The U.S. Bureau of Labor Statistics and workers' compensation insurers reported dramatic drops in rates of occupational injuries and illnesses during the 1990s. The authors argue that far-reaching changes in the 1980s and 1990s, including the rise of precarious employment, falling wages and opportunities, and the creation of a super-vulnerable population of immigrant workers, probably helped create this apparent trend by preventing employees from reporting some injuries and illnesses. Changes in the health care system, including loss of access to health care for growing numbers of workers and increased obstacles to the use of workers' compensation, compounded these effects by preventing the diagnosis and documentation of some occupational injuries and illnesses. Researchers should examine these forces more closely to better understand trends in occupational health.

Thirty-five people with work-related Multiple Chemical Sensitivities were studied to learn about the onset and progression of illness. The subjects were selected from patients at an occupational health clinic. Individuals were identified as subjects if they fulfilled a seven-point case definition for Multiple Chemical Sensitivities and if onset of symptoms was related to workplace exposures. Three occupational exposures to solvents, poor indoor-air quality, and remodeling were associated with onset of Multiple Chemical Sensitivities in 63% of the subjects. Symptoms indicative of a nervous-system disorder topped the list of the most frequently reported symptoms. Commonalities in exposures and symptoms suggest that Multiple Chemical Sensitivities represents a distinct diagnostic category. Even with an incomplete understanding of etiology, it may be possible to limit the onset of work-related Multiple Chemical Sensitivities.

The impact of an occupational illness or injury on an injured worker can be severe. This study assessed several dimensions of the impact on a group of 50 injured workers, all patients at an Occupational Health Center. The dimensions assessed included aspects of access to health care, support from treating physicians in obtaining Workers' Compensation benefits, financial impacts, the role of attorneys and "Independent Medical Examiners," and the impact on mental health. Many reported that their treating physician did not want to become involved in Workers' Compensation, despite indicating a belief that the health condition was work-related. The financial impacts of a work-related diagnosis were particularly striking, with respondents reporting that they were burdened both with costs directly related to the medical care of their condition, and with coping with ongoing general expenses on a reduced income. Many respondents reported depleting savings, borrowing money, taking out retirement funds, and declaring bankruptcy in efforts to cope. Emotionally, respondents almost universally reported their diagnosis and related issues were associated with depression, anxiety, and loss of identity and self-worth. This study demonstrates how a work-related injury or illness can extend far beyond the physical impact for injured workers. Existing systems fail to adequately compensate or rehabilitate injured workers, leaving them to their own devices to deal with their losses, medical or otherwise.

In a previous study of older pulp and paper workers in Berlin, New Hampshire, decrements in spirometry results associated with accidental exposures to high levels of irritant gases depended on cumulative levels of pulp mill exposure and cigarette smoking. Many of those subjects were older and retired. A new study was initiated to assess whether gassing events were a problem among current workers. Three hundred white male pulp and paper workers from the mill in Berlin, New Hampshire, were surveyed in 1992. Testing included spirometry and questionnaires. The mean age was 40.4 yr, and the mean tenure with the company was 18.5 yr. A total of 105 of the 300 subjects (35%) reported ever having an episode of high exposure to chlorine gases (i.e., being gassed). The percentage gassed was 51% for pulp mill workers and only 13% for other employees. For subjects with no more than 26 pack-years of cigarette smoking, obstruction (i.e., abnormally low FEV1 and FEV1/FVC) was observed only among those with a history of gassing. Also, the combination of high cigarette smoking (i.e., > 26 pack-years) and gassing had a greater than additive effect on obstruction. These findings suggest that additional controls are needed to minimize the number of gassing events in this and other chemical pulp mills.

Treating physicians' and independent medical examiners' (IMEs') opinions were compared to identify differences of opinion and to develop a basis for understanding the differences. Twenty-three patients of an occupational health center (OHC) who had been examined by an IME were studied. OHC and IME opinions regarding diagnosis, work-relatedness, treatment recommendations, and disability assessment were categorized by degree of agreement. There was agreement on all four issues for only one patient. Opinions were most divergent with regard to disability assessment and least divergent with regard to diagnosis. Disagreement was unidirectional: the IMEs made fewer diagnoses, deemed fewer illnesses work-related, made fewer treatment recommendations, and assessed lower levels of disability than the OHC examiners. The results suggest that differences in opinion between the OHC and IMEs are due to differences in perspective, rather than skill or training.

Integration of workplace wellness with safety and health has gained momentum on the initiative of the state allied with a segment of large employers and some health and safety professionals. Integration has a dual potential: to fundamentally reshape occupational health in ways that profoundly benefit workers, or to serve neoliberal corporate goals. A focus on the workplace and the ways work and health interact broaden the definition of a work-related injury or illness and emphasize and challenge the employer decisions that create hazards and determine risk. However, the implementation of integration is taking place in a context of corporate dominance and the aggressive pursuit of a neoliberal agenda. Consequently, in practice, integration efforts have emphasized individual worker responsibility for health and fail to actually integrate wellness with safety and health in a meaningful way. Can an alternative be envisioned and pursued that realizes the promise of integration for workers?

Experience at a publically funded occupational health clinical center in New York State suggests that patients with work-related illnesses often have great difficulty accessing diagnostic and treatment services. A study was designed to more quantitatively investigate the extent and nature of barriers to medical services for patients with Workers' Compensation claims. Medical practices from 13 selected medical specialties were identified from telephone directories. The directories covered six areas encompassing almost all of a 15-county region. All practices from each selected specialty were contacted by phone and asked a set of standardized questions regarding patient acceptance policies. A number of barriers were identified by the survey including practices closed to new patients and practices closed specifically to patients with Workers' Compensation claims. Barriers also were found to be widespread among practices that did accept Workers' Compensation claims, primarily related to requiring a guarantee of payment prior to seeing the patient. The results were compared by medical specialty and geographic area. While the study showed some of the difficulties patients with occupational illnesses face attempting to access medical services, it most likely underestimated the extent of the problem. Attitudes and practices that impede access, but were not measurable, create additional barriers. Our study strongly suggests that policies that improve access to medical care for individuals with Workers' Compensation claims are necessary to better serve the needs of workers with occupational illnesses.

Pressure is mounting for clinicians to rely solely on objective measures when evaluating workers with possible work-related disease. These measures are intended to largely supplant the worker's history as sources of information regarding diagnosis, work relatedness, and extent of disability. While seeming to promote more accurate and neutral evaluation methods, the underlying agenda is to reduce business costs by denying work-related illness and disability. Promoting the view of occupational health as the province of technical experts, the campaign for the objective finding silences workers as unqualified to comment. The methods proposed to enhance objectivity also suffer from significant specific shortcomings. To resist efforts to fetishize the objective finding, clinicians need to recognize the subjective elements of objective methods as well as the objective value of subjective data. This requires recognition of the central role of workers and histories in the clinical evaluation process.