New York State Occupational Health Clinic Network Report 1988 - 2003
Since 1988, the New York State Occupational Health Clinic Network (OHCN) has contributed to maintaining a healthy workforce in New York State. Utilizing a public health approach, the eight regionally-based clinics in the Network have diagnosed and treated occupational diseases and helped improve the working environments in New York. The work of these Clinics has extended to entire communities by providing education and training tools to workers, employers and medical care providers. The Clinic Network has also contributed to occupational medicine by publishing in peerreviewed journals, developing clinical practice reviews for occupational illnesses, and defining new examples of work-related diseases.
The Clinics employ multidisciplinary teams of physicians, nurses, industrial hygienists, health educators and social workers trained in occupational health to perform a variety of prevention activities as well as provide clinical services. Staff are able to provide diagnosis and basic treatment for the full range of occupational diseases, evaluate the work conditions of the patients to determine whether other co-workers are at risk and suggest measures and make recommendations to improve the workplace environment. The Clinics are open to anyone in NYS with a potential work-related illness. A sliding fee scale assures access for those without health insurance. Receiving funding from NYS allows Clinic staff to spend more time with each of their patients than typical health care facilities. Patients are seen primarily for work-related conditions, but are also seen for environmental exposures. The Clinics offer screening services for groups of exposed workers.
The Clinics are located throughout the state in order to meet specific regional needs. One clinic is specifically designated to provide services in the area of agricultural safety and health. While occupational medicine practice is generally similar through all regions of the United States, integration of practice with specific local needs is desirable. Therefore, each Clinic maintains a local advisory committee which is used to reach into its own community and raise awareness of its services and learn more about local needs. Each Clinic also focuses on the high-risk industries and occupations within its area. The Clinic Network works together to meet the general needs of New York workers.
The Clinics have developed nine clinical practice reviews, which were published in the January 2000 issue of the American Journal of Industrial Medicine.1 These were designed to assist clinicians in the diagnosis, treatment and prevention of the following occupational conditions: asbestos-related diseases, work-related asthma, workrelated upper extremity disorders, carpal tunnel syndrome, low back disorders, lead poisoning, noise-induced hearing loss, and solvent-related disorders. A guide for respirator clearance examinations was also developed. The reviews integrate public health approaches (primary, secondary and tertiary disease prevention) into the clinical model by emphasizing a team approach to the diagnosis and treatment of occupational diseases. These clinical practice reviews were utilized by the OHCN as a tool to guide clinical practice and to foster quality of care and consistent practice. A quality assurance/quality improvement (QA/QI) program was developed and implemented to evaluate the level and consistency of care provided in the diagnosis of each of those conditions chosen for the clinical practice reviews. The QA/QI process also enables the Network to evaluate the quality and consistency of case management and the degree to which prevention is integrated into the Clinics' practices.
The World Trade Center (WTC) disaster on September 11, 2001 provided a number of significant public health challenges. The Clinics worked closely with local, state and federal governmental agencies, as well as with employers and unions to assist in providing a coherent public response. The Clinics helped obtain and/or interpret environmental and occupational samples to evaluate the physical, chemical and psychological risks posed by the disaster and its cleanup. They assisted in providing medical certification and fit-testing for respirator use. The Clinics were also part of a nationwide consortium of providers, led by Mount Sinai in NYC, funded by the CDC's National Institute for Occupational Safety and Health (NIOSH) and private philanthropic funding that developed, coordinated and provided medical evaluation, monitoring and treatment services for WTC responders. This program continues to provide free, standardized medical assessments, clinical referrals, and occupational health education for workers and volunteers exposed to hazards during the WTC rescue and recovery effort.
This report includes more than 100 figures and tables describing the patient population seen by the New York State OHCN from its inception in 1988 through 2003. Overall, there were 47,210 patients seen in 115,406 visits. In 2003, the Clinics conducted 127 industrial hygiene site visits, and reached out to a minimum of 35,437 people at educational events and meetings.
- Patients were seen from all but one county in New York State with large percentages residing in counties with large metropolitan areas such as New York City, Albany, Erie, Monroe and Onondaga counties.
- Among those patients seen for occupational exposures, 23% were employed in the services industry, and 22% were employed in construction with another 22% employed in public administration.
The primary diagnoses for both males and females were diseases of the respiratory system, nervous system and musculoskeletal system.
- Almost one-third of the work-related non-WTC respiratory system disease diagnoses were classified as pneumoconioses, including asbestosis.
- Other respiratory diagnoses included conditions due to chemical fumes and vapors and work-related asthma.
- World Trade Center-related respiratory system disease diagnoses included chronic pharyngitis, sinusitis and asthma.
- Diseases of the nervous system included carpal tunnel syndrome, noise-induced hearing loss, and cubital tunnel syndrome.
- Half of the nervous system diagnoses among males were noise-induced hearing loss.
- Over half of the nervous system diagnoses among females were carpal tunnel syndrome.
- There has been a steady increase in the number of diagnoses and patient visits for musculoskeletal conditions.
- 28% of the diagnoses of musculoskeletal diseases worked in administrative support occupations, while 26% worked in executive and professional specialty occupations.
- The majority of the diagnoses were disorders of the cervical region and other disorders of the back.
- More than a third of the diagnoses were due to repetitive stress injuries.
Patients seen by the NYS OHCN are evaluated to determine not only the medical diagnosis, but also the likely etiologic agents responsible for causing or exacerbating the disease. Appropriate identification of an etiologic agent can sometimes improve the treatment and management of a disease. More importantly, identification of workplace hazards can also be used to prevent occupational diseases through training and education of workers and companies; along with establishing effective workplace intervention programs.
- Almost a quarter of the exposures were to mineral and inorganic dusts which includes asbestos, silica and non-specified dusts.
- Diagnoses due to these exposures included pleural thickening due to asbestos, asbestosis, asthma, chronic obstructive pulmonary disease, and chronic bronchitis.
- Among those patients with World Trade Center dust exposures, diagnoses included chronic pharyngitis, chronic sinusitis, and asthma.
- Patients exposed to mineral and inorganic dusts worked primarily in the construction industry, followed closely by the services industry.
- Another quarter of the exposures were to ergonomic factors.
- 66% were repetitive motion including keyboard use, 8% were stress, and 6%were lifting.
- Exposures to repetitive motion were primarily associated with diagnoses of carpal tunnel syndrome, tenosynovitis of the hand or wrist, lateral or medial epicondylitis, and cubital tunnel syndrome.
Industries and Occupations
The patients seen for occupational exposures by the Clinics were employed primarily in services, construction and public administration industries.
- The principal service occupations included cleaning and building services, and protective services (primarily firefighting and fire prevention).
- Almost half of these patients were seen as part of group screenings due to potential exposures.
- Diseases diagnosed among the patients working in the services industry were primarily diseases of respiratory system including asthma, chronic pharyngitis and sinusitis, asbestosis, and pleural thickening due to asbestos. A large percent of these patients were also diagnosed with diseases of the musculoskeletal system.
- Exposures among patients working in the service industry included mineral and inorganic dusts, primarily asbestos exposure; and ergonomic factors, primarily repetitive motion.
- Among patients working in construction, 57% of the patients were seen as part of group screenings.
- Diagnoses were primarily respiratory diseases including pleural thickening due to asbestos, asbestosis and asthma, and lead poisoning.
- Almost half of the patients employed in the public administration industry were seen as part of group screenings; 27% were for exposures to microorganisms, 23% were screened for exposures to miscellaneous inorganic compounds, and 21% were screened for exposures to combustion products, fumes and smoke inhalation.
- The primary diagnosis among this group was diseases of the respiratory system of which 47% were among patients involved with the World Trade Center rescue and recovery.
- Patients were also diagnosed with diseases of the musculoskeletal system and diseases of the nervous system, including noise-induced hearing loss.
New York State Workforce
The patients seen by the NYS OHCN represent a unique subset of the NYS working population. It is important to be familiar with the current and expected future characteristics of NY workers in order to identify future directions for the Clinic Network.
- In 2003, New York State (NYS) had over 8,726,000 full-time employees - with approximately 3.4 million in NYC and 5.4 million in NYS outside of New York City (NYC).
- Women make up about 47% of the workforce in NYS. Women in NYS are primarily employed in administrative support occupations (22.6%), professional specialties (20.9%), and service occupations (21.4%).
- The largest Hispanic population in the nation resides in NYC where there are more than 1.1 million Hispanic workers. Compared to Whites in NYS, Hispanic workers in NYS account for a disproportionate percentage of those working in occupations in the services, machine operators, and laborers.
- Approximately 15% of the NYS workforce is Black, compared to 11% nationally. This percentage varies substantially between NYC where approximately 26% of the workforce is Black, compared to the remainder of NYS where only 8% of the workforce is Black. In NYS, Blacks work primarily in services occupations and in administrative support.
- 60% of those aged 55 to 64 are in the labor force, and 14% of those aged 65 years and older are working. On average, over 10,000 workers 55 to 64 years old and over 1,400 workers 65 years and older in NYS are reported with a work-related injury or illness. The hazards encountered by older workers are similar to those faced when they were younger; however, the injuries experienced are often more severe and require longer recovery times.
- Young workers are believed to be at increased risk of occupational injury due to limited job knowledge, training and skills. It is estimated that between 70 to 80 percent of teens have worked for pay at some time during high school.
- In 2004, there were 4,009,000 workers in NYS paid hourly rates, of which 128,000 were paid below minimum wage of $5.15 per hour. Over three-fourths of minimum wage workers were in service occupations - primarily food preparation and serving (59%) and personal care (8%).
- The Clinic Network screens patients with high-risk exposures. Lead, asbestos and physical/ergonomic work factors continue to be important exposures of concern.
- The aging population will result in a need for workers to care for them including nurses and home health aides.
- There is an expected increase in international immigration which will increase the racial and ethnic diversity of the NYS workforce.
Challenges and Recommendations
Since the establishment of the NYS OHCN, the nature of workplace hazards has changed rather significantly. There remains a pressing public health need to diagnose, treat and prevent work-related illness. There is still a profound shortage of trained occupational medicine practitioners. Few other practitioners provide comprehensive preventive services; thus the NYS OHCN remains uniquely qualified to provide this care. Analysis of the data provided by the Clinics, as described in the report, reveals specific areas upon which Clinics may want to focus in the future.
Flat funding of the NYS OHCN since 1997 has inhibited the ability of the Clinics to continue to address their mission due to rising costs and newly emerging occupational health needs. Satellite Clinics that were started have had to close, thus limiting access to the Clinics. Hours have been cut, staff has been reduced, and services such as physical, occupational and medical massage therapy have been cut. New initiatives have had to be cancelled and the Clinics have had to reduce the number of patients seen in order to identify other funding sources. The patient load on the Clinics continues to increase, but many Clinics have found it difficult to offer both continued care to their existing patient population and to identify and assist new patients.
- The Clinics should ensure that they continue their focus on the diagnosis of occupational disease.
- The Clinics should continue to be able to identify new associations between workplace exposures and diseases.
- Clinics need to plan accordingly to handle the patient load expected due to repetitive stress disorders.
- The Clinics should continue to screen for co-morbid conditions, such as diabetes, hypertension and hypercholesterolemia, during patient visits.
- Mechanisms need to remain in place to assist the patients and their families with psychological and sociological issues.
Prevention ServicesWorkforce Issues
- Further focus needs to be placed upon low-income and immigrant populations.
- Efforts should continue to reach high-risk female workers, particularly those of Hispanic and Black ethnicities, and those of low-income.
- Outreach should be conducted to aging workers providing prevention information.
- Education regarding physical and ergonomic factors and avoidance of needlestick injuries should be offered, particularly to low-income workers in the medical fields.
- The Clinics need to continue to screen high-risk workers for toxic effects of lead exposure.
- Screenings for asbestos-related diseases should continue.
- Clinics encountering patients who reside in NYC should consider conducting audiometric exams for high-risk populations.
- Clinics should consider conducting audiometric exams among their female populations.
- Clinics need to offer screenings, prophylaxis, education, and/or treatment to people who work outdoors for insect-borne diseases.
- Skin cancer screenings should be included in the list of services provided to workers who spend long periods in the sun.
- The Clinics should utilize research being conducted regarding health condition associated with World Trade Center disaster-related exposure to assist in treating and managing patients with WTC disaster-related exposures.
The continuing occupational health challenges speak to the need for the network to expand its outreach efforts to raise the level of awareness about the prevalence, cost, and preventable human suffering which result from occupationally-related disease. There needs to be enhanced collaboration between the Clinics, to allow them to utilize their individual skills to address larger occupational health issues. Materials developed for select populations should be available to all network members, as should translations for immigrant populations.<Research
Balance needs to be maintained between the primary clinical missions and the benefits to occupational disease prevention to be obtained through research. Each Clinic should be involved in internal evaluation identifying effective non-medical interventions and worker training methods to accomplish prevention goals.<Supply of Occupational Health Professionals in NYS
In order to strengthen and expand training programs in occupational health, the Clinics should work on integrating occupational medicine into mainstream medical care. Awareness of the NYS OHCN should be increased through fellowships and residencies with as many medical centers as possible.
This report was prepared for publication by the staff of the New York State Department of Health, Center of Environmental Health, Division of Environmental Health Assessment, Bureau of Occupational Health.
This report was prepared by:
- Kitty H. Gelberg, Ph.D., M.P.H.
- Alicia M. Fletcher, M.P.H.
- Rebecca L. Hoen, M.S.
Generous contributions are acknowledged from:
- John P. Sestito, J.D., M.S., from the National Institute for Occupational Safety and Health (NIOSH), for his editorial review and assistance, and his on-going encouragement.
- Susan Dorward, Dianna Cook and David Sternburg for development of the Occupational Health Network Information System database.
- Susan Brown for technical web assistance.
- Chelsea Valente for assistance in document formatting.
We would also like to thank the staff of the NYS Occupational Health Clinic Network for their contributions to this report:
- Occupational & Environmental Health Center of Eastern New York (OEHC)
Medical Director: Dr. Jean McMahon
- Union Occupational Health Center (UOHC)
Medical Director: Dr. Michael Rosenburg
- New York Center for Agricultural Medicine and Health (NYCAMH)
Medical Director: Dr. Jay May
- Long Island Occupational and Environmental Health Center (LIOEHC)
Medical Director: Dr. Linda Cocchiarella
- Bellevue/NYU Occupational and Environmental Medicine Clinic (BNYUOEMC)
Medical Director: Dr. George Friedman-Jimenez
- Mount Sinai - I.J. Selikoff Center for Occupational and Environmental Medicine (COEM)
Medical Director: Dr. Stephen Levin
Medical Co-Director: Dr. Robin Herbert
Deputy Medical Director: Dr. Jaime Szeinuk
- Finger Lakes Occupational Health Services (FLOHS)
Medical Director: Dr. William Beckett
- Central New York Occupational Health Clinical Center (CNYOHCC)
Medical Director: Dr. Michael Lax