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Lippin Papers > Alternative medicine in the workplace
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Alternative Medicine in the WorkplaceRichard A Lippin, MD Workplace settings are ripe for the application of alternative medical interventions for a variety of reasons. Included among them are a shared interest in prevention hy hoth the occupational and alternative medicine communities, economic incentives hy corporations as major purchasers of healthcare to reduce healthcare costs and improve employee productivity, and the willingness of corporations to be dfferentially creative in their approach to delivering and purchasing health-care. This paper describes the US workforce in transition, provides an overview of occupational medicine including current programs and emerging issues, describes the current applications of alternative medicine interventions in the workplace, and argues forfuture expanded application of alternative medicine in workplace settings. (Alternative Therapies in Health and Medicine. 1996;2(1):47-51) WHAT IS OCCUPATIONAL MEDICINE? An inquiry into the application of alternative medicine in the workplace should begin with the recognition that this activity falls within the specialty of occupational medicine.1 This branch of preventive medicine is concerned with: •appraising, maintaining, restoring, and improving the health of workers through application of the principles of preventive medicine, emergency medical care, rehabilitation, and environmental medicine •promoting
a productive and fulfilling interaction of the worker with the
work through the application of the principles of human behavior SOCIOLOGY AND DEMOGRAPHICS To characterize and plan for alternative medicine at the worksite, it is important to describe the basic sociology and demographics of the US workforce. According to workforce expert and sociologist Ross Koppel, the civilian US workforce now totals more than 125 million, with adult men representing approximately 55.6% of this force and adult women, nearly 44.4%. White men no longer dominate the US workforce; the numbers of women and ethnic minorities continue to increase. The numbers of working older people, very young workers, and workers from other countries are also increasing. Furthermore, the average number of hours worked by an individual per year is increasing. In her book The Overworked American: The Unexpected Decline of Leisure, Juliet Shore reported that with more women holding down “real jobs” and the continuing need for labor at home, the total hours worked by Americans of both genders has increased since 1969 by 163 hours per year to nearly 2000 hours (on average and not counting another 900 hours of work done at home).2 In addition, workers are expected to change careers two to five times during a productive lifetime. Goods-producing industries employ approximately 29.3% of working individuals; service-producing industries including government employ more than 25.7%; and 45% of workers are employed in offices.3 The number of agricultural workers dropped from 7.1 million in 1960 to 3.1 million in 1985. The need for new personnel in environmental protection, energy development, and healthcare will increase openings for professional workers. Expansion of retail trade will lead to a greater number of salespeople; the hospitality, computer manufacturing, and robotics industries are growing as well. The number of businesses with a small number of workers exceeds the number of firms with large labor forces. Large firms are more likely to use some form of on-site occupational health facility; small businesses are likely to use the services of outside healthcare consultants because of the lower costs of ad hoc external medical care.4 LEGISLATION AND REGULATION To a large extent, occupational medicine programs are driven by federal and state regulations—pertaining to workplace safety and health as well as hiring, personnel, and benefits practices—that have accelerated over the past 20 years. Among the more important laws relevant to alternative medicine are the Occupational Safety and Health Act (OSHA) of 1970 and the Americans with Disability Act (ADA) of 1992. Both laws directly address human health and capacity issues that influence the requirements of occupational health programs. ON-SITE OCCUPATIONAL MEDICAL PROGRAMS A fundamental reality of the workplace as a site for medical services is that it is convenient for on-site employees who live in an increasingly busy society. This phenomenon and fundamental health economics increase pressure on employers to provide more primary healthcare at the workplace. Because the American workforce is essentially healthy, the more logical goal of occupational medicine should be to prevent illness rather than to treat the ill and injured. The various kinds of health-related activities that may be undertaken as part of an occupational medicine program are outlined below. • For regulatory and other reasons, occupational health professionals engage in a wide variety of examinations and evaluations.5 Examples include: (1) preplacement surveillance exams targeting specific exposure, (2) return-to-work and fitness for duty, (3) pre-expatriation and repatriation, and (4) periodic health maintenance evaluations. Besides providing an opportunity for the physician to detect occupational and nonoccupational risks and diagnoses, and provide data for individual and group analysis, these examinations allow the physician to interact with individual employees to discuss lifestyle and behavioral change. • Often, on-site occupational health programs also provide palliative care for limited, uncomplicated conditions. This care is geared primarily toward maintaining workplace productivity. For example, the practitioner may provide medication for mild upper respiratory infection, mild gastrointestinal upsets, menstrual cramps, headaches, and mild skin conditions. • The primary responsibility of the occupational physician is the management of occupational illnesses and injuries that can be both complicated and prolonged. • In corporate settings emphasis on fitness and wellness programs, including scientifically based exercise, recreation, and a wide array of health education and behavioral change seminars, is growing. • Employee assistance programs, which began in the 1970s, have successfully addressed many mental health issues affecting workers but often have failed to address adequately the major issue of workplace stress. • The workplace can be viewed as a logical, accessible location for delivering a wide range of primary and secondary preventive medical services including medical screening and immunizations. • Many safety-sensitive industries (such as transportation, nuclear, and chemical) conduct drug and alcohol screening. •
Occupational physicians and other health professionals are in
a unique position to advise employees on appropriate uti • Occupational physicians may also participate in planning, providing, and assessing the quality of employee health benefits. MAJOR AND EMERGING ISSUES IN OCCUPATIONAL MEDICINE Because of the trend in the 1980s toward corporate restructuring, which led to corporate downsizing, workplace stress has increased. In addition, the cost crisis in healthcare is forcing companies to use the workplace to emphasize prevention and the importance of managing both nonoccupational and occupational illnesses and injuries in a cost-effective manner. The Circadian Group, based in Cambridge, Mass, has stated that in order to be competitive in the 21st century, US industry must move from a machine-centered technology to a human-centered technology that requires increasing reliability on human performance, with an emphasis on protection of human assets. These issues all affect planning for occupational medicine, including alternative practices, at the worksite.6 Some work-related issues that may prove amenable to alternative medical practices are described below; potential alternative medical approaches to these problems are presented in the following section. In
1983 the National Institute of Occupational Safety and Health
(NIOSH) listed 10 leading work-related diseases based on their
frequency of occurrence and amenability to prevention (Table).
Although viewed by some as highly controversial, these 10 remain
on NIOSH’s priority list, a list that has been borne out
in part by recent so-called epidemics in occupational medicine,
including occupational stress and cumulative trauma disorder. Work-related diseases based on frequency of occurrence and amenability to prevention
Job stress is another problem at an epidemic level in this country.8 Stress clearly is the major cause of productivity decline in the US workplace, with three stress-related disorders—chronic pain, hypertension, and headache—accounting for 54% of all absences, or $15.7 billion of the $80 billion loss in wages every year. Although definitions of job stress vary and more objective measures must be developed, 30% of adults report high job stress nearly every day, and an even higher percentage, once or twice a week. In a 1991 study by Northwestern National Life Insurance it was reported that more than one third of the respondents were considering changing jobs because of job stress. In California the prevalence of claims for gradual mental stress more than doubled from 1980 to 1982, whereas claims for all other disabling injuries actually decreased by more than 10%. Furthermore, mental disorders are the most prevalent (21%) of disabling conditions among recipients of Social Security Administration funds for disability. When the New York Business Group on Health polled 201 personnel and medical directors of small, midsize, and large corporations, the results were that depression affected 24% of their employees on the average, and led to an average loss of 16 days of work annually.9 Violence in the workplace, including homicide, is also a growing concern. In a June 1991 letter10 the author proposed a new research model for the common cold that implicates stress, suggesting that although the presence of a virus may be indisputable in each case, it does not necessarily play a causative role and that, anecdotally, a direct correlation has been found (by the author) between periods of intense stress and the onset of a cold. The situation is proposed to involve a parasympathetic breakthrough or payback phenomenon that others have misdiagnosed as being caused by a virus. The phenomenon produces symptoms typical of an overactive parasympathetic nervous system, including increased mucus, sweat, and tear production; generalized muscle aches; and nausea and diarrhea. Related to this hypothesis, in August 1991 Sheldon Cohen and colleagues at the University of Pittsburgh reported an association of psychological stress with increased incidence of the common cold.’5 Other topical issues that are emerging in occupational medicine are air quality, multiple chemical sensitivity, environmental tobacco smoke exposure, shift work, vigilance and fatigue, and travel, especially international. Upper respiratory infections still account for a large percentage of lost work days, and back injuries make up 20% of occupational injuries in the United States, costing as much as $30 billion each year. Some sources predict that 80% of the working population will at some time during their careers experience significant low-back pain. Some 20% to 25% of all the back claims in industry account for 90% of the costs of such injuries.12 The National Safety Council estimated that in 1986 approximately 10,800 deaths resulted from accidents in the workplace. In addition, 1.9 million people sustained work-related disabling injuries, and total work accident costs for 1984 were estimated at $32.4 billion.4 APPLICATION OF ALTERNATIVE MEDICINE INTERVENTIONS IN THE WORKPLACE Alternative medicine is practiced infrequently in the US workplace, with some notable exceptions such as massage, acupuncture, and informal nutritional interventions. Procedures that promote alertness, relaxation techniques, and arts-medicine (a study of the relationships between human health and the arts) interventions are beginning to be used as well. • Among the more successful alternative medicine interventions in the workplace is on-site massage therapy. Although precise statistics in the field are not yet available, Elliot Greene, past president of the American Massage Therapy Association, indicated in a 1995 letter (to the author) that more than 80 companies, many of which are Fortune 500 companies, are using massage therapy to counter such ills as musculoskeletal problems, stress, and poor ergonomic design of furniture. The association itself has grown from 1500 members in 1983 to 22,000 members in 1995, with accredited schools increasing from 12 to 60 during the same period. Companies offering on-site massage include Apple Computer in California, Merrill Lynch and NBC in New York, the Dallas Herald Tribune, SmithKline Beecham and Conrail in Philadelphia, Ben and Jerry’s Ice Cream in Waterbury, Vt, and Wampler Longacre Chicken Company in Virginia. The latter provides an around-the-clock massage therapist for more than 1000 workers in its large poultry plant in an effort to decrease the incidence of cumulative trauma disorder. A typical on-site massage takes about 15 minutes and costs much less than a full-body treatment, with charges based on the length of the session. The client remains fully clothed and sits on a stool or a specially designed chair. The finger pressure techniques used in this approach are adapted from traditional massage and Oriental styles of acupressure massage. Similarly, the growing popularity of office massage appears to be linked to a dramatic increase in repetitive stress injuries related to intensive use of computers; the emphasis is on massage of the neck and shoulders.’3 In an unpublished 1993 manuscript, Field and colleagues of the Touch Research Institute, based at the University of Miami School of Medicine, reported preliminary findings of a job stress study designed to assess the effects of massage therapy on job-related stress and anxiety and also productivity and job satisfaction. A 15-minute chair massage was provided twice weekly during lunch for S weeks. In preliminary results participants reported feeling less fatigued and being able to think more clearly. Electroencephalogram, alpha, beta, and theta waves were altered in ways consistent with enhanced alertness. Math problems were completed in approximately half the time required without massage, with approximately 50% fewer errors by the end of the intervention; also, anxiety levels were lower at the end of a 1-month period. • Acupuncture has been used in some smoking cessation interventions. According to corporate medical director Peter Devine, MD, of Bell Telephone of Pennsylvania, an auricular acupuncture “clip” technique has been successful in some cases. • Regarding nutritional interventions in the workplace, current practices are likely to be informal and voluntary, with workers dosing themselves with vitamins or other nutrients that they believe are likely to improve their health. However, if clearer proof becomes available that such practices do promote health, company cafeterias can be readily modified to take advantage of an increased emphasis on nutrition and health and the link between food, stress, and performance.’4 Because upper respiratory infections occur frequently in the workplace, vitamin therapy, as first promoted by Linus Pauling in 1970 and recently confirmed by researchers from the University of Helsinki and the Linus Pauling Institute of Science and Medicine, might be of particular interest as a potential method of reducing the severity of colds.’5 In addition, interest is increasing in the concept of chemoprevention, or use of (antioxidant) vitamins (vitamins C and E, for example), as a method of reducing one’s risk for cancer.’6”7 Although only a decade or two ago efforts at chemoprevention were not regarded seriously, this approach is now being studied in many major cancer centers around the world.” This development has implications for prevention of both occupationally and nonoccupationally induced cancer. The incidence of occupational cancer ranges from 0% to 5% of all cancers”; however, the public has the perception that industrial processes contribute to and possibly cause cancer in a significant number of cases. It may be helpful for industries to engage in chemoprevention techniques at the workplace—supplying antioxidant regimens to their employees to decrease the risk of contracting cancer, regardless of the cause. •Employee alertness is beginning to be addressed by some alternative medicine techniques. Dr Martin Moore-Ede, president of Circadian Technologies, Inc, and associate professor of physiology at Harvard Medical School, has stressed the importance of alertness, indicating that modern managers must learn how to select and train teams of employees, schedule work and rest time, and organize work paths to ensure that safety, productivity, and quality are maintained 24 hours a day. Because of increased international travel, Moore-Ede also cites the need to learn how to combat jet lag by using scientific breakthroughs that have enabled us to control the biological clock. For example, the discovery of the role of suprachiasmatic nuclei in the hypothalamus in generating rhythms of sleep and wakefulness, and the identification of the phase-response mechanisms by which bright light (approximately 2500 lux) resets this biological clock, have laid the groundwork for new techniques for precise control of the timing of sleeping and waking, alertness, and performance. In The Twenty-Four Hour Society,7 a book that addresses the future of work, Moore-Ede describes technological breakthroughs for increasing alertness including strong doses of bright light, redesign of control room environments, and visors that supply strategic shots of light while the wearer is aloft. Because the alertness or drowsiness of employees can now be precisely measured using brain wave (electroencephalogram) and eye movement (electro-oculogram) analysis, precise design specifications for ensuring employee alertness can be determined. Jobs and workplaces can be designed to promote alertness by building in such stimuli as muscular activity, light, temperature, sound, and aroma. Interestingly, third shift workers at the Nestle Food decaffeination plant in Illinois do not need to drink coffee to stay awake, perhaps because an aroma promotes alertness either by psychological association or by direct inhalation of caffeine.6 • Among the most widely accepted methodologies for addressing workplace stress are various relaxation techniques. Herbert Benson, MD, a mind-body pioneer at Harvard Medical School, defined the relaxation response in 1974.~’ The relaxation response is defined as a series of coordinated physiological changes elicited when a person engages in a repetitive mental or physical action and passively ignores distracting thoughts. The alterations include decreases in oxygen consumption, heart rate, respiratory rate, and blood pressure, and increases in the intensity of alpha, theta, and delta brain waves. These are the opposite of changes that occur during the stress response. The Center for Corporate Health and the Center for Training in Mind/Body Medicine have become integral parts of the Mind/Body Medical Institute that Benson directs. Other prominent leaders in the work-stress management area are Robert Elliot of the Institute of Stress Medicine International in Littleton, Cob; Richard Rahe at the Nevada Stress Center, University of Nevada School of Medicine, Reno, Nev; and Myrin and Joan Borysenko of the Mind/Body Health Sciences, Boulder, Cob. It is also notable that Mutual of Omaha Insurance Company recently decided to provide coverage for a program designed by Dean Ornish, MD, a cardiologist who integrates nutritional principles and meditation into his regimen of cardiovascular disease prevention.2’ •In another approach to stress reduction, the new field of arts medicine involves the application of the arts as a therapeutic or preventive intervention in the form of one or more types of art therapy.22 Also of interest to employers and employees is the potential for the arts to serve as a creativity enhancer. ARCO Chemical Company, an international corporation headquartered in Newtown Square, Pa, under the author’s medical direction, sponsored art and creativity workshops led by a professional artist who taught techniques for drawing faces in a self-esteem—building exercise. It is now generally recognized that aesthetic stimuli including light, color, sound, rhythm, and even words may have a salutary impact on human health.23’24 Furthermore, ARCO Chemical Company has introduced, as part of the health education component of its fitness and wellness program, a session called “Lunch and Laugh,” which exposes employees to humorous stimuli and elicits laughter to reduce stress during the lunch hour. This program is based on the hypothesis—advanced by Norman Cousins25 and the physiological research of William Fry26 of Stanford University—that laughing has a salutary effect that can be measured. Similarly, in 1985 the author proposed using stress-releasing techniques at the worksite to reduce both illnesses and accidents.27 Techniques besides laughter that are likely to reduce stress include crying, writing, and hitting or kicking exercises.2’ FUTURE APPLICATIONS OF ALTERNATIVE MEDICINE IN THE WORKPLACE Future applications of alternative medicine in the workplace are limited only by the creativity of healthcare providers and the courage of the business leaders who control the purse strings of health coverage. As we enter a postindustrial era in which human-centered technology is stressed, health and human performance will be increasingly valued in corporations whose leaders wish them to remain competitive. Emphasis at the workplace will continue to be on prevention of health problems and on alternative medicine practices whose products and interventions achieve this goal. Some of these approaches have been discussed in this paper. Many other legitimate alternative medical interventions are likely as well to have potential application in the worksite. Alternative medical interventions are relevant to off-site as well as on-site healthcare services. Because corporations represent a major purchaser of off-site healthcare services, creative corporate medical directors can assist with benefits planning to ensure appropriate consideration of alternative medical third-party coverage. Hence, corporate medical directors should make an effort to understand alternative medical practices that relate to treatment as well as those that are useful for worksite prevention practices. Off-site healthcare services may include those that are targeted to pain management and short-term and long-term occupational and nonoccupational disability case management. The burgeoning area of human performance issues for employees from executives to hourly workers also provides opportunities for alternative medical interventions. These issues, which include alertness, stamina, and certain cognitive or physical skills, represent a recognition that the prevention and treatment of illness are not medicine’s only goals. In healthy working populations, the enhancement of human performance may be addressed. A positive aspect of this trend is that capacity enhancement emphasizes that which is healthy within an individual, rather than stressing pathology, as Western medicine so often—and perhaps necessarily—does. This approach might be described as the rebirth of medical optimism. Occupational medicine professionals must exercise caution in the area of employee performance and not be tempted to prioritize performance over health, which might place the employer’s interests ahead of the employee’s. Properly integrated, performance and health should support one another. SUMMARY Applications of alternative medicine at the worksite are already being used in a limited way, especially massage therapy and relaxation techniques. Corporations, as both major providers and purchasers of healthcare, can be an especially potent force in advancing safe and effective alternative medicine at the worksite. Many social factors argue strongly for advancing alternative medicine at the worksite. These include the centrality of work in our lives, the rapidly changing face of America’s work-force and the nature of work, and the desire for the United States to remain competitive in a world economy.
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