Occupational fatality under-reporting in rural areas of the Western Cape Province, South Africa

Safety Science Vol. 25, No. 1-3, pp. 113-122. 1997 0 1997 Elsevier Science Ltd. All rights reserved Printed in the Netherlands 09257535/97

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OCCUPATIONAL FATALITY UNDER-REPORTING IN RURAL AREAS OF THE WESTERN CAPE PROVINCE, SOUTH AFRICA G.H. Schierhout, A. Midgley, J.E. Myers

*

Occupational and Environmental Health Research Unit, Department of Community Health, Medical School, University of Cape Town, Observatory, 7925, South Africa

Abstract-Following a previously published study which reported that 28% of occupational fatalities in the Cape Town metropole of the Western Cape Province of South Africa had not been reported in terms of statutoty regulations, this rural-based study found that 85% of occupational fatalities were unrepotted. Two hundred and twenty four work-related deaths occurring in 10 rural magisterial districts in the Western Cape Province over a two and a half year period (January 1990 - August 1992) were identified by examination of state mortuary death registers and police inquest reports. A review of the registers of the occupational safety inspectorate found that only 15% (n = 33) of these deaths had been reported. Drowning (68%), chemical poisoning (10%) and tractor accidents (9%) accounted for the greatest number of unreported fatalities. Only 5% of fatalities in women were reported. Underreporting of even the most direct occupational accidents highlights the gross inadequacy of the current reporting system for rural areas. Greater co-ordinated efforts within and between the government departments of health and labour are urgently required to address environmental hazards in rural areas and in particular on farms. Differential underreporting of occupational fatalities by gender to the disadvantage of women needs further investigation. 0 1997 Elsevier Science Ltd.

1. Introduction A previous study (Lerer and Myers, 1994) reported that 28% of fatal occupational injuries identified from a pool of 8562 registered deaths at the Cape Town metropolitan mortuary had not been reported in terms of statutory regulations. None of the fatal occupational injuries in fishing and agriculture had been reported. This raised interest in doing a study particularly of rural areas where large numbers of agricultural workers would be found, as the metropolitan mortuaries are unlikely to deal with these fatalities.

* Corresponding author. [email protected].

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It is difficult to obtain precise estimates of occupational fatality even in urban and more developed areas. Conventional sources of occupational fatality data are the compensation authorities, death certificates and autopsy reports based on mortuary records. Wide disparities exist between the effectiveness of these various documentary sources in identifying occupational fatalities. Death certificates and medical examiner records in the United States have been consistently noted to identify a greater proportion of occupational fatalities than the other sources (Cone et al., 1991; Fingar et al., 1992; Stout and Bell, 1991). Complete reporting is important for the identification and prevention through surveillance of fatal occupational injuries (Robertson, 1992). Even in countries with developed infrastructure, reporting to governmental agencies with preventative functions is surprisingly low (Stout and Bell, 1991). Few studies have been conducted in less developed settings with poor infrastructure, where it could be expected that reporting rates may be even lower. In addition to poor social infrastructure, farms in South Africa are characterised by paternalistic social relations. Employee populations are captive and spend their working and other living time on the domain of the farmer who has near total social control. Farm workers have poor access to independent transport and means of communication and are unlikely to be able to access the governmental authorities. This means that reporting of accidents is the responsibility of the farmer and subject to the farmer’s motivation and knowledge of reporting mechanisms. It is likely therefore that many fatal or disabling injuries in these areas are neither reported nor investigated by the relevant authorities, despite the existence of various statutory regulations. This study attempted to identify all work-related fatalities that occurred in a densely populated agricultural area in the Western Cape province of South Africa, over a two-and-a-half year period. Those deaths identified solely by medical examiner records (as represented by state mortuary data) were compared with records of the Occupational Safety Inspectorate of the Department of Labour (DOL) to ascertain the extent of under-reporting to the authorities. The objectives were to identify patterns of under-reporting by industry, by cause of occupational fatality, by age and by gender, and to highlight areas of particular need for prevention and surveillance. Implications of the findings are discussed in the context of the intense health policy and planning activities currently under way in the Western Cape province and nationally.

2. Methods 2.1. Legal requirements

for the reporting of fatal occupational

injury

In terms of existing legislation, all deaths in South Africa due to causes other than natural (Inquests Act, 1959) are subject to autopsy examination as part of a police investigation and subsequent inquest held in order to determine a cause of death. This includes mortality related to homicide, transportation, suicide, therapeutic misadventure and accidents. An inquest magistrate can decide whether a death was due to an act or omission on the part of any person and refer such cases for criminal investigation and charges. The Occupational Health and Safety Act (OHSA, 1993) requires that any incident resulting in a fatality that is consequent on the use of machinery, hazardous working conditions, or any accident at the workplace, be reported to the occupational safety inspectorate of the Department of Labour (DOL). Occupational fatalities are also compensated and surviving families are entitled to compensation

Occupational fatality

under-reporting

115

support in terms of the Compensation for Occupational Injuries and Diseases Act, 1993. Currently in South Africa, the system for obtaining compensation operates separately from the preventive functions of the Occupational Safety Inspectorate, while both are divisions of the DOL. In rural areas of the Western Cape province, occupational fatality cases are transported initially to the nearest police station or hospital. Most of these facilities have a state mortuary attached to them. If not, cases are transferred to the nearest mortuary where a police autopsy is performed and the circumstances of death are recorded. Routinely available data by cause of death as recorded on death certificates are produced by the Department of Health, but the completion of death certificates is notoriously unreliable (Van der Met-we et al., 1991). In urban areas, one or two large state mortuaries deal with the greater proportion of deaths due to unnatural causes including work-related deaths. In rural areas of the Western Cape identification of work-related fatalities requires reviewing registers of unnatural deaths and autopsy reports of individual cases at numerous small local mortuaries where these cases may be transported following a fatal accident. Matching of mortuary cases to DOL data by district, age or other sociodemographic variables necessary to describe patterns in under-reporting is not possible using centralised figures (Director, Occupational Safety Inspectorate, 1994, personal communication). A report of any fatal work-related accident is expected to be submitted to the DOL by the employer, whose workplace may be inspected and in some instances the employer is liable for prosecution. These reports are kept in a central office in the metropole. 2.2. Study population

and sampling

A case-series of occupational fatalities was conducted for selected rural areas using individual record reviews at local mortuaries and the files of the provincial offices of the Occupational Safety Inspectorate to determine patterns of underreporting. Magisterial districts were selected in areas of intense agricultural activity outside of metropolitan Cape Town. Districts selected comprise statistical regions 2, 3 and 7 which together account for 52% of farm workers employed in Development Region A (Appendix A). Other agricultural areas were more sparsely populated and were not included in the study. Appendix A shows the agricultural workforce by statistical region. The contiguity of districts minimised the chances of fatality cases being transferred to a mortuary not included in the study. Each magisterial district had at least one mortuary. All mortuaries in these districts were selected as data collection sites. 2.3. Sources of data 2.3. I. Selection of cases The death registers located at each of the mortuaries were scanned in order to locate any fatal occupational injury between January 1, 1992 and August 30, 1994. Inclusion criteria were based upon a four-category classification of work-relatedness, viz. direct cause, contributory cause, aggravating factor, and enhanced access to hazards arising from work @chilling and Andersson, 1986). This last category was particularly important in the farm work situation in South African conditions. Motor vehicle accidents on pubic roads, homicides and suicides were excluded.

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All likely occupational fatalities were isolated using a range of non-specific descriptors designed to locate deaths not expressly described in the register as occupational deaths. These descriptors included drownings that took place on farms and also included falls, freak accidents, undetermined causes, electrical injury, nondomestic bums, poisoning, exposure to gases and vapours, tractor injuries and non-public road transportation accidents. The autopsy reports were studied for each of these cases in order to exclude non-occupational deaths. 224 were confirmed as occupationally-related deaths. The registers of the DOL centralised at the Cape Town head office were reviewed for the study period, identifying 34 deaths for the study period in our magisterial districts.

3. Analysis Fatalities that were recorded at the state mortuaries only and ones that were recorded at both the mortuary and the DOL were summed to form the denominator. From this, the overall proportions of both reported and unreported fatalities were calculated. Patterns of underreporting were examined by industry, gender and age. Another definition of the denominator included the previous definition plus the fatalities that were located in DOL records, but were not included in the mortuary data. Proportions were calculated for both sets of deaths.

4. Results The total pool of occupational fatalities included 224 cases constituting the first denominator. Of these, 34 were found in the records of the occupational inspectorate of the DOL, amounting to an under-reporting proportion of 85% overall. Corrected for the 19 cases in the DOL records which were not found in the mortuary records (the second denominator), the overall under-reporting proportion would be 78%. Because no further information was available for these 19 cases, the rest of the analysis is based on the pool of 224.

Table 1 Reporting

of work-related

Cause

fatality by cause Reported (n = 34)

Unreported

number

(%o)

number

(%I

Falls Drowning Struck by object Machinery accident

5 5 4 1

(15) (15) (12) (3)

6 129 2 2

(2) (68) (1) (1)

Vapours and Electrical injury gases Chemicals and pesticides Tractor accident Other transport accident Freak accident Bums Ill-defined

36 0 5 3 0

(18) (9) (0) (15) (9) (0) (3) (3)

02 19 17 4 4 3 3

(1) (0) (10) (9) (2) (2) (2) (2)

1 1

(n = 190)

Percentage

45 4 61 33 1: 0 23 43 0 33 25

reported (o/o)

117

Occupational fatality under-reporting Table 2 Reporting

of work-related

Industry

Agriculture Construction Forestry Fishing Manufacturing Services Unknown

fatality by industry

Reported (n = 341

Unreported

number

(Yoo)

number

(So)

15 7 4 0

(441 (21) (121 (0)

150 3 1 4 1 2 29

(791 (2) (0) (2) (01 (11 (151

I

(0)

4 3

(12) (91

(n = 190)

Percentage

reported (“/cl

9 70 80 0 50 67 9

Table 1 shows the number and percentage of occupational fatalities by cause and by reporting status. As would be expected, the highest reporting rates are found for causes that are traditionally regarded as work-related. These include falls, being struck by an object, vapours and gases, electrical and transport injuries. Notable exceptions to this expectation are traditional categories of work-related accidents like machinery accidents, chemical and pesticide poisonings, tractor injuries and bums which show high levels of under-reporting. Another feature of Table 1 is the large number of drownings. These comprised predominantly drowning by way of unguarded access to water in farm dams and by way of bridge repairs or other farm worker activity involving water. Drownings were very infrequently reported and accounted for the greatest proportion of unreported deaths (68%) followed by chemicals and pesticides (10%). Table 2 shows that the bulk of fatalities overall were from agriculture (74%), as would be expected in a densely farmed area. Four percent of all fatalities were from construction and 2% from fishing (Table 2). The unknown category of industry represents fatalities occurring at small workplaces, which were named in the police reports, but were untraceable. These most probably represent informal sector activities. While other rural industries report the bulk of their fatalities, agriculture only reports 9% of fatalities. Work-related fatalities occurring in children are fairly common, constituting 38% of fatalities overall, and 29% of reported fatalities. Table 3 shows that there is no age specific

Table 3 Renortine

of work-related

Age group

Infant-9 years lo-19 years 20-39 years 40-49 years 50+ years Age unknown

fatalitv bv aee

( n = 190)

Reported (n = 34)

Unreported

number

(%I

number

(%1

10

(29)

76 _

(40)

12

1 15 0 8

(3) (44) (01 (24)

10 66 17 20

(5) (35) (9) (111

9 19 0 28

Percentage

reported (%)

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G.H. Schierhout et al.

Table 4 Cause of work-related

fatality for children and for adults a

Cause

Falls Drowning Struck by object Machinery accident Vapours and gases Electrical injury Chemicals and pesticides Tractor accident Other transport accident Freak accident Bums Ill-defined

Children ( < 19 years) n = 86

Adults n = 109

No.

% reported

No.

% reported

1 63 3 1

100% 0% 100% 100%

6 61 2 2 6 2 13 11 3 3 I 0

50% 2% 50% 0% 83% 100% 0% 18% 33% 33% 100% _

1 1 4 8 3

0% 100% 0% 38% 33%

1

0%

0 0

_ _

a 29 fatalities are excluded from this analysis as age was not recorded for these cases in the autopsy reports; greatest single category of fatalities in people of unknown age was drowning (34%). followed by falls (14%).

Table 5 Reporting

of work-related

Gender

Males Females

the

fatality by gender Unreported

Reported (n = 34)

( n = 1901

number

(%I

number

(%)

31 2

(94) (61

157 33

(831 (171

Percentage

reported (%b)

16 6

pattern with regard to reporting status. Table 4 shows the causes of occupational fatalities occurring in children and in adults. It is striking that most categories of work-related fatality, and in particular, drowning, tractor accidents and deaths involving chemicals and pesticides occurred equally commonly in both adults and children, Reporting by cause was equally low for both adults and children, with tractor accidents slightly more under-reported in adults. Fatalities in females (including women and girls) accounted for 15% of all fatalities and 6% of reported fatalities (Table 5). Under-reporting was high overall for both females and males, although slightly higher for females at 95% compared to 84% for males. All fatalities in women or girls occurred in agriculture. The largest category of fatalities in females was drowning (74%) followed by chemicals and pesticide poisoning (11%).

5. Discussion The previous publication raised the suspicion that under-reporting of occupational fatalities in rural areas was likely to be a problem of greater magnitude than in metropolitan Cape Town. This has been borne out by the results. These findings highlight the serious problems of occupational injury surveillance in the rural areas and the absence of effective mechanisms to prevent occupational injury. Fatalities represent the most extreme and therefore the most visible part of the spectrum of occupational injury and it can be predicted with confidence that

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less visible injuries constitute an even more serious problem with regard to ascertainment, prevention and management (including rehabilitation). Results may be marginally over-estimated due to the exclusion of the 19 cases reported to the DOL, for which no detailed information is available, but this is unlikely to change the overall picture substantially. These cases are likely to have been non-instant fatalities who were transported to distant hospital facilities in the metropole for treatment and who died there, and were then reported to the DOL. It was not possible to trace these cases to the Cape Town metropolitan mortuaries. It is conceivable that there are some cases who were transported out of the study area who died and were not reported to the DOL but it is not possible to estimate these. However, the effect of including the 19 reported cases on the overall reporting percentage was small, and it can reasonably be assumed that these cases are similarly unlikely to alter the patterns observed in the more detailed analyses. Of all rurally based industries, agriculture and fishing report the lowest proportion of their fatalities. The number of fatalities identified in the latter sector are too small for meaningful interpretation. The use of mortuary data to identify fishing fatalities is problematic because many bodies lost at sea are not recovered. Other data sources for fishing fatalities, such as harbour reports, were not available for our study area. Hence most of the remainder of this discussion focuses on the agricultural sector. Agriculture in South Africa is one of the largest single employment sectors (CSS, 1992). A sizeable proportion of farm workers are employed as seasonal/casual workers (40-45% nationally and 40-60% for the Western Cape) and agriculture remains the biggest source of employment for women in South Africa (Donaldson and Roux, 1994). Agriculture has been recognised as one of the most hazardous work environments (Chisholm et al., 1992) but is arguably the most difficult to regulate in a climate of scarce resources. In South Africa, the percentage of total fatalities in agriculture reported by the Compensation Commissioner for Occupational Injuries and Disease is almost double the percentage of the total workforce in agriculture, indicating that agriculture is a high risk sector (Fatal accident claims, WCC, 1988). Adult agricultural sector work-related fatalities numbered 103, yielding an annual rate of 0.49 deaths per 1000 farm workers for an estimated farm worker population of 83234 (Appendix A) over a period of 2.5 years. An understanding of the high risk nature of agriculture in South Africa needs to be informed by an analysis of the social conditions of farmworkers. Agricultural sector social relations can at best be described as paternalistic (Waldman, 1993). Social control is almost entirely in the hands of the employer, and racism is a key feature of labour relations (Segal, 19921, with physical assault of farmworkers by farmers commonly reported (Segal, 1992; Emanuel, 1992). The farmworker-farmer relationship has been underpinned by decades of political oppression and discrimination, and attempts to re-define the relationship are fraught with difficulties due to an entrenched culture of paternalism, exploitation and violence (Du Toit, 1992). While the low reporting proportions in this sector are clearly linked to the situation described above, another source of underreporting arises from small workforce size. This varies with the nature of production, and ranges for fruit farms, which are most common, from 10 to 100 (London, 1994). Small workforces, irrespective of their industrial sectoral location in South Africa, are typically worse off with regard to safety practices, levels of worker organisation and access to regulatory enforcement agencies than larger workforces. Reporting rates, even for traditional (mostly direct) causes of occupational injury, are surprisingly low. This is particularly so for pesticide poisonings, given the exclusion of suicides. The finding of substantial underreporting of pesticide poisoning is well validated.

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Although official figures of the extent of the problem show a fairly low incidence, recent surveys of hospital admissions in the rural Western Cape, suggest that only about 20% of cases (fatal and non-fatal) are being notified (London et al., 1994; Emanuel, 1992). In a context where employers’ control limits the independent activity of workers, low reporting rates are not surprising. The poor transport and communication infrastructure in rural areas is virtually totally dominated by employers hindering workers’ ability to report. Wages in this sector are extremely low reaching only about 20% of incomes earned elsewhere in the economy (Donaldson and Roux, 1994) with workers often paid in kind. An infamous and illegal remuneration system known as the tot system (payment in kind with wine) is still in force for approximately 20% of farm workers in this region (Scully, 1992; Waldman, 1993) and alcohol consumption and abuse in the farm worker population are universal and very high respectively (London, 1994). Illiteracy and low educational levels are also extremely common; a study in the Western Cape found that 64% of farmworkers in Rural Foundation farms (with typically more enlightened management) were functionally illiterate according to the intemationally accepted norm of having had less than 4 years of schooling (Weidepoel, 1984). Children on these farms participate substantially in casual labour. The situation of farm workers is unique in that they both live and work on farms, and therefore the boundary between workplace and home is virtually non-existent. The elision of working and living environments enhances access to hazards and gives rise to the appearance of atypical causes of work-related fatality (e.g. drowning) on the one hand, and the appearance of atypical groups (e.g. children) vulnerable to workplace hazards. The fact that children’s injuries are being reported to the DOL at all indicates that injuries to an atypical working group (e.g. children on farms) receive some recognition as being work-related when the causes are traditional (e.g. tractor accidents). Without such recognition one would have expected reporting rates for children to be much lower than those for adults. Almost no drownings were reported. This atypical cause of fatality could be considered to be work-related by virtue of easy access to unfenced expanses of water in a context where working and living environments are indistinguishable. A further striking feature of the results is that there is no age gradient, indicating that both traditional and atypical causes of fatality are common in both adults and children, underlining the need for a broader conception of work-related fatality in agriculture. Proportionately fewer fatalities were identified in women, which is in keeping with internationally accepted gender differences in injury occurrence. Small gender differentials in reporting must be interpreted in the light of overall low reporting rates, but given the paternalistic social system referred to above, these will need to be closely monitored. Pesticide poisoning is a notable cause of mortality in women. An additional source of fatalities in women is domestic and inter-personal violence. Although domestic violence would fit into a broad conception of work-related fatality in an environment where workers live and work on farms, we excluded associated deaths as it is difficult to argue that these fatalities are a result of working and living on farms. There is currently substantial and rapid health systems development both provincially and nationally, consequent on the election of a popular democratic government in 1994. New departmental policy predicated on the primary health care approach and a district based organisation of health services with a redistributive focus on underserved and rural areas is being developed and implemented. It is envisaged that district health authorities will perform occupational health preventive functions in future, including surveillance. These results have highlighted the need for improved provision of rural health and welfare

Occupational

fatal@

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under-reporting

services. However, unless particular strategies are developed to enable farm workers to access relevant authorities and health services, they will remain the most underserved of all workers in South Africa with the least visible health and safety status and conditions. More resources need to be directed towards developing surveillance systems and improving safety practices on farms which will not be unhinged by the social context in which injuries are currently occurring. Ongoing intervention, evaluation and research in this area is urgently needed.

References Cone, J.E., Daponte, A., Makofsky, D., Reiter, R., Becker, C., Harrison, R.J. and Balmes, J. (1991) Fatal injuries at work in California. Journal of Occupational Medicine 33, 813-817. Chisholm, C.J., Bottoms, D.J., Dywer, M.J., Lines, J.A. and Whyte, R.T. (1992) Safety, health and hygiene in agriculture. Sufev Science 15, 225-248. Donaldson, A. and Roux, A. (1994) Education, employment and income of black South Africans in 1985. Det,etopment, Southern Africa 11(l), 13 13- 143. Du Toit, A. (1992) The Farm as Family. Paternalism, management and modemisation on Western Cape wine and fruit farms. Centre for Rural Legal Studies, Stellenbosch. Emanuel, K. (1992) Poisoned Pay: Farm workers and the South African Pesticide Industy. Group for Environmental Monitoring and the Pesticide Trust, Johannesburg. Fingar, A.R., Hopkins, R.S. and Nelson, M. (1992) Work-related injuries in Athens County 1982-1986. A comparison of emergency department and workmen’s compensation data. Journal of Occupational Medicine 34, 779-787.

Lerer, L.B. and Myers, J.E. (1994) Application of Two Secondary Documentary Sources to Identify the Underreporting of Fatal Occupational Injuries in Cape Town, South Africa. American Journal of Industrial Medicine 26, 52 l-527. London, L., Erlich, R., Rafudien, S., Krige, F. and Vurgarellis, P. (1994) Pesticide poisoning notification in the Western Cape 1987- 199 1. South African Medical Journal &1, 269-272. London, L. (1994) An Investigation into the Neurological and Neurobehavioural Effects of Long-term agrichemical exposure among deciduous fruit farm workers in the Western Cape, South Africa. October 1994. Doctoral Dissertation, Medical Faculty. University of Cape Town. Robertson, L.S. (1992) Injury Epidemiology. Oxford University Press, New York, p. 54. Schilling, R. and Andersson, N. (1986) Occupational epidemiology in developing countries. Journal of Occupational Health

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Scully, P. (1992). Liquor and labour in the Western Cape, 1870- 1900. In Liquor and Labour in Southern Africa. ed. J. Crush and C. Ambler. Ohio University Press, Athens. Segal L. (1992) A Brutal Harvest. The roots and legitimisation of ciolence on farms in South Africa. Black Sash and the Project of the Study of Violence, Johannesburg. Stout. N. and Bell, C. (1991) Effectiveness of source documents for identifying fatal occupational injuries: A synthesis of studies. American Journal of Public Health 81, 725-728. Van der Merwe, S., Yach, D. and Metcalf, C. (1991) Peering into the black hole: The quality of African mortality data in the city of Port Elizabeth and South Africa. South African Medical Journal, Waldman. P.L. (1993) Here you will remain: Adolescent experience on farms in the Western Cape. MA thesis. Department of Anthropology, University of Cape Town, Cape, South Africa. WCC: Workmen’s Compensation Commissioner (1988) Workmen’s Compensation Act 1941 - Report on The 1988 Stutistic. Pretoria. Weidepoel, L. (1984) Learning From a Literacy Project. A Suwex of Adult Extra-Mural Studies, University of Cape Town, Cape Town, South Africa.

(Appendix

A owrleafl

Literacy

in South Africa.

Centre for

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Appendix A A.l. Agricultural

workforce by statistical

region, 1987

Statistical region

Farms

Total farmworkers

% farmworkers

Greater Cape Town

200

4733

0.6

Stellenboscb / Paarl Grabouw-Swellendam

1230 1390

25 417 23 848

11.0 24.3

George/Mossel Bay Uniondale Oudtshoom/Ladismith

1360 160 610

12821 1602 7445

11.9 21.5 13.0

Ceres /Worcester / Montagu

1500

33 969

22.6

Malmesbury/Piketberg Clanwilliam/Vredendal Namaqualand Walvis Bay

1240 1200 450 0

17 993 13 378 2265 -

14.2 28.1 0.9 -

Beaufort West Calvinia Willeston Development Region A South Africa

1010 690 210 11250 65 170

10 308 5697 1876 161352 1 117959

22.1 33.7 56.8 9.1 4.0

From London, 1994; sources: CSS (1987); CSS (1992). Regions included in the present study are indicated in bold.

of population