Workers’ Health in Latin America and the Caribbean
Summary and Keywords
In different countries and regions of the world—particularly in Latin America and the Caribbean—the term “workers’ health” may have different meanings. From a more traditional perspective, defined on economic and demographic bases, this term introduces a delimitation characterized by economically active people, usually over 10 years of age, of both sexes, and who are working, have worked at some point in their life, or are in search of work. This condition usually ceases in case of retirement or disability. Such a criterion, as can be imagined, is extremely imprecise, particularly in regions such as the ones analyzed here, since it includes great variability of situations, including work considered informal; the work of children and adolescents (prohibited or restricted in accordance with international labor standards); clandestine and illegal work; domestic work (sometimes not formally recognized); and slave and forced labor. It is not clear, either, when work activity actually ceases, especially when there are no social protection systems for elderly and disabled people. But even if this definition is adopted, it is already possible to foresee the complexity of the theme, both in the conceptual perspective and in the scope of health programs, as well as in the health and illness problems of this population.
However, in some countries, the term “workers’ health” (or “worker’s health”) goes beyond the economic or demographic delimitation, and includes a paradigm shift about the role of workers in the struggle for their health. This perspective, political and ideological, originates in the concepts and experience of the “Italian Labor Model”; brings in elements of the Marxist discourses and Liberation Theology; takes advantage of and improves the perspective of “Social Epidemiology” or “Social Medicine”; and, in our continent, can be considered as an unfolding of “Latin American Social Epidemiology.” This understanding of workers’ health also depends on social movements—such as unions and other forms of organizing workers—as well as on political leaders committed to the struggle of workers against precarious work, unemployment and the destruction of already established social rights, especially in the context of neoliberalism.
Therefore, workers’ health is a polysemic and complex concept, and its discussion is a living, dynamic, and extremely rich agenda.
“Workers’ health” is a polysemic term that gives rise to different conceptual and programmatic perspectives, not yet finished and more provisional than definitive, which has continued to provoke intense debates, particularly in Latin America, especially from the 1980s onwards.
In this region—but also globally—the term “workers’ health” was born as a counterpoint to the terms “occupational health” and “occupational medicine” as part of academic reflections and intense debates about defining (or redefining) the meaning and scope of “social medicine,” “community medicine,” and “social epidemiology” (including “critical epidemiology”). This movement is also associated with the critical revision of “public health” on the way to the construction of “collective health.”
There have been some minor semantic issues, including the translation of the term “occupational,” questioned by those who speak Spanish or Portuguese; this has led to freer translations, such as “health at work,” to avoid the conceptual and linguistic imprecision of the term “occupational.” Similarly, it has been questioned whether, in the Portuguese language, “worker’ health,” in the singular, is equal to “workers’ health” in the plural. In this case, the focus would be on the collective dimension, closer to the “class” or “working class” dimension, in the classical Marxist sense, or in more contemporary meanings. Moreover, it has been pointed out that “worker” in Spanish or Portuguese (and other languages as well) is a masculine gender name and that it would be desirable for the feminine to be considered as well (Mendes, 2018b).
However, the most important questions concern the place and role of workers in the concept and praxis: whether “workers’ health” would be a historical and undeniable agenda of workers in their emancipatory struggle, or a concern of the ideologues of health or social policies of health—or whether it would be possible to reconcile both agendas, especially in political and social contexts and economic policies increasingly dominated by neoliberal ideology. They could be diametrically opposed agendas and intentions, in fact polar and antagonistic, which would reflect the irreconcilable struggle between capital and labor. Or perhaps the appropriation of health by capital, aiming only to guarantee a healthy workforce capable of ensuring productivity, with health being less and less a concern of public policies, and increasingly an object of markets, where the “workers’ health” space would be located (Feo, 2018).
These and other questions are at the root of this brief article, which perhaps generates more questions than answers, thus fulfilling its role of provoking reflections in search of much-needed new and alternative ways of approaching the subject.
Historical Roots of Workers’ Health Studies
Despite the different theoretical-conceptual perspectives on workers’ health as a field of public health or collective health, it is mandatory to identify its historical roots, which show that it is a theme with a long history and global scope.
In fact, since antiquity there have been records of heavy and adverse working conditions and health problems that differed among workers, especially those in the condition of slaves and servants. Therefore, it is not difficult to imagine the existence of important differentials of health, sickness, and death, when compared with the owners, the masters, the elites. For this reason, too, the subject might not interest medical doctors, historically assiduous in attending palaces and elite cohorts (Rosen, 1993).
Records on working conditions and workers’ health began to flourish in the late Middle Ages and early Renaissance period. These usually appeared in mining regions in Europe, focusing on the health problems of underground mine workers resulting from exposure to dust or to toxic or hazardous chemicals. The classical studies of Ulrich Ellenbog (1435–1499), Paracelsus (1493–1541), and Georg Agricola (1494–1555), among others, are paradigmatic examples of this phase of history (Mendes, 2018a; Rosen, 1993; Sigerist, 1936).
In the period before the First Industrial Revolution, the important contribution of the Italian physician Bernardino Ramazzini (1633–1714) stands out. He brought together and systematized knowledge about workers’ illnesses in the book De Morbis Artificum Diatriba (Discourse on the Diseases of Workers), launched in Modena in 1700. It is an important work of occupational pathology, but also a significant contribution to medico-social thought and to epidemiology. As pointed out by several authors, Ramazzini paved the way for understanding the importance of social position in vulnerability to illness, disability, and early death, taking “occupation” as a proxy for individual and collective social position (Franco, 2014; Rosen, 1993).
Drawing on deep bibliographical scholarship, extensive clinical experience, and astute epidemiological, political, and social thinking, Ramazzini sought to associate living conditions and work environments with profiles of morbidity, longevity, and mortality. In addition, Ramazzini drew the attention of physicians to the importance of providing proletarian patients with the same quality of care as rich patients, as well as the importance of always asking about the professional activity performed by the patient. After more than 300 years, these teachings remain valid and are increasingly necessary (Franco, 2014).
With the advent of the First Industrial Revolution in European countries, awareness spread of its numerous impacts on living conditions, sanitation, housing, and food in large cities, as well as the effects of the excessive exploitation of labor in factories. The work of children and women, as well as the direct health effects of work on workers of all ages, became a concern of English and French social reformers. It can be said that workers’ health issues came to occupy the agenda of social reformers and the nascent public health system.
Some examples may be cited, such as the work of the French physician Louis-René Villermé (1782–1863), best known for his study of the health conditions of textile workers. This report, published in 1840 under the title “Tableau de l’état physique et moral des ouvriers employés dans les manufactures de coton, de laine, et de soie” (Survey of the Physical and Moral Condition of Workers Employed in Cotton, Wool and Silk Factories), is a historical landmark in workers’ health, but has also become a methodological reference for descriptive epidemiology (Mendes, 2018a; Rosen, 1993).
In England, the contributions of Charles Turner Thackrah (1795–1833) stand out. Thackrah wrote many medical texts, but his greatest work, for which he is most remembered, dates from 1831 and has a long and intriguing title: “The Effects of the Principal Arts, Trades and Professions, and of Civic States and Habits of Living on Health and Longevity, with Suggestions for the Removal of Many of the Agents which Produce Disease and Shorten the Duration of Life.” Of course, the categories analyzed by this author broaden the scope of public health concerns, and particularly in workers’ health, as they include health, longevity, disease, and abbreviation of life span in the extensive list of possible adverse impacts of work (Mathie, 2017).
Sir Edwin Chadwick (1800–1890) was a prominent English social reformer of the 19th century. Among his several contributions, the study entitled “Report on the Sanitary Condition of Labor Population of Great Britain,” published in 1842, remains a reference work due to its content and methodology. In 1843, a supplementary document was added. These studies, produced with quantitative and meticulously analyzed data, consolidated the hypothesis of the relation between the living conditions of the poor and their illnesses and deaths, drawing attention to the reduction of the life expectancy of the socially more depressed classes. Chadwick’s contributions subsidized the debate and health and sanitation reforms instituted in the landmark Public Health Act of 1848. The reforms included the creation of a National Board of Health, and Chadwick was named as its first director, where he remained until 1854 (Rosen, 1993).
It is important to point out the valuable contributions of the English physician and biostatistician William Farr (1807–1883), who demonstrated in an objective and irrefutable manner that underground coalminers in Cornwall became sicker and died earlier than the general population, especially of respiratory diseases. These were not necessarily “occupational diseases,” but diseases that later came to be labeled “work-related diseases” (Eyler, 1978).
In this brief history there is room for the important contributions of the philosopher, social scientist, journalist, and Communist militant Friedrich Engels (1820–1895). Among his many works, including those written with Karl Marx (1818–1883), the classic work Die Lage der arbeitenden Klasse in England (1845), translated as The Condition of the English Working Class in 1844 (1887), stands out. Based on his personal observations in Manchester, mainly in spinning and weaving mills, Engels denounced the capitalist mode of production, associating it with the empirical demonstration that workers and their families had higher morbidity rates and died earlier when compared with the populations of less industrialized cities. The social determinants of health were being demonstrated through the lenses of social science and political economy (Engels, 1975; Rosen, 1993).
In this brief article, which also aims to identify the foundations of thought in “collective health” and, by extension, the view of “workers’ health” adopted here, reference to Rudolf Virchow (1821–1902) is critical. This versatile German physician is included here for his role as a social reformer and as one of the founders of social medicine. For him, “Medicine is a social science, and politics is nothing other than large-scale medicine.” He argued, too, that “doctors are the natural advocates of the poor, and social problems must be addressed by them.” Indeed, among his many activities, which included relevant contributions to the construction of modern pathology, Virchow helped found the weekly journal Die Medicinische Reform (The Medical Reform), which conveyed ideas on social reform, political reform, and health reform. For reasons of pressure and repression, the newspaper had to be closed, and Virchow was temporarily expelled from its official board (Brown & Fee, 2006; Eisenberg, 1984).
Of course, the list of contributions to the formation of the constituent bases of workers’ health, which has been (and is being) expanded with inputs from public health, collective health, community health, social medicine, and social epidemiology is very large. To this long list, several Latin American thinkers, theorists, researchers, and others who have contributed to this construction deserve mention, and their names and contributions will appear in other sections.
Scope, Conceptual Models, and Approaches
“Descriptive” Scope Based on Demographic, Economic, and Epidemiological Criteria
Workers as “Denominators”
In the logic of public health and epidemiology, an obvious way of delimiting the scope of the area or field of workers’ health has been, on the one hand, to define criteria of “inclusion” in the “denominator,” that is, who should be considered as “workers.” On the other hand, it is necessary to define “numerators,” that is, what health problems are being sought in the “worker” population. Although it seems simple, both procedures are extremely complex, and their methodological complexity becomes even greater if political criteria, ethical criteria, and the evolution of concepts and practices are taken into account. In the perspective of public policies of “social protection,” there will be a tendency to loosen and broaden the criteria, towards maximum protection. The opposite is expected when the criteria are defined by “market” logic, and when provision of services or payment of indemnities (such as workers’ compensation for work-related injuries and diseases) are at stake.
Thus, the most restrictive criterion, which still prevails in some countries and regions, is to delimit the universe of the “denominator” to the fraction of the population that is formally employed, that is, employees who have one or more employers. In some countries an even more restrictive delimitation is used, for example, where the target is only those employees who contribute to some insurance system, whether it is a so-called social insurance or private insurance (health insurance, work-related injuries or illnesses, age-related retirement plan, retirement due to disability, etc.). Therefore, the “denominator” dimension will be only a fraction of the universe of workers, and if it is considered that in regions such as Latin America, more than half of the workers are informal, that is, they do not have formal jobs, the fraction of workers supposedly included in social protection programs is extremely small. Far from being social inclusion policies, they are policies and practices of social exclusion.
According to the OECD,
“employees are all those workers who hold the type of job defined as paid employment jobs. Employees with stable contracts are those employees who have had, and continue to have, an explicit (written or oral) or implicit contract of employment, or a succession of such contracts, with the same employer on a continuous basis. On a continuous basis implies a period of employment which is longer than a specified minimum determined according to national circumstances. Regular employees are those employees with stable contracts for whom the employing organization is responsible for payment of taxes and social security contributions and/or where the contractual relationship is subject to national labor legislation.”
It should be noted that within the United Nations, different agencies work with different statistics related to the universe of workers. Thus, estimates and projections of the total population and their components by sex and age group are produced by the UN Population Division, of the employed by the ILO, and of the agricultural population by the Food and Agriculture Organization (FAO). For the purposes of these reflections, it is important to cite the concept of “worker” adopted by the World Health Organization (WHO) (see Table 1).
Table 1. Concepts of “Worker” and “Workers” Adopted by the World Health Organization
Worker: A person who provides physical and/or mental labor and/or expertise to an employer or other person. This includes the concept of “employee,” which implies a formal employment contract, and also informal workers who provide labor and/or expertise outside of a formal contract relationship. In a larger enterprise or organization it includes managers and supervisors who may be considered part of “management” but are also workers. It also includes those who perform unpaid work, either in terms of forced labor or domestic work, and those who are self-employed.
Workplace: Any place that physical and/or mental labor occurs, whether paid or unpaid. This includes formal worksites, private homes, vehicles, or outdoor locations on public or private property.
Source: WHO (2010), p. 108.
An example of the different and expanding conceptions of what it means to be a “worker” is that adopted in the National Worker Health Policy document in Brazil, where “workers” are defined as follows: “All workers, men and women, irrespective of their urban or rural location, of their form of insertion in the labor market, formal or informal, of their employment bond, public or private, salaried, autonomous, temporary, cooperative, apprentice, trainee, domestic, retired or unemployed are subjects of this Policy.” The same document also states that “The National Worker’s Health Policy should include all workers, prioritizing, however, persons and groups in situations of greater vulnerability, such as those inserted in activities or in informal and precarious working relationships, in activities of greater risk to health, subjected to harmful forms of discrimination, or to child labor, with a view to overcoming social and health inequalities and seeking equity in care” (Brasil, 2012).
It should be noted that defining who is a “worker” may not be based solely on demographic, economic, and legal criteria, but also a political decision referencing public policies of inclusion and social protection.
Extending the Criteria for Inclusion in the “Numerators”
In epidemiological reasoning, it is always necessary to clearly define the health problems that will be investigated, analyzed, and measured, as well as the people who will be considered “cases” or “subjects” of these procedures. It is worth mentioning the well-known aphorism attributed to Claude Bernard: “whoever does not know what he is looking for cannot interpret what he finds.”
In the traditional field of health and safety at work, and as a reflection of the international guidelines proposed by the ILO, some outcome indicators are valued: number of occupational injuries and diseases, number of workers involved, and work days lost, among others (ILO, 2018) (see Table 2).
Table 2. Terms and Definitions—ILO Resolution Concerning Statistics of Occupational Injuries (Resulting from Occupational Accidents), Adopted by the Sixteenth International Conference of Labor Statisticians (1998)
(a) occupational accident: an unexpected and unplanned occurrence, including acts of violence, arising out of or in connection with work which results in one or more workers incurring a personal injury, disease or death; as occupational accidents are to be considered travel, transport or road traffic accidents in which workers are injured and which arise out of or in the course of work, i.e. while engaged in an economic activity, or at work, or carrying on the business of the employer;
(b) commuting accident: an accident occurring on the habitual route, in either direction, between the place of work or work-related training and:
(c) occupational injury: any personal injury, disease or death resulting from an occupational accident; an occupational injury is therefore distinct from an occupational disease, which is a disease contracted as a result of an exposure over a period of time to risk factors arising from work activity;
(d) case of occupational injury: the case of one worker incurring an occupational injury as a result of one occupational accident;
(e) incapacity for work: inability of the victim, due to an occupational injury, to perform the normal duties of work in the job or post occupied at the time of the occupational accident.
Source: ILO (2018).
It is important to draw attention to the evolution of the concept of “occupational disease” in relation to the concept of “work-related disease.” Far from being just a semantic issue, or a detail of national or international legislation emanating from the ministries of Labor or Social Security, this evolution values epidemiological reasoning and broadens the understanding of how work can impact workers’ health (Milles, 1985).
In fact, since 1985 the WHO has been promoting the adoption of the concept of “work-related diseases,” drawing attention to the programmatic developments resulting from this expanded concept. For the WHO, “occupational diseases” would be those caused by occupational exposure to physical, chemical, or biological hazards (or risk factors), when exposure levels exceed permitted limits or threshold limits. However, in the case of “work-related diseases” (or “other work-related diseases”), the environment or working conditions could represent risk factors, which add to other risk factors in diseases of complex or multifactorial etiology. These diseases would have a higher incidence in certain occupational categories or occupations; or they would have appeared earlier; or they would have a more severe or accelerated evolution. Populations of comparison would be of other professions or economic categories, but could also be the general population. Hence, the causal relationship would be epidemiological (WHO, 1985).
Thus, in occupational disease, according to the WHO,
“there is a direct cause-and-effect relationship between hazard and disease. In work-related diseases, in contrast, the work environment and the performance of work contribute significantly, but as one of a number of factors, to the causation of a multifactorial disease. Occupational diseases therefore stand at one end of the spectrum of work-relatedness, where the relationship to specific causative factors at work has been fully established and the factors concerned can be identified, measured, and eventually controlled. At the other end, diseases may have a weak, inconsistent, unclear relationship to working conditions; in the middle of the spectrum there is a possible causal relationship, but the strength and magnitude of it may vary.”
(WHO, 1985, p. 9)
The same WHO document analyzes in more depth five “work-related diseases of public health significance,” namely: (a) behavioral responses and psychosomatic illness; (b) hypertension; (c) ischemic heart disease; (d) chronic non-specific respiratory disease; (e) locomotor disorders (WHO, 1985).
In addition to this important conceptual advancement promoted by the WHO, which greatly broadens the nature and scope of studies on workers’ morbidity and mortality (compared with the general population), it is important to note that the ILO also follows this movement. Since 1919 the ILO has drawn up international lists of occupational diseases that are constantly revised, updated, and expanded; since 2010, “work-related diseases” have been included. The ILO not only extended its list (used as a reference in most countries), but also included the epidemiological criteria in drawing up its list. And by including the epidemiological criteria, it enunciated a paradigmatic concept that comparisons of incidence or prevalence would be made with the general population. In fact, the ILO noted that “the criteria used by the tripartite experts for deciding what specific diseases would be considered in the updated list include that . . . they occur among the groups of workers concerned with a frequency which exceeds the average incidence within the rest of the population; and there is scientific evidence of a clearly defined pattern of disease following exposure and plausibility of cause” (ILO, 2010, p. 8).
This brief analysis of international trends on the broadening of work-relatedness concepts of workers’ illness, incapacity, and death allows us to infer that workers’ health and illness issues have reached higher levels of health thinking and deserve greater space in the field of public health. This perception is strengthened in the context of an aging population and the growing importance of chronic non-communicable diseases, both trends related to work ability issues.
Finally, it could be said that in terms of “denominators” and “numerators” of public health and epidemiology there is a trend, on the one hand, towards increasing the population base of the universe of “workers” (with the projection that all adult men and women are part of this universe). On the other hand, the expansion of inclusion criteria in “numerators” has also been noted. That is, all illnesses of all people would tend to be included in the frame of reference of “work.” Of course, enlargement and dilution bring gains, but perhaps also some losses. On the horizon, “workers’ health” would tend to be synonymous with “public health.”
“Critical” Alternative Approaches and Models
Apart from the “descriptive” and, in a way, neutral and uncritical approach, it is important to draw attention to some analytical and critical approaches developed from the 1960s onwards in various countries around the world, and especially in Latin America. Such approaches and models of analysis and intervention have their roots in historical Marxism and the “critical theory” of the Frankfurt School, which in the field of health are present in the theory and practice of “community medicine,” “social medicine,” “social epidemiology,” “critical epidemiology,” and more recently “collective health” (Borde, Hernández-Álvarez, & Porto, 2015; Breilh, 2003, 2008; Campos, Minayo, Akerman, Drumond, & Carvalho, 2006; Krieger, 2011; Navarro, 1986; Nunes, 1983, 1994; Osmo & Schraiber, 2015; Spinelli, Librandi, & Zabala, 2017; Susser & Stein, 2009).
In Latin America, the growth and development of these alternative movements of analytical and critical “workers’ health” owe much to the important contributions of a number of thinkers, academics, researchers, and militants who deserve posthumous mention. They include the Argentine Juan César Garcia (1932–1984); the Brazilians Cecília Donnangelo (1940–1983), Sergio Arouca (1941–2003), and Davi Capistrano da Costa Filho (1948–2000); the Chileans Hernán Oyanguren Moya (1909–2005) and Gustavo Molina Guzmán (1910–1976); the Ecuadorian Edmundo Granda Ugalde (1946–2008); the Italians Giovanni Berlinguer (1924–2015) and Ivar Oddone (1923–2011) and their disciples in Latin America; the Mexican Jorge Renán Fernández Osorio (1923–2009); and the Venezuelan Emigdio Cañizales Guédez (1922–2005), among others (Mendes, 2018a). Many others have contributed and continue to contribute to building a new history for Latin American and global workers’ health (Betancourt, 1999; Breilh, 2013; Mendes & Dias, 1991; Dias, 1994; Dias & Silva, 2013; Feo, 2003, 2018; Kohen, 1997; Lacaz, 2007; Laurell & Noriega, 1989; Mendes & Lacaz, 1996; Minayo-Gómez, 2012; Minayo-Gómez & Thedim-Costa, 1997; Navarro, 1986; Rodríguez, 2005; Tambellini, 1978; Tambellini & Schütz, 2009; Vasconcellos, 2011)
As pointed out by Osmo and Schraiber (2015), in Latin America the social medicine movement emerged at the end of the 1960s and beginning of the 1970s. It was centered on appreciation of the social dimension as the sphere that determines the emergence of illnesses and health possibilities in disease prevention and health promotion. “Furthermore, the social dimension is the adequate sphere for intervention, beyond and in articulation with medicine as intervention in individual cases. Therefore, it is an alternative view to the biomedical reduction in which medical knowledge and practice structured themselves, even though with diverse explorations regarding the meaning of the appreciation of the social sphere” (Osmo & Schraiber, 2015, p. 205).
In fact, social thought in health in Latin America, including the important contributions of Juan César Garcia (1932–1984), Edmundo Granda Ugalde (1946–2008), and later Asa Cristina Laurell, among others, pointed to the importance of social class as an explanation of the distribution of health and disease in local, national, and regional society. Although this understanding was not new, historically in this region it was associated with social and popular movements. The causal social and economic explanations were not only academic or theoretical, but served as an argument and nourishment for mobilization against prevailing capitalist oppression. Movements such as “liberation theology,” struggles for land tenure, struggles for agrarian reform, the struggle against perverse working conditions, the defense of indigenous issues, issues of national sovereignty, popular participation, and others are, of course, of the original expressions of the workers’ movements for their own health. Hence the understanding that “worker health” is part of this movement and cannot be just a technical, scientific, or bureaucratic issue, but is a vital political and social issue, necessitating that workers themselves play an important role as protagonists (Breilh, 2003, 2013; Oddone, Marri, & Brainte, 1986; Spinelli et al., 2017).
For Jaime Breilh, “thanks to the social influence of the 1970s, the conditions were created for several nuclei of social medicine in Latin America to focus on the relationship between the capitalist social order and health, a scenario in which we were able to propose directly and in detail the use of the notion of social determination of health in epidemiology.” This notion, like any idea of rupture, argues Breilh, “is not the isolated product of personal ideas, but the expression of critical thinking that had taken over the Latin American movement of Social Medicine (now better known as Collective Health); to whose origin converged the concerns of mobilized groups, the development of new instruments of analysis and the presence of an express project of transformation of the obsolete paradigm of the old empirical-functionalist Public Health of the 1970s” (Breilh, 2013, pp. 14–15).
It is within this framework of reference, strongly Latin American, that the ideas of “worker’s health” were born and developed in this part of the world. Indeed, “they result from all assets accumulated in the field of Collective Health, with roots in the Latin American Social Medicine movement and significantly influenced by the Italian experience” (Minayo-Gómez & Thedim-Costa, 1997, p. 25).
For another Latin American thinker, workers’ health was born and developed “from concepts originating from the bundle of scattered discourses formulated by Latin American Social Medicine concerning the social determination of the health-disease process; Public Health in its programmatic aspect, and Collective Health in addressing suffering, sickness, and death of classes and social groups inserted in productive processes” (Lacaz, 2007, p. 757).
A distinct way of understanding work and health–disease relations, argues Lacaz, is introduced by the analysis of the social determination of the disease–health process, privileging the work. “Latin American Social Medicine apprehends it through the labor process, an explanatory category that is inscribed in the social relations of production established between capital and labor” (Lacaz, 2007, p. 758).
In fact, workers’ health considers work as the organizer of social life, as the space of domination and submission of the worker to capital, but also of resistance, constitution, and historical doing. “Workers assume the role of actors, of subjects capable of thinking and thinking for themselves, producing their own experience in the set of representations of society” (Mendes & Dias, 1991, p. 347).
Consequently, explain Mendes and Dias, the object of workers’ health can be defined as the health and disease process of human groups in their relation to work. It represents an effort to understand this process—how and why it occurs—and the development of intervention alternatives that lead to the appropriation by workers of the human dimension of work from a teleological perspective (Mendes & Dias, 1991).
However, “the analysis of work processes, by their complexity, make interdisciplinarity an intrinsic requirement that needs, at the same time, preserve the autonomy and depth of research in each area involved and articulate the fragments of knowledge, surpassing and expanding the multidimensional understanding of objects” (Minayo-Gómez & Thedim-Costa, 1997, p. 28).
In summary, “Workers’ Health comprises a body of interdisciplinary theoretical practices—technical, social, human—and inter-institutional, developed by various actors located in different social places and linked by a common perspective” (Minayo-Gómez & Thedim-Costa, 1997, p. 25).
As a field of knowledge, workers’ health “is a construction that combines an alignment of interests, at a certain historical moment, where the issues, politically placed, acquire relevance and there are intellectual conditions to discuss and face from scientific and epistemological points of view.” As a field of research, “Worker’s Health adopts certain methods of analysis, conceptualizations, or approaches. It applies its analytical instruments according to procedures that represent successive stages of approach to a problem or set of problems” (Minayo-Gómez & Thedim-Costa, 1997, pp. 25–26).
For the same authors, no single discipline can comprehensively capture the work–health process in its multiple and overlapping dimensions, from its socio-historical roots to the way it is concretized in work spaces. It is necessary, therefore, that “different researchers—imbued with an ethics that gives meaning to the task of thinking to transform—are capable of establishing convergent connections and correspondences between the parcels of knowledge that their disciplines contribute, in the construction of a common proposal” (Minayo-Gómez & Thedim-Costa, 1997, p. 28).
Finally, it is important to point out, most importantly, that “workers’ health starts from the premise that the empirical knowledge of the worker is essential knowledge for the transformation of processes and work environments and the set of interdisciplinary knowledge in the construction of new objects of knowledge” (Vasconcellos, 2011, p. 417).
These concepts and principles, inherited from “social medicine” and put into practice in “worker’s health,” have led to important advances in public health policies in Latin America and the Caribbean, including in Argentina, Brazil, Cuba, Ecuador, and Uruguay. The participation of workers and social movements in the formulation and implementation of public policies can be taken as a positive, concrete, and visible expression of this. However, advances in participatory policies and social control in worker’s health in these countries (whose results have been widely documented in studies, research, and publications) are subject to social shifts and can slip backward, due to macroeconomic policies and attacks on civil rights of free expression and popular participation. Therefore, the positive results obtained may not be long-lasting, and in some ways are an annoyance to neoliberal policies and new capital formations in this region of the world, as well as in other regions.
“Services” Approaches Based on “Occupational Health” Delivery
Finally, workers’ health could be seen as a practice of providing services, whether in health systems—public or private—or in or near workplaces. The focus of this conceptual and operational modality is to offer preventive, curative, and rehabilitation services so that workers can work healthily and productively. Some programs also offer health promotion activities, or health promotion at work. The spectrum of health services may include guidance on improving working conditions and environments, and other public health activities. Activities can focus exclusively on the prevention of work-related accidents and diseases, or can focus on all causes and expressions of morbidity, including those more common among aging workers. The best example, in this case, is programs and activities that are also targeted at chronic non-communicable diseases. Thus, the scopes are distinct, from the narrowest to the most comprehensive and inclusive. Extending programs and activities to workers’ families can broaden the relevance of these initiatives (Dias & Silva, 2013; Guidotti, 2011a, 2011b; Mendes & Dias, 2011; Minayo-Gómez, Vasconcellos, & Machado, 2018; Rantanen, 2011).
As explained by Rantanen, several countries have developed systems of occupational health protection, social insurance, and medical services that reduce the burden on the worker and reduce the loss to the economy. However, “these systems are not perfect, and they are often under stress. Developing countries often lack these systems or have them only in rudimentary forms . . . Occupational injuries and illness can become a significant drag on the economy by reducing productivity, increasing the burden of disability and illness on people, and causing financial insecurity” (Rantanen, 2011, pp. 4–5).
An example of the basic, fundamental (but too narrow) scope of occupational health services is found in Convention 161 of the ILO: “for the purpose of this Convention, the term occupational health services means services entrusted with essentially preventive functions and responsible for advising the employer, the workers and their representatives in the undertaking on: (i) the requirements for establishing and maintaining a safe and healthy working environment which will facilitate optimal physical and mental health in relation to work; (ii) the adaptation of work to the capabilities of workers in the light of their state of physical and mental health” (ILO, 1985, Article 1).
However, a more comprehensive scope is visible in the formal definition of the “objectives of Occupational Health,” as stated by the Joint ILO/WHO Committee on Occupational Health, in 1995 (see Table 3).
Table 3. Objectives of Occupational Health, According to ILO/WHO Joint Committee on Occupational Health, Updated in 1995
“Occupational health should aim at: the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the workers in an occupational environment adapted to his physiological and psychological capabilities; and, to summarize, the adaptation of work to man and of each man to his job.
The main focus in occupational health is on three different objectives:
Source: ICOH (2014).
As clearly stated by the International Commission on Occupational Health,
“it cannot be overemphasized that the central purpose of any occupational health practice is the primary prevention of occupational and work-related diseases and injuries. Such practice should take place under controlled conditions and within an organized framework involving competent occupational health services universally accessible for all workers. This practice must be relevant, knowledge-based, sound from scientific, ethical and technical points of view, and appropriate to the occupational risks in the enterprise and to the occupational health needs of the working population concerned.”
(ICOH, 2014, Introduction, Item 11)
In summary: “the primary aim of occupational health practice is to safeguard and promote the health of workers, to promote a safe and healthy working environment, to protect the working capacity of workers and their access to employment” (ICOH, 2014, Duties and Obligations of Occupational Health Professionals, Item 1).
Therefore, as can be seen, this section is more related to the traditional focus of “occupational health” than the “workers’ health” focus adopted in this text. There are not only small semantic differences, but historical, epistemological, methodological, and, in a way, political differences between the two as well.
It is worth noting that concerns for the health and safety of workers are part of the UN Agenda 2030 for Sustainable Development, in particular in its Goal 8, which aims at “Promoting sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all.” Goal 8 incorporates 10 topics, highlighting the issue of “decent work,” a traditional ILO point of struggle, now included in the goals of Agenda 2030. The challenges are immense, and depend on global development policies and full employment that values and respects workers (UNDP, 2019).
This brief article started from the historical roots of “workers’ health,” that is, from the historical place of the health of workers in public health. In constructing the workers’ health field, however, the inadequacy of traditional public health approaches (which gave rise to what is currently known as “occupational health”) becomes clear, as well as the increasing need for other approaches and interventions. These new or more structured approaches and interventions, characterized by the investigative focus on the processes of sickness of workers and their relation to work (why and how?), are to be constructed by organized workers, as builders of their own history.
However, from the perspective of the future, all signs point to a growing difficulty in achieving advances in the emancipatory agenda, given the destructive force and the intelligent strategies of capital in the context of the rapidly globalized neoliberal hegemony.
What to do? How to make it work? Who should do it? These are some of the big issues that remain to be addressed. In the current context, there are many more questions than answers. As the nature of work and the profile of workers changes, the health–illness profile of workers changes, and new ways of thinking and acting on “workers’ health” are required.
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