The general rule that state intervention begins when major state goals are threatened has been true not only in the hi
story of the public health system but for safety and health in the work place as w e l l . T o d a y 's system has a long history going back about 150 years and preceded by an even longer period when the knowledge of the deleterous effects of working conditions on health were known but no prevention was undertaken. The
state began to intervene in labour conditions only when serious threats arose to other goals, i.e. when the health of young men as recruits for the army was threatened.
There has been a large push of legislation at the Federal level in the 1 9 7 0 's to improve working conditions. This is most noti
cable in the area of toxic substances, where a fairly elaborate system of controls has been set up since. Knowledge of health effects formerly available only to a few experts is now begin
ning to be spread through the system of continuous education and thus to the shop floor. Although we have a long way to go yet, at least substances are controlled for their health ef
fects and labelled accordingly before being marketed (in amounts above 1 t per year in the European Commu n i t i e s ).
The improvement of rulemaking and enforcement in relation to dangerous substances in the work place might be considered a late adaptation to a risk structure that had really developed since the end of the century before. Other important areas of policy making, however, set rules that enabled preventive acti
vities in the work place in response to currently changing risk. They included a strengthening of the rights of employees and their representatives both in the enforcement of safety at work rules and in the planning stage of new machines, technolo
gies and procedures in their place of work; the right to conti
nued education for works council members; the provision of ex
pertise to the enterprise who now had to employ safety engi
neers and medical officers in an advisory capacity. These
improvements were not however, based on a thorough analysis of the risk structure of modern production regimes and the design of an appropriate preventive strategy. A thorough analysis re
veals the traces of expansion of the then existing organiza
tions into new areas offered by conflict over changing working cond i t i o n s . The resulting organizational setup between normset
ting and norm controlling agencies, as well as the resulting norms are, to say the least, complex, and show control deficits in relation to various risks. To give but one example, civil servants and public employees are not covered by the same pre
ventive provisions as private employees. Without further refe
rences to the deficiencies of the rule book it may be said^5 however, that the outstanding feature of todays' organization of work and health in the FRG are procedures to anticipate changes in the risk s t r ucture.
Health and safety in the work place as it stands today is an example of the complex cooperation between private, non-govern
mental and state organizations and includes the involvement of the person's whose health is at stake and their representatives.
Going through institutions existing today, the mandatory
workers' compensation funds38 cover almost all employees. They are administered jointly by representatives of workers and entrepreneurs, but financed solely by the entrepreneurs. These funds are important in
setting preventive standards in industry advising on technological innovations
training safety personnel for the companies
to name but a few of their obligations in primary prevention.
In tertiary prevention, the workers' compensation funds reha
bilitate employees who have suffered injury or sickness at w o r k 3 7 . Other than the general sickness benefit fund system, w o r k e r s ' compensation funds employ doctors and maintain hospi
tals and resthomes themselves.
Although the number of accidents in the work-place reported an
nually shows the necessity to improve this situation consi
derably, one should also say that with this system we have had a decrease of accidents per year and thousand workers from 118 in 1961 to 54 in 19893 8 . This is, of course, not only due to the quality of prevention, other reasons which promoted this decrease are changes in the type and risk structure of work.
Major criticism is directed at the Workers Compensation Funds because long-term health effects of working-conditions do not receive sufficient attention in their work. The most obvious problems are the occupational diseases, which are narrowly de
fined: They must be attributable to working-conditions and have to be contained in the catalogue of the w o r k e r s ' compensation fund. For more than 50 work related diseases plus, in theory, other conditions not specifically named, the employee has a
right to be healed, rehabilitated and compensated through the workers' compensation funds. However, this system of com
pensation and prevention does not function too well: Because the direct link between working-conditions and health effects is not as visible as it is in the case of an accident, these conditions are generally diagnosed first in the general medical system and many of the cases are probably ascribed to other causes. It is believed that only a fraction of ill health ac
tually due to working-conditions is ever notified to the
Workers Compensation Fund and a large fraction of these cases are rebutted because of the causality clause: Since the work relatedness of disease has to be shown beyond doubt, cases of litigation are drawn out and frequently end with non-recogni
tion, e.g. in cases of smokers working with chemicals known to cause lung c a n c e r ^ . One of the Workers Compensation Funds estimated in 1979 that only 1:1000 cases of cancer were due to working conditions, while conservative experts arrived at 5%
the same year and trade unions set the figure at 30%40. oi- seases that can also be caused during non-working-life have little chance to be recognized through the instrument of the Workers Compensation Fund, for example stress related diseases resulting from bad work organization.
An unsolved health problem are the so called work related di
seases (arbeitsbedingte Erkrankungen). This is the group of d i seases not contained in the catalogue of the Workers Com
pensation Fund but known to be related to working conditions, for example from occupational morbidity data.
State control over working conditions is organized by the L ä n der (Labour Inspectorate), it is organized on a Länder basis and encompasses both social conditions of work (working hours, protection of young people, women, mothers, disabled persons) and technical organization of work (machine safety, dangerous substances e t c .). This dual system of control by both Workers Compensation Funds and Labour Inspectorates is unique in Europe
(with the exception of Luxemburg). The two control agencies co
operate and cooperate also with the safety personnel and works councils within organizations. If this dual organization con
veys the idea that here a huge control system exists and every
thing therefore should be well in health at the work place, that impression will immediately be revised if one considers the meager staffing of these organizations, leading to few ac
tual control events of places of work.
In creating a healthy environment in the work place the elected body of the employees, the works councils, should also take an active r o l e . W o r k s ' councils are elective bodies of all em
ployees independent of their trade union membership, but to date, trade union representation on works councils is very high. Employee representation was an achievement of the revolu
tion at the end of the First World War; it was abolished during National Socialism but reinstated with added powers after the Second World War. After reforms in 1972 strengthening its rights still further, the works council now has rights which, if used in a proper manner, can influence conditions of work quite considerably. There are some severe limitations, however.
Enforcement can only be carried to the extent of the rule book, and there is the problem of limited resources as to time and knowledge. Works council members have the right to three weeks of further education per year in relation to their duties, but work and health is but one of them. In relation to planning new products and services, production lines, buildings and equip
ment, the rights of the works councils are rather vague and are a field of contest with the employer.
Practically all works councils collaborate with the trade union of their industry, who advise them on specific questions in the health and safety field. The trade unions have also set up an extended net of training for works council members in this area and special technology advisory agencies. These agencies have developed their capacities mostly in the field of information technology, but are getting into other fields, for example dangerous substances. Works councils also have the right to en
gage experts on matters of their concern with the employer ha
ving to pay.
Depending on size of the firm (by number of employees) and risk assessment' of the work places, the employers also have to ap
point qualified safety engineers and medical officers as ad
visers (since 1974) to the employer on matters of safety and health in the work place. Not covered are the smaller firms, where almost 50% of employees work. One full time doctor is generally required for a company of 2000 to 2500 employees, b e low that, time is bought on a part time basis. The system is most effective in large companies with a strong workers repre
sentation and not in the many smaller enterprises, where w o r king conditions deleterious to health may nevertheless exist.
Within the larger companies, which frequently also maintain their own sickness benefit fund for employees and their fami
lies, which have appointed medical officers to their safety staff, and which have active workers councils, activities of health promotion, support of health maintaining activities such as sports or canteens can frequently be found as w e l l .
Evaluations of the health and safety system carried out in the late 1980s found that employees in larger companies with a com
fortable economic situation are
- more likely to have their work conditions controlled by Workers Compensation Funds and Labour Inspectorate
- more likely to have works councils effective in the field of safety and health
- more likely to gain support from the in house safety at work organization
- more likely to enjoy social benefits such as canteens and sports fields supported by the employer, and health promotion pro g r a m m e s .
The whole system of safety and health at work is supported by research activities. There is a series of research institutes
starting with the Federal Research Institute for Health and Sa
fety at Work (BAU). Some institutes are carried by the A s s o ciation of the workers' compensation funds (HVBG) and also by the technical surveillance associations (TÜV) who are responsi
ble for the control of certain types of machinery in industry (but also for that of cars and machines in private use).
Currently the European Community is gaining more and more importance in standard setting in safety and health at work.
Although there are some examples of positive developments in relation to health and safety rules currently in force in the Federal Republic, overall consequences in the health and safety field are far from clear for the long run. To give an example, following the new EC-procedures, it will be possible to sell machinery in Germany conforming to the different safety stan
dards of other European nations, if test prescriptions and E u ropean industrial norms are lacking. As a result, works coun
cils would have to take an even larger responsibility for safe machinery than they had hitherto, putting larger demands on their working time and on their abilities. Another example is the shift in standard setting in relation to chemicals from the national to the EC-level. How will these new structures respond to the protective claims of a healthy public policy? An unknown influence on the quality of working life in the FRG is the cur
rent labour market situation in the now unified FRG, most li
kely to have negative effects on the quality of working life h e r e .
Although the German system offers fairly good structural so
lutions for the risk analysis of that very important aspect of the social environment, the work situation, it does not respond to all health risks of the working population. Currently, de
mands are being placed on the system to deal with these risks as well, expanding the responsibility of the health system just described. Efforts are being made to introduce health education and health promotion in relation to non-work-related risk fac
tors into the work place4 ■*■. Such an extension of preventive
ac-tivities would require some further improvements in the current system, since a recent a n a l y s i s ^ of the this system shows se
rious limitations within the structure of primary prevention in the work place:
- qualification and staffing of the professionals engaged now in the workplace health system are too narrow to deal with all risks of the chronic diseases with high prevalence in the
(working) population. In addition, these health risks cannot be dealt with by medical methods alone.
- the duties of the experts in the work place are narrowly defined, little scope is left for additional activities. This is as it should be since these experts were engaged to deal with the particular risk structure of that firm. Empirically, it is found that the system of experts is none too well inte
grated in the decision structure of most enterprises, since from the point of view of management their contribution to pro
blem solving has little bearing on existing technological and management p r o b l e m s .
If the scope of duties of the medical officers in the firm were to be widened to include preventive activities in relation to chronic diseases, this would very likely be possible only if management could integrate and use their knowledge for their own purposes; this opens a dilemma since the effectiveness of the medical officers to control actual working conditions would probably be lessened.
There are some other problems hindering a broader view of pre
vention by the medical system of the firm. One of them is the mechanistic definition of a health risk - that a certain health
impairment has to be measurable and is due to measurable and apportioned c a u s e s . This mechanistic view makes it easy to do nothing in an actual situation, where there is a mix of condi
tions. Hauß believes that in applying this concept, the pro
fessional avoids conflicts over the social, economic, indivi
dual and technical conditions of work. To acknowledge this mix would require, within the firm but also at the regulatory le
vel, new solutions beyond the narrow means of medicine as prac
tised today: Qualifications, time-regulations, social solutions would have to be discussed in relation to the current disease spectrum and regulated.
A second set of questions relates to the main thrust of ac
tivities of the medical staff in the firm. There is probably no disagreement that occupational medicine is a preventive disci
pline; but should medical activities concentrate more on the individual or on the technical conditions of the firm? No doubt it should be both, but how to decide on the proper allotment of effort? Empirical findings on performance and time distribution of medical o f f i c e r s ' on the shop floor show a heavy emphasis on person oriented activities such as examinations before and du
ring work, ordering personal safety equipment rather than spen
ding time in advising or consultancy in technical solutions.
This is certainly not the best time distribution in relation to the efficiency of primary prevention. In interviews it is ex
plained by time economy, exclusion from the planning process in the firm or simply by lack of technical understanding, since the principles of engineering are not included in the training of occupational medicine, at least in the FRG.
Companies following modern management principles, however, are beginning to place new demands on their d o c t o r s . They do not cherish their traditional orientation towards individuals which is often accompanied by attempts at health education. This view of the relationship between doctor and staff-member does not fit modern management approaches anymore. The doctor's opinion on health implications of new technologies may also be consi
dered valuable because investment in new technology is so costly that changes after the installment for health reasons cannot be tolerated.
A third complex of questions results from the new technologies the m s e l v e s . Will occupational medicine or work safety enginee
ring be able to deal with the demands for new design of work?
Designing new work flows, work-places and factories may increa
singly be the work of new specialists outside the field of the current disciplines. As far as the ever increasing use of che
micals in the work-place is concerned, their proper control may have to be dealt with by chemists, rather than e n g i n e e r s .
There are other developments of occupational medicine that are being discussed in primary prevention. One such development would be a greater emphasis on firm related epidemiological
studies. This is a duty which is defined in the present catalo
gue of legal obligations but does not seem to be in wide-spread use. A systematic application of this instrument could offer new insights for health promotion within the enterprise, and would serve to reorient the medical o f f i c e r s ' work away from the control of existing norms towards a wider understanding of primary prevention.
Whatever road towards extending preventive activities in the w o r k place taken, some conditions will have to be met:
- The time allotted to the medical staff should be increased.
The expert time calculated on the number of persons at risk is a rather limited resource considering the specified duties of the medical staff. In order to do more, the support of the e m ployers is needed. There are many cases where employers have demanded extended services in the past for example in the field of company programmes against alcohol or for f i t n e s s .
- Cooperation between employees and experts should be improved.
The employees themselves have to be involved in preventive ac
tivities, since they themselves are experts of their own health. It is they who should have the motivation to carry through health related activities, because they have to demand
healthy work places and support their representatives in the works council and in the trade u n i o n s .
- Criteria for success of increased health activities in the firm have to be defined and agreed upon between employers and e m p loyees. Obviously such criteria would have to reflect re
sults both in relation to economic as well as to health out
comes. For example, a reduction in the days of sick leave might be a measure for success that employers, employees and health
comes. For example, a reduction in the days of sick leave might be a measure for success that employers, employees and health