The experts tell us that 870,000 workers get sick and 55,000-60,000 workers die each year in the United States from an occupational disease.  They typically follow up these numbers with a caveat that these are undoubtedly underestimates. How much of an underestimate? Nobody knows. The image of an iceberg, with only its tip showing above water, and its massive bulk lurking unseen below, is frequently called upon to illustrate the idea.  Unseen workplace disease can neither be prevented nor compensated, and in fact, study after study confirms that the majority, probably the vast majority, of workers with an occupational disease never receive Workers’ Compensation benefits for their ailment.

The reasons for the under-recognition of workplace disease are multiple, and can involve all of the major actors in the Workers’ Compensation arena: employers, insurers, legislators, the workers’ compensation administrative systems, doctors, lawyers, and workers.  Part of the problem is simply an absence of data on the health effects of hazardous exposures. Since chemicals and other materials are introduced into workplaces without testing for adverse health impacts, absolutely nothing is known about potential toxicity for more than 85% of chemicals in use in industry. Obviously this burdens all the actors in the system with a huge handicap. But, in addition, routine training on known hazards and their effects is typically lacking, including for physicians who provide day to day health care for workers. The average doctor receives 4 hours or less of training in occupational medicine in a 4 year medical school curriculum.

The creation of more active barriers to the recognition of occupational disease also plays a major role in determining the size of that unseen part of the iceberg. Employers and Workers’ Compensation insurers have major incentives to deny a connection between a workplace exposure and disease. Every occupational disease that is not recognized saves them money by socializing the cost on to someone else, mostly injured workers, their families, and taxpayers.  Workers themselves may not want to suggest their health problem is work related, fearing they might lose their job or suffer retribution from an employer angered by a Workers’ Compensation claim.  And physicians are increasingly refusing to see patients with Workers’ Compensation claims, or are billing work related issues to regular health insurance. Physicians cite paperwork, delays obtaining diagnostic testing and treatment, and the overall hassles of Workers’ Compensation as reasons for their exodus.

Finally, aspects of occupational disease itself impede easy recognition. Some occupational diseases, particularly cancer, have long delays between the exposure and the occurrence of disease. Many occupational diseases cause symptoms that are easily confused with other more routine health problems. In addition, a disease might be caused by several factors of which a workplace exposure is just one. All of these characteristics make it more difficult for a worker or a doctor to make the connection between the workplace and the illness.

How can these issues be addressed so that workers made sick on the job receive the benefits they need and deserve? Reforming Workers’ Compensation to meet workers’ needs requires both an agenda and a strategy. Unfortunately, the Workers’ Compensation reform efforts of the last 20 years or more have been driven by insurance and employer interests trying to reduce their costs. Their savings have come at the expense of injured workers in most states across the country.  In this context, it has been difficult for injured workers and their allies to do much besides defend against the worst aspects of the business assault in a salvage operation. Despite the difficulties, injured workers and their allies need to go beyond defense to proposing and fighting for a broad agenda that offers a stark contrast to the business approach. Otherwise, further erosion of injured worker rights and benefits will be inevitable.

In the remaining space I will briefly suggest some of the general principles of an injured worker-focused Workers’ Compensation reform as well as a general approach to strategy. What is needed is an ongoing discussion among injured workers and advocates to flesh these and other ideas out in order to achieve a unified vision and action to move forward.

With regard to an agenda I would offer the following as a framework:
1) Workers’ Compensation reform should be focused primarily on realizing the original promise of Workers’ Compensation: rapid and adequate benefits for injured workers
2) Injured workers with an occupational illness (or injury) should not be denied health care or disability benefits while insurers and employers fight over issues of causation, treatment, and level of disability
3) Employers and insurers should pay for the real and whole costs of occupational disease and injury, without being able to socialize those costs onto injured workers and their families, or taxpayers
4) The direct financial relationship between physicians and insurers/employers should be severed, ending a significant conflict of interest.
5) Requirements for employers to facilitate injured workers’ return to safe work should be a part of the expected ‘treatment’.
6) The data collected by Workers’ Compensation should be available and utilized to discern patterns of occupational disease and injury which can in turn be used to guide preventive efforts to control workplace hazards.

The realization of the reform we envision will occur only with a movement that is politically powerful enough to effectively demand it. This means that it is essential for Workers’ Compensation to break out of its perception as a technical insurance issue of relevance to only a small minority of people.  To make the essential connections with potential allies we need to find a common language that will move people to see Workers’ Compensation in a new light. That could begin with the recognition that no one goes to work expecting to die or be exposed to a hazard that will drastically change the rest of their life. Workers have a right to expect their bosses will make every effort to protect workers’ health and safety, and that if they are injured or made ill on the job they will be taken care of medically, financially, and emotionally. Insisting on reframing the issue in this way could resonate broadly, and could win many allies who would now understand workplace health and safety as part of a broader array of not only worker rights, but moral and human rights.

Michael Lax is Medical Director of the Occupational Health Clinical Center in NY.