Book Review

Hazards of the Job: From industrial disease to environmental health science

N Engl J Med 1997; 337:355-356July 31, 1997

Article

Hazards of the Job: From industrial disease to environmental health science
By Christopher C. Sellers. 331 pp., illustrated. Chapel Hill, N.C., University of North Carolina Press, 1997. $45. ISBN: 0-8078-2314-7

Hazards of the Job traces the development of the field of occupational health from a “highly diverse, localized, and contradictory” body of knowledge to a more modern science based on quantitative, experimental techniques.

In late-19th-century America, occupational diseases such as lead poisoning and silicosis were on the rise but went unrecognized. Physicians were stymied by nonspecific clinical presentations, the lack of scientific data, an orientation toward individual patients rather than groups, and their own loyalties to factory owners. Workers tended to ignore symptoms, avoid doctors, and resist attributing their illnesses to their occupations, which could lead to job loss. Legal traditions favored employers and usually precluded linking workplace exposures to illnesses.

All this began to change in the early 20th century, at a time of rapid industrialization. An academic medical establishment arose, with faculty members dedicated to systematic observation and investigation. As social science grew, population data were systematically analyzed, both in academia and in organizations like the American Association for Labor Legislation, presaging what we would now call epidemiology. Social reformers and muckraking journalists denounced the unsafe working conditions the new information revealed.

Three people figure prominently in Sellers's account. The first is the legendary Alice Hamilton — Hull House activist, factory inspector, and the first woman on the Harvard medical faculty. Sellers emphasizes certain aspects of Hamilton's work — her reliance on empirical data (even if they were narrowly clinical and sometimes anecdotal), her exhortatory approach, and her direct appeals to the factory owners, with whom she shared a class background.

The next step was taken by Joseph Schereschewsky, an 1899 graduate of Dartmouth Medical School and an official of the Public Health Service. He saw his primary audience as physicians rather than factory owners. He pioneered what is now called the industrywide study, characterizing the entire health profile of a work force rather than the prevalence of a particular ailment, such as lead poisoning, and preferring direct clinical measurement to the reporting of symptoms. While Schereschewsky brought a certain objectivity to the field, his approach may, ironically, have diverted attention from occupational diseases. He focused on common diseases such as tuberculosis, minimized workers' reports of symptoms, and floundered, as Hamilton rarely did, on questions of causality.

The climax of Sellers's story is the pax toxicologica of David Edsall, the physician who founded Harvard's division of industrial hygiene after World War I. Here the emphasis shifted from field investigations to the laboratory. Exposure levels were measured, replicated in experiments, and codified with “permissible exposure limits.” Multidisciplinary research brought together physicians, engineers, and toxicologists. Public health advocacy soon gave way to “disinterested science.” Large-scale corporate donations were sought, initiating an uneasy partnership between industry and academia that survives today. For Sellers, Edsall's approach, with its “new levels of abstraction, generality, and detachment,” marked the emergence of occupational health as modern science and laid the groundwork for the environmental era of Rachel Carson's Silent Spring, René Dubos, and Barry Commoner.

Few aspects of medical history can be more richly textured than occupational health, with its roots in industrialization, labor struggles, Progressive Era politics, and early epidemiology and toxicology. Sellers's narrative includes plenty of engaging anecdotes, and the depth of scholarship, both primary and secondary, is impressive. But the book is difficult to read. The writing is dense and meandering. Historical narrative often raises more questions than it answers, but the most frequent question in my mind was, “What is he saying here?” The recurring, unconventional use of the term “industrial hygiene” is distracting; this term refers to a specific profession these days and has done so since World War II, but Sellers uses it to refer to all occupational health professionals from the 1890s to the 1940s, including physicians, social reformers, engineers, laboratory scientists, and others. And when the narrative turns to scientific issues, errors are disturbingly frequent. For example, Sellers suggests that carbon monoxide decreases hemoglobin levels, that inpatient treatment for lead poisoning was beneficial before the age of chelating agents, and that by studying individual chemicals the scientific challenge presented by mixed exposures could be overcome.

Hazards of the Job is full of historical parallels and lessons for today. With the French historian Michel Foucault, Sellers believes in the “disciplinary” power of knowledge and suggests that occupational health came of age through the force of its scientific paradigm. Perhaps. But as in 1900, many occupational diseases still go undiagnosed. Too many clinicians still think in purely clinical terms, ignoring the insights of clinical epidemiology. Some adverse consequences of work are still considered inevitable and are not categorized as “disease.” The profit motive still does battle with the protection of workers, and often wins. The power of knowledge about occupational health may have increased in the past 100 years, but in many ways the past echoes loudly in the present.

Howard Frumkin, M.D., Dr.P.H.
Rollins School of Public Health of Emory University, Atlanta, GA 30322