Journal of Health Sciences Management and Public Health SHORT HISTORY AND CURRENT STATE OF THE OCCUPATIONAL HEALTH IN

Lali Japaridze1

Abstract Following the break-up of the Soviet Union in 1991, there has been a significant decline in the standard of occupational health and safety in the newly independent Georgia.

This study was carried out as part of MSc dissertation work at the University of Birmingham, Institute of Occupational Health, to understand the existing status of occupational health care in Georgia, including its key legislation, human resources, professional development, arrangements for occupational health services provision, and occupational health research. Considering that Georgia is currently undergoing the process of legal harmonisation with Europe, this information was reviewed against some of the national European examples of occupational health services, and the provisions of certain EU and other international framework documents on occupational health.

The study involved series of interviews with the members of the occupational health and public health societies of Georgia, representatives of different Ministries, industries, and other relevant entities. Relevant literature and legislation was reviewed and analysed.

MATERIALS AND METHODS As part of this work, expert public health society of Georgia. Also interviews were conducted to included were Representatives of the understand the main features of the Ministry of Labor, Health and Social occupational health function in the Affairs’ State Sanitary Supervision country before independence. Inspection, the State Minister of Review its current status, and source European Integration. The expert opinions about what future management and safety represen- role occupational health should have tatives from three large industries in Georgia, and what steps need to that once had their own built-in be taken for its achievement. health care services including staff members of those health care units; The interviewees were comprised of and the representative from the distinguished members of the Georgian Trade Unions Amalgamation. academic, occupational health and Additional short discussions were held with people from organisations collecting data on current health 1 MSc degree in Occupational Health, University of activities in the country; Birmingham, UK 101 Journal of Health Sciences Management and Public Health

representatives of the State Medical In the Soviet Union all information University and its continuing about the registered occupational medical education unit, the diseases was confidential and was Academy of Sciences of Georgia. marked “for service use only”. This Internet and libraries were searched circumstance was partially for national Occupational Health responsible for instances of under- Care system descriptions. Occupational reporting or biased reporting of Health Care system analysis and occupational diseases by the international comparisons; examples enterprises. In addition, under- of financial systems used in funding reporting has been claimed to occur, Occupational Health Services; most because of the high incidence of significant international framework/ industrial injuries or occupational guideline documents on occupa- diseases contradicted the “image” of tional health; medical history books a Soviet enterprise. This was about health care in Georgia before supposed to ensure maximal care for and after Soviet rule. the well being of the workers. Whereas in reality, working HISTORICAL OVERVIEW conditions very often didn’t meet the OF OCCUPATIONAL HEALTH established norms. That were IN GEORGIA BEFORE established with the Basic Law on INDEPENDENCE Health in the USSR and Soviet A mandatory system of registration Republics, primary, specialised and, of occupational illnesses was to an extent, preventative health care introduced in the Soviet Union by a for workers was organized on an State decree as early as 1924. In “industrial” basis, with Medical - Georgia, all information about cases Sanitary Departments (MSD) existing of occupational illness was within large industrial enterprises. concentrated in one place, the Health care in the Soviet Union was Makhviladze Institute of Industrial curative in its orientation, reliant on Hygiene, Occupational and Health inpatient care and, to a lesser extent, and Ecology. Here experts analyzed on outpatient care delivered at the received data, prepared quarterly polyclinics. The system of MSD’s reports about the detected became particularly popular after the occupational diseases and 2nd World War when it served well intoxication’s, and forwarded it to the for the defense enterprises. Each Ministry of Health of Georgia with MSD was financed by a particular an accompanying explanatory note. enterprise, and usually included a Further, the report, checked and large multi-profile outpatient clinic. signed by one of the deputy Also a hospital with diagnostic and ministers, went to the Ministry of laboratory with in-patient Health of USSR in Moscow. capabilities a system of support facilities, access to designated

102 Journal of Health Sciences Management and Public Health recreational centers and spas, all of Apart from industrial MSD’s there which were designed to look after was a network of large departmental the health of the workers of that medical facilities that fell under enterprise and their families and parallel systems besides the Ministry were provided free of charge. of Health and served employees of a particular industrial branch or high- 15 MSD’s existed in Georgia, these ranking officials or dignitaries. belonged to the industries in Kvaisa Examples include the hospitals, (lead and zinc production); outpatient clinics, maternity homes (coal mining); Gori (light and other facilities under the Railway industry); (coal mining); Department; outpatient clinics of the Zestaphoni (ferro-alloy industry); Academy of Sciences, and so on. (machine – building industry); (manganese In most cases, MSDs did not employ mining); Inguri (paper and cellulose an occupational physician, but even manufacturing); 2 in (Aviation if they did, all suspected cases of factory and Isani); Kochubei (sheep occupational diseases had to be farming); 2 in (Metallurgy referred to the Institute in Tbilisi (see factory and Chemical plant “Azot”); below). During this time, despite the Madneuli. lack of formal occupational health training, over the years of experience For example, the MSD designated with a specific industry MSD doctors for Rustavi Metallurgic factory usually became familiar with the employed 300 staff1, and the MSD of more typical industrial hazards and the Chemical plant “Azot”, located occupational health problems for within 15 minutes’ drive from it, was that enterprise and were able to pick of a comparable size. The MSD at the cases at their early stages and refer Chiatura manganese mining plant them to the Institute. had a 250-bed hospital along with a large polyclinic, sanitary- A mandatory starting point of epidemiological station and a rendering health care on a site was a network of site facilities. Usually, so-called “health office” (zdravpunkt) the head doctor of an MSD run by a “shop doctor”, a “shop participated in weekly meetings nurse”, or a “feldsher” (who usually with the management of the had more training and clinical enterprise. autonomy than a nurse), - the staffing and the size were usually Where no designated MSD’s were determined by the enterprise as its available, an enterprise was assigned financier. These were not to a regional outpatient polyclinic. independent facilities; their work was supervised by one of the senior 2 At the peak of its activity the factory itself had MSD doctors; in case no MSD was approximately 15,000 employees available, by the head of a regional 103 Journal of Health Sciences Management and Public Health

outpatient polyclinic looking after showed that out of 207 “shop that enterprise [7]. Often MSD or doctors” participating in a polyclinic doctors ran daily sessions qualification improvement course in at the “health offices” and this was a occupational medicine in one of the formal part of their job duty. At the educational centres in Moscow. Only enterprise level, shop doctors were 12.5% (26 people) had ever attended accountable to the safety engineer. a similar course before and only 4 of them more than once. Most of those In Georgia, in the early days of the doctors had worked as “shop Soviet State, the number of doctors” for 15 or more years’ [8]. It “zdravpunkts” grew from 43 in 1931 is reasonable to assume that the to 206 in 1934 [6]. The same Chiatura situation in Georgia would have manganese enterprise had, for been similar. example, three doctors – and fourteen nurses – run “health offices” Each large enterprise had a Safety [9]. Department led by a Safety Engineer, usually a deputy Chief Engineer of The duties of a “shop doctor” the enterprise. The head of Safety was included first aid and emergency responsible for all occupational medical care in acute occupational health and safety provisions, intoxication’s and injuries; routine including organisation of site medical care; referral of workers for medical facilities. further treatment; regular reporting to MSD and the enterprise Some large enterprises also had management. In many cases a “shop special departments and labs looking doctor” played an important role in after working environment (air, the prevention of occupational ill water, soil) and industrial hygiene. health, participating in periodic For example, at Rustavi Metallurgic health checks, health awareness and factory this department used to be education site visits and risk under a deputy Chief Engineer and assessments, advice to management, had 15 employees looking after 125 regular health surveillance and workplaces (a workplace defined as rehabilitation of workers after illness. where people spent at least 5 hours Not infrequently, however, their role every day). Its roles included was limited to rendering first aid, carrying out risk assessments, stabilisation and referral. regular sampling, measurements of the levels of noise, vibration, In the majority of cases, neither MSD humidity, radiation, chemical staff nor shop doctors had special composition of air and so on. The training in occupational medicine. A staff was mainly chemical engineers, study, carried out in Moscow in 1987, sometimes doctor – hygienists, but this wasn’t mandatory. People were

104 Journal of Health Sciences Management and Public Health usually trained on the job; 2 – 3 key players responsible for months’ long training courses were environmental and occupational also available from Sanitary health in the country. The role of the supervision in Tbilisi; some people san-epid network was to undertake were sent to Russia for further risk assessments, inspections, and training. The factory paid for all such epidemiological surveillance, qualification courses. Where present, investigate disease outbreaks, carry these departments had close out environmental health functions working relationships with the local and other. The service covered the (city) sanitary – epidemiological use of chemicals, radiation, stations, as well as the Tbilisi-based communal services, work hygiene, Institute of Work Hygiene. There children – related hygiene, food didn’t appear to be any formal link hygiene, and was supported by their between these departments and the own labs for chemistry, bacteriology, enterprise “health office” or MSD toxicology, and physical factors. It staff; any relevant information was was a powerful service position for channelled through the safety whoever was chosen to hold the title, department. The Head Sanitary Physician of the Georgian Republic, was appointed Another key participant in the by the Cabinet of Ministers; his system of industrial health and safety orders were mandatory for were worker Unions. As part of a authorities of any level. Union’s overall role of carrying out public observation over labor Sanitary doctors work with protection activities, a system of so- hygienists to carry out inspections called “trusted doctors” existed, with and work site assessments; they one such doctor assigned to each issued hygiene certificates to all new industrial branch; in Georgia there facilities prior to their were 30 “trusted doctors” in total. commissioning; established Their main role was to observe how workplace hazards; carried out joint the industry complied with the assessments with the enterprise IH implementation of health and safety services in residential areas around legislation. Any unresolved issues the plant. They examined “sanitary were first raised with the top books” of employees; conducted industry management (e.g. a workplace assessments if an Minister, where applicable); if the occupational illness was suspected. issue persisted, in some cases the They also played one of the central Union’s management was raised it in roles in the organization of periodic front of the Government of the health assessments (see more below) country. in the industries and other eligible facilities. The Sanitary – Epidemiological Service, or “san-epid”, was one of the 105 Journal of Health Sciences Management and Public Health

The inspection work was divided as work hygiene research centres into two main parts: preliminary under the Workers’ Union system. assessments of facilities before their The VI Congress of Georgian commissioning; and ongoing Physicians (1934) had identified assessments per established occupational diseases as one of the schedule. Each facility “belonged” to main agenda topics. Industrial a particular san-epid station and each toxicology developed into a separate of the sanitary doctors – hygienists department within the Institute of used to have a specific number of Industrial Hygiene and enterprises assigned to them. Occupational Diseases in 1962. Additional visits were carried out if there were any complaints. The Department of Industrial Hygiene of Tbilisi State Medical Inspectors had significant power: Institute was formed in 1943; it was they issued warnings, participated in located at the Scientific – Research the development of improvement Institute of Industrial Hygiene and plans. Some enterprises were fined Occupational Diseases. Since 1974 it or stopped. is known as the Department of Industrial Hygiene and Occupational Being part of the law enforcement Diseases. From this time, system on environmental and development of work hygienists and occupational health issues in the occupational physicians started country, as far as the enterprises were actively in Georgia. In parallel, the concerned, san-epid also played a safety engineer’s position became constancy role and covered certain mandatory at large enterprises and areas of occupational health service these were mostly graduates from provision for them. the Georgian Technical University.

In Georgia, Prof. N. Makhviladze, Professional Development in following his return from Germany Occupational Health. Even in Soviet in 1926 founded the first polyclinic times, professional development in focussing on occupational diseases occupational pathology was in Tbilisi. During the very first year recognised as a problem area. Within of its existence, the clinic’s roles the system of higher medical became so diverse that in 1927 it was education, occupational pathology reorganised into a Scientific – was a mandatory clinical discipline Research Institute of Industrial at the faculties of Therapy, Hygiene and Occupational Diseases. Paediatrics, Military and Post 1929, in Tbilisi there were Preventative medicine (formerly, the institutes of Sanitation and Hygiene, Sanitary/Hygienic faculty). The full Social Hygiene, Industrial Hygiene undergraduate course of lectures in and Occupational Diseases, as well occupational medicine constituted

106 Journal of Health Sciences Management and Public Health

36 hours with an examination at the number of occupational disease end of the course. Any graduate from cases. the faculty of Therapy was then considered eligible to work as a The types of exposures, scope and “shop doctor” or an occupational composition of the examining team, physician [2]. along with the frequency of checks for each category, were prescribed by In contrast, the graduates of the law. Regional san – epid stations Sanitation and Hygiene faculty were responsible for determining (currently the faculty of Preventative eligible job categories at each Medicine) of the same Institute, enterprise in their area of whose syllabus included 144 hrs of responsibility based on the assessed work hygiene and 106 hrs of workplace exposures; the enterprise occupational diseases, were not management (with workers’ union’s allowed to work as occupational participation) developed individualised physicians. Upon graduation, they lists of employees and ensured their worked as doctor-hygienists in work, timely attendance. The checks were food, communal services and other carried out by a team of physicians fields of hygiene, mainly under the working for MSD or, in its absence, a system of sanitary – epidemiological regional polyclinic. The main stations. Occasionally these hazards of the job (e.g. lead) were graduates ended up working as usually identified. Across the occupational physicians but this was country, the Institute rendered arranged illegally. professional guidance for this process. Pre-employment and Periodic Health Assessments The system of Each identified occupational disease mandatory pre-employment and was registered and investigated. The periodic health checks for designated results of the periodic checks were professions existed in the Soviet discussed jointly with the relevant Union from 1922/25, while the latest medical staff and the enterprise Soviet Order (N555) on this subject management (safety engineer or the came out in 1989. Such checks were head of the safety department). The seen as the key to detecting results were documented. Often this occupational illness at its early summary document served as the stages, preventing its development basis for the planning of health and and improving working conditions. safety measures at this enterprise. It would be fair to say that periodic health checks were the central activity Depending on the condition detected in the field of occupational medicine during health checks the workers in general, and were regarded as the could have been offered the main lever towards reducing the following options:

107 Journal of Health Sciences Management and Public Health

1) ongoing surveillance by a doctor, pathology and work hazards by the if an illness or intoxication was examining physicians; poor suspected; organisation of the assessments, 2) treatment, - out-patient, in- including the available diagnostic patient or at a recreational centre; methods and tools, lack of attendance 3) temporary job transfer ( e.g. in the by the employees. The overall early stages of an occupational reduction in financing of the health disease or poisoning); care system from the early 70’s lead 4) permanent job transfer [7]. to its significant bureaucratisation. In some cases health assessments were By law, all patients suffering from done as a mere formality that occupational diseases, including at resulted in a “tick in a box”. Thus, the very early stages, had to be very often even quite advanced enrolled into a so-called forms of occupational illnesses “dispanserisation” program. A remained undetected, sometimes for regular supervision by a specialist years physician(s) carried out per strictly defined special guidelines and Diagnosing, Recording and schedules depending on the nature Reporting Occupational Illnesses. of the illness (e.g. cases of vibration Recognising the lack of knowledge illness were supervised by a of occupational pathology by shop neurologist. While occupational doctors, general practitioners or other dermatitis was treated by a non-occupational physicians, by law, dermatologist). Patients with only specialist occupational occupational diseases had to receive pathology centres had the right to in-patient treatment annually at the confirm the diagnosis of a chronic occupational diseases clinic of the occupational disease (acute Institute in Tbilisi. Once enrolled, poisonings were treated as industrial most of those suffering from an accidents). In Georgia, every patient occupational disease remained with a suspected case of an under the programme for the rest of occupational disease had to be their life, even when retired by age. referred to the Institute [1]. Prior to this, however, the employer or the Even though the management, san- referring physician, had to provide epid stations and others involved in a detailed sanitary and hygiene the process, usually took compliance description of the individual’s with the programme of pre- workplace prepared by a work employment and periodic health hygienist, and approved by the Head checks seriously, their quality left of the regional (city) Sanitary – something to be desired. This was Epidemiological station (its Sanitary mainly due to the poor Supervision Department). Without understanding of occupational such a report, as well as a detailed

108 Journal of Health Sciences Management and Public Health clinical reference, the case would not work due to an acute or chronic be considered. occupational ill health condition, and the cases of a temporary job transfer A clinical diagnosis must be based (up to 2 months), were decided by a on a published “List of Occupational Clinical / Expert Commission (CEC) Diseases” accompanied by its user that existed within the MSD or the guide. The latest “List” (Order N555, designated regional polyclinic. 1989) contained 7 broad headings Those affected received 100% of their (e.g. “poisonings”) and was pay; any difference between the organised in three columns: the permanent and the temporary job names of the diseases; hazards that salaries was compensated through a could lead to these diseases; and, a social security fund. tentative list of jobs and industries where the mentioned diseases may All cases of a more permanent loss occur. While the first two columns of professional ability had to be were exhaustive, the 3rd one referred to a MLEC to establish the provided only examples. degree of disability (I, II or III) and to quantify the percentage of loss of Apart from confirming/rejecting the professional ability due to an occupational nature of the referred occupational ill health condition. cases. The Institute experts Pensions for a disability, or the loss developed treatment plans, of the breadwinner, due to an provided specialist in-patient and occupational ill health condition, out-patient treatment of confirmed were given regardless of the cases, jointly with the sanitary – employee’s duration of work, and epidemiological stations developed were usually higher than those given proposals for measures to prevent for non-occupational disability. occupational ill health at certain Apart from the basic pension, those enterprises, carried out periodic suffering from occupational ill health visits / consultations / audits at had the right to seek financial “zdravpunkts” and MSD’s across the compensation from the enterprise, in country [7]. Part of the Institute’s an amount corresponding to the services was paid for by the percentage of their loss of enterprises where occupational professional ability established by illnesses occurred. MLEC (except in pneumoconiosis). The enterprise only paid this Disability and Compensation: In the compensation if it was found to be Soviet Union, in all confirmed cases at fault in the occurrence of the ill of occupational ill health that health condition. Often, such cases resulted in a degree of disability, the were resolved through a court. employees were eligible for certain benefits. Temporary release from

109 Journal of Health Sciences Management and Public Health

Current Status of Occupational population have led to worsening of Health Provision in the Country. living conditions of the population Following the break-up of the Soviet and have had a negative effect on the Union and declaration of the health of the nation [11; 23]. country’s independence in 1991, Georgia experienced a series of HEALTH CARE SYSTEM dramatic economic declines, which REFORM resulted in a sharp fall in the standard Since 1995 the health care system in of living. The economic collapse, civil Georgia has been undergoing a wars and flows of refugees, as well major reorganisation as part of health as the drastic reduction in public care reform supported by moneys to fund the system led to a international donor organisations. breakdown in health care. New concepts such as social Government expenditure on health insurance, privatisation, official user as a percentage of GDP dropped fees and new provider payment substantially from just over 4% in mechanisms have been introduced. 1991 to 0.59% in 1999 and is currently among the lowest in the European In 1999 the Ministry of Health joined region [15]. with the Ministry of Welfare to become the Ministry of Labor, Health Large enterprises went out of and Social Affairs (thereafter the business, dramatically reduced their Ministry). The Ministry is capacities or changed their profile. responsible for the implementation The main producers of agricultural1 of government policy on health care products (more than 90%) in today’s and medical research; its social Georgia are farming households, of welfare responsibilities include which there are more than 600 000. distribution of pensions and [25] provision of care for the disabled and other vulnerable groups. As a result of the decline in heavy industry, changes in agricultural As part of the reform, the practice, the development of small overwhelming majority of health enterprises, increased care providers in the country have unemployment and child labour, been privatized; they are including among internally autonomous from the Ministry, and displaced people, the country also are expected to manage their own experienced a structural shift in affairs. Republican hospitals, occupational exposure. In addition, research centers and medical schools wars, unemployment, and internal were kept at a national level. Much and external migration of the decision – making power and responsibility for funding at local 1 Agriculture contributes about 20% of Georgia’s level have been handed to twelve total GDP 110 Journal of Health Sciences Management and Public Health regional health departments that Inspection provide their have responsibility for the hospitals, methodological guidance and polyclinics and primary health care supervision. (PHC) services in the local area. According to the Code, the As part of the health care reform, the Ministry’s roles include: former Sanitary – Epidemiological - Establishment of the priority Service was divided into two parts: directions in this field the Department of Public Health and - Establishment of state norms the State Sanitary Supervision - Organization of scientific – Inspection within the Ministry. In research work; approval and 2003, the Parliament adopted the financing within the limits of the Law of Georgia, The “Sanitary Code state health care subsidy of Georgia” (8th May 2003), which program was designed to regulate legal - Organization and management relationships related to the provision of state sanitary supervision of a safe environment for human - Coordinating san – hygiene – health. Also to prescribe, the way the epid activities carried out by state supervision over the other agencies implementation of sanitary norms - Organization of social – hygienic and preventative sanitary-hygienic monitoring (such monitoring is and epidemiological measures. defined as the analysis, assessment and forecasting of the The author felt that a more detailed environmental and health data, as review of this law here would be well as establishment of causal appropriate and a brief informal relationships between the summary is provided below. population’s health and environmental factors, aimed at According to the Code [18], the providing safe environment for Ministry executes state control over the population’s heath) the State Sanitary Supervision Central - Development of the program of Inspection1 managed by the Head of sanitary and hygienic education Inspection appointed or released by of the public. the Minister. City and Regional State Sanitary Supervision Inspection All physical and legal bodies in the services are established with local, country are responsible for: city and regional, governing bodies2. - Observing sanitary norms The Ministry and the Central - Developing and implementing preventative sanitary-hygienic 1 And At-border Crossing Points Sanitary and sanitary – epidemiological Inspection 2 These are former san-epid stations that employ measures aimed against work hygienists and/or environmental health pollution of the environment; officers 111 Journal of Health Sciences Management and Public Health

occurrence of infectious and other They have the right: mass, non-infectious diseases and - To enter the facility under poisonings; the improvement of supervision according to the working conditions. legally established rule; - Informing relevant state bodies - Demand compliance with the about emergency situations, established sanitary – hygienic about industrial and norms within certain deadlines; technological processes that may - Only in exceptional affect the sanitary norm circumstances, take samples (free compliance; of charge) of air, water, soil or - Providing institutions of the State water… Sanitary Supervision with - Investigate and establish the information requested for the reasons for and the conditions of execution of their supervisory role. occurrence of occupational, infectious and mass non- The State Sanitary Supervision: infectious diseases and - controls poisonings; - develops measures aimed at a - Raise before the management of safe environment and issues the enterprise the issue of hygiene conclusions temporary release from work of - carries out hygiene evaluation those employees who have not and certification of facilities or been through medical products examination established for - applies official power over the certain “prescribed” jobs, and violators who carry the causal agent for the disease. The responsibilities of the inspectors include, (among other things): The Head State Sanitary Doctor (or ensuring timely implementation of his deputy) has the right to ban or norms by various physical and legal stop the operation of a facility, or bodies. Issuing them with hygiene industrial activity, until the violation summaries; taking part in the has been rectified or a hygiene identification, investigation of the certificate issued. S/he has the right spread, and the implementation of to take such cases to court. liquidation measures against occupational, infectious and non- Every facility is subject to a hygiene infectious mass diseases and certification, which is issued by State poisonings; controlling hygiene Sanitary Supervision’s institution. education of the “prescribed1” Such certificate is a mandatory pre- groups of workers. condition for the exploitation of a facility. The procedure implies 1 “Prescribed” refers to food and water-handlers as well as children care takers, health care and hygiene assessment of the facility (if communal services workers 112 Journal of Health Sciences Management and Public Health necessary with laboratory testing); INDUSTRIAL HEALTH CARE review of the presented documents After the collapse of the USSR the (hygiene certificates for the materials industrial health care system used, equipment, etc) and issue of described above fell apart. Like the the certificate. rest of Soviet health care, this system was very resource intensive and was According to the Code, any physical not economically viable: during or legal body must ensure Soviet times the state could afford to implementation of sanitary norms at spend even unnecessary funds. With their facilities and stop the activity the emergence of private enterprises where the norms are exceeded. It it could no longer be responsible for states that working conditions, the risks created by them, therefore workplace and work process must maintaining the industrial health care not harm worker’s health. facilities became both impossible and, to an extent, unnecessary for the The Code sets requirements for state. mandatory health examinations in that representatives of certain As a result of health-care reform in professions, enterprises, institutions the country, many of the old MSDs or organizations1 shall, as per and regional outpatient polyclinics Georgian law, undergo pre- have been privatized in the form of a employment and periodic medical Limited Liability Enterprise. examinations and that the enterprise administration (physical or legal In some cases MSDs continue to bodies) shall ensure the timely cooperate with “their” enterprises on examination of employees. Those a contractual basis. For example, who refuse to undergo such employees of Rustavi Metallurgic examinations shall not be employed. factory (now approximately 2000 of them) have been offered the It further states that the opportunity to purchase a private administration of an enterprise, insurance package allowing them to institution or organization shall, at get medical care from the MSD with its own expense, provide those a 60% discount. The plant continues employees working in hazardous to cover part of MSD’s costs (whose and dangerous conditions with staff is still 300), and the chief doctor medical care. continues to meet with the plant management. Until recently the MSD had real problems running itself as due funds didn’t get transferred for 1 The Ministry develops the list of hazardous and dangerous factors, work activities and long periods of time, while the occupations, as well as of those enterprises, customers’ ability to pay for the institutions and organizations, whose employees services has also been very low. must undergo medical examinations.

113 Journal of Health Sciences Management and Public Health

Now the situation has slightly Some of the former MSDs have improved reportedly. ceased to exist. The number of “shop” medical A similar system operates at the facilities and personnel has also currently privatized departmental reduced dramatically. It appears in polyclinic of the Academy of Sciences general that, even where large of Georgia. Those employees who industrial enterprises continue some volunteer to procure services from form of health care provision for staff, this polyclinic pay 3% of their salary1 it is limited to general health care, (and 4% for each family member they first aid and, in some cases, periodic subscribe) to access the agreed list of health checks, and does not extend services from this facility free of to any other occupational health charge. services.

MSD’s of the chemical plant “Azot” It must also be noted that and Tkibuli coal mining enterprise information on the existing MSDs are completely independent from (their numbers / form of activity) is these enterprises. Recently these hidden in the overall health statistics. MSDs started a program of periodic While data on site “health offices”, health assessments for the workers “shop” doctors, nurses, feldshers, or based on the contracts. Pre- the coverage of the working employment health assessments for population by these services is totally “Azot” employees are carried out at missing, - These entries do not even two local facilities different from the appear as separate items in any MSD, while for general medical care available statistical sources. the plant offers a voluntary medical insurance scheme, and the Despite the lack of official data it employees are free to go to any clinic could be assumed with a degree of or hospital they wish if they decide confidence that a large number of to purchase it. The MSD in small and medium size enterprises Zestaphoni is financed by the local that appeared in Georgia since the municipality. independence2 do not provide any form of workplace health service to All of these clinics are in a very their employees. difficult financial state, while their former patients cannot afford The largest Western Company treatment there in most instances. operating in Georgia has been offering its employees a combination of in-house and sub-contracted 1 This is on top of the 1% state health care tax. occupational and primary health 2 Estimates by the State Department of Statistics show that the non-observed economy accounts care services following a Western for more than half of the entrepreneurial sector’s model. The main provider of these activities and 33-34% of the country’s GDP [25] services is a recently established local 114 Journal of Health Sciences Management and Public Health private health care centre that offers malignant neoplasm’s –10.7%; GP, emergency and occupational gastrointestinal diseases - 2.8%; health care services, though the latter diseases of the respiratory system – is limited in its scope due to lack of 2.6%. Cardiovascular, respiratory, certain skills (e.g. industrial hygiene, ontological and certain infectious occupational psychology, diseases are generally on the rise. It ergonomics). Health professionals would be irresponsible not to involved in this service have better question whether cases of access to Western training occupational ill health are “masked” opportunities and are generally under general morbidity and better paid. mortality data, and what contribution uncontrolled workplace CONCLUSIONS AND exposures make in reality. Likewise, RECOMMENDATIONS even though no estimates of the According to the WHO, each year economic impact of occupational ill work-related injuries and diseases health have been made for Georgia, kill an estimated 1.1 million people the country cannot be immune from worldwide. This figure includes its significant burden on the national about 300,000 fatalities from 250 economy. million accidents that happen in the “In making the working conditions workplace annually. An estimated safe and healthy – the raison d’ être of 160 million new cases of work- occupational health – is in the related disease occur worldwide interests of workers, employers and each year, including respiratory and the government, as well as the public cardiovascular diseases, cancer, at large” (WHO) [27]. It is, therefore hearing loss, musculorskeletal and very easy to justify the need for reproductive disorders, mental and taking prompt action in the field of neurological illnesses. The economic occupational health in Georgia. impact of occupational ill health is Where, despite significant historical also well documented; the ILO has experience and a number of recent estimated that in 1997 the overall legislative and organizational economic losses resulting from work- initiatives, the overall impression is related diseases and injuries were that occupational health as such has approximately 4% of the world’s been forgotten or not given gross national product [27]. meaningful recognition by the In Georgia, occupational illness and decision-makers. injury data collection is extremely Experts interviewed as part of this poor. At the same time, according to dissertation work expressed their the official Medical Statistics Manual views about what needed to be done for 2002 [23], out of all deaths, 71.6% to improve the situation with died from cardiovascular diseases; workplace health and safety in the

115 Journal of Health Sciences Management and Public Health

country. Their recommendations can occupational health and be summarised as follows: industrial hygiene issues - New legislation, including 9 The process of legal harmonization 9 Enforcement of employers’ between Georgia and the European responsibility for Health and Union, as part of the Partnership and Safety Cooperation Agreement between the 9 Penalising system for non- two, covers the area of employee compliance protection in the workplace, 9 Mandatory insurance of identified as one of the legal workers against occupational harmonization priorities. Hence, the illnesses and injuries actions recommended below take 9 Provision of health care for the into account the latest European working population guidance and experience in the field 9 Strengthening primary health of occupational health care; their care provision likely feasibility under the country’s - Re-establishing the system and economic state; and Georgia’s increasing the quality and the historical experience and resources effectiveness of pre-employment in the field. and periodic health assessments - Strengthening the role of the The recommendations are in line Scientific – Research Institute of with WHO’s Global Strategy for Industrial Hygiene, Occupational Occupational Health for All [43]; Diseases and Ecology ILO’s Occupational Health Services - Increased role of the Workers’ Convention 161 [29]. They also meet Unions some of the main directions and - Improved understanding of new objectives outlined in the strategic occupational health hazards that document” Georgian Health System have emerged in the country Reorientation Major Directions” since independence (1996) [15]. Some of these - Improved financing of recommendations are also reflected occupational health and san - in the Sanitary Code of Georgia [18]; epid services, including facilities if addressed, they would facilitate the and installations available to implementation of the Code’s strong them principle “that working conditions, - Educating the general public workplace and work process must (including employees, not harm worker’s health”. employers and decision makers) A. Framework Legislation about their legal rights and labor It appears that in contrast to most protection issues industrialized states, Georgia still - Educating general practitioners doesn’t have a single legal act that and other health care providers in would establish a clear legal framework on occupational health

116 Journal of Health Sciences Management and Public Health and safety. The country’s policy in resources, shouldn’t follow the relation to occupational health isn’t positive examples, and mandate clearly stated; the roles and provision of modern occupational responsibilities of different players, health services for all employees by including various existing H&S employers, thereby pioneering this resources, aren’t specifically defined. initiative in the region.

Recommendations: Recommendations: - Adopt a national policy on - Mandate the provision of Occupational Health and Safety, occupational health services by and a framework “National employers for all employees by Health and Safety Act” in line law. Those self-employed may be with European Commission excluded from this requirement, Council Directive 1989/391/EEC but should nevertheless be [28]. Clearly define the roles of provided with a mechanism to different players: the state; the easily access occupational health employers; the workers and their services (e.g. through compul- representatives sory insurance) - Stress the significance of the - Formalise the new definition of employers’ responsibility for “Occupational Health Services” health and safety in workplaces; as being primarily preventative their legal obligation to perform (rather than curative) and multi- documented risk assessments, profile; and their minimum and to properly manage all health scope, with the focus on risk and safety risks involved in their evaluation and assessment; business activity surveillance of the work - Ensure that all other legislation environment and the health of concerning workplace health and workers; health education and safety is in line with the new Act promotion - Support (financially and B. Provision of Occupational Health institutionally) a Primary Health Services Care model of occupational As of today, most workplaces in health service (OHS) provision, Georgia provide no occupational but allow other forms; establish health service at all. Even though employers’ flexibility in how they globally only 5%-10% of workers in meet their legal obligation to developing countries, and 20%-50% provide OHS. Establish a of workers in industrialised Quality Control and an countries1 have access too adequate accreditation system for the new occupational health services. [27], OHS. There is no reason why Georgia, with its wealth of recent experience and

117 Journal of Health Sciences Management and Public Health

C. Other Relevant Legislation - Consider improvement of the Despite the existence of both new financial state of the San – Epid and old legal acts concerning Inspection: consider splitting workplace health and safety, some of their work into law-enforcement them do not address the issues and consulting roles, which they adequately, or in line with best could get paid for avoiding international practices, while others conflict of interest implications. even hinder the process. OCCUPATIONAL HEALTH Recommendations: RESEARCH AND DATA - Withdraw the piece of legislation COLLECTION that restricts the access of sanitary Despite the emergence of new, – epidemiological inspectors to poorly controlled or understood workplaces occupational hazards, brought about - Revise and update the by socio-economic changes, as well Presidential Decree N275 (1997 as other serious concerns, research in May 30) about “Medical the field of occupational health and examination of citizens etc.” in medicine has been extremely line with best European examples limited. Occupational health research - Introduce compulsory insurance priorities haven’t been established. against industrial injuries and Data collection systems and illnesses. Introduce a “no-fault” occupational health statistics are compensation principle virtually non-existent in the country. - Mandate reporting of occupational illnesses to the Recommendations: authorities and introduce - Identify priority occupational penalties to deal with non- health research areas for Georgia. compliance with this requirement Seek international technical - Develop an updated Georgia – assistance for this project specific List of Occupational - Include the identified priority Diseases based on European occupational health research recommendations topics into research topics supported centrally (or seek D. Law Enforcement sponsorship from international Recommendations donor organisations) - Improve the enforcement of H&S - Conduct an inventory of types of legislation through enhanced activities / hazards in Georgia in authority of the law enforcement collaboration with the State bodies; their staffing; Union’s Department of Statistics who have participation; employee experience in similar tasks education; system of penalties for - Conduct population-based non-compliance; other. epidemiological studies to assess

118 Journal of Health Sciences Management and Public Health

the occurrence and determinants education and awareness into the of work-related illness list of health promotion topics - Improve occupational health supported centrally or by local data collection and statistics on governments1. the following: Occupational illnesses Occupational injuries Such training courses on occupational health hazards / risks THE INSTITUTE OF / risk mitigation measures / risk INDUSTRIAL HYGIENE, assessment process, for the OCCUPATIONAL HEALTH AND industries, employees, medical ECOLOGY practitioners and others could be provided by the Institute, the It appears that the potential role of Institute of Hygiene, Sanitary the Institute’s resources and Inspection etc. experience, and the contribution it - Strengthen the existing under- could make to the management of graduate training program at the environmental and public health Medical University, which would concerns in the country have been require less money and would seriously underestimated. capture more people.

Recommendations: - With the involvement of leading - Clearly define the place and the local and, if possible, roles of the Institute in the international OH experts, Occupational Health Care consider what can be done System (see 6.3 above) regarding post-graduate training - Finance strategic parts of the availability in the country. Seek Institute’s activities centrally international sponsorship for this initiative TRAINING AND ROFESSIONAL - Likewise, consider the DEVELOPMENT IN introduction of professional OCCUPATIONAL HEALTH development of: occupational Training and professional health nurses, agronomists, development in occupational health occupational psychologists, and safety in Georgia needs to be agricultural advisors, and other addressed at different levels: OH OH staff in country - priority professionals, government officials, should be placed on the employers, employees, and the identified higher risks for public at large.

1 Such training courses on occupational health Recommendations: hazards / risks / risk mitigation measures / risk assessment process, for the industries, - Include occupational health, employees, medical practitioners and others safety and labor protection could be provided by the Institute, the Institute of Hygiene, Sanitary Inspection etc.

119 Journal of Health Sciences Management and Public Health

Georgia (see Research GENERAL recommendations above). The Government needs to recognize - Plan and deliver tailor-made Occupational Health and Safety as training programs addressing the one of its priority areas with needs of Primary Health Care significant implications for the units offering OH services. Train nation’s health and the country’s well the trainer – type programs with being. The Parliament of Georgia, the particular emphasis on risk Ministry of Labor, Health and Social assessment and other key tools of Affairs of Georgia, and other relevant ill health prevention in the ministries should give the above workplace should be given recommendations. Technical priority. Technical assistance assistance from international donor should be sought for these. organizations should be sought for supporting improvements in the field of Occupational Health and Safety in Georgia.

REFERENCES 1. Saakadze V. Occupational 9. Lezhava G., Tsereteli S. Public Diseases. 1st Edition, Tbilisi, Health Care in Soviet Georgia. “Zekari”, 2000 “Sabchota Sakartvelo”, 1984 2. Maltseva L.M. Current Problems 10. Ashurkov E., Barsukov M. of Occupational Pathology. Historical notes on the health care Moscow, 1989 in the USSR. 1957 3. Izmerov N.F. Work Hygiene and 11. Jaakkola JJK, Egorov A. Human Occupational Diseases. N1, 1983 health and environment. In: 4. Izmerov N.F. Occupational Environmental Performance Diseases. 2nd Edition, Vol.1, Reviews – Georgia. New York Moscow, “Meditsina”, 1996 and Geneva, United Nations 5. Big Soviet Encyclopaedia (BSE), Economic Commission for Vol. 20, p. 427 Europe, Committee on 6. Shengelia M.S. The History of Environmental Policy, 2003: 161- Medicine in Georgia. 1967 175. On-line version:http:// 7. Gratsianskaya L.N. Pocket www.unece.org/env/epr/ Consultant (“Spravochnik”) in studies/georgia/ Occupational Pathology. 3d 12. Big Medical Encyclopedia (BME), Edition, Moscow, “Meditsina”, Vol. 26, p. 1233 1981 13. Big Medical Encyclopedia (BME), 8. Maltseva L.M. Current Problems Vol. 6 of Occupational Pathology. 14. Georgia National Review on Moscow, 1989, pp. 18-21 Labour Protection prepared by

120 Journal of Health Sciences Management and Public Health

Occupational Safety and Health 19. Law of Georgia About Medical Information Centre. 2003 and Social Expert Certification. 15. Gamkrelidze A., Atun R., Tbilisi, 2001. Gotsadze G., MacLehouse L. 20. The Presidential Decree N48 Health Care Systems in About the rules of compensating Transition, Georgia. European damages to health occurred as a Observatory on Health Care result of accidents at work, Systems. Vol.2, n-2, 2002 Tbilisi, 1999 16. Telyukov. A., Paterson.M., 21. Regulation on the Investigation Gotsadze.G., Jugeli.L. Situation and Registration of Cases of Analysis for a New Strategy of Industrial Accidents, Georgian Technical Assistance in the Social Protection, Labour and Health Care Sector of Georgia. Employment Ministry. State PHRplus, Abt Associates Inc, Labour Inspection. Tbilisi, 1997 2003. 22. Information note on the scientific 17. The Register of the documents of directions of research in the common State sanitary–hygienic fields of occupational pathology, and epidemiological norms as of work hygiene and industrial 12 June 2003. toxicology in Georgia. Prepared 18. The Law of Georgia the by Scientific – Research Institute “Sanitary Code of Georgia”, 8th of Industrial Hygiene, May 2003. Occupational Diseases and Ecology in 1997.

profesiuli paTologiis ganviTarebis mokle istoria da Tanamedrove mdgomareoba saqarTveloSi

lali jafariZe statiaSi ganixileba profpaTologiis, rogorc calke saeqimo specialobis Camoyalibebis istoria saqarTveloSi. moyvanilia monacemebi, romelic Seexeba am dargis saorganizacio struqturis Seqmnisa da moqmedebis Taviseburebebs, muSa-mosamsaxureTa Sromis dacvis problemebs. avtori calke ganixilavs Sromis higienisa da profesiuli daavadebebis samecniero-kvleviTi institutis da imave dasaxelebis Tbilisis saxelmwifo samedicino universitetis kaTedris TanamSromelTa farTo samecniero-praqtikul saqmianobas, romelmac gadamwyveti roli iTamaSa dargis ganviTarebaSi. statiaSi agreTve moyvanilia monacemebi profpaTologiis samsaxurebis moqmedebis Taviseburebebis Sesaxeb evropis sxadasxva qveyanaSi.

121