Workplace medicine: What is workplace medicine and what do workplace physicians do?

First of all, let us begin by saying that the emergence and development of worker health services and workplace medicine in history are the fruits of class struggle. Workplace medicine can only be understood as having been attained in the context of labor – capital relations. Unless we realize this aspect of workplace medicine, we cannot comprehend the difference between workplace medicine and general medicinal services.

The most important aspect separating workplace medicine from general medicine is this:  the essence of workplace medicine is preventable or avoidable health problems. Ramazzini, the acknowledged father of workplace medicine, identified this situation by giving his book, published in 1713, the title De Morbis Aritificium Diatriba (On Artificially Caused Diseases), or “artificial illnesses”. Using the phrase “artificial epidemic” in his famous Upper Silesia Typhus Epidemic Report, Virchow, who investigated the epidemic that erupted in the mines there, stressed that these illnesses are preventable. 

Doubtless, the roots of workplace medicine go back to Imhotep and Hippocrates, but in the modern context workplace medicine really began with the French Revolution. While it is true that there is data in the Ebers Papyrus about workers suffering injury to their skeletal systems because of their jobs, and that Hippocrates perfectly diagnosed the indicators of lead poisoning, the first concrete steps taken to protect workers from these problems began to be implemented after the French Revolution. The basic workplace medicine applications, such as the first legal measures for the protection of women and children from the negative health effects of their work environments, shortening work hours and entrance examinations and periodic health checks for workers to evaluate whether or not they are suitable, from a health standpoint, for the jobs they will work at, spread in developed capitalist countries alongside the industrial revolution.

These and many other implementations for workers’ health and safety are the rights won during the period of struggle which the working class pressed for by demanding the reformation of living and working conditions. European workers put forth their reactions to unbearable working and living conditions with the 1848 uprisings and they began to threaten capitalist hegemony with the 1871 Paris Commune. In Germany, the Bismarck government, by introducing health insurance, was forced to send a message to workers their working and living conditions would be improved, albeit “without changing the system”.

In Germany, when insurance institutions started to open health units and hospitals in workplaces to provide health services to workers and to employ physicians in these institutions, it was apparent that labor and capital had differing expectations from workplace medicine. Labor expected that workplace medicine would protect it from preventable illnesses, while capital was inclined to see the workplace physicians as staff that would ensure production economies for it by resolving workers’ health problems at the workplace, to the extent possible. It would not be an exaggeration to say that the workplace physicians, who were paid by the employer, adopted the role outlined for them by the employer.

The first example in history of the implementation of workplace medicine in the modern understanding is seen in the Soviet Union, which was established by the 1917 October Revolution. The Soviet government, rather than setting up a separate health organization for workers as capitalist countries had done, organized workplace medicine as the backbone of the national health system. In 1924, it established the “Hygiene” medical schools and began to train physicians to take up duty in factory health units when they graduated.  These physicians only provided preventive workplace medicine services in the workplace, whereas sick workers were sent to family physicians, graduates of “General” medical schools, at primary care institutions near their residences.   

After the Second World War, countries following the path of socialism adopted the Soviet model for workplace medicine, while the Bismarck model spread in Western countries. In 1997, the Workplace Medicine Expertise section was established within the structure of the European Union of Medical Specialists. In 2000, the World Health Organization recognized the criteria for workplace medicine and brought standardization to this field. Workplace medicine is a medical expertise that concerns: evaluating workers’ health; the relationship between working conditions and processes and workers’ health; assistance to managing the health, skills and working capacities of the entire working population; and case management in regard to working ability and production. In 2002, the minimal standards for Workplace Medicine Expertise were set¹ and it was decided that the training period would be not less than 4 years.

How did these processes develop in Turkey?

The first arrangement regarding workers’ health in the Ottoman Empire was the requirement for a physician to be present at worksites for workers toiling in the coal mines in the Zonguldak region. In reality, we have no data as to whether or not this order, contained in the 1865 Dilaver Pasha Regulations and the 1869 Maadin (Mines) Regulations, was implemented, and if it was implemented, we don’t know what the employed physicians may have actually done. However, we do know that this sentence appeared in a brochure entitled Everyone Should Know About Tuberculosis, written by Dr. Reşat Rıza in 1913: “workmen are being put to work in humid, airless, dark, stable-like places; there is no concern whatsoever for the measures necessary for the health of the workmen.” In other words, Ottoman physicians were aware of the rather advanced work being done in Germany in those years for workers’ health.

During the Republic period, the first arrangement relating to workers’ health was made in the Umumi Hıfzısıhha Kanunu (Law for the Protection of Public Health) of 1930, in which there are regulations to ensure the healthy suitability of workplaces and their surroundings; provision of medical care for workers in worksites where more than 50 people are employed; and the establishment of health units. There are articles concerning workplace medicine in copies of the Sendika Gazetesi (Union Newspaper) published in 1946: in one of these articles it is stated that “establishments consider the provision of a physician as merely a legal formality” (Öztürk, 2009: 22).  

Most of the time these institutions did not hire a workplace physician and instead they rented the diplomas of retired physicians to give the appearance that there was a physician at the workplace. In another article, the following sentence appears: “in advanced industrial countries such as England, America, France and Belgium physicians who will work in this field are enrolled in additional courses; it is a requirement that the information about hygiene, social hygiene, biochemistry and bacteriology provided to them be increased” (Öztürk, 2009: 21). 

In other words, Turkey knew by the 1950’s that workplace medicine was a “field of expertise”². In an article written by Dr. M. Hulusi Dosdoğru, based on German sources, it is stated with regard to defining community medicine that “the primary focus of social medicine is to provide the means for people to live before they become ill” (Öztürk, 2009: 21).

In short, workers’ health has been known about in the geography where we live (Turkey) since the 1860’s but it wasn’t implemented. Up until the 1960’s professional and political organizations for the worker class were forbidden and their demands were forcibly suppressed. In the relatively democratic environment provided by the 1961 Constitution the worker class succeeded in being able to organize around its demands, but in the coups of first 12 March 1971 and then 12 September 1980, workers were again subjugated and ultimately left without their organizations. 

During all these developments workers’ health was, for employers, a “legal formality”. When workers became ill or needed to have a prescription written, they went to a place where they would be an “additional income source” for physicians. Medical education was put on the back burner and universities, political parties and unions couldn’t get on the agenda.

What have been the actions of the TTB (Turkish Medical Association) on this subject?

TTB’s involvement in the issue of workers’ health has been a relatively recent development.  As is known, TTB is essentially a corporate institution that the state established with the role of organizing and supervising medical activities. However, with the increase in the momentum of the class struggle in Turkey in the 1960’s, progressive elements among physicians saw TTB as a focal point and began to make efforts to take control of this organization. 

Toward the end of the 1970’s, TTB became a center in the class struggle and began to provide support to the struggle of the workers’ class. TTB’s first concrete action in this regard was the National Workers’ Health Congress held in 1978. We see that in this Congress TTB exhibited a pro-labor stance with regard to workers’ health. The Congress enunciated demands that included employers not paying the salaries of workplace physicians so that they could properly dispose of their duties and the imposition of harsher penalties for employers who did not fulfill their legal responsibilities. This Congress can truly be considered a milestone in workplace medicine activities in Turkey.

These developments were retarded two years later by the fascist military coup of 12 September 1980, with the TTB being shuttered and its directors arrested. In 1984, permission was once again given for TTB activities and social democrat physicians took control.  Toward the end of the 1980’s, despite the fact that physicians who identified themselves as more to the left in social democracy were the majority in TTB’s directorship, TTB never again achieved the character it had at the end of the 1970’s. This difference is quite apparent when comparing the second National Workers’ Health Congress held in 1988 with the first Congress organized in 1978. Demands like workers being the decision-makers with regard to production, put forth when workers controlled the agenda in 1978, were retarded to become merely requests for the ruling class to at least comply with the laws they had promulgated.

In this period, TTB intervened in this field by opening the first Workplace Medicine Certificate Program in Istanbul. Using the law and regulations about workplace medicine, TTB exerted pressure on the Labor Ministry and employers and demanded that only physicians who obtained of certificate from TTB be authorized as workplace physicians. Certainly, when one looks at the history of workplace medicine in Turkey, this step taken by TTB was very valuable and important. But it is clear that it is impossible through these courses to attain the knowledge and skills required for workplace medicine, which is a separate field of expertise in medicine. These courses only explain to physicians that there is such a field of expertise in medicine and serve to introduce them to the medical activities contained in workplace medicine.

In the 1990’s, in Turkey, physicians working for salary and wages were in a bad way and tried everything to increase their incomes. During this period, on the one hand, the progressive physician elements tried to elevate the economic and democratic struggle by organizing White Actions, and on the other, a great many physicians were intent on “saving themselves” and for a large number of physician workplace medicine began to be seen as a “door to extra income”. Pressure on TTB to open more courses and to provide more workplace medicine certificates to many more physicians increased and populist TTB directors bowed to this pressure, arranging workplace medicine documents for about 30,000 physicians in a rather short period of time. 

Of course, there were progressive physicians who opposed these developments within TTB, but in the years after 1980, when the left was ideologically and politically crushed, the voice of this sector could not be heard. With the coming of the 2000 years, workplace medicine has become in the true meaning of the phrase an “extra income” gateway. A large portion of physicians working in workplace medicine provide polyclinic services in factories as prescribed by the employer and these services are remunerated in accordance with a minimum wage schedule set up by the TTB.  There are certainly workplace physicians who try to fulfill their duties in accordance with their profession, but their numbers are small in relation to their overall population.

The 2000’s have been the years when labor forces have lost all their historical gains in Turkey. During this stretch, the numbers of uninsured workers have surpassed those with insurance, labor union organizing has fallen behind even the level of 1946, when unions were outlawed, and slave conditions, in the true sense of the words, has taken over the work environment. In such an atmosphere, TTB’s say in workplace medicine has come to an absolute end, in accordance with the demands of employers.  The organizing monopoly of workplace medicine courses that TTB had was both an important income source for TTB and a vehicle for TTB to establish an organic link with physicians. This has been taken away from TTB and the courses have been opened up to private learning centers.

In conclusion, in a few sentences we can talk about the change brought about in the field of workplace medicine by the Work Health and Safety Law number 6331, approved in 2012, and the regulations associated with it.  These regulations have essentially two goals: the first is to reduce the cost of workplace medicine services by lifting the pressure of the TTB minimum wage schedule from employers and the second is to lessen employer responsibility for possible occupational illnesses and workplace accidents by sharing this responsibility with workplace physicians and work safety experts.  So although it has only been a short time since the legal regulations have come into effect, workplace physician wages have begun to fall quickly but, conversely, by greatly reducing the time physicians are required to spend at workplaces, the situation has arisen whereby workplace physicians must provide services to many more workplaces in order to attain their former income levels.

As a result, we can say today that TTB has been entirely excluded in regard to workplace medicine and that this field has been completely abandoned to the mechanisms of the free market. As in other countries, the level of the class struggle will determine the fate of workplace medicine in Turkey.

Akif Akalın

¹http.//www.who.int/occupational_health/regions/en/oeheuroccmedicine.pdf.

²As this article is being written in 2013, workplace medicine is still not a field of expertise and physicians can become workplace physicians with 220 hours of “courses” given by private learning centers.

Source: Workplace Medicine. in Tıp Budur! Akıl Giren Bedene Doktor Girmez. Ed. Ilknur Arslanoglu. İstanbul: İthaki.Pp. 149 – 158