ARTICLES AND REVIEWS

Global Occupational Health: Current Challengesand the Need for Urgent ActionRoberto G. Lucchini and Leslie London

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ABSTRACT

Background: Global occupational health and safety (OHS) is strictly linked to the dynamics of economic globalization. As theglobal market is increasing, the gap between developed and underdeveloped countries, occupational diseases, and injuries affect avast number of workers worldwide. Global OHS issues also become local in developed countries due to many factors, includinguntrained migrant workers in the informal sector, construction, and agriculture.

Objective: To identify the current status and challenges of global occupational health and safety and the needs for preventive action.

Findings: Absence of OHS infrastructure amplifies the devastating consequences of infectious outbreaks like the Ebolapandemic and tuberculosis. Interventions in global OHS are urgently needed at various levels:

1. Increased governmental funding is needed for international organizations like the World Health Organization and the In-ternational Labor Organization to face the increasing demand for policies, guidance, and training.

2. Regulations to ban and control dangerous products are needed to avoid the transfer of hazardous production to developingcountries.

3. The OHS community must address global OHS issues through advocacy, position papers, public statements, technical andethical guidelines, and by encouraging access of OHS professionals from the developing countries to leadership positions inprofessional and academic societies.

4. Research, education, and training of OHS professionals, workers, unions and employers are needed to address global OHSissues and their local impact.

5. Consumers also can influence significantly the adoption of OHS practices by demanding the protection of workers who areproducing he goods that are sold in the global market.

Conclusions: Following the equation of maximized profits prompted by the inhibition of OHS is an old practice that hasproven to cause significant costs to societies in the developed world. It is now an urgent priority to stop this process and promotea harmonized global market where the health of workers is guaranteed in the global perspective.

Key Words: ethics, globalization, inequality, occupational health, social and global impact

� 2014 Icahn School of Medicine at Mount Sinai. Annals of Global Health 2014;80:251-256

WHAT IS GLOBAL OCCUPATIONALHEALTH?

If global health entails a wider approach of public health atthe international level, occupational global health focuseson prevention of illnesses and injuries in the workplaceunder a worldwide perspective. The global implications of

14-9996/ª 2014 Icahn School of Medicine at Mount Sinai

m the Icahn School of Medicine at Mount Sinai, New York, NY andiversity of Brescia, Brescia, Italy (RGL); Center for Environmental andcupational Health Research, University of Cape Town, Cape Town,uth Africa (LL). Address correspondence to R.G.L.; e-mail: roberto.chini@mssm.edu

e authors declare they have no conflicts of interest.

tp://dx.doi.org/10.1016/j.aogh.2014.09.006

occupational health and safety (OHS) are directly related tothe internationalized dynamics of the global economy.Given the tight connection of global occupational healthwith global economics, multidisciplinary expertise is neededto understand the links between economic developmentand the potential effects on the health and safety of workers.The theme of global occupational health also is promptingdiscussion on the new directions for research, advocacy, andcapacity building to prevent andmanage health and safety inworkplace settings worldwide.1

Globalization, understood as the removal of barriersthat prevent growth of trade and cross-border invest-ment, is typically considered a positive transformation ofmodern times. The Cato Institute is a “policy researchorganization dedicated to the principles of individualliberty, limited government, and free markets” that be-lieves in globalization: “There are at least three

252 Gl o b a l Oc cu p a t i o n a l H ea l t h

fundamental blessings of globalization on nations thatembrace it: faster economic growth, reductions inpoverty, and more fertile soil for democracy.”2 In reality,globalization is not an entirely even phenomenon anddoes not necessarily promote growth and wealth at theglobal scale. A rigorous analysis of income and wealthdistribution in more than 20 countries over the past 2centuries has shown mounting inequality and anincreasing gap between developed and developingeconomies that seem inevitable without major policychanges.3 Globalization has promoted the introductionof market systems in many countries with the weakestcapacities to create and enforce a regulatory system toprotect workers and consumers.

This has resulted in the appearance of existinghazards in new forms. For example, market liberalizationof pesticide distribution under structural adjustmentprograms in Tanzania led to an 80-fold proliferation ofpesticide retailers,4 accompanied by sale of decanted andunregistered pesticides5 as well as the involvement ofchildren in the sale of pesticides.6 Globalization also hascreated new types of hazards, like the explosion of e-wastein China, Ghana, and other developing countriesreceiving electronic detritus from more developed coun-tries, creating huge risks to populations scavenging offuncontrolled waste dumps.7,8

Economists generally assume thatOHS is a later step inthe sequence of development and should normally be un-dertaken once the economy is strong enough to absorb theadditional expenses required by preventive action. Rapidindustrialization is thought to require investment in pro-duction first and that, only once wealth is created, can it beinvested in social goods such as improved health, workerprotection, and protection of the environment. Therefore,these social goods are generally considered to be amenities,satisfying but not essential.9 This acceptance of health risksin the name of industrialization has catastrophic implica-tions, not only for the developing countries but also globally.Many multinational corporations interpret globalizationmore as an opportunity to take advantage of free-tradeliberalization, low-wage labor, and removal of protectiveregulations for workers’ health and the environment, ratherthan a contribution to improve health and wealth of the lessdeveloped parts of the globe. In fact, rather than an op-portunity to harmonize health and safety standards upward,4

globalization risks becoming a “race to the bottom.”10

Current Challenges in GlobalOccupational HealthOccupational health and safety should have higher priorityon the international agenda, but improvement of OHSinfrastructures and systematic preventive approaches inindustrializing countries are extremely slow. Althoughmany countries have developed laws and enforcement ac-tivities, working conditions for the majority of the world’sworkers do not meet the minimum standards and guide-lines set by the World Health Organization (WHO) and

the International Labor Organization (ILO).11 Until now,only 24 countries have ratified the ILO Employment InjuryBenefits Convention (No. 121), adopted in 1964, whichlists occupational diseases for which compensation shouldbe paid and only 31 have ratified the Convention onOccupational Health Services (No. 161). The adoption ofthese conventions should be the first step toward theimplementation of anOHS system. OSH regulations coveronly about 10% of the population in developing countries.These laws omit many major hazardous sectors like agri-cultural and domestic work, typically not considered “in-dustries.” The informal sectors typically include moresensitive subpopulations in the workforce like child labor,pregnant women, and the elderly, with limited access tohealth care.

Only 5% to 10% of workers in developing coun-tries and 20% to 50% of those in industrializedcountries have access to adequate occupational healthservices.12 Although in a survey among InternationalCommission on Occupational Health members from47 industrialized and industrializing countries, 70%reported OHS being in place and 80% noted the ex-istence of a national institute for OHS, the estimatedcoverage of workers with OHS services was only18%.13 The WHO and the ILO have elaborated pro-grams to foster the development of internationaloccupational health, but the real effect of this effort isstill not optimal likely due to insufficient funding.12

ILO plays an important role in promoting OHS pol-icies and sets minimum standards in conventionsbased on ethical principles.14 ILO conventions includeNo. 81(labor inspection), No. 155 (occupational safetyand health), No. 161 (occupational health services),No. 170 (chemical safety), and No. 174 (prevention ofmajor industrial accidents). Additionally, the core ILOconventions include freedom of association, child la-bor, forced labor, and discrimination issues, whichprecludes OHS conventions from full budgetary re-sources. Although the ILO is an important referencefor OHS standards, conventions and recommenda-tions require national ratification and the lack of rati-fication and subsequent enforcement undermines theimpact of the conventions. Moreover, some have criti-cized the shift in ILO standards away from specificmeasures with high levels of accountability towardpromoting high-level global labor standards that allowflexibility in application, ostensibly to allow countrieswith different levels of economic development to adaptstandards to their local context. This, in practice, al-lows greater accommodation of management discretionat the workplace.15

The WHO promotes action in global OHS througha network of WHO Collaborating Centers for Occupa-tional Health. The strategy is now defined by the WHOGlobal Plan of Action for Workers’ Health, 2008-2017.16 Reports of the action are given periodically17

regarding the updates of the plan’s objectives:

Anna l s o f G l o b a l Hea l t h 253

1. Definition and implementation of workers healthpolicies.

2. Health protection and promotion in the workplace.3. Improvement of performance and access to OHS

services.4. Communication of evidence for action in practice.5. Incorporation of workers health in other policies like

international trading.

The Global Occupational Health Network newsletteris published on the WHO’s Occupational Health websiteand provides a forum for the implementation of theWHOGlobal Plan of Action forWorkers’Health. (http://www.who.int/occupational_health/publications/newsletter/en/). The effectiveness of the WHO plan at the nationallevel is limited by the inadequate resources that arenecessary to reach a successful level of implementation.

The WHO provides also OHS documentation,mostly accessible online and with detailed recommen-dation and protocols on a variety of issues (www.who.int/occupational_health/publications/en/).

Regardless of these international plans of action andavailability of documentation, OHS remains underde-veloped in the poorest countries that need more directsupport with capacity building and technical assistance,as well as the policy space to pursue less directed andrestricting models of economic development in thecontext of unequal global relations.

Lack of OHS Infrastructure and GlobalConsequencesThe inadequacy of OHS protections in developingcountries is dramatically illustrated in the consequencesof the 2014 outbreak of the Ebola virus, during whichmore than 100 health care workers were infected andmore than half have died, among them Sierra Leone’sleading doctor in the fight against Ebola, Sheik UmarKhan, considered a national hero. The implication of alack of knowledge and functional preventive OHSinfrastructure has enormous implications in these cases,where the shortage of health care workers is already apublic health problem that is further amplified by thedisease and deaths caused by the exposure to biologicalagents. In endemic or at-risk areas like West Africa, OHSshould ideally be well established and ready to handlecritical situations with adequate safety procedures andpersonal protective equipment. Drug-resistant tubercu-losis (TB) is another important biological hazard affectinghealth workers in many parts of the world. With amortality rate comparable to Ebola, this occupationalhazard also has endemic characteristics.18,19 The lack ofan OHS infrastructure in South Africa, one of thecountries with the highest drug-resistant TB burdenglobally, remains a serious challenge for the control ofthe disease, evident in that more than half of the par-ticipants at a provincial workshop in March 2014

reported that they had never conducted a TB infectioncontrol workplace assessment in response to TB cases.20

The health burden of poorly controlled industriali-zation is not limited to communicable diseases. Pro-jections of the incidence of chronic neurodegenerativediseases indicate a dramatic increase in industrializingcountries likely due to environmental exposure over-lapping prolonged aging of the population, resulting inhigher cumulative lifetime exposure.21

What is to be Done about GlobalOccupational Health and SafetyDevelopment?The multiple causes of global OHS inequalities requirecoordinated and multidisciplinary responses that includecapacity development in developing countries, policyinterventions to retain skilled professionals in countriesthat need them most, checks and balances on interna-tional trade, restructuring of trade agreements to priori-tize OHS commitments, and challenging the existingdomination of global economic relations by rich coun-tries acting in the interests of large vested interests. Forexample, the continued promotion of chrysotile asbestosas “safe” by countries with vested industrial interests inthe asbestos industry remains a blot on the integrity ofglobal OHS.22

Insufficient availability of OHS services has anegative connotation not only on a strictly clinicalperspective, in terms of diagnosis and treatment ofwork injuries and disease, but also on awareness ofhealth risk and hazards. A large number of workers donot benefit from any right-to-know entitlements, andare accordingly not properly informed, instructed, andtrained on risk hazards and safety procedures indeveloping countries. The increased mobility ofworkers from the informal sector, as it typically takesplace in most developing countries, amplifies theselimitations even further. Noneducated and poorlytrained supervisors and workers also may carry unsafebehaviors across borders when migrating, especially injob sectors like construction, agriculture, cleaning, andthe restaurant industry. This is one of the reasons whyglobal OHS becomes a local issue for the industrializedcountry, due to the large and constantly increasingnumber of migrant workers.

A number of educational programs for employers,supervisors and workers are available through interna-tional bodies like the ILO, WHO, Pan American HealthOrganization, and Salud, Trabajo y Ambiente. Theavailability of OHS e-learning programs offers increasingopportunities to access good-quality information. TheWorkers’ Health Education program (www.workershealtheducation.org) of the Coronel Institute ofAmsterdam offers a variety of freely available onlineeducational resources, in English and Spanish, anduseful networking facilities.

254 Gl o b a l Oc cu p a t i o n a l H ea l t h

Global TradeThe other reason that global OHS is also a local problemfor developed countries lies in the economic systemslinking high-development countries with those in theglobal South. The wealth of many countries in the Northis built on economic systems whose success is inextri-cably linked to the extraction of production and primaryresources from countries of the South in ways that keepthe costs of labor low in the sending countries. Theprocessed materials are then re-exported to the Southwithin an economic system that provides immense ob-stacles to developing countries seeking to break out of thecycle of poverty and to spend scarce resources on healthand safety measures.

For this reason, there has been intense interest atinternational level in establishing human rights normsfor transnational corporations and other business en-terprises that would ameliorate the worst excesses ofexploitative working conditions in developing countriesand establish a normative framework to guide states andcorporations in the protection of workers’ rights,including rights to health and safety.23 Significantly, theUN Special Rapporteur on Health included in a 2012report a special focus on the right to occupational healthas a component of the right to health recognized in In-ternational Human Rights Law.24 Whether such mea-sures will ultimately provide adequate checks andbalances remains to be seen, but deserves maximumsupport from the international OHS community toprovide a counterbalance to the current situation.

Similarly, there is currently a vigorous discussion ininternational circles on the ethics of internationalmigration of skilled human resources in health withsuggestions that receiving countries should carry anobligation to compensate the developing countries thattrained such professionals and who are losing suchvaluable human capital to countries of the north.25,26 Inthe occupational setting, this problem has not yet arisen,principally because countries of the South are so lackingin skilled OH professionals to the extent they could be“poached” for Northern industrialized countries. How-ever, any policies on capacity development in OHS forthe South would have to seriously consider the long-termsustainability of retaining skilled OHS professionals incountries where they are needed most. Thus, the impli-cations of free trade for OHS are myriad, not just in theproduction process, but also in the global distribution ofhuman resources trained in OHS.

An example of well-intended international policy toprotect occupational health in the South is the GloballyHarmonized System for Chemical Hazard Classificationand Communication (GHS), a standardized system forcharacterizing hazards associated with chemicals acrossthe globe that was adopted by the UN under the auspicesof the Inter-Organization Programme for the Safe Man-agement of Chemicals in 2002. The GHS is intended to

enhance the protection of the people and the environ-ment by providing an internationally comprehensivesystem for hazard communication, including establishinga recognized framework for those countries without anexisting system; reduce the need for duplicative evalua-tion of chemicals for hazards; provide an informationalframework on which countries can base programs for thesound management of chemicals and thereby facilitateinternational trade in chemicals whose hazards havebeen properly assessed.

However, preliminary findings in developing coun-tries have shown that comprehensibility as envisaged bythe GHS is far more complex than imagined, particularlyfor workers with limited education and where trainingprograms are scant, as a result of which, comprehensionof chemical hazards is low and systems to protect workersfrom hazards accordingly flawed.27-29 As a result, theGHS, intended to protect developing country pop-ulations from chemical risks, may inadvertently end updoing the converse, by facilitating trade in chemicals incountries without the systems to regulate chemicalseffectively for safety.30

Ethical Guidelines in Global OHSIn a relative absence of regulatory systems, ethical codesprovide OHS professional with guidance especially indeveloping countries like Africa31 although the process isstill far from being in place on a large scale. OHS pro-fessionals face challenges of dual loyalty in many of theirworkplace settings where the interests of worker-patientsare subjugated to third-party interests in ways thatthreaten to violate the rights of workers.32 This requiresboth high ethical conduct from the professional and alsoinstitutional interventions to protect the independence ofOHS professionals and address systemic factors that giverise to unethical practice. Negotiating reasonable resolu-tion of dual loyalty conflicts in developing countries isrendered difficult by generally weak legal protections forworkers and health professionals, a dominance ofneoliberal thinking in state policy and the preference offoreign direct investment above other social goods. Forthat reason, ethical codes have to take robust positionson maintaining OHS independently and avoiding con-flict of interest.

CONCLUSION: THE NEED FOR RAPIDMAJOR INTERVENTIONS

Occupational health and safety should be an integratedcomponent of social and economic development, both atthe global and country levels. This means that when, forexample, policy reform of health systems is undertaken,inclusion of workplace health and safety should be in-tegral to such measures, such as occurred in Brazil underthe National Health System programs.33 Strong legal

Anna l s o f G l o b a l Hea l t h 255

systems supported by uncorrupted governments, willingto adopt full rights for women, children, and workers,and provide social insurance such as workers’ compen-sation are needed for the success of an OHS program.Academic OHS professionals can advance knowledgeand disseminate training, but for capacity developmentefforts to be truly sustainable, they must be linked towider interventions aimed at achieving more equitablelegal and economic systems that promote the social de-terminants of OHS.

Interventions in global OHS are therefore urgentlyneeded at the following levels:

1. Increased governmental funding is needed for inter-national organizations like the WHO and the ILO toface the increasing demand for policies, guidance, andtraining.

2. Regulations to ban and control dangerous productsare needed to avoid the transfer of hazardous pro-duction to developing countries.

3. The OHS community must address global OHS is-sues through advocacy, position papers, public state-ments, technical and ethical guidelines, and byencouraging access of OHS professionals fromdeveloping countries to leadership positions in pro-fessional and academic societies.

4. Research, education, and training of OHS pro-fessionals, workers, unions, and employers areneeded to address global OHS issues and their localimpact.

5. Consumers also can influence significantly theadoption of OHS practices by demanding the pro-tection of workers who are producing the goods thatare sold in the global market.

A significant component of the textile market is pro-duced by countries like Bangladesh, where a high incidenceof fatal injuries is due to fires caused by insufficient ornonexisting fire protection.34 Sandblasted blue jeans aremarketed from countries where the production of thesegoods causes exposure to silica.35 Consumption of agricul-tural products treated with pesticides implies worker expo-sure in countries with poor OHS standards and preventiveinfrastructures. There aremany examples, the list of which isseemingly endless, as the globalized economy transfers theproduction of global goods to sites where OHS is notimplemented and standards are not enforced. Maximizingprofits where OHS does not exist has proven to cause sig-nificant costs to societies at the global level. It is now anurgent priority to stop this process and promote a harmo-nized global community where the protection of workers isuniversally guaranteed.

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