OCCUPATIONAL HEALTH &PRIMARY HEALTHCAREDr Brian Brink – Chief Medical Officer

HEALTHEffective management of occupational health risks protects our

people, enhances productivity, and helps maintain our licence to

operate and our global reputation.

Promoting a healthy community and a safe and healthy

workforce is beneficial for all of us

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HEALTH STRATEGY

Benchmarking Standards Guidelines Support Assurance

Occupational HygieneLeading indicators

Occupational MedicineLeading and Lagging indicators

Occupational HealthAnglo American Occupational Health Way

Employee Health and WellnessIncluding HIV/AIDS and TB

Families

Communities

GlobalHealth

Health ManagementInformation Systems

OCCUPATIONAL HEALTH

Zero harm to healthCreating and instilling a company culture that protects people from harm and improves their health and well-being

Operational excellenceRealising exceptional operational value by managing health risks and identifying value-creatingopportunities

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KEY OCCUPATIONAL HEALTH CONCEPTS

• Occupational Health is driven by two disciplines – Occupational Hygiene and Occupational Medicine. The two work in tandem through a process of health risk assessment and management.

• Occupational Hygiene is a scientific discipline devoted to the anticipation, recognition, evaluation and control of health hazards in the working environment.

• Occupational Medicine is a branch of clinical medicine concerned with employee fitness for work; medical surveillance of employees; medical emergency management; and management of return to work (rehabilitation and disability).

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HEALTH RISK

Health Risk arises from exposure to a health hazard at a level which can cause harm either in the short or long term.

The level of risk is determined by:– the toxicity (stored energy);– the level of exposure; and – the amount of time over which exposure occurs.

Most health hazards require a certain dose (exposure level X time) before they cause a health effect.

The dose can be delivered fast in high level exposure or slowly (over many years) with low level exposure. In the former there may be acute illness whereas in the latter illness may develop over a long period of time.

This is the basis of the occupational exposure limit (OEL).

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OCCUPATIONAL EXPOSURE LIMITS

The OEL is defined as a level at which nearly all workers can be repeatedly exposed, day after day, over a working lifetime without adverse health effects.

The work day is taken as an 8 hour day and a 40 hour work week, and a working lifetime is typically taken as 40 years.

OELs are constantly being revised downwards as new information on health risk becomes available.

If exposure is constantly above the OEL then an adverse outcome is highly likely over time; the higher the exposure the shorter the time required for the adverse affect to appear.

Since many people are exposed the number of people who will experience an adverse outcome is always large.

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MANAGEMENT OF HAZARD EXPOSURE AND HEALTH RISK

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10% 50% 100%C

Supervision

Do not need active control Verify periodically

Control

Need active control to ensure exposure remains below OEL

Intervention

Need intervention to reduce exposure to below OEL

Extreme exposure

Safety risk

Exposure level relative to OEL

No health effect expected

Health effect unlikely but possible

Health effect will occur

OEL

B A

The level of exposure determines the likelihood of an adverse outcome

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EXAMPLES OF HEALTH HAZARDS IN MINING

Hazard Occupational Exposure Limit (OEL)

Airborne pollutants

Silica dust 0.1 mg/m3

Coal dust 2 mg/m3

Nickel 0.1 mg/m3

Diesel particulates 160 µg/ m3

Sulphur dioxide 2 ppm

Carbon Monoxide 30 ppm

Blasting fumes (NOX) Individual components

Acid mist 0.2 mg/m3

Platinum salts 0.002 mg/m3

Noise 85 dB(A)

Thermal stress Combination of thermal load, workload & time exposed

Ionising radiation 20 mSv

Hand-arm vibration 2.5 m/sec2

Whole body vibration 1.15 m/sec2

SOME MEDICAL CONSEQUENCES OF EXCESSIVE EXPOSURE TO OCCUPATIONAL HEALTH HAZARDS

• Occupational Lung Disease– Silicosis– Coalworkers’ pneumoconiosis– Massive pulmonary fibrosis– Silico-tuberculosis– Occupational asthma– Lung cancer

• Noise induced hearing loss• Nasopharyngeal cancer• Occupational skin disorders (irritant or allergy)• Altitude sickness• Heat exhaustion or Heat Stroke• Hand Arm Vibration Syndrome• Back pain and injuries• Repetitive strain injuries• Occupation related stress disorders• Radiation induced occupational cancers

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WHAT WE ARE DOING TO ADDRESS OUR MAIN HEALTH RISKS?

APPLICATION OF OCCUPATIONAL HEALTH STANDARDS

• Focus on preventing the adverse health consequences of exposures tooccupational health hazards

• Programmatic approach

Risk assessmentEducation and trainingControlsMonitoring and review

• Initial standards address priority risks

Noise Airborne pollutants Fatigue Emergency Medical Response Alcohol and Substance Abuse Ergonomic Factors (musculoskeletal) – in development

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• The process for managing health risk is exactly the same as for safety using the same terminology and skills as the Operational Risk Management Process (ORMP)

– Documented in the Anglo American Occupational Health Way

– Risk and (Critical) Control Registers

– Issue based risk assessment

– Identification of gaps

– Reporting and investigationof health incidents

– Learning From Incidents

– Health Improvement Plans

HEALTH RISK ASSESSMENT

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HIERARCHY OF CONTROLSFOR DEALING WITH HEALTH HAZARDS

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ELIMINATION AT SOURCE

SUBSTITUTION

ENGINEERING

ADMINISTRATIVE

PPE

Most Effective

Least Effective

SEPARATION

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ALLOWABLE EXPOSURE

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Noise level (dB) Allowable exposure

85 8 hours

88 4 hours

91 2 hours

94 1 hour

97 30 minutes

100 15 minutes

103 7 min 30 sec

106 3 min 45 sec

109 1 min 52.5 sec

112 56.25 sec

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MANAGING OUR HEALTH RISKS: INTRODUCING THE DANGERS FROM DUST AND NOISECommunication and engagement programme

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KEY ELEMENTS

KEY ELEMENTS

● Dedicated “Why dust and noise matter for our future” briefing pack for site General Managers/leadership teams to be used in Mineco meetings, site meetings, etc.

● Interactive tools to walk managers through the issues and requirements

● Range of materials for use with frontlineto highlight how they can best manage the health risks, emphasising the options within their influence

● Introducing the dangers from noise and dust

● The dangers of dust

● Keeping safe and sound from noise

● Toolbox talks 17

Example Occupational Health Standard

RESPIRATORY PROTECTION PROGRAMME STANDARD

AIMTo provide a consistent and rigorous approach to the prevention of ill-health from airborne pollutants occurring in the work environment. The Standard provides the basis for a programme to manage the risk from inhalable hazards.

STANDARD ELEMENTS● Risk assessment

Identify the sources and characteristics of the hazard, the tasks and people that are affected. Assess the level of exposure (intensity and dose) for each task. Indentify the opportunities for control and protection of any employees who may be exposed.

● Education and training of employees On the respiratory hazards to which they are exposed, the controls that are in place and how to

prevent exposure.● Controls

Application of the hierarchy of controls to management of sources of airborne particulate and gaseous emissions.

● Monitoring and Review Monitoring the effectiveness of controls and of the exposure of the employees at risk through the

occupational hygiene and medical surveillance programmes and using the information obtained to further improve the controls.

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Have you identified allthe sources of dustand noise wherever you operate?

Critical questions

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Do you know what’s in the dust that your employees might be exposed to?

Critical questions

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Critical questions

Are you constantly measuring your employees’ exposure to dust and noise with the right tools, equipment and expertise?

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Do you know who’s doing what job and for how long? –location, duration ofemployee exposure.

Do you have records to prove it?

Critical questions

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Do your people understand the healthrisks that they might be exposed to and are they sufficiently trained on how to protect themselves from them?

Critical questions

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Are your supervisors clear on their role?

Do they understand which machines and activities pose the biggest threat?

Critical questions

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Have you committedsufficient resources –time, money andpeople – to ensurecompliance with occupational health standards andultimately to protectyour people?

Critical questions

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WE NEED TO MINIMISE THE IMPACT OF DUST AND NOISE ON OUR PEOPLE AND OUR BUSINESS

WE NEED TO MAXIMISE EVERY OPPORTUNITY TO CONTINUOUSLY IMPROVE

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EMPLOYEE HEALTH AND WELLNESS

• All employees should receive an annual health screening and basic medical examination:

– Medical history screening for common diseases and lifestyle risks– Height, Weight, Body Mass Index (BMI)– Visual acuity– Blood pressure– Haemoglobin– Blood sugar– Cholesterol– Substance abuse screening– Voluntary counselling and testing (VCT) for HIV

• Early diagnosis, early access to counselling, care, support and treatment

• Reduces absenteeism, improves productivity

• Allows for analysis of health trends over time

HIV AND AIDS

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• AIDS Policy - Human rights framework

• Strong line management leadership

• HIV counselling and testing (the entry point for both prevention and treatment)

• Prevention through education, reproductive health, condoms

• Care, support and treatment for HIV +ve employees & families

• Results focus

• Engaging the business supply chain and customer base

• Community partnerships and health systems strengthening

ANGLO AMERICAN’S STRATEGIC APPROACH TO MANAGING HIV/AIDS

HIV/AIDS Policy

HIV Prevention and Treatment are inseparable

Early Diagnosis is essential

Early access to treatment gives the best results

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PROGRESSION OF HIV INFECTION OVER TIME

AIDS TREATMENT

HIV TREATMENT

Deteriorating healthAbsenteeismTuberculosisDisabilityRisk of death

YEARS

IMMUNITY    (CD4

 COUNT)

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HIV COUNSELLING AND TESTING AT ANGLO AMERICANSOUTHERN AFRICAN SITES

Uptake of HIV testing2003 <10%2004 21%2005 31%2006 63%2007 72%2008 77%2009 82%2010 94%2011 92%

HIV/AIDS KEY INDICATORSSOUTHERN AFRICAN SITES

2008 2009 2010 2011

Number of employees 81,450 66,661 73,129 77,075

Best estimate of HIV prevalence 18% 18% 16.5% 16.7%

Estimated number of HIV positive employees 14,444 12,057 12,066 12,864

Number of employees participating in HCT during year 63,817 54,662 68,741 70,909

Percentage HCT uptake 78% 82% 94% 92%

New HIV infections 902

HIV incidence 1.17%

Number of HIV positive employees enrolled in HIV wellness programmes 7,361 6,116 7,105 7,846

% HIV Wellness programme enrolment 51% 51% 60% 61%

Number of employees taking ART 3,072 3,211 3,971 4,730

% of HIV positive employees taking ART 21% 27% 33% 37%

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• Access to treatment has transformed the management of HIV and AIDS

• New evidence supports the vital role that treatment plays in prevention

• Anglo American was the first large business in South Africa to offer free antiretroviral therapy to all its employees – 6th August 2002

• This commitment was extended to the dependants of all employees in 2008

• AIDS treatment costs ~R900 per employee per month, but can save up to R1500 per employee per month through reduced absenteeism, reduced hospital costs, reduced staff turnover and reduced benefit payments

THE IMPORTANCE OF ACCESS TO ANTIRETROVIRAL TREATMENT

Source: UNAIDS – AIDS at 30 : Nations at the crossroads

HIV Incidence trend amongst employees at Thermal Coal

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

2005 2006 2007 2008 2009 2010 2011 2012

HIV Incidence

HIV Incidence

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94% ofemployeesretested forHIV every yearsince 2006

MOAE0203Company-level ART provision to

employees is cost saving A modelled cost-benefit analysis of the impact of

HIV and ART in a mining workforce in South AfricaGesine Meyer-Rath1,2,3,4, Jan Pienaar10,11, Brian Brink11, Andrew van Zyl6, Debbie

Muirhead5,6, Emma Beruter6, Alison Grant6,7, Rory Leisegang6,8,9, Lilani Kumaranayake5, Gavin Churchyard6, Charlotte Watts5 , Peter Vickerman5

1 Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, UK 2 Center for Global Health and Development, Boston University, US

3 Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, South Africa4 Faculty of Health Sciences, University of the Witwatersrand, South Africa

5 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK 6 The Aurum Institute, South Africa

10 Anglo Coal Highveld Hospital, South Africa 11Anglo American, South Africa7 Department of Clinical Research, London School of Hygiene and Tropical Medicine, UK

8 Division of Clinical Pharmacology, University of Cape Town9 Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town

38*Benefits include: disability, ill-health early retirement, death benefits, dependant pensions

CONCLUSIONS OF LSHTM STUDY

The cost of AIDS in the workforce is due to:• Increased benefit* payments 44%• Absenteeism 39%• Training and recruitment 7%• Medical costs 10%

The cost of ART makes up only 5% of the cost of AIDS

The savings under ART are mainly due to reductions in benefit payments and absenteeism costs

Anglo American Thermal Coal mines have been saving 9% on the annual cost of HIV/AIDS by making ART available to their workforce since 2003 ($31.2 million reduced to $27.6 million)

These results are based on real programme experience over 10 years

The results demonstrate strongly that investment in treatment is worthwhile

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• Stopping the new HIV infections

• Moving from measuring prevention processes tomeasuring prevention outcomes

• Early diagnosis of HIV infection

• Early access to treatment

• Ensuring treatment adherence and retention

• Improving access to HIV testing and care, support and treatment for dependants

• Ensuring that contractors have access to care, support & treatment

• Containing the tuberculosis epidemic

• Health systems strengthening in communities associated with Anglo American operations

HIV/AIDS CHALLENGES FOR ANGLO AMERICAN

TUBERCULOSIS

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• TB in the mining industry has reached crisis proportions. It is fuelled by the HIV/AIDS epidemic.

• People living with HIV are about 37 times more likely to develop TB, than people without HIV.

• TB is difficult to diagnose, especially in people living with HIV.

• TB is curable, but treatment takes at least 6 months and requires meticulous adherence.

• If treatment is not taken properly, then the TB bacilli rapidly become resistant.

– Multidrug Resistant TB (MDR-TB) requires two years of treatment at more than 30 times the cost

– Extensively Drug Resistant TB (XDR-TB) is untreatable

TUBERCULOSIS

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ANGLO AMERICAN TUBERCULOSIS INDICATORSSOUTHERN AFRICAN SITES

2009 2010 2011

Employees 66,661 73,129 77,075

Pulmonary TB 786 582 758

Extra‐Pulmonary TB  133 145 148

Total new TB cases  919 727 906

TB Incidence per 100,000 population 1,379 994 1,175

MDR TB Cases

TB Deaths 86 65

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TUBERCULOSIS IN SOUTHERN AFRICASADC DECLARATION ON TB IN THE MINING SECTOR 18TH AUGUST 2012

We the Heads of State orGovernment of;

The Republic of AngolaThe Republic of BotswanaThe Democratic Republic of Congo The Kingdom of Lesotho The Republic of MadagascarThe Republic of MalawiThe Republic of MauritiusThe Republic of MozambiqueThe Republic of SeychellesThe Republic of South AfricaThe Republic of SwazilandThe United Republic of TanzaniaThe Republic of ZambiaThe Republic of Zimbabwe

CONCERNED that the mining sector is one of the hardest hit by the TB and TB/HIV crisis imposing many costs on the business and eroding the positive contribution made by the mining sector to the economic development agenda of the region

RECOGNISING that the mining sector contributes to TB prevalence in the Region and that mineworkers are disproportionately affected by TB

FURTHER RECOGNISING that the TB and TB/HIV epidemics in the mining sector are driven by many factors including high prevalence of Silicosis resulting from long term exposure to silica dust in the mines and that in addition, high prevalence of HIV in the mines combined with generally poor living conditions of mineworkers further increases the risk of contracting and developing active TB

AWARE of the challenges being experiences by mineworkers and ex-mineworkers (including migrant mineworkers and contract or casual workers) their families and communities.

COMMIT to moving towards a vision of zero new infections, zero stigma and discrimination , and zero deaths resulting from TB, HIV, Silicosis and other occupational respiratory diseases

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• SADC Heads of State have highlighted a critical development challenge:

– a regional crisis where a key economic sector (mining) is accelerating the spread of TB throughout the continent to the extent that Africa is the only region in the world that is not on track to reach the Millennium Development Goal (MDG) for Tuberculosis

• South Africa’s half-a-million mineworkers have the highest TB incidence in the world: 3,000 per 100,000 compared with a global incidence rate of 128 per 100,000

• Contractors are a significant and neglected part of the problem

TUBERCULOSIS IN SOUTHERN AFRICA

AFTER KNOWING FOR MORE THAN A CENTURY THAT

THE SOUTH AFRICAN MINING INDUSTRY IS RICH

WITH TB, WE FINALLY HAVE THE POLITICAL WILL IN

THE REGION TO CREATE AN EMERGENCY

RESPONSE TO ARREST ITS SPREAD.

FOR THE HEALTH OF THE REGION—AND TO

PROTECT A WORLD AT GREATER RISK FROM TB—

WE MUST SEIZE THE OPPORTUNITY AND END THIS

DISEASE.

ARCHBISHOP EMERITUS DESMOND TUTU

WALL ST JOURNAL 8TH NOVEMBER 2012

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theHealthSource

APPLAUD AWARD FINALIST 2012 FOR INNOVATION

• A sophisticated Health Management Information System

• Provides the solution to managing many of the “Health” problems in the SA mining industry

– Contractors, migrancy, HIV/AIDS, TB, occupational health records

• An innovation which goes far beyond anything else that is available in the health field today

• Also holds huge potential for dealing with the multitude of health problems encountered in developing countries

• Represents a major opportunity for Anglo American, together with its contractors, to be at the forefront of managing health issues in the mining industry.

COMMUNITY HEALTHFacilitating tangible health improvements in local communities

and

Being a positive influence on health in developing countries

THANK YOU