Book Review

Occupation and Disease: How social factors affect the conception of work-related disorders

N Engl J Med 1996; 335:1245October 17, 1996

Article

Occupation and Disease: How social factors affect the conception of work-related disorders
By Allard E. Dembe. 344 pp. New Haven, Conn., Yale University Press, 1996. $37.50. ISBN: 0-300-06436-5

Technological changes in societies give rise to changing patterns of illness in populations. Shifts from farming, hunting and gathering, and reliance on walking or use of animals for transportation to mechanized modes of industry, communications, and transportation have been accompanied by a shift from the prominence of infectious diseases to the prominence of injuries and chronic illnesses. Innovation in medical technology has paralleled and often surpassed advances in the methods of manufacturing and production of goods in developed societies. Improvements in the way we diagnose diseases, identify their etiologic pathways, and develop methods of prevention also have profound effects on the patterns of illness in populations. In Occupation and Disease, Allard E. Dembe describes the history of the changing nature of work, the increasing prevalence of three groups of occupationally induced disorders, and the concomitant evolution of medical technology and specialties.

This book is unique in its focus on three very common conditions that often have an occupational cause, but that less often are the topic of historical discourse: cumulative trauma disorders of the hands and wrists, back pain, and noise-induced hearing loss. One chapter is dedicated to each disorder, with historical examples of the role of selected social, economic, and political factors in establishing the patterns with which these disorders present themselves in diverse populations. Woven throughout each chapter are powerful examples of the manner in which changes in physicians' perspectives have influenced social definitions of these conditions, the role of organized labor and workers' compensation laws in defining these disorders as work-related, and improvements in medical technology that have arisen from the increasing prevalence of these three groups of ailments.

Another theme that ties these three conditions together is the ambiguity of their signs and symptoms, the difficulty in reaching the diagnoses, and the multifactorial nature of their causation. This complex of factors has resulted in changing perspectives, diagnoses, clinical descriptions, and scientific understanding of each set of disorders. Another important common theme is the methods of prevention introduced by various industries in their efforts to reduce the economic and health effects of these conditions.

For those of us who took great pleasure in reading Bernardino Ramazzini and Alice Hamilton, this book is rich with historical examples. And for those who prefer to go straight to the point, each chapter includes a concise summary of the social, political, economic, and technological factors that accompanied the rise of back pain, cumulative trauma disorders, and noise-induced hearing loss. Appendixes summarize these factors and give the author's assessment of the importance of each factor in influencing each condition. Preceding and following the three disease-related chapters are an introduction to concepts and issues and a summary of how medical, technical, and social factors affected the recognition of these disorders as having diverse causes in the workplace.

To some extent, Dembe misses his own target. He does not develop a theory of the determinants of occupational disease, nor does he provide much evidence that social factors influence the medical definition of disease or its relation to work. Rather, he provides very clear evidence that changing clinical observations and new scientific knowledge affected physicians' recognition of these three conditions. He then demonstrates ways in which physicians' new understandings influenced social and economic definitions of the disorders.

Similarly, in his discussion of sex and cultural influences, he provides evidence that stereotypes influenced who was given a diagnosis, but not necessarily whether the diagnosis was determined to be occupationally induced. As for the development of a theory of the determinants of occupational disease, Dembe identifies 12 discrete social, technological, and political factors, describing their relation to the rise of each set of conditions. However, he offers little in the way of integrating these factors into an explanatory model.

Despite its limitations, this work is a useful contribution to the history of occupational medicine. It goes beyond the usual clinical and technical concerns, enabling the reader to understand the social context of the changing patterns of occupational disorders. The 12 factors Dembe assesses (new forms of technology, financial compensation, labor activism, economic instability, environmental concerns, cultural stereotyping, medical specialization, media attention, marketing efforts, military conflicts, political action, and economic costs) encompass a wide range of issues. The result is a classification of these factors in relation to the three occupational diseases.

Although these factors are well known to have influenced patterns of disease and our understanding of their relation to specific occupations, before this book was published, one would have had to bring together several treatises to obtain insight into all of them. This work brings them together in a single, comprehensive discussion of three common forms of illness and disability that arise from a wide variety of workplace conditions.

G. Marie Swanson, Ph.D., M.P.H.
Michigan State University College of Human Medicine, East Lansing, MI 48824