1 Rapid growth economies

One such force is global economic development. Rapid economic growth has shifted from high income countries like the United States and Germany to middle income countries (MIC) such as China, India and South Africa.^{4, 5} This has caused major changes in the market focus for global and domestic corporations including the sizes and locations of their operations in these MIC countries. Rapid growth MIC countries present complicated admixtures of low income country (e.g. Chad, Cambodia and Bangladesh) and high income country health, environmental and safety challenges. For example, MIC countries share many of the following health problems with low income countries: poor access to basic medical care and essential drugs, effective communicable disease control, adequacy of essential public health services related to water, hygiene, sanitation, maternal and child health, unsafe sex and indoor smoke from solid fuels. Problems of high income countries are now also beginning to appear in MIC income countries. These often include violence, tobacco, alcohol and substance abuse, behavioral health, noncommunicable diseases and environmental contamination from toxic discharges. A decade ago, occupational and environmental professionals in a limited number of industries such as textile, energy and petrochemicals were challenged by occupational and public health threats in low and middle income countries. Today these are priorities for occupational and environmental medicine professionals in all major industries ranging from agriculture and construction to information technology and telecommunications since all are present in middle income country markets.

2 Urbanization

Changes in the distribution of the world’s population between rural and urban are also causing major disruptions in society and in health, creating additional opportunities for value from occupational and environmental medicine services. Urbanization is reshaping societies worldwide. Today more than half the world’s population lives in cities, and each week approximately 1.5 million more people are added to the urban population.⁶ It is projected that between 2011 and 2050 the global urban population will grow from 52% to 67% of the world’s population. This massive urban growth will be driven primarily from increases in less developed regions (from 47% to 64%) than from increases in the developed world (78% to 86%).⁷ Urbanization is advantageous for economic development by increasing paid labor opportunities and by concentrating people for more efficient services delivery such as education, health care and transportation. Often, however, poor urban planning, limited resources, corruption and other factors create urban conditions for slums, air pollution and excessive noise, poor built environments (e.g. walkability), low nutritional value food sources, violence and crime, drug trafficking and sexual exploitation and disease transmission.⁸ These urbanization hazards can impede economic development in cities and produce major adverse impacts on the health, productivity and costs of employed populations. Examples of such impacts include absenteeism, presenteeism, reduced flexibility due to transport or public safety, density related communicable disease transmission or rates of high cost chronic conditions such as HIV, hypertension, diabetes and depression.

3 Noncommunicable diseases

Noncommunicable diseases are adversely impacting economies, governments and the private sector. These conditions are challenging existing systems and structures for health care delivery, wellness and care management as well as economic development.⁹ Noncommunicable diseases accounted for 63% of global mortality in 2008 affecting 36 million individuals of which 25% or 9 million were in the working ages under 60 years old.¹⁰ Noncommunicable diseases cause 86% of healthy years of life lost in high income countries, 65% in middle income countries and 35% in low income countries due to its impact on premature death and disability (DALY –disability adjusted life years).¹¹ While DALY from noncommunicable diseases will grow only 2.3% in high income countries between 2008 and 2030, it will increase during this period by 17% in middle income countries and 49% in low income countries.¹¹

The cost of noncommunicable diseases is staggering. In the United States, noncommunicable diseases account for more than three quarters of all national health expenditures which are expected to increase from 17.8% of gross domestic product GDP (USD$2.76trillion)in2013to19.6$4.53 trillion) by 2021.¹² Annual executive survey data in the private sector reveal that half of executive leaders perceive noncommunicable diseases as a direct threat to their bottom line in the next five years and a bigger business threat than communicable diseases including HIV/AIDs, tuberculosis and malaria.⁸

Noncommunicable diseases are known to be related to addressable risk factors including tobacco use, physical inactivity, low nutritional diets, obesity, excess alcohol consumption, and exposure to environmental pollution. Many of these risk factors and others have been shown in two landmark occupational and environmental medicine studies to account for 22% to 25% of total health care expenditures in the companies studied.^{13, 14} Currently, occupational and environmental medicine workforce strategies to mitigate these noncommunicable diseases risks are employee-focused programs and services. While this approach can be cost beneficial when high quality wellness and health promotion interventions are delivered, the long term maintenance of healthy behavior, improved health status and cost control are unknown with this approach alone.¹⁵ The challenge of durable risk modification is related to the determinants of risk for noncommunicable diseases which are outcomes of complex interactions involving people in socio-environmental systems of which the workplace is only one subsystem. Education, food sources, housing, the built environment, social networks and families, the media and other subsystems interact continuously to influence healthy or unhealthy behaviors. Noncommunicable diseases challenge occupational and environmental medicine to redesign strategies for prevention and care management around communities in order to help impact the root determinants of risk.

4 Health care delivery system transformation

Health care delivery system crises of cost, access, equity and quality are causing significant changes in the organization, technology, financing and delivery of care. This transformation will affect occupational and environmental medicine strategies for healthy workforces as well as occupational and environmental medicine skills and job functions. In the United States, changes to the organization of health services are well underway to shift from episodic fragmented medical care to comprehensive and coordinated care with outcomes based payment. “Medical homes” for primary care and “accountable care organizations” (ACO) are two examples of current initiatives to accomplish this shift. In primary care “medical homes”, physician led teams are organized to provide enhanced access, comprehensiveness, coordination and person- centered care.¹⁶ ACOs are organizations of integrated health care providers (including primary care, specialist, and facilities) which receive specified payments with performance objectives and assume all health care and financial responsibilities for their patient populations.¹⁷ These concepts of a single accountable locus for comprehensive care suggest that occupational health, wellness, fitness for duty and work accommodation services will need to coordinate with or be integrated into these models. This change may be accelerated by the pursuit of employers for greater cost efficiency by having one provider for all health-related services. Occupational and environmental physicians will be challenged by the need to engage these new models of care in productive ways, including supporting these new systems of care with an appropriate level of occupational and environmental health competency.¹⁸

Middle and low income countries are also undergoing health systems transformations to improve health equity, cost efficiency and service delivery. Primary care is a key delivery system priority in these countries and is increasingly being viewed as the means for providing basic occupational health services which are generally unavailable to large proportions of working populations.¹⁹ Training for community health workers, medical technicians, nurses and general practitioners are major challenges for occupational and environmental medicine in these countries. New models of service delivery which extend the reach of available resources and creative uses of mobile and other low cost technologies for health are required to address these occupational and environmental medicine needs.

5 Retail and on-site clinics

Retail and on-site medical clinics are proliferating in the United States and are additional sources of care delivery system changes which will impact occupational and environmental medicine service models. Retail clinics located in pharmacies, large grocery stores and other retailers grew from approximately 250 in 2006 to over 1400 in 2013, and are projected to grow to 4000 by 2015.²⁰ These clinics began as sources of simple, protocol driven non-urgent care such as vaccinations and upper respiratory infections, but are expanding to include wellness, care management and an array of primary care and other medical services for employers such as fitness for duty and periodic examinations. This trend is being fueled by employer needs to control health care costs and improve worker productivity.²¹

There are few comprehensive data on the number of on-site clinics, but one survey of 72 companies by World At Work reported that 25% of respondents representing more than a dozen industries had on-site clinics.²² In a separate larger survey of on-site clinics 66% offered occupational health services, 56% performed ergonomic assessments and 55% performed United States Occupational Safety and Health Administration required testing. ²¹ Occupational and environmental medicine services are only partially integrated into on-site clinics today but the potential exists for this to accelerate. Most on site clinics are third party vendor arrangements which offer flexibility to employers for scaling up or down without incurring costs of adding or reducing employees. These outsourced clinics have the potential for integration of routine health, safety and environmental services, which are often outsourced to environmental or site services companies.

How to move upstream

Moving upstream requires extending the systems approach which has been applied successfully inside the workplace to the broader ecosystem in which workers live and interact. Participation and leadership are needed in the development of strategies and interventions directed at shared pathways that impact social, environmental and physical conditions in communities. New analytic methods and use of new forms and varieties of data will be essential to identify with greater confidence and precision where the best opportunities exist for intervention and what the next best choice for action is at given points in time.

We need to create the same strong and effective partnerships with multi-sectoral leaders and communities that we have for safety and health at work with management, government, workers, unions and suppliers. Forging and sustaining these complicated partnerships, however, will be significantly more challenging. Unlike partnerships created in the pursuit of healthy workplaces and safe products, community public private partnerships involve relatively autonomous parties, the need for compromise in strategies and tactics, demanding leadership and governance requirements, and challenging liability, funding and other requirements. But these challenges can be overcome when motivated by shared significant hardship and when objectives are aligned, communication and accountability are clear and collaborative ways of working are established.³⁰ Effective community public private partnerships have addressed various community wide needs ranging from infrastructure development to natural disasters, terrorism preparedness, infectious disease pandemics, and deaths from motor vehicle accidents.^{31, 32}

Employers have been deeply engaged historically in community improvement and crisis preparedness and are now increasingly becoming active participants in community health and environmental improvement partnerships. An early example is the Mid-America Coalition on Health Care (MACHC) in the Kansas City/Missouri area.³³ It began as an employer coalition focused on health care costs and outcomes of employees and their families, and has since expanded to include diverse health stakeholders and broader initiatives in depression, cardiovascular disease, nutrition, fitness and tobacco. Other partnerships have pursued a range of community health priorities ranging from water fluoridation and oral health to obesity, walkable communities, schools, chronic diseases and access to primary care and medical homes.³⁴

Community partnerships

The role of social determinants in the health of populations including workers has been recognized for many years in the public health community,^{29, 35} but sustained and effective multi-sectoral partnerships for addressing these have been limited. However, the threat to national economies and economic development from health care cost, equity and access issues has garnered the attention of government and private sector leaders in an unprecedented fashion.³⁶ Government and private sector leaders now recognize that noncommunicable diseases including cardiovascular, respiratory, cancer, diabetes and injuries are driving health care cost increases and disease burdens, are rooted in interactions among multiple sectors, and require community-based approaches for mitigating these impacts. Examples of such initiatives include the Million Hearts campaign sponsored by the US Department of Health and Human Services, the City of Philadelphia’s campaign to reduce smoking and childhood obesity, and the Ripple Foundation’s new ReThink Health initiative.

The Million Hearts Campaign (MHC) involves extensive public private partnerships to improve health care delivery system performance related to improved aspirin use, blood pressure control, cholesterol disorders control, and smoking reduction (“ABCS”).³⁷ The campaign targets health care providers and outpatient health care facilities and uses reporting, measurements and communication to promote engagement and change. Health insurers, pharmacy chains and health care delivery systems are prominent employer partners in the campaign.

The “Get Healthy Philly” initiative of the City of Philadelphia is a multi-sectoral initiative designed to reduce smoking, increase physical activity, improve nutritious food consumption and reduce rates of childhood obesity. Extensive collaboration is occurring in this initiative between diverse community sectors including the business community, city government agencies, community groups, health care payers and providers, the school system and the media. Targets for improving the healthiness of the community in support of easy, healthy behaviors include: changes to the physical environment (walkability, bike ability, parks and recreation), school nutrition, retail food outlet stocks of fruits and vegetables, restaurant industry and food preparation and tobacco control policies.³⁸

The Ripple Foundation’s mission is to bring innovation and systems thinking to major challenges in health and its main initiative is ReThink Health.³⁹ ReThink Health supports multi-sectoral collaboration strengthening leadership and the use of evidence-based approaches to stewardship of community resources along with training and tools for using systems science and taking action. In 2011, it began the Healthy Columbia, South Carolina campaign in zip code 29203 to improve access to primary care, reduce emergency department visits and improve the health of the population. This region is characterized by high rates of uninsurance, hypertension, over weight and diabetes and high rates of emergency department visits. The initiative has recruited strong participation and leadership from health care providers, private sector insurers and employers, the City of Columbia, South Carolina, the South Carolina Health Department and Environmental Control, faith-based and other community organizations. Early priorities have included successfully recruiting and training leaders, engaging community members and initiating work to develop community-based wellness activities, health literacy interventions and planning for improving access to primary care.

Sources of Funding: None

Other Sources of Support: None