Personal Observations: Report on the 4th ADF Environmental and Occupational Health (EOH) Conference, Brisbane, March 2015

In   Issue Volume 25 No. 1 .

Commander Neil Westphalen

Dear Editor,
The JMVH article by Licina et al, reporting on the 4th Australian Defence Force (ADF) Environmental and Occupational Health (EOH) Conference in Brisbane in March 20151, merits the following observations.

The article initially refers to a range of future challenges in the Asia-Pacific region, such as climate change, environmental degradation, political
instability and terrorist threats, as well as poverty, population displacement, infectious disease, potable water shortfalls and inadequate sanitation. It also refers to the increasing incidence of lifestyle-related conditions in the region, such as cardiovascular disease, cancer and diabetes.

However, none of these otherwise important public health issues directly pertain to what should be one of the primary roles of the ADF’s health services: ensuring the occupational and environmental health-related employability and deployability of ADF personnel.

The article then asks how these challenges will affect what it refers to as the ‘EOH profession’, with respect to disaster relief and public health for local civilian populations, and force protection for deployed ADF personnel. It also describes how the United States is building regional partnerships via activities such as PACIFIC PARTNERSHIP, and how ADF EOH practitioners can contribute.

However commendable these aspirations, their scope remains limited to deployable ADF public health (as opposed to OEH) services, either as primary mission components in their own right, or as force protectionenablers for ADF operations.

Next, the article refers to the development of a JHC concept paper for the Defence Work Health and Safety Committee (DWHSC), to outline options to support the ADF’s Occupational Medicine/ Occupational Hygiene (OMOH) Project. It notes that some OMOH capability shortfalls were first exposed by Comcare seven years ago, during its investigation that resulted in its Hazardous Chemical Enforceable Undertaking in 20102, while others had been identified a further eight years ago, at the 2001 F-111 Deseal/Reseal Board of Inquiry3. The article also refers to the lengthy development period of other JHC initiatives, in particular Health Manuals 20 (Preventive Medicine) and 21 (Pest Control), the scopes of which are arguably also limited to deployable ADF public health services.

The article then lists a series of key points as outcomes from the following panel discussions:

Strategic perspectives from senior officials and policy perspectives on how Service EOH is supporting Defence requirements;

• EOH on exercise and deployment;
• EOH in garrison operations and academia, and
• Health surveillance informing health intelligence

I note that the key points raised per each of these panel discussions considered only some of the Fundamental Inputs to Capability (FICs) required to
sustain an ADF EOH capability4.

Finally, despite highlighting the extended timeframes that some of the conference topics remain outstanding, the article refers to the ‘reassuring’
level of motivation to find common solutions, and the need to properly resource ‘the EOH community’.

In short, the conference topics continued to perpetuate the view that the scope of military occupational and environmental health is limited to
managing the public health hazards associated with ADF deployments. This misperception stems from flawed assumptions (extending throughout military history), regarding the functions and roles of military health services. The latest Australian iteration of these assumptions arguably began with the performance audit report by the Australian National Audit Office (ANAO) in 19975, which indicated that:

• ADF personnel only require clinical treatment services, and
• The sole justification for uniformed ADF health personnel stems from the requirement to provide clinical treatment services while deployed

Both of these assumptions fail to address any other functions and roles of military health services, such as (in this case) occupational and environmental health. The anecdotal high incidence of ADF workplace illness and injury (in particular musculoskeletal injuries and mental health issues), suggests the need to better manage all the occupational and environmental hazards associated with all ADF workplaces (deployed and non-deployed), with more emphasis on prevention rather than treatment.

In support of these assertions, the Australian Faculty of Occupational and Environmental Medicine (AFOEM) website indicates that occupational
medicine takes a preventative approach to workplace health as follows6:

• Firstly, considering how workplaces affect employee health. It is suggested that the scope of this task in the ADF context is far broader than
the topics raised at this Conference: even in the ‘garrison’ setting, the ADF arguably constitutes one of the largest, most hazardous and complex
workplaces in Australia7,8.

Despite this, unlike other Australian employers (including the Public Service), the ADF via JHC appears to remain unique in Australia, in that
it provides health care for its employees without ascertaining whether or not any of the clinical presentations are work-related. Furthermore, at
present JHC does not collect work-related illness/ injury data, or record lost time or restricted duties, or identify the health care costs resulting
therefrom.

This baseline information is not only essential for monitoring the effectiveness of the ADF’s OEH services: it also facilitates accounting for the
high cost of providing health care for a fit young working-age medically-selected population, as well as the high health care and compensation
costs incurred by DVAS for current and exserving ADF personnel9.

• Secondly, considering how an employee’s health can affect their ability to work. The relevance of this task in the ADF setting is based on
the requirement to ensure that commanders, managers and supervisors are adequately informed of the health status of their personnel. It
is conducted in accordance with the Temporarily Medically Unfit (TMU) process, the ADF Medical Employment Classification (MEC) system10,11 and
the relevant single-Service references where these exist12,13.

However, personal experience of managing sickbays ashore and afloat for 14 of my 29 years in the permanent Navy indicates that:

• ‘Garrison’ MOs are unable to assess medical suitability for employment/deployment unless they fully understand what their patients
actually do in their workplace, and

Acquiring this understanding takes fulltime neophyte Service and civilian health practitioners 12 months; part-timers take longer and it simply doesn’t happen for itinerant sessional personnel who lack prior Service experience.

These assertions are supported by evidence indicating that medical certification of fitness for work can be challenging for civilian GPs for a number of reasons, including:

• The doctor-patient relationship;
• The GPs patient advocacy role;
• Consultation time pressures;
• Lack of occupational health expertise; and
• Lack of knowledge of the workplace14,15

These reasons are compounded by further evidence indicating that at least some civilian GPs do not accept their responsibilities with respect to how they manage long-term work absence, work disability and unemployment16,17.

Moving on, the AFOEM website also indicates that environmental medicine considers the human health impacts of industrial practices on the broader
environment. I simply note recent media articles that highlight the importance of this issue for the ADF in its base settings, and their co-located civilian communities within Australia18,19,20,21. These articles confirm that the scope of military environmental medicine is far broader than that indicated at this conference.

It therefore seems reasonable that, as a (military) health service that ostensibly provides health care for a (military) workforce in a variety of (military)
workplace settings, the ADF’s health services should be based on an OEH delivery model. Among other attributes, such a model would entail a
combination of Service and civilian occupational and environmental physicians (OEPs) as well as GPs and other health professionals. These need to collaborate in both the ‘garrison’ and operational (not just ‘deployed’) settings, not only regarding health policy development, but also providing clinical primary and other health care for ADF employees.

The current state of the ADF’s OEH services suggests that implementing such a model would take at least 10-15 years of sustained effort. It therefore seems unfortunate that the 4th ADF EOH Conference continued to limit the perceived scope of military occupational and environmental health, to managing the public health hazards found in many – but by no means all – ADF deployed settings.

Even so, I trust this letter will be considered a constructive contribution to the eventual development of a truly holistic health care model for the ADF.

Such a model would facilitate ADF operational capability by being premised on supporting a military workforce, who perform their duties in a wide range of, at times, extraordinarily demanding operational and non-operational workplaces.

This model would also require all ADF health staff to become military ‘OEH professionals’, each within their area of expertise, irrespective of whether or not they wear a uniform.

Yours Sincerely

N Westphalen
MBBS (Adel), Dip Av Med, MPH, FRACGP, FACAsM,
FAFOEM (RACP) psc
Commander, RANR

Acknowledgements

References

1 Licina D, Brittain A, Tout A, Strickland T, Taplin D. Aligning Defence Environmental and Occupational Health (EOH) Capbility with future requirements: the 4th Australian Defence Force EOH Conference. Journal of Military and Veterans’ Health, Vol 24 (2), Apr 2016 pp. 21-27 2 Enforceable undertaking given by Commonwealth of Australia as represented by the Department of Defence to Concare for the purpose of clause 2 of Schedule 2 of the Occupational Health and Safety Act 1991 [online] http://www.comcare.gov.au/_data/assets/pdf_file/0006/64581/EU_Dept_of_Defence.pdf [2016, 22 Jul] 3 Clarkson JW, Hopkins A, Taylor KV, (2001), Chemical Exposure of Air Force Maintenance Workers: Report of the Board of Inquiry into F-111 (Fuel Tank) Deseal/Reseal and Spray Seal Programs. Air Force Headquarters, R1-1-D003, Russell Offices, Canberra. 4 In the ADF setting, there are eight FiCs: organisation, personnel (including individual training), collective training, facilities, supplies, major systems, command and management, and support. See the Defence Capability Development Handbook 2012 [online] http://www.defence.gov.au/publications/DefenceCapa bilityDevelopmentHandbook2012.pdf [2016, 14 Aug] 5 Australian Government Auditor-General (1997). Performance Audit Report No 34: Australian Defence Force Health Services. Australian Government Publishing Service, Canberra, 26 May 1997. 6 Australasian Faculty of Occupational and Environmental Medicine. [online] https://www.racp.edu.au/ about/racps-structure/australasian-faculty-of-occupational-and-environmental-medicine [2016, 22 Jul] 7 As of Sep 15, the ADF consisted of 57,982 permanent and 45,398 active and standby Reserve personnel. Of these only 2,241 were deployed. Non-deployed personnel work at 60 major bases and many other facilities throughout Australia. These numbers do not include Defence civilian public service or contractor personnel. See Australian Defence Force [online] https://en.wikipedia.org/wiki/Australian_Defence_ Force [2016, 22 Jul] 8 The Defence recruiting website lists 214 different jobs across all three Services: see online at http://www. defencejobs.gov.au/recruitment-centre/job-finder [2016, 22 Jul] 9 As of 30 Jun 15, Australia had an estimated 339,000 veterans, including about 150,200 with peacetimeonly service between 1972 and 1994. Of these 339,000 veterans, 208,181 (61.4%) were in receipt of health care services for Service-related conditions (white and gold cards) from DVA. The net cost of these health care services was $5.525b. Non-health compensation and disability DVA costs came to another $3.220b. See DVA Annual Reports 2014-15. [online] 10 ADF Military Personnel Manual (MILPERSMAN), Part 3, Chapter 2, Australian Defence Force Medical Employment Classification (MEC) System (only available on Defence Intranet). 11 JHC Health Manual (HLTHMAN), Volume 3 Retention Standards, Chapter 1 Medical Employment Classification System (only available on Defence Intranet). 12 Australian Book of Reference (ABR) 1991 RAN Health Services Mnaual Chapter 8 The Australian Defence Force Medical Employment Classification System and the Maritime Environment (only available on Defence Intranet). 13 Army Standing Instruction (Personnel), Part 8, Chapter 3 The Application Of The Medical Employment Classification System And PULHEEMS Employment Standards In The Australian Army (only available on Defence Intranet). 14 AFOEM. Australian and New Zealand Consensus Statement on the Health Benefits of Work [online] 15 Richards Taylor, Keay AJ, Thorley K. Do GPs record the occupation of their patients? Occupational Medicine. 2013, 63, (2): pp. 138-140 16 Cohen D, Marfell N, Webb K, Robling M, Aylward M. Managing long-term worklessness in primary care: a focus group study. Occupational Medicine. 2010, 60, (2): pp. 121-6. 17 Beaumont D. Rehabilitation and retention in the workplace: the interaction between general practitioners and occupational health professionals: a cionsensus statement. Occupational Medicine. 2003, 53, (4): pp. 254-5. 18 Murphy, S. Williamstown. [online] http://www.abc.net.au/landline/content/2016/s4493433.htm [2016, 22 Jul] 19 Doherty, B. Pressure builds on Defence Force to remove deadly asbestos. [online] http://www.smh.com. au/national/pressure-builds-on-defence-force-to-remove-deadly-asbestos-20090108-7cwb.html [2016, 22 Jul] 20 Oakes, D. RAAF jet fuel damaged ground crews’ body cells; long-term consequences unknown, says groundbreaking research [online] http://www.abc.net.au/news/2015-04-30/raaf-personnel-exposed-tojet- fuel-suffered-cell-damage/6433360 [2016, 22 Jul] 21 Jones, A. Abuse in the military: running with a pack of wolves. [online] http://www.abcnet.au/news/2012- 01-23/jones-abuse-in-the-military3a-running-with-a-pack-of-wolves/3786652 [2016, 22 Jul]