disease. If you put that in context, I think, cancer and heart disease are one and two in terms of most frequent causes of death. And they're up around, maybe 35,000-40,000 deaths, something like that.

But then number three is accidents, and accidents is about 7,500 deaths. So occupational disease is right up there in terms of causes of death, higher than stroke, higher than Alzheimer's disease, higher than deaths from opioids or overdoses. So that's what I'm talking about, a problem that'svery present, but not paid attention to. I think occupational disease kind of gets lost in terms of its importance when you think about it in that context. In terms of occupational disease, the morbidity, or people not dying from the disease but getting sick from an occupational disease, those numbers we did a little differently because again, limitations in the data that we had.

So at any given time in New York state, we estimate that a little over 13% of the total disease volume in the state, in other words, all the people with all different kinds of diseases, that occupation is playing some role in contributing to that disease. So about 13% of disease at any one time in the state, which is huge.

I mean, it's a big, very big burden, but if you look at deaths versus people getting sick, they kind of are different in terms of what those diseases are. In terms of occupational disease deaths, I forget the exact number, but I think it was about three-quarters or more was due to heart disease and cancer. Those were the two big ones.

For occupational illness, that's where people are not dying from the illness, it's more like over 50%, I think, were musculoskeletal disorders, and another big chunk were respiratory disorders. So there's a contrast there. And when I say musculoskeletal disorders, again, I'm talking about musculoskeletal disorders, not your sprains and strains and falls. No, we're talking about musculoskeletal disorders that occur from a repetitiveoveruse of a person's body that results in things like carpal tunnel syndrome or tendinitis at the elbow or shoulder tendinitis or chronic back problems, those kinds of things.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with the medical director of the Occupational Health Clinical Center at Upstate, Dr. Michael Lax. He's the medical director of the Occupational Health Clinical Center at Upstate. And we've been discussing a new report about occupational disease in New York state.

I know there's emphasis on safety in the workplace, but is occupational disease always preventable?

Michael Lax, MD: Well, theoretically, yeah, because if you can identify hazards in the workplace that are connected with the risk of occupational disease, then those hazards can be reduced or eliminated in the workplace. So theoretically, yes. In practice, obviously, that's not happening.

Host Amber Smith: Your report focused on New York state, obviously, but do you believe other states have similar issues?

Michael Lax, MD: Oh, sure. Yeah. And I think that every state, has the same sort of issues in terms of having occupational disease, that's present, but really not paid much attention to. What may differ from state to state is the actual profile of diseases, because, obviously in certain states the workplace profile is different, so that there may be more mining, there may be more construction, there may be more manufacturing or things in different states where there are different kinds of hazards. But overall, yeah, this is a national problem and one in which I wouldn't want to give the impression that New York state lags behind other states in this area, even though I'm saying, yeah, there's a lot of issues and it's still clearly very prevalent because New York state actually has been a pioneer in trying to address the issue of occupational disease, because 30 years ago or 30-some years ago, which is the reason I came to Upstate and originally was to become the medical director of the Occupational Health Clinical Center, which is a part of a statewide network of occupational health centers that New York state publicly funds and has publicly funded since 1987 specifically to address the issue of diagnosis, treatment and prevention of occupational disease. So New York state, I think, has, not just a clinic network, but other infrastructure to address this problem. The fact that the problem still exists and is, such a huge problem, says something about the immensity of the problem and also the difficulty of addressing it, that you don't just address it by having a few clinics and send relatively few number of doctors and staff trying to address it. It's a problem that needs, really, attention from a whole array of participants.

Host Amber Smith: What are the most common hazards or the top hazardous industries in New York?

Michael Lax, MD: In the original report that was done 30-some years ago on occupational disease, they actually had lists of the most hazardous industries, from data that at the time was being collected by national organizations, OSHA, the Occupational Safety and Health Administration, and NIOSH, which is the National Institute for Occupational Safety and Health, which is the research side of things at the federal level. So we tried to do the same thing. We tried to access data that would allow us to list, like you just asked, what are the most hazardous industries? It seems like a pretty straightforward, simple question and turned out to be impossible to answer because that data that they collected 30-some years ago has never been collected since.

Michael Lax, MD: As a result of that, we wrote a whole chapter on trying to estimate risk of occupational disease and try and figure out what are the hazardous industries in the state and how many people might be exposed in them. But we had to do that really piecemeal. For each specific hazard, like asbestos or silica or lead or chemical exposures generally, we had to use different data sources and different technique for trying to estimate it. That's why that section is really, I think, I look at it as kind of like trying to put the pieces of a puzzle together, and we sort of have gotten some of those pieces to fit together, but we don't have the complete picture.

But to get back, to try and answer your question: so what we did was, we thought that, even though, like we talked about before, New York state's economy has changed pretty dramatically, that doesn't mean that all of those traditional hazards that we think about as being associated with manufacturing or mining or dangerous sorts of occupations, those have not disappeared.

So we looked at chemical exposures. We found several hundred thousand, I think, workers exposed to a relatively small list of potential, chemical exposures. We found significant people still working with asbestos, found a lot of people still working with silica. Musculoskeletal hazards are huge in terms of, again, this repetitive overwork kind of thing. Literally probably net numbers in the millions of workers exposed to that. Stress, is huge as an issue. And as the last couple of years have shown, we have to pay attention to infectious disease, because that's sure proved to be a major problem, in the last couple of years with COVID.

Those, I think, give a sense of some of the issues, but some of the issues also are not necessarily traditional, are not necessarily what you would think of as occupational health issues, for example, stress. When people think about stress, it's a vague term, and I think a lot of people use it that way. And 30 years ago, I think, when people said your disease or your problem is caused by stress, it's like the last resort when you go to the doctor, if they can't find an answer, it's oh, it must be stress. But I think that there's been a lot of work since then to really define what we mean by stress and to make stress into something that can be defined. It can be looked at like any other hazard in the workplace, like a dust or like a chemical or whatever. And some of the factors that they've found out that are associated with stress are on the combination of if a person is working at a job where there's a lot of demand on them, not necessarily physical demands, but more like the psychological demands to produce or deadline or to keep up with an assembly line or,if you're working in a warehouse, you're on a timescale to really pick those items fast and get them out to where they need to go.

Michael Lax, MD: So, those kinds of demands linked with lack of control over the job so that the less control a person has over the job, in other words, the less control they have over the speed of that conveyor, no control over how the work gets done, and working on heavy deadlines or working with somebody always breathing down their neck to get it done, get it done.

Those sorts of things, linked with the high demands, is one thing that has really, I think, been well-defined as linked to cardiovascular disease, heart attacks, high blood pressure, stroke, as well as a range of other health problems: mental health- as well as physical health-related issues.

But in addition to that, I think that there's things like social supports at work. So does a person feel alone? Are they dealing with the problems that they have on their own? And just to give you an example of that, I had a woman who was working in a factory and she had worked there for many years, a manufacturing plant, and, she was promoted to become a forklift driver, and she was the first woman to ever get the seniority, to achieve that position. And as soon as she got into that position, she started getting harassed by men on the job, because for whatever reason, they couldn't deal with a woman who had achieved this position. So she was getting harassing messages on the little display that dispatched her on her forklift to where she was supposed to go. Comments, all kinds of stuff going on at the workplace. And she was completely alone. She was the only woman doing this. And so for her, that lack of social support, along with the harassment and incivility and bullying that she was experiencing, was a big issue in terms of creating that stress for her.

I think that stress is something that is rampant. It's in many, many different workplaces. We find that when we go out and speak to workers in all kinds of situations that stress is often No. 1 concern. And with good reason. I think the more we learn about stress, we're also learning that it's linked with many different kinds of health issues, some of them really, really, obvious and overt, like a heart attack or a stroke, but some of it more subtle, like things you don't see, like effects on the immune system, for example, or does thatlink to pathways that break down the body's ability to resist things, like even the development of cancer in the long term?

So stress is a big issue, and a lot of people think of it as not a big deal, but how we deal with stress, I think really is a big deal from a health standpoint.

Host Amber Smith: Would a worker who believes they were injured or became ill because of something in their workplace, would they go to their own primary care doctor or would they try to find an occupational medicine specialist, like yourself?

Michael Lax, MD: Well, there's two parts to that answer.One Is from the medical standpoint, they can go to any doctor they want. When I first came in the '80s, a lot of docs in the community handled the routine stuff. They handled routine sprains and strains and all that kind of stuff. And some of them, are interested in or have experience dealing with more complicated occupational disease issues. But the reason our clinic was set up and our clinic network was set up was precisely to deal with the problem (for) many docs in the community. When you look at medical school training, virtually no doctor comes out of medical school with training in occupational -- recognizing occupational -- disease. The amount of time spent in curriculums and medical school is almost nothing. So, a lot of docs need help in terms of figuring out what's going on with a person who may have an occupational disease. So a patient may initially try and go to their primary care person, but then that primary care person may then refer the person to us, to an occupational medicine specialist, or the patient can go directly to an occupational medicine specialist. What's complicated things over the last probably 15 years, is that many doctors in the community, primary care doctors as well as specialists, have stopped accepting workers' compensation insurance. And that's for a lot of patients reached kind of crisis level because they can't find a doctor in the community who will take workers' compensation, even for a simple, run-of-the-mill thing that primary care doc or specialist can handle easily.

So that has created problems because our facilities are limited. Our occupational clinic network is limited. I think there's, eight clinics around the state. And what we've seen is that workers not only with occupational disease, but occupational injuries, now are coming to us or trying to come to us because docs in the community don't take workers' compensation, which I think is a real shame because I would argue that, it's part of your deal as a physician or your reason for being as a physician, is to advocate for your patients. Right? And I think that in order to fully advocate for your patients, you need to advocate for them, with them when they have a work-related disease or injury as well as if they don't. I think a lot of patients are getting shortchanged that way, but on the other hand, I understand also that the workers' compensation system is a very difficult system for patients and also for doctors to deal with and their offices to deal with. A lot of doctors just get fed up with the paperwork, with the hassles, the demands, the denials, and it's hard to practice decent medicine under workers' comp a lot of times. So, a lot of offices decide that it's just not worth it. And they have been dropping out, butthe workers' comp board tells us that they've been listening to these issues, they're not oblivious to them, and that they've really been trying to find ways to keep docs in the system and bring docs back into the system, improving communications, improving the accessibility to the comp board. And so they're actually involved in a kind of active outreach I think you're going to see it over the next, year or more that they're going to try and bring docs more in, but "Will that be successful?" is a good question. Because I train residents; for example, I go talk to residents in family medicine about, workers' compensation and dealing with the comp system and trying to be practical about it.

And, their attitude when I start the session is, most of them are like groaning, "Oh God, I can't stand it. We have had to deal with these forms and the comp system and all that." And by the end, there might be some of them that might be convinced that yeah, maybe we should be doing workers' comp, but there's still some, I've had, it's not uncommon at the end of the session, I ask them, they're all third-years (final year of medical school), where are you going after you finish? They say, yeah, I'm going to go here or there or wherever. But some of them say flat out, "I'm not doing worker's compensation, period. You didn't convince me." So that's a big problem.

Host Amber Smith: Well, Dr. Lax, I appreciate you making time for this interview.

Michael Lax, MD: Thank you for having me. I appreciate the opportunity.

My guest has been Dr. Michael Lax. He's a professor of family medicine at Upstate and the medical director of the Occupational Health Clinical Center. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/info. This is your host, Amber Smith, thanking you for listening.