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Medico-economic implications of industrial hand injuries in India
MEDICO-ECONOMIC HAND
IMPLICATIONS INJURIES IN N. MATHUR
OF INDIA
1IAL
IN
and K. K. R. SHARMA
From the Department of Orthopaedics, E.S.I. Hospital, Jaipur, India 625 five consecutive cases of industrial hand injuries attending the Employee’s State Insurance Hospital, Jaipur, have been studied from 1983 to October 1986. The incidence of injuries was 361 per 10,000 workers per year. 47% were due to entrapment of the hand in active machines, 25010 occurred during lifting and transportation of heavy objects and 12% while handling tools. The injuries resulted in residual deficit in 55% of cases and were serious enough to require absence from work of more than four weeks in 48% of cases. On an average 35 days were lost per injure worker. The average economic loss per injured worker was Rs. 6900 (approximately 5275) for workers in the wage-range of Rs. 5400 to 19,200 ($216 to $768) per annum. during the period 1983 to October 1986, were studied for the following:
In developing countries, in the vast areas becoming industrialised, the factory regulations ensuring safety to the workers are frequently implemented with laxity. As a result, the incidence of hand injuries is likely to be high. Further, an improperly organised health delivery system often compounds the issue and leads to excessive disability. Though reports of industrial hand injuries are available from the U.K. and U.S.A. (Absoud and Harrop, 1984; Goldwyn and Day, 1969; Johns, 1981; Gardner et al., 1968; Page, 1975), no such report is available from a developing country. The present study was initiated to analyse the circumstances leading to, and the socio-economic surrounding, industrial hand injuries in a city that is in the process of industrialisation. In India, a statutory corporation with central control and state-level health delivery systems has been operating to ensure medical benefits to industrial workers. Named the Employee’s State Insurance Corporation (E.S.I.C.), it receives revenue through contributions from central and state governments. State government hospitals, run by the corporation, provide an excellent opportunity for the study of industrial hand injuries, as every injured worker covered by the scheme has to go to the specified hospital to receive medical and other benefits. Jaipur city, with a population of 1,015,600 (1981 census) has 42,900 workers in medium and small-scale industries covered by the E.S.I.C. Although dispensaries cater for minor illnesses and injuries, all injured workers are subsequently referred to a large regional hospital, as are cases that need hospitalisation. The present study was undertaken to evaluate industrial hand injuries in such a hospital.
The percentage distribution of the industrial workers in the different age groups is based on the available census records. The percentage distribution of the injured workers studied was tabulated to assess the weighted age-incidence (Table 1). It revealed that 32(‘/aof workers belonging to the 18-25 year group suffered 38Vo of the injuries. The incidence was low in those aged 36-45, in whom 23% of the worker population suffer’ed 18% of the injuries. The incidence of injuries in the other agegroups was commensurate with their percentage distribution in the worker population.
Materials and methods
Mechanism of injuries
625 consecutive cases of hand injuries attending the Department of Orthopaedics, E.S.I. Hospital, Jaipur, Received: 9 September 1987 Navnendra Matbur MS (Orth), Jaipur, 302 016, India
A-28/2
VOL. 13-B No. 3 AUGUST
1988
Ugam
Path,
Sawai
Jaisingh
Highway,
Banipark,
1. 2. 3. 4.
Incidence, type and pattern of injuries. Loss of wages to the workers. Man-hours and economic loss to the nation. Residual permanent physical deficit and disability.
Results Age incidence
Table 1 Age incidence Age group (in years)
18-25 26-35 36-45 4b-
Number of injured workers
Percentage distribution of workers
Percentage of injured workers
273 241 116 31
32 41 23 4
38 39 18 5
Entrapment of hands in active machinery was of injury in 47% and lifting and transportation objects in 25%. The rest of the patients injuries while handling tools (12Vo) and miscellaneous ways (16%).
the cause of heavy sustained in other
325
N. MATHUR AND K. K. R. SHARMA
Type of job and industries 73% of the ,injured came from engineering industries, followed by 10% from textile and approximately 5% from transport industries. The percentage distribution of injuries amongst the different industries is commensurate with the percentage distribution of workers among the types of industries. Of the 460 injured workers from the engineering industries, 44% were employed as helpers and 37% as operators. Of the 61 injured textile workers, 64% were operators and only 23% were helpers.
permanent physical deficit amounted to Rs .15,42,000 (&61,680). The workers themselves lost a total of Rs.62,000 (&2,480) in wages during their time off work as they were paid only part of their salary during that period. Finally, the owners of the various industrial units lost a total of Rs.2,57,000 @10,280) as a result of loss of production. This amount was computed on the basis of the salary of the absentee workers. From the above figures, it may be computed that the total economic loss is Rs.43,00,000 (f 173,125) for the period of four years, or Rs.6900 (f275) per worker for 625 workers.
Hand and digits involved A total of 812 digits and 49 palms were injured. In 71% of workers, only one digit was involved. The percentage distribution of the injuries is set out in Table 2. TABLE 2 Site of hand injury Site Thumb Index finger Middle finger Ring fmger Little finger Palm of hand
Cases (o/o) 13 26 28 17 10 6
TABLE 3 Severe injuries Type of injury
Extensive skin loss Fracture Closed Compound Tendon injury Neurovascular injury Traumatic amputation Total
Site Thumb Index Middle Ring
Total Little
Palm
8
26
19
14
6
-
73
9 8 5
8 13 9 568
7 14 10 45
2 11 1 1 20
4 6
19
1 19 19 4 73
-
31 71 44 10 225
49
142
122
90
41
10
454
Discussion
Type of injury The injuries were minor or severe. Minor injuries (56%) were those which healed within four weeks with little or no permanent physical deficit. The majority of these minor injuries were lacerated and incised wounds (33%) of the index and middle fingers. Severe injuries (44Vo) were those which took more than four weeks to heal and resulted in permanent physical disability. Traumatic amputations (22%) and fractures (10%) constituted the majority of these injuries, the index and middle fingers being most affected (Table 3).
Time off work Data are available for only 471 patients who lost a total of 16806 days work. The average time off work was 35 days. 58% were off work for longer than four weeks. Patients with neuro-vascular and tendon injuries required the longest period (more than 12 weeks) off work.
Economic loss Claim settlement data for 295 patients showed that a total of Rs. 1,83,000 (approximately E7,320) was paid as temporary disability benefit to injured workers by the E.S.I.C. (48-87% of the workers’ salary). The total amount paid by the E.S.I.C. as compensation for 326
The high incidence of injuries reflects the laxity in provision of and adherence to safety measures in the industries. There was a surprisingly high (25%) incidence of injuries in the process of lifting and transporting heavy objects, which should be preventable by taking more care. It reflects the casual and indifferent manner in which the workers are required to handle heavy objects. While prevention of entrapment injuries requires evolution of, and insistence upon, safety measures in operating machines, caution and simple mechanisation could largely prevent the mutilation of hands during the handling and transportation of heavy objects. The age group 18-25 years had a disproportionately high incidence of injuries, possibly due to lack of proper training of young workers during their initiation period. In the engineering industries, more helpers (44%) than operators (37%) were injured, while in the textile industry, it was the reverse (helpers: 23070, operators: 64%). On enquiry, it was found the helpers are more likely to be allowed to handle machinery in the engineering industry during their initiation, as compared to the textile industry where a certain amount of skill is required before such activity is permitted. There is no obligation on&e part of the management to investigate all cases of injury. Under prevailing laws, industries contribute to the E.S.I.C. for each worker employed. Since the medical care and compensation of THE JOURNAL OF HAND SURGERY
INDUSTRIAL HAND INJURIES IN INDIA
the worker is then the responsibility of the E.S.I.C., the employers themselves have no financial obligation towards the worker, nor any conscious desire to improve the working environment, both which would otherwise involve expenditure for the management. The study reveals the many working days lost and the large economic loss caused by industrial hand injuries in Jaipur, a city which is in no way a major industrial centre. The estimated loss of Rs. 1 million (f40,OOO) to industry, workers and society per year is high enough to cause concern, but the loss of Rs.6900 (f275) per injured worker whose wages are only in the Rs.5400 to 19,200 (E216 - f768) per annum is disproportionately high. This loss could be drastically reduced if the management of the industries in question were to exercise more care in the layout and design of their machinery and provide adequate safety measures. Laws defining safety at work have been framed, but their implementation is poor. Industrial workers are often uneducated and ignorant and their employers are indifferent to the dangers that employees face at work.
VOL. 13-B No. 3 AUGUST 1988
This study also suggests that, for many o encountered, skilled orthopaedic and plastic surgical services are necessary to improve the quality of surgical care and reduce the time a worker would be off work. Existing facilities at the regional E.S.I. hospital are inadequate. Strict implementation of safety measures on the shopfloor, better education of the workers, a concerned management and improved medical facilities are all required to minimise industrial hand injuries and their physical and economic consequences. References ABSOUD, E. M. and HARROP, S. N. (1984). Hand Injuries .4t Work. Journal of Hand Surgery, 9B: 2: 211-215. GARDNER, D. C., GOODWILL, C. J. and BRIDGES, P. K. (1968). Absence from work after fracture of the wrist and hand. Journal of Occupational Medicine, 10: 3: 114-117. GOLDWYN, R. M. and DAY, L. H. (1969). Acute industrial hand iniuries: a socio-medical study. Plastic and R&zon&uctive Surgery, 44: 6: 567-575. JOHNS, A. M. (1981). Time off work after hand injuries. Injury, 12: 5: 417-424. PAGE, R. E. (1975). Hand injuries at work. (An analysis of patients attending hospital). The Hand, 7: 1: 51-55.
327
IMPLICATIONS INJURIES IN N. MATHUR
OF INDIA
1IAL
IN
and K. K. R. SHARMA
From the Department of Orthopaedics, E.S.I. Hospital, Jaipur, India 625 five consecutive cases of industrial hand injuries attending the Employee’s State Insurance Hospital, Jaipur, have been studied from 1983 to October 1986. The incidence of injuries was 361 per 10,000 workers per year. 47% were due to entrapment of the hand in active machines, 25010 occurred during lifting and transportation of heavy objects and 12% while handling tools. The injuries resulted in residual deficit in 55% of cases and were serious enough to require absence from work of more than four weeks in 48% of cases. On an average 35 days were lost per injure worker. The average economic loss per injured worker was Rs. 6900 (approximately 5275) for workers in the wage-range of Rs. 5400 to 19,200 ($216 to $768) per annum. during the period 1983 to October 1986, were studied for the following:
In developing countries, in the vast areas becoming industrialised, the factory regulations ensuring safety to the workers are frequently implemented with laxity. As a result, the incidence of hand injuries is likely to be high. Further, an improperly organised health delivery system often compounds the issue and leads to excessive disability. Though reports of industrial hand injuries are available from the U.K. and U.S.A. (Absoud and Harrop, 1984; Goldwyn and Day, 1969; Johns, 1981; Gardner et al., 1968; Page, 1975), no such report is available from a developing country. The present study was initiated to analyse the circumstances leading to, and the socio-economic surrounding, industrial hand injuries in a city that is in the process of industrialisation. In India, a statutory corporation with central control and state-level health delivery systems has been operating to ensure medical benefits to industrial workers. Named the Employee’s State Insurance Corporation (E.S.I.C.), it receives revenue through contributions from central and state governments. State government hospitals, run by the corporation, provide an excellent opportunity for the study of industrial hand injuries, as every injured worker covered by the scheme has to go to the specified hospital to receive medical and other benefits. Jaipur city, with a population of 1,015,600 (1981 census) has 42,900 workers in medium and small-scale industries covered by the E.S.I.C. Although dispensaries cater for minor illnesses and injuries, all injured workers are subsequently referred to a large regional hospital, as are cases that need hospitalisation. The present study was undertaken to evaluate industrial hand injuries in such a hospital.
The percentage distribution of the industrial workers in the different age groups is based on the available census records. The percentage distribution of the injured workers studied was tabulated to assess the weighted age-incidence (Table 1). It revealed that 32(‘/aof workers belonging to the 18-25 year group suffered 38Vo of the injuries. The incidence was low in those aged 36-45, in whom 23% of the worker population suffer’ed 18% of the injuries. The incidence of injuries in the other agegroups was commensurate with their percentage distribution in the worker population.
Materials and methods
Mechanism of injuries
625 consecutive cases of hand injuries attending the Department of Orthopaedics, E.S.I. Hospital, Jaipur, Received: 9 September 1987 Navnendra Matbur MS (Orth), Jaipur, 302 016, India
A-28/2
VOL. 13-B No. 3 AUGUST
1988
Ugam
Path,
Sawai
Jaisingh
Highway,
Banipark,
1. 2. 3. 4.
Incidence, type and pattern of injuries. Loss of wages to the workers. Man-hours and economic loss to the nation. Residual permanent physical deficit and disability.
Results Age incidence
Table 1 Age incidence Age group (in years)
18-25 26-35 36-45 4b-
Number of injured workers
Percentage distribution of workers
Percentage of injured workers
273 241 116 31
32 41 23 4
38 39 18 5
Entrapment of hands in active machinery was of injury in 47% and lifting and transportation objects in 25%. The rest of the patients injuries while handling tools (12Vo) and miscellaneous ways (16%).
the cause of heavy sustained in other
325
N. MATHUR AND K. K. R. SHARMA
Type of job and industries 73% of the ,injured came from engineering industries, followed by 10% from textile and approximately 5% from transport industries. The percentage distribution of injuries amongst the different industries is commensurate with the percentage distribution of workers among the types of industries. Of the 460 injured workers from the engineering industries, 44% were employed as helpers and 37% as operators. Of the 61 injured textile workers, 64% were operators and only 23% were helpers.
permanent physical deficit amounted to Rs .15,42,000 (&61,680). The workers themselves lost a total of Rs.62,000 (&2,480) in wages during their time off work as they were paid only part of their salary during that period. Finally, the owners of the various industrial units lost a total of Rs.2,57,000 @10,280) as a result of loss of production. This amount was computed on the basis of the salary of the absentee workers. From the above figures, it may be computed that the total economic loss is Rs.43,00,000 (f 173,125) for the period of four years, or Rs.6900 (f275) per worker for 625 workers.
Hand and digits involved A total of 812 digits and 49 palms were injured. In 71% of workers, only one digit was involved. The percentage distribution of the injuries is set out in Table 2. TABLE 2 Site of hand injury Site Thumb Index finger Middle finger Ring fmger Little finger Palm of hand
Cases (o/o) 13 26 28 17 10 6
TABLE 3 Severe injuries Type of injury
Extensive skin loss Fracture Closed Compound Tendon injury Neurovascular injury Traumatic amputation Total
Site Thumb Index Middle Ring
Total Little
Palm
8
26
19
14
6
-
73
9 8 5
8 13 9 568
7 14 10 45
2 11 1 1 20
4 6
19
1 19 19 4 73
-
31 71 44 10 225
49
142
122
90
41
10
454
Discussion
Type of injury The injuries were minor or severe. Minor injuries (56%) were those which healed within four weeks with little or no permanent physical deficit. The majority of these minor injuries were lacerated and incised wounds (33%) of the index and middle fingers. Severe injuries (44Vo) were those which took more than four weeks to heal and resulted in permanent physical disability. Traumatic amputations (22%) and fractures (10%) constituted the majority of these injuries, the index and middle fingers being most affected (Table 3).
Time off work Data are available for only 471 patients who lost a total of 16806 days work. The average time off work was 35 days. 58% were off work for longer than four weeks. Patients with neuro-vascular and tendon injuries required the longest period (more than 12 weeks) off work.
Economic loss Claim settlement data for 295 patients showed that a total of Rs. 1,83,000 (approximately E7,320) was paid as temporary disability benefit to injured workers by the E.S.I.C. (48-87% of the workers’ salary). The total amount paid by the E.S.I.C. as compensation for 326
The high incidence of injuries reflects the laxity in provision of and adherence to safety measures in the industries. There was a surprisingly high (25%) incidence of injuries in the process of lifting and transporting heavy objects, which should be preventable by taking more care. It reflects the casual and indifferent manner in which the workers are required to handle heavy objects. While prevention of entrapment injuries requires evolution of, and insistence upon, safety measures in operating machines, caution and simple mechanisation could largely prevent the mutilation of hands during the handling and transportation of heavy objects. The age group 18-25 years had a disproportionately high incidence of injuries, possibly due to lack of proper training of young workers during their initiation period. In the engineering industries, more helpers (44%) than operators (37%) were injured, while in the textile industry, it was the reverse (helpers: 23070, operators: 64%). On enquiry, it was found the helpers are more likely to be allowed to handle machinery in the engineering industry during their initiation, as compared to the textile industry where a certain amount of skill is required before such activity is permitted. There is no obligation on&e part of the management to investigate all cases of injury. Under prevailing laws, industries contribute to the E.S.I.C. for each worker employed. Since the medical care and compensation of THE JOURNAL OF HAND SURGERY
INDUSTRIAL HAND INJURIES IN INDIA
the worker is then the responsibility of the E.S.I.C., the employers themselves have no financial obligation towards the worker, nor any conscious desire to improve the working environment, both which would otherwise involve expenditure for the management. The study reveals the many working days lost and the large economic loss caused by industrial hand injuries in Jaipur, a city which is in no way a major industrial centre. The estimated loss of Rs. 1 million (f40,OOO) to industry, workers and society per year is high enough to cause concern, but the loss of Rs.6900 (f275) per injured worker whose wages are only in the Rs.5400 to 19,200 (E216 - f768) per annum is disproportionately high. This loss could be drastically reduced if the management of the industries in question were to exercise more care in the layout and design of their machinery and provide adequate safety measures. Laws defining safety at work have been framed, but their implementation is poor. Industrial workers are often uneducated and ignorant and their employers are indifferent to the dangers that employees face at work.
VOL. 13-B No. 3 AUGUST 1988
This study also suggests that, for many o encountered, skilled orthopaedic and plastic surgical services are necessary to improve the quality of surgical care and reduce the time a worker would be off work. Existing facilities at the regional E.S.I. hospital are inadequate. Strict implementation of safety measures on the shopfloor, better education of the workers, a concerned management and improved medical facilities are all required to minimise industrial hand injuries and their physical and economic consequences. References ABSOUD, E. M. and HARROP, S. N. (1984). Hand Injuries .4t Work. Journal of Hand Surgery, 9B: 2: 211-215. GARDNER, D. C., GOODWILL, C. J. and BRIDGES, P. K. (1968). Absence from work after fracture of the wrist and hand. Journal of Occupational Medicine, 10: 3: 114-117. GOLDWYN, R. M. and DAY, L. H. (1969). Acute industrial hand iniuries: a socio-medical study. Plastic and R&zon&uctive Surgery, 44: 6: 567-575. JOHNS, A. M. (1981). Time off work after hand injuries. Injury, 12: 5: 417-424. PAGE, R. E. (1975). Hand injuries at work. (An analysis of patients attending hospital). The Hand, 7: 1: 51-55.
327