What is occupational health provision like in South Africa? Diane Smith, an OH nurse based in South Africa, explores the key differences with the UK and reflects on the case of a worker with asbestosis.
There are some differences in the role of an occupational health nurse in the UK and South Africa, but my personal experience has been that we hold common skills and with minor adjustments and training. OHNs can apply their skills in other countries.
In South Africa, two pieces of legislation define and support OH service provision: the Occupational Health and Safety Act 85 of 1993 (OHS Act) and the Compensation for Occupational Injuries and Diseases Act of 1993 (COID Act).
Unlike the UK’s Health and Safety at Work etc Act 1974, which does not refer explicitly to occupational health, in South Africa the OHS Act defines an occupational health nurse (OHN) as a person who holds an occupational health qualification recognised by the South African Nursing Council (SANC).
Generally, organisations provide in-house, on-site, OH services delivered by an OHN directly employed by them, but some use external service providers on a full- or part-time basis, either based on site or via a mobile unit.
As most people in South Africa cannot afford private healthcare, OH services commonly provide a limited primary health care service for all employees. The general health service provision for the population is applied in two ways: government health services and private health care membership. The choice of service is affordability-based; private healthcare provision is speedy but costly, and is usually funded by private medical insurance, but for the majority of South Africans (71% of the population) a government option is available.
The management of chronic medical conditions, family planning, and the provision of health promotion programmes are common requirements of an OHN-led service in South Africa. OHNs also have a significant role in HIV counselling, testing and, where necessary, undertaking nurse-initiated and managed anti-retroviral treatment for those who are HIV positive.
Drug and alcohol misuse is a community health challenge in many areas of the country and many organisations have zero tolerance policies to drugs and alcohol. Drug and alcohol support programmes are available at most workplaces, and most OHNs support employees dependent on these substances and provide guidance for referral to recovery services, which are funded by either the business or the employee themselves.
Training and regulation
OHN training in the country is undertaken as a post-basic qualification. Unlike in the UK, a prerequisite for undertaking the training is that the nurse must also have a post-basic qualification in midwifery.
Many are required to be on call 24 hours a day to provide guidance, advice and support to organisations’ health and safety representatives.”
Until 2022, most training for OHNs had been offered at a Bachelor (Hons) degree level, but South Africa has now implemented a 10-level National Qualification Framework, and the specialist OH qualification is offered as a postgraduate diploma. The transition to this framework has resulted in a hiatus in specialist nurse training, which is contributing to a shortage of specialist OHNs. At present, five universities have been approved by the SANC to provide OH training for nurses, which will hopefully improve the availability of OHNs.
Like the UK’s Nursing and Midwifery Council, the SANC regulates the education and training of nursing and includes the registration of additional qualifications. The OHS Act requires that a trained OHN manages OH services in all settings.
As is the case in the UK, health surveillance – termed “annual medicals” in South Africa – is a statutory requirement for employees exposed to workplace hazards such as noise, vibration, biological agents, and hazardous chemicals. As many services have a primary care facet, OHN training includes skills in physical assessment, diagnosis, treatment and dispensing of medication. Dispensing licence training must be completed, and a dispensing licence must be obtained from the National Department of Health. OHNs who undertake audiometry are required to have the relevant certification and registration with the Department of Labour as an audiologist.
The OHN is supported by an occupational physician who takes responsibility for the overall provision of the OH service. Nurses undertake clinical assessments and, in consultation with the physician, treatment and support plans are defined and implemented. In the event of a site emergency, the physician is available to support the OHN.
Emergencies and injuries
OHNs are responsible for the provision of a workplace emergency response for all work-related injuries and/or illnesses. Many are required to be on call 24 hours a day to provide guidance, advice and support to organisations’ health and safety representatives. As the OHN has knowledge of the employees` medical history, they can make informed decisions about care or treatment to support an early recovery and timely return to work.
Under the COID Act, organisations must pay a percentage of their annual salary bill into a fund, which pays compensation to workers who are injured or contract a disease at work and experience a loss of earnings. The COID Act defines what an injury is and its accompanying financial compensation, and the fund pays all accompanying medical costs for treatment in a private facility.
It is this fund that would potentially compensate employees who have been exposed to asbestos at work, which is a major issue in South Africa. Miners exposed to asbestos are covered in a similar way by a fund, under the Occupational Diseases in Mines and Works Act 78 of 1973.
Case study: health surveillance and asbestosis
As in the UK, health surveillance is a statutory requirement and a crucial element of an OHN’s role. The following case highlights the role of the OHN in health surveillance and the importance of considering both the medical and social circumstances of workers.
Asbestos
A maintenance fitter with more than 10 years’ service attended my OH unit for their annual medical assessment. Part of this assessment required a triennial chest X-ray, which identified lesions, probably the result of asbestosis.
There is a legacy in South Africa, whereby all employees underwent a pre-employment medical assessment prior to joining an organisation. Organisations would define the nature of the medical assessment and the interval period between assessments, including three-yearly for chest X-rays. South Africa has a high incidence rate of Tuberculosis, predominantly Pulmonary TB, and had an incidence of 615 per 100,000 population in 2019, which has likely influenced this chest X-ray requirement (Conan et al, May 2022).
I documented a full occupational, medical, social and lifestyle history. It emerged that this employee had grown up in an area of South Africa where asbestos mining took place, and as a child would play in large mine dumps.
There appeared to be little or no environmental controls in place in such mining villages during the early years of asbestos mining. Asbestos was mined in South Africa from the late 19th century until 2002. Of the six types of asbestos, amosite, crocidolite, and chrysotile were mined in the country, the bulk of which was exported around the world (Selby, 2023). In some areas of the Northern Cape and Northern Transvaal, mine workers used asbestos mixed with sand to produce bricks for construction of their homes (Braun and Kisting, 2006). Many miners lived in mine-owned villages close to their workplaces, where homes, schools, shops, and hospitals were provided by the mining company.
Historically there appears to be limited legislation on environmental management in South Africa until the National Environmental Management Amendment Act 46 of 2003 commenced on 1 May, 2005.
Asbestosis is reportable to the Compensation Commissioner under the COID Act. In this worker’s case, the factory had corrugated asbestos sheeting and pipe lagging, which was believed to contain asbestos. The employee had not been involved in the removal of any lagging, and the asbestos sheeting in the manufacturing area appeared to be in a sound condition.
The COID Act required that a full work and social history be obtained and submitted to the Compensation Commissioner. An in-depth investigation of the employee’s work health risk assessment and previous employment history was undertaken – this identified potential exposure to suspected asbestos containing lagging, although the risk was deemed low.
Materials in use today which are considered safe may have hidden dangers which only become evident because of enhanced knowledge and better monitoring. Such materials may have the potential to become the ‘asbestos’ of tomorrow.”
From a social perspective, although current legislation, including the Mines Health and Safety Act 29 of 1996 and associated regulations exist, the closure of mining companies has led to a lack of funding to complete the remediation required for the few remaining asbestos mine dumps. As a result, exposure to asbestos continues to be a risk to many people living near the mines.
Although South Africa banned the mining, processing, transporting and use of asbestos in 2008, decades of past work and environmental exposures has resulted in it having the highest incidence of mesothelioma in the world. Mesothelioma is not the only disease resulting from asbestos exposure, as Braun and Kisting (2006) note. It is also associated with cancers of the larynx and ovaries, with further evidence suggesting that it may also cause cancer of pharynx, stomach and colorectum.
Asbestosis is a chronic lung disease. It is caused by the inhalation of asbestos fibres, which cause scarring of the lung tissue, resulting initially in shortness of breath. The condition has a long latency period of 30 to 40 years, dependent on the nature of the exposure (Huh, Chae, Choi, Kang, Lee, and Moon, 2022).
The Asbestos Relief Trust (ART) provides information on the claims process and legal and financial information for potential claimants in South Africa. It also provides further training to public health nurses in the local community, so they are equipped to refer clients with suspected occupational health disease to their district hospital for further care and treatment. Public health nurses are also able to provide early detection of the disease and advise on its management, prevention of any further deterioration of their condition, and compensation access. The ART further provides palliative care programmes for persons who have been diagnosed with asbestos-related lung conditions.
When managing this case, I reflected on the mining and use of asbestos. This material was originally deemed to provide many benefits to industry and was incorporated as fireproofing in domestic and commercial buildings. Materials in use today that are considered safe may have hidden dangers which only become evident because of enhanced knowledge and better monitoring. Such materials may have the potential to become the “asbestos” of tomorrow.
Although asbestos is no longer in use, workers may still be exposed to asbestos during remedial or demolition work. It will remain an issue in South Africa and beyond for many years to come.
References
Asbestos Relief Trust (2023). Asbestos Relief trust policy statement on social projects. Available at: https://asbestostrust.co.za/social-projects/
Braun,L and Kisting, S (2006). ‘Asbestos-Related disease in South Africa’, Am J Public Health, 96(8) 1386-1396
Conan N, Simons E, Ohler L, Mbatha M, Van Cutsem G, and Huerga H (2022). ‘Prevalence of TB and health-seeking behaviour’ The International Journal of Tuberculosis and Lung Disease, 26 (5) 463-465. Available at: DOI 10.5588/ijtld.22.0001
Huh D-A, Chae WR, Choi YH, Kang M-S, Lee YJ, and Moon K-W (2022). ‘Disease Latency according to Asbestos Exposure Characteristics among Malignant Mesothelioma and Asbestos-Related lung cancer cases in South Korea’ International Journal of environmental Research and Public Health, 15934, 19. Available at: DOI 10.3390/ijerph192315934
Selby,K. (Last updated June 2023) Mesothelioma in South Africa. Available at: https://www.asbestos.com/mesothelioma/south-africa/
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