By NORTIN HADLER, MD

Etiology, pathogenesis and translational science beat drums to which modern medicine marches – with escalating cadence. Yes, there is cacophony on occasion and missteps, but we all wait for the next insight to trigger a wave of enthusiasm at the bench and beyond. “Disease” is no longer an elusive monster in the swamp of ignorance; “disease” is prey. It can be defined, parsed, deduced, and sometimes defeated.

Little of this pertains to “health.” Health does not objectify itself. Nor is it simply the absence of disease. Health has temporal and geographic dimensions. Health is inseparable from the context in which it is experienced. Health has a narrative laced with peculiar, often idiosyncratic idioms.  Furthermore, there is a crucial difference between the health of a person and the health of the people.

Science has limitations when it comes to studying health. For one, the studying becomes a component of the experience of health. Nonetheless, we have accumulated a great deal of substantive information that serves to define the boundaries of healthfulness and offers options with salutary potential. Much of this reflects a century of considering the personal ramifications of gainful employment. Much of this falls under the purview of occupational medicine and should be a source of pride.

The Health of the Worker

To live a year without an episode of headache, heartache, heartburn, respiratory symptoms or back pain is abnormal. To live several years without shoulder, neck, or knee pain likewise is abnormal. Health is having the wherewithal to cope so effectively that the last episode is not long memorable. Functioning may be compromised, but usually to a degree we can tolerate and largely circumvent; “presenteeism” is a choice that need not be medicalized or penalized (even my computer is afflicted on occasion.) Myriad remedies, from poultices to pills, have always been purveyed for remittent and intermittent predicaments of life. These options cater to “common sense”, which is neither geographically or temporally common. None is “indicated” on an evidentiary basis.

Predicaments of life are a bane at work, just as they are at home. In both settings, one can turn to “community” for emotional and physical support if “community” is available. The importance of social cohesiveness and social capital in the industrial age was a seminal contribution of the social philosopher, David Émile Durkheim (The Division of Labour in Society, 1893). When, despite personal and community support, a worker is overwhelmed by any morbid challenge the morbidity qualifies as illness and the functional compromise as the illness of work incapacity.

The political climate in Durkheim’s day was partisan and contentious. An imperious establishment was ill prepared to assuage a labor force angered by disenfranchisement, poverty, insecurity, and rampant work incapacity from disease, injury and age. Labor’s plaint was bolstered by the development of the union movement and plaintiff’s bar and by the stridency of the likes of Marx and Lassalle. Violence was postponed by Prussia’s “Iron Chancellor”, Otto von Bismarck, who shepherded a “welfare monarchy” through the Reichstag.  This ground breaking social legislation rewarded the citizenry with personal security based on their value to society (1). For predicaments of life and other illnesses, health care would be provided. However, recourse was not universal for the illness of work incapacity itself. If incapacity arose out of and in the course of employment and occurred by accident, there would be no loss of income. If incapacity precluded further gainful employment but was not causally related to work, a modest pension would be provided. But if this individual never had substantial earnings, the pension was meager.

The industrialized and industrializing world rapidly accepted stratification by worthiness as sensible. With some modifications (2), Prussia’s Workmen’s Accident Insurance, Public Pension Insurance, and Public Aid have left their mark on social legislation and social conscience ever since. Most tried to bend the Prussian paradigm to their preconceptions. For example, David Lloyd George and W.J. Braithwaite fashioned the British version to dull the cutting edge of the welfare monarchy (3). Meanwhile, in America Theodore Roosevelt was trying to reprise his presidency on the Progressive (Bull Moose) Party ticket. His platform called for universal health insurance and many other features of the Prussian precedent. Roosevelt lost and so did the platform. Only Workmen’s Compensation Insurance made landfall – and not easily. It was declared a breach of the commerce clause of the Constitution. Hence it reverted to the states, one at a time, each with distinctive features. Federal disability insurance waited a half century, and universal health insurance is barely out of the oven.

The Health of the Workforce

There have been great strides in assuring that illnesses, including the illness of work incapacity, are not consequent to exposures that are peculiar to a workplace. Sadly, most of these strides represent efforts after-the-fact. If a worker suffers physical, thermal or toxic injury in the modern workplace, it is considered a reproach to regulatory agencies and management. The victim will be afforded optimal care without wage loss and usually return to gainful employment if possible. As for any responsible party, a financial penalty, sometimes more, awaits.
This is not the case for the illnesses of work incapacity consequent to predicaments of life. For some predicaments, risk analysis impugns the workplace more than the home. For example, one might be more likely to be infected with influenza at work than at home given the differential intensity of exposure to respiratory droplets. But we do not consider it sensible to consider “flu” an occupational disease, let alone a compensable injury. A worker with “flu” can elect presenteeism or “sick leave” and go home without anyone questioning the presumptive diagnosis. Besides, no one would raise an eyebrow if the real reason was that their child had flu.  Furthermore, if the co-worker didn’t return promptly, one is inclined to reach out to offer assistance.

Another course of events is likely if the co-worker chooses absence for regional back pain (4) and other predicaments of life that are considered “work related” despite the absence workplace-attributable risk. For the regional musculoskeletal disorders, the causal inference is a social construction, understandable but sophistical. Biomechanical forces that exacerbate regional back pain are no more likely a feature of tasks at work than similar tasks outside work, nor are they proximally causal (5). Calling a backache an “injury” is akin to calling angina “stair climber’s chest.”  Furthermore, it has been clear for decades, that for many a worker the complaint of a regional “back injury” is surrogate for “My back hurts but I can’t cope with this episode.” The latter narrative could suggest a range of solutions (6). But for the past 85 years a worker’s back pain has been considered a compensable injury sending far too many into a vortex of disability determination (7).
The Disabled, the Disallowed, the Disaffected, and the Disavowed (8)

All this is entrenched in governmental policy, labor-management agreements, and the public mind. All this has generated bureaucracies, professions, indemnity schemes, and political agendas that have gained wide acceptance and a life of their own. All this has become an important cost of doing business, so important that primary prevention is a priority. Despite expending fortunes on wellness programs and ergonomic ingenuity, little has been accomplished to spare the worker the illness of work incapacity. To the contrary, workers with the illness of work incapacity abound and many have been harmed by the recourse they are offered.  Too often they find themselves in a Kafkaesque gantlet: the work-relatedness of their injury is contested, they are blamed for therapeutic failures, and the magnitude of their work incapacity is discounted. This is a gantlet that converts the illness of work incapacity into a pervasive, recalcitrant morbid state in a milieu structured to blame the victim (9). The result is a life course that is colored by persistent illness, meager income and disenfranchisement and that leads to death before their time (10).

Much of 20th Century social legislation leaves a proud legacy. Recognizing the plight of the worker with the illness of work incapacity is an example. However, while the remedy foisted on society a century ago was expedient and seemed sensible at the time, it is ineffective if not iatrogenic for the 21st C. Furthermore, it is anchored by the entropy of its familiarity, political influence, and the enormous transfer of wealth it drives. As many have learned the hard way, substantive reform is not possible. It must be supplanted by an approach that takes advantage of the precedent object lessons.

That conclusion will seem counterintuitive to many, fatuous to some. After all, it is a reproach not just to one of the pillars of modern society but to minions employed to push the pillar upright. This brief, solicited editorial presents only an outline of the basis for my conclusion. For references, I chose articles that mark its evolution. However, the conclusion grows out of 45 years of my scholarship and my close review of the scholarship of many others. I have written 7 books since 2004, each considering the literature that relates to many aspects of the illness of work incapacity. These volumes are more than systematic reviews, they are exercises in hermeneutics. The Last Well Person is a treatise on medicalization written for a broad audience (McGill MQUP, 2004). The 3rd Edition of Occupational Musculoskeletal Disorders (LWW, 2005) was written with the involved professional disciplines in mind. The next 5 are published by UNC Press (11). Stabbed in the Back details the arguments in this editorial.

The most recent, By the Bedside of the Patient, includes a discussion of a rational indemnity scheme that could well supplant the Prussian precedents. It is a scheme that has been 25 years in development. It is a defined contribution scheme that covers what is now called health, compensation, disability and life insurance in a single benefits instrument. It is designed so that the premium will be less per capita than the average cost of health insurance alone for OECD members. Interventions that have been demonstrated to offer no clinically meaningful efficacy need not be covered. It is fiduciary and sufficiently cost-effective that a goodly percentage of the premium will be returned to employees to purchase ancillary health insurance policies that serve personal circumstances. And it is designed to revolve around the patient-physician dialogue.

Lewis Carroll’s Alice could believe in 6 impossible things before breakfast. I’ll settle for just one, before it’s too late.
References

1. Beck H. The Origins of the Authoritarian Welfare State in Prussia. Ann Arbor: The University of Michigan Press, 1995.
2. Hadler NM. The disabling backache. An international perspective. Spine 1995; 20:640-9.
3. Grigg J. Lloyd George. The people’s champion. London: Eyre Methuen, 1978.
4. Hadler NM.  Regional back pain.  N Engl J Med 1986; 315:1090-2.
5. Hadler NM, Tait RC, Chibnall JT. Back pain in the workplace. JAMA 2007; 297:1594-6.
6. Hadler NM. The injured worker and the internist. Annals Intern Med 1994; 120:163-4.
7. Hadler NM. Workers with disabling back pain. N Engl J Med 1997; 337: 341-3.
8. Hadler NM. The disabled, the disallowed, the disaffected and the disavowed. J Occp Environ Med 1996; 38:247-51.
9. Hadler NM. If you have to prove you are ill, you can’t get well. Spine 1996; 21:2397-400.
10. Marmot M. The Status Syndrome. New York: Henry Holt, 2004
11. Hadler NM. http://uncpress.unc.edu/browse/author_page?title_id=3262